病历_3_18_59
{"patientName":"** Priyawat Khuwiangern","Based on the diagnostic conversation, the following is a standardized outpatient medical record for the patient Priyawat Khuwiangern:":"","Basic Information:":"Patient Name: Priyawat Khuwiangern\nDate of Consultation: [Date of Consultation]\nProvider: [Provider's Name]","Chief Complaint:":"Follow-up consultation to review results of blood tests and discuss overall health.","History of Present Illness:":"The patient has no specific complaints but is here for a follow-up visit regarding their recent laboratory work.","Past Medical History:":"Unspecified in the conversation.","Personal and Family History:":"Unspecified in the conversation.","Physical Examination:":"Unspecified in the conversation.","Auxiliary Tests:":"1. Complete Blood Count: Normal; not anemic.\n2. Platelet count: Normal.\n3. Blood Chemistry including glucose, kidney function (BUN, creatinine), electrolytes (sodium, potassium, chloride, bicarbonate, calcium): Within normal limits.\n4. Liver enzymes: Normal.\n5. Lipid Profile:\n- Total Cholesterol: Normal.\n- Triglycerides: Normal.\n- HDL (High-Density Lipoprotein): Normal.\n- LDL (Low-Density Lipoprotein): Slightly elevated.\n6. Hepatitis Panel:\n- Hepatitis B (HBV): Negative.\n- Hepatitis C (HCV): Negative.\n- Hepatitis A (HAV): No immunity (patient requires vaccination).\n7. Glycated Hemoglobin (HbA1c): 5.7%, indicating pre-diabetes status.\n8. Thyroid Function Tests: Within normal limits.","Diagnosis and Assessment:":"1. Mild elevation in LDL cholesterol.\n2. Pre-diabetes (HbA1c of 5.7%).\n3. No existing immunity to Hepatitis A.","Treatment Plan:":"1. Dietary guidance: Lower intake of fats, refined carbohydrates, and sugar. Reduce consumption of high sugar foods and beverages, and limit carbohydrate intake from sources such as rice.\n2. Monitor and manage pre-diabetes:\n- Emphasize regular exercise and a balanced diet.\n- Follow up with routine screening every 6-12 months.\n3. Hepatitis A Vaccination: Patient to schedule vaccination upon return from their trip.\n4. Follow-up Appointment: Patient to schedule after their trip for Hepatitis A vaccine.\n5. Patient education on the implications of slightly elevated LDL and pre-diabetes for the patient's reference and health improvement.\nThe patient is advised to follow the given treatment plan and return for a follow-up appointment after their scheduled trip. Further nutritional counseling may be beneficial, and repeat lipid profile screening is recommended in 6 months."}