Patient: [Patient Name] MRN: [Medical Record Number] Date: [Date of Visit]
主诉 (zhǔ訴) Chief Complaint: This section may be blank for asymptomatic patients. Some patients with very high triglycerides may experience:
Abdominal pain (especially after a heavy meal)
Pancreatitis (severe abdominal pain, nausea, vomiting) – a serious complication
现病史 (xiàn bìng shǐ) History of Present Illness:
Duration of hypertriglyceridemia diagnosis (if known)
Highest recorded triglyceride level
Presence of symptoms (see Chief Complaint)
Recent changes in diet or lifestyle (e.g., increased alcohol intake, weight gain)
Medications (current and recent) – some medications can increase triglycerides
既往史 (jì wàng shǐ) Past Medical History:
Underlying medical conditions that can contribute to hypertriglyceridemia (diabetes, metabolic syndrome, hypothyroidism)
Prior surgeries or procedures
History of pancreatitis
家族史 (jiā zú shǐ) Family History:
Family history of hypertriglyceridemia or familial hypercholesterolemia
社会史 (shè huì shǐ) Social History:
Diet (high intake of saturated fat, sugary drinks)
Alcohol intake (excessive intake can worsen hypertriglyceridemia)
Smoking history (smoking may contribute to risk factors)
Exercise habits
查体 (chá tǐ) Physical Examination:
Vital signs (blood pressure)
General appearance (signs of eruptive xanthomas – yellow bumps on skin, in severe cases)
Abdominal exam (palpation for tenderness)
辅助检查 (fú zhu zhuān chá) Laboratory Tests:
Fasting lipid panel:
Triglycerides
Total cholesterol
LDL cholesterol
HDL cholesterol
Fasting blood sugar or HbA1c (to assess for diabetes)
TSH (thyroid stimulating hormone) – to rule out hypothyroidism
影像学检查 (yǐng xiàng xué jiǎn chá) Imaging Studies:
Imaging studies are not typically used for hypertriglyceridemia diagnosis unless pancreatitis is suspected (abdominal ultrasound or CT scan).
诊断 (zhěn duàn) Diagnosis:
Hypertriglyceridemia (confirmed by elevated triglyceride level)
Severity of hypertriglyceridemia (based on triglyceride level)
Underlying cause of hypertriglyceridemia (if identified)
Presence of pancreatitis (if applicable)
治疗方案 (zhì liáo fāng àn) Treatment Plan:
Lifestyle modifications (diet changes to reduce saturated fat and sugar intake, weight loss if overweight, regular exercise)
Medications (fibrates, niacin) – considered if lifestyle changes are insufficient
Management of underlying conditions (e.g., diabetes, hypothyroidism)
预后 (yù hòu) Prognosis:
Discuss the outlook based on the severity of hypertriglyceridemia, adherence to treatment, and presence of other risk factors.
Lifestyle modifications and treatment can effectively lower triglycerides and reduce the risk of cardiovascular disease and pancreatitis.
健康指导 (jiàn kāng zhǐ dào) Patient Education:
Importance of dietary changes (refer to a registered dietitian for guidance)
Importance of weight management (if overweight or obese)
Importance of regular exercise
Importance of medication adherence (if prescribed)
Warning signs of pancreatitis (severe abdominal pain, nausea, vomiting)
Importance of regular follow-up to monitor triglycerides 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 hypertriglyceridemia and response to treatment.
Regular follow-up is essential to monitor triglycerides and adjust treatment as needed.