病历_5_2_30
{"patientName":"Patient's Name","Patient Basic Information":"Name : Patient's Name\nGender : Unspecified\nAge : Unspecified\nConsultation Date : 2023-09-29\n","Chief Complaint":"Patient needs a medication prescription refill and assessment of blood pressure.\n","History of Present Illness":"Onset of symptoms: Patient mentions episodes of dizziness uncertain if caused by high blood pressure or hypoglycemia.\nSymptom description: Dizziness occurs suddenly and subsides with rest.\nAggravating/Alleviating factors: Occurs occasionally, especially during work.\nPrevious management: Patient takes measures to manage hypoglycemia and has checked blood sugar levels at home regularly, but not A1C.\nAdditional context: Increased activity during Amazon Prime weeks; experiences normal blood sugar but uncertain about high blood pressure.\n","Past Medical History":"Type 2 diabetes, managed partly with insulin.\nMedication History : Insulin prescribed by the physician; no recent use of an oral hypoglycemic agent (second-degree dual flower).","Personal History":"Not specified.","Family History":"Not specified.\n","Physical Examination":"Vital signs: Blood pressure at home ranges from 110 to 138/85 mmHg; exact in-office measurement pending.\nExamination findings: Awaiting new blood pressure measurement.\n","Auxiliary Examinations":"A1C checks not regularly updated; last A1C was 7.\n","Diagnosis and Assessment":"Preliminary Diagnosis : Type 2 diabetes with well-controlled symptoms, suspect of possible hypertension.\nDifferential Diagnosis : None provided.\n","Treatment Plan":"1. Medications : Prescription of insulin needles and additional insulin (unspecified type) to be sent to the Safeway pharmacy in Newcastle.\n2. Lifestyle Interventions : None specified.\n3. Further Examinations : Recommends a comprehensive blood test including A1C, liver function tests, and possible follow-up with a sleep specialist if sleep disturbances continue.\n","Notes:":"The patient will have a blood pressure check during the visit. If patients' blood pressure readings are consistently high at home or during office visits, starting antihypertensive medication may be considered.\nRecommends reserving anti-hypertensive medication for confirmed cases of hypertension rather than intermittent high readings.\nEye examination for diabetic retinopathy is advised annually.\nA colonoscopy appointment is overdue and should be scheduled.\nContinues monitoring blood sugar levels at home, adjusting insulin dosage accordingly."}