Follow-Up Visit

Name: Carls Weasley

Age: 36 Years Old

Date of Birth: 1st December 1988

Location: GP Clinic

Occupation: Food Vendor

“I have been doing well doctor. Recently, I've went to my local health screening event and they performed a few tests. The attending doctor insisted I consult my nearest GP”.

• SOCRTES nil findings

• Associated Symptoms:

  • Xanthelasma: "I've noticed I have some yellow deposits at the corners of my eye"

• Red Flag Symptoms

  • NO previous episode of chest pain, palpitations, sweating, shortness of breath (▲Myocardial Infarction)

  • Snoring at night, daytime sleepiness (▲Obstructive Sleep Apnea)

• Otherwise, NO fever and loss of appetite.

• Noticed weight has increased by 10kg over the past 6 months.

• Occasional fatigue and tiredness

• Mood and Psychosocial: Low Self-Esteem

• Previous episodes: Never experienced this before.

• Ideas: “Does it have to do with my weight?"

• Expectations: “Tell me more, I want to change!”

• Concerns: “Will I get a heart attack if I don't stop my bad habits?”

• NO fever, recent infections, cough, flu, chest pain, and shortness of breath

• NO abdominal pain, vomiting, diarrhea, constipation

• Normal urinary flow and bowel habits.

Previous hospital admissions: None

Previous surgeries: None

Medical conditions: None

Medications:

• None

Over the counters:

• None.

Allergies:

• None.

Father had a heart attack at 45 years old. Needed to insert a stent and is on blood thinning medications. Compliant with medications.

If asked, "My father and siblings are also larger in size on the weighing scale.."

• Smoking: Smokes 5 cigarettes a day for 10 years.

• Alcohol: Drinks 2 pints of beer on the weekends.

• Recreational drugs: Never

• Diet: Often eats at fast food chains

• Exercise: Never.

• Ill contacts: No one around me was recently ill

• Home: Lives with parents.

• Active Daily Living: Sells fried chicken skewers.

• Occupation: Food Vendor