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 hyperkalemia.
Muscle weakness, fatigue (common symptoms)
Numbness, tingling (paresthesias)
Nausea, vomiting, abdominal cramps (less common)
Arrhythmias (palpitations, irregular heart beat) – in severe cases
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
Muscle weakness (location, severity, progression)
Medication use (including over-the-counter medications and herbal supplements)
既往史 (jì wàng shǐ) Past Medical History:
Underlying medical conditions that can contribute to hyperkalemia (chronic kidney disease, diabetes, heart failure, adrenal insufficiency)
History of hyperkalemia
Prior surgeries or procedures
Medications (current and recent) – including diuretics, potassium supplements, renin-angiotensin-aldosterone system (RAAS) inhibitors
家族史 (jiā zú shǐ) Family History:
Family history of kidney disease (not typically relevant for hyperkalemia, but may be helpful for overall risk assessment)
社会史 (shè huì shǐ) Social History:
Diet (high potassium intake)
Alcohol or illicit drug use (can worsen hyperkalemia)
查体 (chá tǐ) Physical Examination:
Vital signs (blood pressure, heart rate, temperature) – may be abnormal in severe hyperkalemia
General appearance (muscle weakness)
Neurologic exam (muscle strength, reflexes) – may show weakness
Cardiovascular exam (irregular heart beat) – in severe cases
辅助检查 (fú zhu zhuān chá) Laboratory Tests:
Serum potassium level (confirmed diagnosis)
Electrolytes (may show abnormalities like low sodium)
Kidney function tests (creatinine, BUN) – to assess for kidney function
ECG (electrocardiogram) – to assess for heart rhythm abnormalities caused by hyperkalemia
影像学检查 (yǐng xiàng xué jiǎn chá) Imaging Studies:
Imaging studies are not typically used for hyperkalemia diagnosis unless kidney function tests suggest further investigation is needed (e.g., ultrasound for kidney stones).
诊断 (zhěn duàn) Diagnosis:
Hyperkalemia (confirmed by elevated serum potassium level)
Severity of hyperkalemia (based on serum potassium level and EKG findings)
Underlying cause of hyperkalemia (if identified)
治疗方案 (zhì liáo fāng àn) Treatment Plan:
Treatment depends on the severity of hyperkalemia and the presence of symptoms.
Emergency interventions for severe hyperkalemia may be needed to stabilize heart rhythm.
Other treatment options may include:
Intravenous fluids (hydration)
Medications:
Diuretics (to increase potassium excretion through urine)
Insulin with glucose (shifts potassium into cells)
Nebulized albuterol (may help lower potassium in some cases)
Ion exchange resins (bind potassium in the gut)
Addressing the underlying cause of hyperkalemia (e.g., medication adjustments, dietary changes)
预后 (yù hòu) Prognosis:
Discuss the outlook based on the severity of hyperkalemia, the underlying cause, and response to treatment.
Early diagnosis and treatment are crucial to prevent serious complications like cardiac arrhythmias.
健康指导 (jiàn kāng zhǐ dào) Patient Education:
Importance of maintaining a balanced diet (potassium restriction if advised)
Importance of medication adherence (including avoiding potassium supplements unless prescribed)
Warning signs of worsening hyperkalemia (muscle weakness, numbness, tingling)
Importance of regular follow-up to monitor potassium levels and adjust treatment as needed
下次随访 (xià cì suí fǎng) Next Follow-up:
Schedule for the next appointment depends on the severity of hyperkalemia and response to treatment.
Close monitoring of potassium levels is essential until they are normalized.
Regular follow-up to monitor for recurrence and manage underlying condition.