病历_3_11_49
{"patientName":"[Redacted]","Outpatient Medical Record":"Basic Information\nPatient's Name: [Redacted]\nDate of Birth: [Redacted]\nAge: [Redacted]\nGender: Male\nVisit Date: [Redacted]\nChief Complaint\nLow energy and recent troubles with sleeping.\nHistory of Present Illness\nThe patient reported experiencing low energy and tiredness in the past two weeks. He mentioned that he has been exercising almost every day but lately finds it difficult to fall asleep, with instances of sleeping as late as 4 a.m. Despite feeling tired, the difficulty in initiating sleep persists. The patient denies intake of caffeine but mentioned intense physical activity in the evenings, which includes playing volleyball and going to the gym.\nPast Medical History\nPre-diabetes diagnosed previously.\nPrevious upper respiratory infection (referred to as "flu" by the patient) about three weeks ago.\nDenied significant complications or severe lost activity.\nPersonal and Family History\nFamily history of diabetes on the maternal side.\nPhysical Examination\nVital Signs: Unremarkable.\nEyes: Normal.\nNeurological: Normal cranial nerves examination.\nRespiratory System: No abnormalities.\nCardiovascular System: Heart sounds normal.\nMusculoskeletal: No obvious skeletal abnormalities.\nAuxiliary Tests\nPast blood glucose levels noted, with concern for pre-diabetes.\n\nDiagnosis and Assessment\n1. Pre-diabetes (follow-up required).\n2. Sleep disturbances, potentially related to evening physical activities.\nTreatment Plan\n1. Lab orders: A comprehensive metabolic panel including blood glucose, CBC, liver function, kidney function, thyroid function tests, and lipid profile. Hepatitis A and C serologies to be included as well.\n2. The patient was advised to adjust workout times to possibly morning to determine if this relieves sleep disturbances.\n3. Follow-up: The patient was instructed to schedule a follow-up visit in one week to review lab results and assess the impact of changes in the workout routine.\nComments\nFlu shot was discussed, but the patient expressed reluctance due to past experiences of adverse reactions. The potential benefits were acknowledged without insistence on getting the flu shot this year.\nProvider Signature: [Redacted]\nDate: [Redacted]"}