病历_5_17_58
{"patientName":"Mei Hai Yang","":"","Patient Basic Information":"Name : Mei Hai Yang\nGender : Female\nAge : Unspecified\nConsultation Date : [YYYY-MM-DD]","Chief Complaint":"Knee pain with recent episodes of swelling and stiffness.","History of Present Illness":"Onset of symptoms: Chronic condition with exacerbations.\nSymptom Description: Pain and intermittent swelling in the knee. Reports difficulty getting up and down and mention of stiffness.\nAggravating/Alleviating Factors: Exacerbated by prolonged standing and weight-bearing activities.\nPrevious Management: Use of calcium tablets (Mofree) as highlighted; physical therapy was suggested.\nAdditional Context: History of significant physical labor contributing to degenerative changes. No history of fractures mentioned; mild degenerative changes found in knee joints on X-ray.","Past Medical History":"Chronic knee discomfort.\nCardiovasuclar disease with long-term medication use including Telmisartan and Atorvastatin.\nMedication History : Telmisartan 40 mg daily, Atorvastatin 40 mg daily. Calcium supplement (Mofree).","Personal History":"Unspecified habits. Mention of a diet rich in carbohydrate-heavy foods like noodles and pancakes, particularly due to cultural dietary staples.","Family History":"Unspecified","Physical Examination":"Vital Signs: Unspecified.\nExamination Findings: No fractures on knee X-ray. Mild degenerative changes noted. No current visible swelling.","Auxiliary Examinations":"X-ray: Mild degenerative changes in the knee joints.\nBlood sugar: Elevated to 6.4% from a previous 6.2% hemoglobin A1c.\nLipids: Slight elevation in triglycerides.","Diagnosis and Assessment":"Preliminary Diagnosis : Osteoarthritis of the knee. Possible metabolic syndrome with elevated blood sugar and lipids.\nDifferential Diagnosis : Exclusion of fracture or severe joint pathology as per X-ray findings.","Treatment Plan":"1. Medications :\n- Prescribed antihyperlipidemic continuation (Atorvastatin) and antihypertensive drug (Telmisartan).\n- Consider the start of an oral hypoglycemic agent if dietary measures are insufficient over time.\n2. Lifestyle Interventions :\n- Reduce carbohydrate intake including rice and noodles. Increase dietary consumption of proteins such as eggs, tofu, and legumes.\n- Recommended physical therapy focusing on rehabilitation (boost facility suggested).\n- Consider over-the-counter analgesic patches for pain relief.\n3. Further Examinations :\n- Monitor blood sugar levels and reassess HbA1c after dietary changes and potential medication use.\n- Evaluate efficacy of physical therapy and potential orthopedics referral if non-surgical methods are ineffective."}