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病历_5_13_55

Patient Basic Information

  • Name: Timothy Bellocte
  • Gender: Male
  • Age: Unspecified
  • Consultation Date: 2023-09-25

Chief Complaint

  • Follow-up appointment for physical examination and review of recent laboratory report.

History of Present Illness

  • Onset of symptoms: Reviewed during the consultation.
  • Symptom description: Variation in cholesterol levels noted over the past year.
  • Aggravating/Alleviating factors: Potentially aggravated by dietary habits, particularly increased consumption of fatty meats.
  • Previous management: Previous cholesterol management medications tried but discontinued due to severe muscle pain.
  • Additional context: Recent colonoscopy in July - results normal.

Past Medical History

  • History of high cholesterol.
  • Previous borderline anemia corrected with Testosterone Replacement Therapy (TRT). Medication History:
    • Propranolol (as needed for anxiety)
    • Lexapro (daily since this year)
    • Zaloplon (as needed for insomnia)

Personal History

  • Mentioned diet changes contributing to fluctuating cholesterol levels.
  • Attempts to manage anxiety and sleep issues medically.

Family History

  • His spouse had H. pylori infection, treated successfully.

Physical Examination

  • Vital signs: Blood pressure rechecked and found to be within normal limits.
  • Examination findings: Not elaborated in the conversation.

Auxiliary Examinations

  • Hepatitis Panel: Positive immunity for Hepatitis A, non-immune for Hepatitis B, and negative for Hepatitis C.
  • Blood Profile: Hemoglobin, white blood cells, and platelets within normal ranges. AST levels have decreased since earlier in the year.
  • Metabolic Panel: Normal sugar, kidney function, electrolytes, and liver enzymes.
  • Lipid Profile: Elevated cholesterol and LDL levels.
  • Vitamin D: Low level noted.
  • H. pylori Test: Negative.

Diagnosis and Assessment

  • Preliminary Diagnosis: Hypercholesterolemia and Vitamin D deficiency.
  • Differential Diagnosis: Unnecessary due to lack of complex symptoms for differential considerations.

Treatment Plan

  1. Medications:
    • Hepatitis B vaccine, first dose today and a second dose one month later.
  2. Lifestyle Interventions:
    • Low-fat diet, reduce fatty meats, and increase lean protein consumption.
    • Recommends sunlight exposure to increase Vitamin D levels.
  3. Further Examinations:
    • Lipid profile recheck in 3 months to monitor cholesterol levels.
    • Blood pressure monitoring due to historical inconsistencies.
    • Shingles vaccine recommended upon reaching 50 years of age.