Medicare Annual Wellness Visit (Female)
Patient Information:
Eleanor Vance
Date of Birth: 12 March 1954
Visit Details:
Date of Visit: 1 November 2024
Reason for Visit: Annual Medicare Wellness Visit and discussion of ongoing health maintenance.
History of Present Illness:
Type 2 Diabetes Mellitus: Controlled on Metformin 1000mg BID. Recent HbA1c (October 2024) was 6.8%. Last seen by Endocrinologist Dr. Sarah Jones in September 2024, stable condition.
Hypertension: Managed with Lisinopril 20mg daily. Blood pressure readings consistently within target range. Last cardiology review was 6 months ago.
Osteoarthritis (knees): Manages with occasional paracetamol. No recent flares, maintains regular low-impact exercise (walking).
Current health status: Ms. Vance reports generally good health. No new complaints since last visit. She actively manages her chronic conditions with adherence to medication and lifestyle recommendations.
Functional ability and level of safety: Patient reports no recent falls. Lives independently in a single-story home. Uses a cane for longer distances but feels stable. Fall risk assessment indicates low risk; she maintains good balance and strength.
Psychosocial risks: Depression screening (PHQ-2) negative. Cognitive function assessment (MMSE) within normal limits for age. Reports good social support from her daughter and local community groups.
Behavioral risks: Denies tobacco use. Reports occasional social alcohol consumption (1-2 units per week). No illicit substance use reported.
Nutrition and physical activity assessment: Follows a balanced diet with emphasis on fruits, vegetables, and lean protein. Engages in daily walks for 30 minutes and attends a weekly water aerobics class.
Medical History:
Past Medical History: Cholecystectomy (1998), Appendectomy (1975). Obstetric/Gynecological History: G3P3, spontaneous vaginal deliveries. Menopause at age 52. No history of abnormal Pap smears.
Family History: Mother had Type 2 Diabetes and Hypertension. Father had a myocardial infarction at age 65. No known hereditary conditions.
Current Medications and Supplements: Metformin 1000mg BID, Lisinopril 20mg daily, Vitamin D 1000 IU daily, Calcium 600mg daily.
Allergies: Penicillin (rash).
Preventive Services:
Screening tests and preventive services due: Mammogram due March 2025 (last one October 2023, normal). Colonoscopy completed 2 years ago, recommended repeat in 8 years. Bone density scan due next year.
Immunizations status: Up-to-date on tetanus booster (5 years ago). Received influenza vaccine October 2024. Received Shingles vaccine (2 doses) 18 months ago. Pneumococcal vaccine received 3 years ago.
Assessment and Plan:
Assessment of current health status: 70-year-old female with well-controlled Type 2 Diabetes and Hypertension. Good functional status with low fall risk. No signs of cognitive decline or depression. Menopause-related concerns are well-managed.
Plan for addressing health risks and preventive services: Continue current medication regimen. Encourage continued healthy diet and exercise. Discussed importance of upcoming mammogram and bone density scan. Provide educational material on nutrition for older adults. Monitor blood pressure and blood glucose at home.
Referrals to other healthcare providers or specialists: Consider referral to physical therapy for knee strengthening exercises if osteoarthritis symptoms worsen. No immediate referrals needed.
Follow-up appointments: Schedule routine follow-up in 3 months for diabetes and hypertension management. Next Annual Wellness Visit in 12 months.
Patient Education and Counseling:
Topics discussed with the patient: Emphasised importance of medication adherence, continued healthy lifestyle choices, and upcoming preventive screenings. Discussed signs and symptoms of complications related to diabetes and hypertension. Reviewed basic women's health issues pertinent to her age group, including bone health and cardiovascular risk.
Patient's understanding and agreement with the plan: Patient verbalised understanding of the plan and agreed to adhere to recommendations and schedule follow-up appointments.
Advance Care Planning:
Discussion of advance directives and end-of-life care preferences: Ms. Vance has an advanced directive in place and wishes for her daughter to be her primary healthcare proxy. She confirmed her preferences for comfort-focused care should she become incapacitated.
