病历_3_2_40
Here's the medical record based on the diagnostic conversation:
BASIC INFORMATION:
- Patient Name: Mr. Zhong
- Date of Visit: [Insert Date]
- Reason for Visit: Routine follow-up for diabetes management
CHIEF COMPLAINT:
Patient requests renewed prescriptions for insulin and pen needles, as well as further evaluation due to recent symptoms of dizziness which may be associated with blood pressure fluctuations.
HISTORY OF PRESENT ILLNESS:
Mr. Zhong is a known type 2 diabetes mellitus (T2DM) patient on insulin therapy. He also experiences occasional dizziness and suspects it might be related to either low blood sugar levels or hypertension. Although he regularly monitors blood glucose, he finds it challenging to reliably measure glucose levels due to professional constraints. The Patient states that his condition fluctuates but feels controlled with current medication.
PAST MEDICAL HISTORY:
- Type 2 Diabetes Mellitus
- Previous A1c recorded at 7%
- No history of retinopathy or neuropathy
- No documented allergies or specific cardiovascular conditions reported.
PERSONAL AND FAMILY HISTORY:
No mention of significant family history related to diabetes or heart disease. Mr. Zhong works as a truck driver with irregular work hours.
PHYSICAL EXAMINATION:
- Blood Pressure: [Pending measurement, anticipate potential hypertension]
- Others: Unremarkable at the time of the examination.
AUXILIARY TESTS:
- HbA1c, lipid panel, liver function tests, renal function tests, and urine microalbumin to be ordered for comprehensive evaluation.
- Referral for a routine eye examination by an ophthalmologist to monitor for diabetic retinopathy.
- Colonoscopy is recommended given that the patient has reached an age requiring this surveillance.
DIAGNOSIS AND ASSESSMENT:
- Type 2 Diabetes Mellitus, slightly elevated A1c levels.
- Potential hypertension requiring monitoring and further assessment.
- Need for evaluation of possible causes of dizziness and potential revision of diabetes management plan.
TREATMENT PLAN:
- Renew prescriptions for the following:
- Insulin
- Pen needles
- Schedule follow-up for blood pressure measurement and consider antihypertensive medication if consistently elevated.
- Encourage patient to continue monitoring blood glucose levels and maintain a record for review during next visit.
- Advise scheduling a colonoscopy and eye examination.
- Educate the patient about lifestyle modifications to aid in managing both blood pressure and blood glucose levels.
FOLLOW-UP:
The patient will be contacted following the lab results, and a follow-up appointment will be scheduled to discuss outcomes and further adjustments to the treatment plan if necessary.
This record adheres to standard outpatient documentation practices.