病历_3_5_43
{"patientName":"","Outpatient Medical Record":"Basic Information:\nPatient: Jing An Shan (景安山), Male\nVisited: Dr. Jia\nChief Complaint:\nRoutine health check-up with complaints of anxiety and depression over the past 6 months.\nHistory of Present Illness:\nMr. Jing An Shan has experienced increasing anxiety and depression over the last six months, occasionally impairing his work as a software engineer due to high stress levels. He reports intermittent thoughts of self-harm but denies any concrete plans. The patient mentioned waking up feeling anxious, particularly when thinking about work and deadlines.\nPast Medical History:\nNo history of significant surgeries or current medications.\nPersonal and Family History:\nNot discussed in detail.\nPhysical Examination:\nEars: Normal\nThroat: Normal\nLungs: Clear to auscultation\nAbdomen: Soft, non-tender\nAuxiliary Tests:\nRoutine blood work including CBC, liver and kidney function, cholesterol levels, glucose levels, and thyroid function.\nScreening for Hepatitis B, Hepatitis C, and HIV.\nDiagnosis and Assessment:\nGeneralized Anxiety Disorder (GAD)\nMajor Depressive Disorder (MDD), without psychotic features\nDifferential diagnosis includes thyroid dysfunction; confirmation pending lab results.\nTreatment Plan:\nPrescription of Bupropion for anxiety and depression management. Initial dose to be adjusted after two weeks.\nReferral to Psychology Today for finding a counselor/psychologist.\nRecommendation for a follow-up appointment next week after lab results.\nAdministration of Tetanus (Td) vaccine and Influenza (fluer vaccination recommended.\nCOVID-19 booster to be scheduled at a later time.\nPatient Advice and Liaisons:\nPatient is advised to seek immediate help by calling 911 if experiencing thoughts of self-harm.\nEncouraged to communicate feelings of distress with family, significant others, or medical professionals.\nReview and Plan:\nFollow-up appointment is scheduled for next week post-lab results to assess progress and update the treatment plan accordingly."}