Acupuncturist Template

CVRA (. )

A professional Acupuncturist template for healthcare professionals.

About this template

Streamline your clinical documentation with this comprehensive Cardiovascular Risk Assessment template. Ideal for a range of healthcare professionals, including General Practitioners, Cardiologists, and even Acupuncturists focusing on holistic health, this template ensures all vital aspects of a patient's cardiovascular health are meticulously recorded. Capture essential details from medical and family history, lifestyle factors, physical examination findings, and laboratory results to provide a thorough risk assessment. Heidi, our AI medical scribe, can efficiently populate this template from your patient consultations, ensuring accuracy and saving valuable time. This document facilitates clear recommendations and robust follow-up plans, promoting proactive patient care and improved health outcomes. Perfect for 'medical documentation examples' or 'clinical notes template' searches.

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Cardiovascular Risk Assessment: Patient Information: Name: Mrs. Eleanor Vance Age: 58 Gender: Female Contact: 07700 900345 Reason for Assessment: Patient presents for a comprehensive cardiovascular risk assessment following a recent family history of myocardial infarction in her elder sister. She expresses concerns regarding her own risk factors and wishes to understand preventative measures. Patient reports occasional mild palpitations, especially after consuming caffeinated beverages, and general fatigue. Medical History: * Hypertension (diagnosed 5 years ago, managed with medication) * Dyslipidaemia (diagnosed 3 years ago) * Type 2 Diabetes (diagnosed 2 years ago, managed with diet and medication) * No history of previous cardiovascular events (e.g., angina, MI, stroke) * Cholecystectomy 10 years ago Family History: * Mother: Hypertension, Type 2 Diabetes, deceased from stroke at 72 * Father: Hyperlipidaemia, deceased from myocardial infarction at 68 * Sister (62): Myocardial infarction 3 months ago, currently recovering * Brother (55): No known significant medical history Lifestyle Factors: * Smoking status: Non-smoker for 10 years (previously smoked 15 cigarettes/day for 20 years) * Alcohol consumption: 2-3 units per week (socially) * Diet: Reports a varied diet, but admits to frequent consumption of processed foods and sugary snacks. States difficulty adhering to a healthier diet due to work schedule. * Physical activity: Sedentary lifestyle, walks approximately 20 minutes once or twice a week. No regular structured exercise. * Stress levels: Reports moderate stress due to work demands and caring for elderly parents. Medications: * Lisinopril 10mg once daily * Atorvastatin 20mg once daily * Metformin 500mg twice daily * Multivitamin once daily Allergies: * Penicillin (rash) * Sulfa drugs (hives) Physical Examination: * Blood Pressure: 145/92 mmHg (sitting, right arm) * Heart Rate: 78 bpm, regular rhythm * BMI: 31.5 kg/m² (Height: 160 cm, Weight: 80.6 kg) * Waist Circumference: 98 cm * General: Mild central obesity, no peripheral oedema. Lungs clear to auscultation. Heart sounds normal, no murmurs. No carotid bruits. Laboratory Results (1 November 2024): * Total Cholesterol: 5.8 mmol/L * LDL-C: 3.5 mmol/L * HDL-C: 1.1 mmol/L * Triglycerides: 2.1 mmol/L * Fasting Glucose: 7.2 mmol/L * HbA1c: 7.1% * hs-CRP: 2.5 mg/L * eGFR: 75 mL/min/1.73m² Risk Assessment: Based on the collected information, Mrs. Vance is at high risk for cardiovascular disease. Her risk factors include age (58, female), positive family history, hypertension, dyslipidaemia, Type 2 Diabetes, elevated BMI, central obesity, sedentary lifestyle, and suboptimal dietary habits. While her hs-CRP is mildly elevated, it contributes to the overall risk picture. A SCORE2-OP (Systematic Coronary Risk Estimation 2-Older Persons) assessment, considering her age and comorbidities, places her in the high-risk category for a 5-year fatal and non-fatal cardiovascular event. Given the family history of early-onset MI, her genetic predisposition is also a significant factor. Recommendations: * **Lifestyle Modifications:** * **Diet:** Referral to a dietitian for structured guidance on a heart-healthy diet (e.g., Mediterranean-style diet), focusing on reducing processed foods, saturated fats, and sugars. Emphasis on increasing fruit, vegetable, and whole grain intake. * **Physical Activity:** Gradual increase in physical activity. Begin with 30 minutes of moderate-intensity activity (e.g., brisk walking) most days of the week, with a goal of 150 minutes/week. Referral to a community exercise programme. * **Weight Management:** Aim for a 5-10% reduction in current body weight over the next 6-12 months. * **Stress Management:** Explore stress reduction techniques such as mindfulness or yoga. * **Medications:** * Discuss with GP potential for optimisation of current antihypertensive and lipid-lowering therapy given current readings. * Consider initiation of low-dose aspirin, in consultation with GP, after a thorough risk-benefit analysis. * **Monitoring:** Regular home blood pressure monitoring. Patient Education: Comprehensive education provided regarding the importance of managing hypertension, dyslipidaemia, and diabetes. Discussed the link between lifestyle choices and cardiovascular health. Emphasised the significance of adherence to medication and regular follow-up. Information leaflets on heart-healthy eating and physical activity were provided. Patient expressed understanding of her risk factors and willingness to make lifestyle changes. Follow-Up Plan: * Review with GP in 2 weeks to discuss medication adjustments and aspirin initiation. * Appointment with dietitian scheduled for 3 weeks. * Follow-up acupuncture session in 1 month to address general well-being and stress reduction, which can indirectly support cardiovascular health. Focus areas will include liver qi stagnation and spleen qi deficiency patterns identified during initial assessment, aiming to harmonise the body's energy for improved metabolic function and emotional balance. * Repeat lipid profile and HbA1c in 3 months. Repeat blood pressure check with GP in 3 months.

Cardiovascular Risk Assessment: Patient Information: [document patient's name, age, gender, and contact information] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Reason for Assessment: [describe the reason for the cardiovascular risk assessment, including any specific concerns or symptoms mentioned by the patient] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Medical History: [document relevant past medical history, including any history of cardiovascular disease, hypertension, diabetes, hyperlipidemia, and other chronic conditions] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Family History: [document any family history of cardiovascular disease, hypertension, diabetes, hyperlipidemia, and other relevant conditions] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Lifestyle Factors: [describe lifestyle factors such as smoking status, alcohol consumption, diet, physical activity, and stress levels] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Medications: [list current medications, including dosages and any over-the-counter supplements] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Allergies: [document any known allergies] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Physical Examination: [describe findings from the physical examination, including blood pressure, heart rate, BMI, and any other relevant observations] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Laboratory Results: [document relevant laboratory results, including lipid profile, blood glucose levels, and other pertinent tests] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Risk Assessment: [provide an assessment of the patient's cardiovascular risk based on the collected information, including any risk scores or tools used] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Recommendations: [outline recommendations for lifestyle modifications, medications, and follow-up appointments] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Patient Education: [document any patient education provided, including information on cardiovascular risk factors and prevention strategies] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Follow-Up Plan: [describe the follow-up plan, including any scheduled appointments, referrals, or additional tests] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) (Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or omit the placeholder completely.) (Use as many lines, paragraphs or bullet points, depending on the format, as needed to capture all the relevant information from the transcript.)

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