病历_5_8_36
{"patientName":"Unspecified","Patient Basic Information":"Name : Unspecified\nGender : Unspecified\nAge : Unspecified\nConsultation Date : Unspecified\n","Chief Complaint":"The patient reports elevated blood pressure readings in clinical settings and is concerned about hypertension.\n","History of Present Illness":"Onset of symptoms: Recent elevation in blood pressure readings, particularly when in clinical settings.\nSymptom description: Blood pressure rising to 160/88 mmHg during clinic visits but stabilizing at home to approximately 130/80 mmHg. The patient also experiences occasional dizziness lasting about 30 seconds.\nAggravating/Alleviating factors: Stress or agitation seems to temporarily increase blood pressure.\nPrevious management: Monitoring blood pressure at home, using a portable blood pressure device.\nAdditional context: The patient indicates feeling more agitated and is concerned about possible stroke risks due to potential high blood pressure peaks.\n","Past Medical History":"Type 2 Diabetes Mellitus.\nMedication History : Long-acting insulin (15 units) every evening. Short-acting insulin (8 units) taken multiple times daily, especially with meals.","Personal History":"Not specified in the conversation.","Family History":"Not specified in the conversation.\n","Physical Examination":"Vital signs: Unspecified.\nExamination findings: No specific abnormalities noted in the conversation.\n","Auxiliary Examinations":"Recommended: Blood routine, lipid profile, fasting glucose, electrolyte levels, liver and kidney function tests, particularly focusing on renal function due to diabetes.\n","Diagnosis and Assessment":"Preliminary Diagnosis : Suspected hypertension.\nDifferential Diagnosis : Not specified in the conversation.\n","Treatment Plan":"1. Medications : Prescription for 20 mg Lisinopril, an antihypertensive medication, provided. Patient advised to begin intake if blood pressure consistently high.\n2. Lifestyle Interventions : Daily monitoring of blood pressure at home, especially under resting conditions, to assess accurate baseline levels.\n3. Further Examinations : Blood routine, lipid profile, fasting glucose, electrolyte levels, liver and kidney function tests.\n","Notes:":"The patient is advised to monitor blood pressure regularly at home to ascertain the need for antihypertensive medication given the varied readings between clinical and home settings.\nLisinopril is prescribed but patient instructed only to start medication if consistent high readings are observed.\nThe conversation indicates the need for regular follow-ups to evaluate the patient's blood pressure management and overall cardiovascular risk, especially in the context of diabetes."}