Men’s Medicare Annual Wellness Assessment

Medicare Annual Wellness Visit (Male)

Patient Information

Name: Robert Vance (MRN: 842-910-55)

DOB: 14/05/1956

Visit Details

Date: 24/10/2023 09:30 PST

Reason for Visit: Medicare Annual Wellness Visit (AWV)

Health Risk Assessment

1. Gastroesophageal Reflux Disease (GERD) with Barrett's Esophagus: Stable, asymptomatic on omeprazole (Prilosec®) 20 mg PO daily. Last EGD (12/04/2022) showed non-dysplastic Barrett's esophagus; next surveillance EGD due 04/2025. Followed by GI.

2. Essential Hypertension: Well-controlled on lisinopril (Prinivil®) 10 mg PO daily. Recent BMP (10/10/2023) WNL, Cr 0.9 mg/dL, eGFR > 60 mL/min. Home BP averaging 124/76 mmHg. Followed by PCP.

3. Benign Prostatic Hyperplasia (BPH): Stable mild LUTS (nocturia x1) on tamsulosin (Flomax®) 0.4 mg PO daily. PSA 1.8 ng/mL (10/10/2023). Seen by Urology 02/2023.

Overall Health Status: Good. Vitals today: BP 126/78 mmHg, HR 68 bpm, Temp 36.8 °C, BMI 26.4 kg/m². Chronic conditions (GERD, HTN, BPH) are well-managed.

Functional Capacity & Safety: Independent in all ADLs and IADLs. No falls in the past year; Timed Up and Go (TUG) test < 10 seconds (low fall risk). Home environment has good lighting, no loose rugs, and grab bars in the shower.

Psychosocial Risks: PHQ-2 score 0 (negative for depression). Mini-Cog score 5/5 (normal cognitive function). Lives with spouse; strong social support system.

Behavioral Risks: Former smoker (quit 1998, 15 pack-year hx). Alcohol: 1–2 glasses of wine per week. Denies illicit substance use.

Nutrition & Physical Activity: Follows a low-acid, Mediterranean-style diet. Walks 30 minutes 5 days/week.

Medical History

Past Medical History: GERD, Barrett's esophagus, HTN, BPH. Surgical History: Laparoscopic cholecystectomy (2010), inguinal hernia repair (2015). Urological History: BPH diagnosed 2020, medically managed, no hx of nephrolithiasis or hematuria.

Family History: Father died of MI at age 78; hx of BPH. Mother had colon cancer at age 72. Paternal uncle had prostate cancer at age 80.

Current Medications:

• omeprazole (Prilosec®) 20 mg PO daily
• lisinopril (Prinivil®) 10 mg PO daily
• tamsulosin (Flomax®) 0.4 mg PO daily
• cholecalciferol (Vitamin D3) 25 mcg (1,000 IU) PO daily

Allergies: Penicillin (maculopapular rash).

Preventive Services

Screenings Due/Completed:

• Colorectal Cancer: Last colonoscopy 11/2018 showed 2 benign tubular adenomas; due for 5-year surveillance colonoscopy (11/2023).
• Prostate Cancer: PSA 1.8 ng/mL (10/10/2023); DRE deferred per shared decision-making.
• Cardiovascular: Fasting lipid panel (10/10/2023): TC 185 mg/dL, LDL 102 mg/dL, HDL 52 mg/dL, TG 155 mg/dL. AAA screening ultrasound completed 2021 (negative).

Immunizations:

• Influenza: Administered today (24/10/2023).
• Pneumococcal: PCV20 administered 11/2022.
• Shingles: Recombinant zoster vaccine (Shingrix®) series completed 2021.
• Tdap: Administered 2019.

Assessment and Plan

Assessment: 67yo male in good overall health presenting for AWV. GERD/Barrett's, HTN, and BPH are stable. Mild LUTS controlled on current regimen; denies erectile dysfunction. Due for surveillance colonoscopy.

Plan:

• Order 5-year surveillance colonoscopy.
• Continue current medications for GERD, HTN, and BPH.
• Administer annual influenza vaccine today.
• Repeat fasting lipids, CMP, CBC, and PSA in 1 year.

Referrals: Direct-access GI scheduling for surveillance colonoscopy. Continue annual routine follow-up with Urology.

Follow-up: Return in 1 year for next AWV, or sooner PRN. Follow up in GI clinic post-colonoscopy as needed.

Patient Education and Counseling

Topics Discussed: Importance of timely colorectal cancer surveillance given personal hx of adenomas and family hx of colon cancer. Reviewed GERD lifestyle modifications (avoiding late meals, elevating head of bed). Discussed BPH symptom monitoring and continuing regular aerobic exercise.

Patient Understanding: Patient verbalizes clear understanding of the preventive care plan and agrees to proceed with scheduling his colonoscopy.

Advance Care Planning

Advance Directives: Patient has an active Healthcare Proxy (spouse designated) and Living Will on file in the EHR, reviewed today and confirmed no changes desired. Full code status confirmed.