病历_5_5_33
{"patientName":"Jing An San","Patient Basic Information":"Name : Jing An San\nGender : Unspecified\nAge : Unspecified\nConsultation Date : Unspecified\n","Chief Complaint":"The patient reports experiencing increased anxiety and depressive symptoms over the past six months.\n","History of Present Illness":"Onset of symptoms: The patient reports that symptoms have been increasingly severe for the past six months but has had them intermittently for a few years.\nSymptom description: The patient describes anxiety attacks, lack of motivation, concerns about work performance, and thoughts of self-harm without specific plans.\nAggravating/Alleviating factors: The patient indicates that work stress exacerbates his anxiety.\nPrevious management: No medications taken or therapy underwent for anxiety or depression prior to this visit.\nAdditional context: The patient mentions that sleep and appetite are not significantly affected.\n","Past Medical History":"No significant past medical conditions or surgeries reported.\nMedication History : The patient is not currently taking any medications.","Personal History":"Unspecified habits regarding smoking, alcohol consumption, diet, or exercise.","Family History":"No familial diseases or genetic predispositions mentioned.\n","Physical Examination":"Vital signs: Unspecified\nExamination findings: Normal general physical examination with no abnormalities noted during the standard check-up.\n","Auxiliary Examinations":"Blood tests for routine parameters including liver and renal function, cholesterol, blood sugar, neurotransmitter function, and hepatitis screening were recommended.\n","Diagnosis and Assessment":"Preliminary Diagnosis : Generalized anxiety disorder with depressive symptoms.\nDifferential Diagnosis : Unspecified pending results from laboratory examinations.\n","Treatment Plan":"1. Medications : Prescribed Wellbutrin with dosage adjusted after two weeks based on patient response.\n2. Lifestyle Interventions : Recommended psychology/therapy consultations from PsychologyToday.com.\n3. Further Examinations : Laboratory tests on liver function, thyroid function, and complete blood panel. Follow-up scheduled for next week.\n","Notes":"The patient considered a suicide plan but has not made specific arrangements. He was advised to contact 911 or this office immediately if such thoughts recur.\nHe was instructed to receive vaccinations for tetanus, flu, and COVID-19 booster, with the flu and tetanus vaccinations administered during the visit.\nEmphasized the importance of continuing medication even after feeling better and confirmed an appointment for next week to review lab results and treatment progress."}