病历_3_13_56
{"patientName":"Timothy Beall","## Outpatient Medical Record":"","Basic Information:":"Patient Name: Timothy Beall\nDate of Birth: [DOB]\nGender: Male\nDate of Visit: December [Date], 2023","Chief Complaint:":"Follow-up for physical examination and lab results.","History of Present Illness:":"Patient is a [#]-year-old male who was previously seen by Dr. Cindy. Recent lab results show an elevated cholesterol level, particularly LDL. The patient has a history of high cholesterol and has experimented with various statins, resulting in severe myopathy. Diet changes since the summer include increased intake of fattier meats.","Past Medical History:":"High cholesterol with previous adverse reactions to statins.\nHistory of anemia earlier this year.\nTaking Lexapro for anxiety.\nUsing Propranolol PRN for anxiety episodes.\nUsing Zaleplon PRN for sleep initiation issues.","Personal and Family History:":"No significant family history reported in this session.","Physical Examination:":"Patient is alert, oriented, and cooperative. Vital signs are within normal parameters, with a recent blood pressure check being good. BMI and other physical exam components are within the normal range.","Auxiliary Tests:":"1. Lipid Panel:\n- Total Cholesterol: [Current Level] (High)\n- LDL: [Current Level] mg/dL (High)\n- HDL, Triglycerides: [Within normal limits]\n2. Liver Enzymes: ALT decreased from earlier levels this year.\n3. Complete Metabolic Panel: All values within normal range, excluding increased cholesterol.\n4. Hepatitis Panel: Immune to Hepatitis A, non-immune to Hepatitis B, Hepatitis C not present.\n5. Vitamin D: Low levels detected.","Diagnosis and Assessment:":"1. Hyperlipidemia, primarily elevated LDL.\n2. Anemia, resolved with elevated hemoglobin and hematocrit levels.\n3. Deficiency of Vitamin D.\n4. Non-immune status to Hepatitis B.\n5. Strong negative for H. pylori.","Treatment Plan:":"1. Dietary Modifications: Initiate a low-fat diet with lean meats.\n2. F/U: Recheck cholesterol levels and hepatic panel in 3 months.\n3. Vaccinations:\n- Administer 1st dose of Hepatitis B vaccine today, with the 2nd dose scheduled in one month.\n- Recommend Shingles vaccine for when the patient turns 50.\n4. Vitamin D Supplementation: Patient advised to resume Vitamin D supplementation and maintain sun exposure for natural synthesis.\n5. Medication Management: Continue Lexapro and Propranolol as previously prescribed. Reinforce selective use of Zaleplon.","Physician:":"Dr. Z\nNote: Please schedule follow-up in three months to reassess cholesterol and administer the second dose of the Hepatitis B vaccine."}