Patient: [Patient Name] MRN: [Medical Record Number] Date: [Date of Visit]
主诉 (zhǔ訴) Chief Complaint: This section may be blank or contain nonspecific complaints depending on the severity of hypercalcemia.
Nausea, vomiting, constipation (common symptoms of hypercalcemia)
Fatigue, weakness, muscle aches
Bone pain
Neurologic symptoms (confusion, lethargy, seizures) – in severe cases
Abdominal pain (if associated malignancy involves the GI tract)
现病史 (xiàn bìng shǐ) History of Present Illness:
Onset, duration, and severity of symptoms
Recent hospitalizations or emergency department visits
Changes in bowel habits
Mental status changes (confusion, disorientation)
Known underlying malignancy or suspected symptoms suggestive of cancer
既往史 (jì wàng shǐ) Past Medical History:
History of any malignancy (confirmed or suspected)
Prior hospitalizations or surgeries
Medications (current and recent) – including calcium supplements, vitamin D, diuretics, medications for underlying malignancy
家族史 (jiā zú shǐ) Family History:
Family history of cancer (not typically relevant for hypercalcemia, but may be helpful for overall cancer risk assessment)
社会史 (shè huì shǐ) Social History:
Smoking history (risk factor for some cancers)
Alcohol use (can worsen hypercalcemia)
查体 (chá tǐ) Physical Examination:
Vital signs (blood pressure, heart rate, temperature) – may be abnormal in severe hypercalcemia
General appearance (illness, dehydration)
Neurologic exam (mental status, reflexes) – may show signs of confusion or altered mental status
Abdominal exam (organomegaly) – may reveal masses if malignancy involves the GI tract
辅助检查 (fú zhu zhuān chá) Laboratory Tests:
Serum calcium level (confirmed diagnosis)
Electrolytes (may show abnormalities like low potassium)
Kidney function tests (creatinine, BUN) – to assess for kidney damage from hypercalcemia
Complete blood count (CBC) – may show anemia
Tumor markers (if malignancy not yet diagnosed) – may be helpful in identifying the underlying cancer type
影像学检查 (yǐng xiàng xué jiǎn chá) Imaging Studies:
Chest X-ray (may show signs of lung cancer)
CT scan (chest, abdomen, pelvis) – depending on suspected location of primary malignancy
Bone scan (if bone metastases suspected) – may be helpful for some malignancies
诊断 (zhěn duàn) Diagnosis:
Hypercalcemia (confirmed by elevated serum calcium)
Hypercalcemia of malignancy (suspected or confirmed) – suspected if malignancy is known or suspected; confirmed if specific mechanisms of malignancy-induced hypercalcemia are identified
Underlying malignancy (if known) – specify the type of cancer
治疗方案 (zhì liáo fāng àn) Treatment Plan:
Addressment of hypercalcemia:
Intravenous fluids (hydration)
Medications:
Bisphosphonates (inhibit bone resorption)
Calcitonin (inhibits calcium reabsorption from kidneys)
Glucocorticoids (may be helpful in some malignancies)
Diuretics (with caution to avoid dehydration)
Treatment of the underlying malignancy (surgery, chemotherapy, radiation therapy) – depends on the specific type and stage of cancer
预后 (yù hòu) Prognosis:
Discuss the outlook based on the severity of hypercalcemia, the type and stage of the underlying malignancy, and the patient’s overall health.
Hypercalcemia of malignancy can be a serious condition, and early diagnosis and treatment are crucial.
健康指导 (jiàn kāng zhǐ dào) Patient Education:
Importance of maintaining adequate hydration
Importance of following the treatment plan for both hypercalcemia and the underlying malignancy
Warning signs of worsening hypercalcemia (increased nausea, vomiting, confusion)
Importance of regular follow-up to monitor calcium levels and response to treatment
下次随访 (xià cì suí fǎng) Next Follow-up:
Schedule for the next appointment depends on the severity of hypercalcemia and the treatment plan.
Close monitoring is needed until calcium levels are normalized.
Regular follow-up to monitor response