病历_3_10_48
{"patientName":"Yang)","Based on the diagnostic conversation, here is the outpatient medical record:":"Basic Information:\nName: Mei Hai (Last Name: Yang)\nAge: 84\nGender: Female\nFirst Visit\nChief Complaint:\nStiffness in the knee and discomfort exacerbated when climbing stairs.\nHistory of Present Illness:\nPatient reports difficulty in climbing stairs, mentioning pain and discomfort in the knees, primarily the right knee, which has been present for a long time. The severity fluctuates, with periods of improvement.\nPast Medical History:\nThe patient has previously been diagnosed with osteoarthritis, which has affected both knees, but more significantly on the right side.\nHistory of a cerebrovascular accident (stroke) approximately 15 years ago, with no residual motor or sensory deficits. The patient experiences vertigo but no limb weakness.\nPersonal and Family History:\nSmoking: Yes\nAlcohol: Previously consumed, has quit in the past one or two years.\nNo known allergies.\nPhysical Examination:\nObservation reveals swelling around the right knee joint.\nThe patient demonstrated difficulty and pain while walking, especially when changing from a sitting to a standing position.\nNo signs of peripheral edema.\nAuxiliary Tests:\nPrevious MRI (2019) showed no significant abnormalities.\nHemoglobin A1c slightly elevated at 6.2%, suggesting pre-diabetes.\nCholesterol levels remain high on Simvastatin 10 mg; consideration for Atorvastatin is suggested. Further blood work is ordered to assess lipid profiles.\nDiagnosis and Assessment:\nOsteoarthritis of the right knee, contributing to limited mobility and pain.\nHypercholesterolemia, with insufficient control on current medication.\nPre-diabetes, indicated by elevated HgA1c.\nTreatment Plan:\n1. For Osteoarthritis:\n- Order X-ray imaging of both knees to assess the severity and potential need for orthopedic intervention.\n- Discuss physical therapy and possible joint injection therapy.\n\n2. For Hypercholesterolemia:\n- Discontinue Simvastatin and start Atorvastatin pending the results of lipid profile tests.\n3. For Pre-diabetes:\n- Nutritional guidance focusing on blood sugar control and regular monitoring of glucose levels.\n4. Order Influenza vaccination.\n5. Follow-up:\n- Patient to return for review after completion of blood tests and X-ray. Adjust medications and treatment plan accordingly.\n\n6. Additional Note:\n- Monitor blood pressure regularly due to past history of CVA. Consider lifestyle changes to manage blood sugar and cholesterol levels.\nThis record ensures comprehensive, precise information while planning further diagnostic and therapeutic measures necessary for the patient's health."}