Women’s Medicare Annual Wellness Assessment

Medicare Annual Wellness Visit (Female)

Patient Information

Margaret Vance 14/05/1954

Visit Details

24/10/2023 Medicare Annual Wellness Visit and routine chronic disease review.

History of Present Illness

Gastroesophageal Reflux Disease (GERD) with Barrett's Esophagus: Asymptomatic on omeprazole (Prilosec®) 20 mg PO daily. Surveillance EGD performed by GI on 12/08/2023 showed stable short-segment Barrett's without dysplasia. Osteopenia: Stable on cholecalciferol (Vitamin D3) 25 mcg (1,000 IU) PO daily and calcium citrate 500 mg PO BID. Recent lab work (10/10/2023) showed 25-OH Vitamin D at 42 ng/mL and serum calcium at 9.4 mg/dL. Last DEXA scan in 2021 showed T-score -1.8 at the femoral neck. Essential Hypertension: Well-controlled on lisinopril 10 mg PO daily. Home BP logs average 122/76 mmHg. BMP on 10/10/2023 showed creatinine 0.8 mg/dL and potassium 4.1 mmol/L.

Overall health status is good; chronic GI, bone, and cardiovascular conditions are well-managed with current regimens.

Independent in all ADLs and IADLs. No falls in the past year. Home environment has grab bars in the shower and no loose rugs. Normal gait and intact hearing/vision with corrective lenses. PHQ-2 score is 0 (negative for depression). Mini-Cog score is 5/5, indicating intact cognitive function. Lives with spouse; strong social support. Never smoker. Consumes 1 glass of wine per week. Denies illicit substance use. Follows a low-acid, Mediterranean-style diet to manage GERD. Walks 30 minutes 5 days per week. BMI stable at 24.2 kg/m².

Medical History

• Past Medical History: GERD, Barrett's esophagus, osteopenia, essential hypertension.
• Past Surgical History: Laparoscopic cholecystectomy (2010), Cesarean section (1982).
• OB/GYN History: G2P2, menopause at age 51. No history of abnormal Pap smears; exited routine cervical screening at age 65. Father died of MI at age 78. Mother had osteoporosis and history of colon polyps (died at age 85). No family history of breast, ovarian, or esophageal cancer.
• omeprazole (Prilosec®) 20 mg PO daily
• lisinopril 10 mg PO daily
• calcium citrate 500 mg PO BID
• cholecalciferol (Vitamin D3) 25 mcg PO daily Penicillin (hives).

Preventive Services

• Colonoscopy: Due now (last performed 10/2013, normal, 10-year interval).
• Mammogram: Due now (last performed 09/2021, BI-RADS 1).
• DEXA Scan: Due now (2-year interval for osteopenia monitoring).
• Influenza vaccine: Received 01/10/2023.
• COVID-19 (2023–2024 formula): Received 01/10/2023.
• Recombinant zoster vaccine (Shingrix®): Series completed 2021.
• Pneumococcal conjugate vaccine (PCV20, Prevnar 20®): Due today.

Assessment and Plan

69-year-old postmenopausal female in good overall health. GERD, Barrett's esophagus, and HTN are stable. Reports mild, occasional vaginal dryness related to menopause, managed effectively with over-the-counter lubricants; denies postmenopausal bleeding.

• Administer PCV20 0.5 mL IM today.
• Order screening colonoscopy for colorectal cancer prevention.
• Order bilateral screening mammogram.
• Order repeat DEXA scan to evaluate osteopenia progression.
• Continue current medications without changes. Gastroenterology for screening colonoscopy and ongoing Barrett's esophagus surveillance (repeat EGD in 3 years per GI recommendations). Return to clinic in 1 year for next Annual Wellness Visit, or in 6 months for routine HTN and lab follow-up.

Patient Education and Counseling

Counseled on continuing weight-bearing exercises, adequate calcium/vitamin D intake, and fall prevention strategies. Reviewed GERD trigger avoidance (caffeine, late-night meals) and red-flag symptoms (dysphagia, odynophagia, melena, unexplained weight loss). Discussed postmenopausal urogenital health. Patient verbalized understanding of the screening schedule and agreed with the proposed care plan.

Advance Care Planning

Patient has an active Healthcare Power of Attorney and Living Will on file in the EHR (updated 2021), designating her spouse as primary healthcare proxy. Confirmed her wishes remain unchanged (desires full code status currently, but no prolonged mechanical ventilation if prognosis is futile).