病历_5_6_34
{"patientName":"Mr. He Pengfei","Patient Basic Information":"Name : Mr. He Pengfei\nGender : Male\nAge : Unspecified\nConsultation Date : 2023-04-12","Chief Complaint":"Rash persisting for one year, exacerbated by itching.","History of Present Illness":"Onset of symptoms : Approximately one year ago.\nSymptom description : Persistent rash, predominantly on the medial thighs, with periodic exacerbation of pruritus.\nAggravating/Alleviating factors : Intermittent itching with variable severity. Previous treatment with ketoconazole cream resulted in limited improvement. Recent use of hydrocortisone cream has provided better symptomatic relief.\nPrevious management : Ketoconazole cream and hydrocortisone cream applied topically. Oral Clindamycin was discontinued due to potential allergic reaction manifesting as white spots on the skin. The patient reports no recent lab testing.\nAdditional context : Reports intermittent effectiveness of treatments.","Past Medical History":"Significant conditions : Historical diagnosis of myocarditis. Unspecified childhood illness.\nMedication History : Not currently detailed.","Personal History":"Unremarkable. No recent anxiety or depression. Blood pressure reportedly within the normal range. No history of surgeries. Unknown status of smoking, alcohol consumption, diet, or exercise habits.","Family History":"No known familial history of hypertension, diabetes, malignancies, or other significant diseases.","Physical Examination":"Vital signs : Not documented in the transcript.\nExamination findings : General physical examination unremarkable. Specific focused examination on skin rash locations, revealing pruritic lesions.","Auxiliary Examinations":"Recommendations for comprehensive lab tests including CBC, CMP, lipid profile, blood glucose, and serological tests for hepatitis A, B, C. Immunization status suggests the need for tetanus, hepatitis B, and flu vaccines.","Diagnosis and Assessment":"Preliminary Diagnosis : Chronic pruritic dermatitis with suspected fungal component.\nDifferential Diagnosis : Eczema, fungal infection, other forms of dermatitis.","Treatment Plan":"1. Medications : Prescription of a more potent topical steroid for itch relief, continuation of ketoconazole for antifungal therapy.\n2. Lifestyle Interventions : Not specifically mentioned.\n3. Further Examinations : Comprehensive lab testing for serological profiles, including liver functions and hepatitis screenings. Immunizations for tetanus and flu.\n","Notes:":"Follow-up scheduled in one week for test results and further management.\nThe patient is referred to a nearby laboratory for blood draws and vaccinations.\nDepending on lab results, further specialist referral or treatment modifications may be necessitated."}