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病历_5_17_58

Patient Basic Information

• Name: Mei Hai Yang
• Gender: Female
• Age: Unspecified
• Consultation 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.
• Symptom Description: Pain and intermittent swelling in the knee. Reports difficulty getting up and down and mention of stiffness.
• Aggravating/Alleviating Factors: Exacerbated by prolonged standing and weight-bearing activities.
• Previous Management: Use of calcium tablets (Mofree) as highlighted; physical therapy was suggested.
• Additional 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.
• Cardiovasuclar disease with long-term medication use including Telmisartan and Atorvastatin.
• Medication 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.
• Examination 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.
• Blood sugar: Elevated to 6.4% from a previous 6.2% hemoglobin A1c.
• Lipids: Slight elevation in triglycerides.

Diagnosis and Assessment

• Preliminary Diagnosis: Osteoarthritis of the knee. Possible metabolic syndrome with elevated blood sugar and lipids.
• Differential Diagnosis: Exclusion of fracture or severe joint pathology as per X-ray findings.

Treatment Plan

1. Medications:
   • Prescribed antihyperlipidemic continuation (Atorvastatin) and antihypertensive drug (Telmisartan).
   • Consider the start of an oral hypoglycemic agent if dietary measures are insufficient over time.
2. Lifestyle Interventions:
   • Reduce carbohydrate intake including rice and noodles. Increase dietary consumption of proteins such as eggs, tofu, and legumes.
   • Recommended physical therapy focusing on rehabilitation (boost facility suggested).
   • Consider over-the-counter analgesic patches for pain relief.
3. Further Examinations:
   • Monitor blood sugar levels and reassess HbA1c after dietary changes and potential medication use.
   • Evaluate efficacy of physical therapy and potential orthopedics referral if non-surgical methods are ineffective.