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病历_5_9_37

Patient Basic Information

  • Name: Wang Ming
  • Gender: Male
  • Age: 33 years old
  • Consultation Date: [YYYY-MM-DD]

Chief Complaint

  • Follow-up consultation regarding high triglyceride levels.

History of Present Illness

  • Onset of symptoms: Not specified, recent test result showing elevated triglycerides.
  • Symptom description: Triglyceride levels increased to 500 mg/dL from 195 mg/dL over the course of a year.
  • Aggravating/Alleviating factors: Possible postprandial increase, suggesting a later diagnostic test during the day.
  • Previous management: None specified for triglycerides; however, antihistamines initiated for urticaria.
  • Additional context: Urticaria flare-ups suspected to be related to home environment; potential mite allergy considered.

Past Medical History

  • Allergic rhinitis, diagnosed chestnut pollen sensitization.
  • Medication History: Fexofenadine 180mg for urticaria.

Personal History

  • No specific lifestyle habits discussed.

Family History

  • Not mentioned.

Physical Examination

  • Vital signs: Not recorded during this visit.
  • Examination findings: No physical abnormalities mentioned.

Auxiliary Examinations

  • Triglycerides: 500 mg/dL
  • Total cholesterol: Slight elevation noted at 214 mg/dL.
  • LDL cholesterol: Within normal range.
  • Glycated hemoglobin (HbA1c): Normal.
  • Renal function (eGFR, serum creatinine): Normal.

Diagnosis and Assessment

  • Preliminary Diagnosis: Hypertriglyceridemia.
  • Differential Diagnosis: Not specified in this visit. Follow-up blood test to verify triglyceride levels.

Treatment Plan

  1. Medications: Prescription for antihypertensive medication in case of persistent high triglyceride levels after retesting (post-fasting recommended).
  2. Lifestyle Interventions: Recommendation to consume high-quality protein, reduce fatty meat intake, and consider environmental controls for possible dust mite allergy (use of anti-mite bedding covers, frequently washing and heat-drying sheets).
  3. Further Examinations: Schedule a fasting blood test in January for triglyceride reevaluation.