病历_5_19_62
{"patientName":"Raghavan Srinivasan","Patient Basic Information":"Name : Raghavan Srinivasan\nGender : Male\nAge : Unspecified\nConsultation Date : [Unspecified]\n","Chief Complaint":"Concern regarding blood in urine (hematuria) and associated symptoms including a sense of incomplete bladder emptying.\n","History of Present Illness":"Onset of symptoms: Sudden onset on November 27 (specific year unspecified).\nSymptom description: Visible blood in the urine; discomfort and a feeling of incomplete urination; viscous quality of urine; pinching sensation in the bladder area.\nAggravating/Alleviating factors: Unspecified.\nPrevious management: Initial test at a clinic suspected infection but urine culture showed no bacteria. Prescribed antibiotics (Cephalexin) for a presumed UTI and Tamsulosin to ease urination, but later advised by a urologist to stop Cephalexin after finding Citrobacter in urine. Started on sulfamethoxazole-trimethoprim thereafter.\nAdditional context: Patient undergoing tests including an ultrasound, CT scan, and cystoscopy to rule out stones and other abnormalities in the urinary tract.\n","Past Medical History":"No specific past illnesses or hospitalizations mentioned.\nMedication History : Patient is on a stable dose of Metformin (500mg twice daily), Glipizide (10mg twice daily), Atorvastatin (20mg at night), and Lisinopril (10mg daily).","Personal History":"Not discussed.","Family History":"Not discussed.\n","Physical Examination":"Vital signs: Not provided.\nExamination findings: Not discussed; some examinations pending with urology.\n","Auxiliary Examinations":"Laboratory test shows a HbA1c level decrease to 5.3%; kidney function shows normal BUN and creatinine levels; electrolytes and liver enzymes are within normal limits.\nUpcoming tests: Ultrasound, CT scan with contrast, cystoscopy for comprehensive evaluation of hematuria.\n","Diagnosis and Assessment":"Preliminary Diagnosis : Hematuria of uncertain etiology; differential includes urinary tract infection and nephrolithiasis.\nDifferential Diagnosis : UTI, nephrolithiasis, prostatitis, urological malignancy.\n","Treatment Plan":"1. Medications :\n- Continue Sulfamethoxazole-Trimethoprim as advised.\n- Advised to continue antihyperglycemic and antihypertensive medications.\n- Resume Tamsulosin as per necessity before the urologic procedure.\n2. Lifestyle Interventions : Continue glucose monitoring and anti-diabetic medication adherence.\n3. Further Examinations :\n- Follow-up with the results of the upcoming ultrasound and CT scan.\n- Pending cystoscopy to rule out urinary tract abnormalities, including stones and tumors.\n","Notes:":"Patient should be reassured and advised of the likely benign nature of symptoms, pending further test results.\nMonitor for potential adverse effects of current medications.\nEncourage increased fluid intake if kidney stones are suspected."}