病历_5_13_55
{"patientName":"Timothy Bellocte","Patient Basic Information":"Name : Timothy Bellocte\nGender : Male\nAge : Unspecified\nConsultation Date : 2023-09-25\n","Chief Complaint":"Follow-up appointment for physical examination and review of recent laboratory report.\n","History of Present Illness":"Onset of symptoms: Reviewed during the consultation.\nSymptom description: Variation in cholesterol levels noted over the past year.\nAggravating/Alleviating factors: Potentially aggravated by dietary habits, particularly increased consumption of fatty meats.\nPrevious management: Previous cholesterol management medications tried but discontinued due to severe muscle pain.\nAdditional context: Recent colonoscopy in July - results normal.\n","Past Medical History":"History of high cholesterol.\nPrevious borderline anemia corrected with Testosterone Replacement Therapy (TRT).\nMedication History :\n- Propranolol (as needed for anxiety)\n- Lexapro (daily since this year)\n- Zaloplon (as needed for insomnia)","Personal History":"Mentioned diet changes contributing to fluctuating cholesterol levels.\nAttempts to manage anxiety and sleep issues medically.","Family History":"His spouse had H. pylori infection, treated successfully.\n","Physical Examination":"Vital signs: Blood pressure rechecked and found to be within normal limits.\nExamination findings: Not elaborated in the conversation.\n","Auxiliary Examinations":"Hepatitis Panel: Positive immunity for Hepatitis A, non-immune for Hepatitis B, and negative for Hepatitis C.\nBlood Profile: Hemoglobin, white blood cells, and platelets within normal ranges. AST levels have decreased since earlier in the year.\nMetabolic Panel: Normal sugar, kidney function, electrolytes, and liver enzymes.\nLipid Profile: Elevated cholesterol and LDL levels.\nVitamin D: Low level noted.\nH. pylori Test: Negative.\n","Diagnosis and Assessment":"Preliminary Diagnosis : Hypercholesterolemia and Vitamin D deficiency.\nDifferential Diagnosis : Unnecessary due to lack of complex symptoms for differential considerations.\n","Treatment Plan":"1. Medications :\n- Hepatitis B vaccine, first dose today and a second dose one month later.\n2. Lifestyle Interventions :\n- Low-fat diet, reduce fatty meats, and increase lean protein consumption.\n- Recommends sunlight exposure to increase Vitamin D levels.\n3. Further Examinations :\n- Lipid profile recheck in 3 months to monitor cholesterol levels.\n- Blood pressure monitoring due to historical inconsistencies.\n- Shingles vaccine recommended upon reaching 50 years of age.\n"}