病历_3_7_45
Sure, below is the patient's outpatient record based on the diagnostic conversation:
Outpatient Medical Record
Basic Information
- Patient Name: Liang Wang
- Gender: Male
- Age: 40
- Date of Visit: [Insert Date]
Chief Complaint
- Annual physical examination.
History of Present Illness
- Patient reports past COVID-19 infection, with symptoms resolving rapidly after medication. Expresses interest in receiving current flu and COVID-19 booster vaccines.
- Presents concern due to recent increase in heartburn episodes, approximately every one to two weeks. Symptoms not directly correlated with food intake and usually resolve without medication.
- Recent history of constipation, noted to have become more frequent after a previous episode of rectal bleeding diagnosed as hemorrhoids.
Past Medical History
- History of H. Pylori infection, previously treated.
- Elevated blood glucose levels, monitoring with no significant changes.
- Diet includes adequate fluid intake.
- Discusses history of cutaneous lipomas without significant change in size or tenderness.
Personal and Family History
- Family history of gastric issues in mother, including gastritis and esophageal thickening as precursors to potential malignancy.
Physical Examination
- Vital signs: WNL (within normal limits)
- Focused examination of the abdomen and cutaneous tissues for lipomas: WNL
- Cardiovascular and respiratory examination: WNL
Auxiliary Tests
- Ordered standard blood tests, including CBC, lipid profile, liver, and renal function tests.
- Urea Breath Test for H. Pylori redisposition.
Diagnosis and Assessment
- Reflux esophagitis may be contributing to heartburn episodes.
- Constipation with no alarming features thus far; monitoring trends.
- Elevated blood glucose levels, aligned with previous records.
Treatment Plan
- Medications: Recommend trial of Omeprazole for symptomatic relief of heartburn.
- Vaccinations: Administered influenza and COVID-19 booster vaccines.
- Investigations: Schedule further GI assessments dependent on breath test results and persistence of constipation symptoms.
- Follow-Up: Review of test results and symptomatology in one week; arrange specialist referral if necessary.
Please note: this medical record should be appended to the patient's existing records and thoroughly reviewed during subsequent visits.