病历_3_21_65
{"patientName":"Mr. Hua Qianglu","Outpatient Medical Record":"Basic Information\nName: Mr. Hua Qianglu\nAge: Not specified\nGender: Male\nOccupation: Not specified\nAllergies: No known drug allergies\nDate of Visit: Not specified\nChief Complaint\nPatient reports stable health, recent unintentional weight loss, and concern regarding cholesterol levels, expressed during a routine follow-up.\nHistory of Present Illness\nPatient reports continuous weight loss despite maintaining the same diet and exercise routine. He participates in running approximately 100 to 110 kilometers per month and engages in morning runs. A prior cholesterol test revealed elevated levels, leading to the cessation of prescribed medication.\nPast Medical History\nHistory of goiter, with checks for thyroid nodules.\nPast elevated cholesterol management, medication discontinued recently.\nPrior incident of chest pain while running, cleared after a CT scan in Shanghai.\nNo history of diabetes mellitus.\nPersonal and Family History\nFamily history with a predominance of diabetic diagnoses.\nNo familial history of colorectal cancer.\nPhysical Examination\nBlood Pressure: Within normal range.\nNeurological: No tremors or abnormal movements noted.\nCardiac: Regular rhythm without murmurs.\nRespiratory: Clear to auscultation bilaterally.\nAbdominal: Non-tender, no masses, liver and spleen not felt upon palpitation.\nDermatological: No noted lesions or abnormalities.\nAuxiliary Tests\nRecent blood test: Cholesterol levels to be reevaluated.\nStool test: Negative for blood, though patient is advised to undergo colonoscopy.\nNo thyroid nodules detected.\nDiagnosis and Assessment\nHypercholesterolemia pending further blood work.\nUnintentional weight loss suspected secondary to high metabolism and physical activity.\nTreatment Plan\n1. Blood tests including lipid panel, complete blood count, metabolic panel, thyroid function tests.\n2. Consider colonoscopy for comprehensive assessment over stool tests—advised to arrange via Washington GI.\n3. Recommendations to review dietary intake and adjust as needed to compensate for high physical activity level.\n4. Discussion of annual flu vaccination; patient declined.\n5. Advised on pneumococcal vaccination, considering the lowered age recommendation to 50.\n6. Follow-up appointment to discuss results and monitor cholesterol levels.\nDisclaimer: This medical record is a summary generated from the patient's verbal report and physical examination findings. For an accurate and comprehensive health assessment, ongoing examinations and tests are necessary."}