Patient: [Patient Name] MRN: [Medical Record Number] Date: [Date of Visit]
主诉 (zhǔ訴) Chief Complaint: This section will vary depending on the severity of hypoglycemia. Symptoms may include:
Sweating
Trembling
Palpitations (fluttering sensation in the chest)
Hunger
Anxiety
Irritability
Difficulty concentrating
Dizziness
Lightheadedness
Blurred vision (in some cases)
Slurred speech (in severe cases)
Seizure (in severe cases)
Loss of consciousness (in severe cases)
现病史 (xiàn bìng shǐ) History of Present Illness:
Onset and duration of symptoms
Frequency of hypoglycemic episodes
Recent changes in diet, medications, or exercise routine (potential triggers)
Self-treatment measures taken (e.g., consuming sugary drinks or food)
Presence of any triggering events before the episode (e.g., missed meal, increased physical activity)
既往史 (jì wàng shǐ) Past Medical History:
Underlying medical conditions that can contribute to hypoglycemia (diabetes, insulinoma, certain medications)
Prior hospitalizations or emergency department visits for hypoglycemia
History of other endocrine disorders
药物史 (yào wù shǐ) Medication History:
List of all current medications, including insulin dosage (if applicable)
Note any recent changes in medication dosage or type
家族史 (jiā zú shǐ) Family History:
Family history of diabetes (may be relevant for some types of hypoglycemia)
社会史 (shè huì shǐ) Social History:
Diet (regularity of meals, carbohydrate intake)
Alcohol intake (can worsen hypoglycemia)
Exercise habits
查体 (chá tǐ) Physical Examination:
Vital signs (blood pressure, heart rate, temperature) – may be abnormal in severe hypoglycemia
General appearance (sweating, pallor, confusion)
Neurological exam (assessing mental status, coordination) – may be abnormal in severe hypoglycemia
辅助检查 (fú zhu zhuān chá) Laboratory Tests:
Blood glucose level (confirmed diagnosis) – repeat testing may be needed if cause unclear
Hemoglobin A1c (HbA1c) – to assess long-term glycemic control (if diabetes is present)
Insulin levels (if insulinoma is suspected)
C-peptide levels (may help differentiate between different causes of hypoglycemia)
影像学检查 (yǐng xiàng xué jiǎn chá) Imaging Studies:
Imaging studies are not routinely used for hypoglycemia diagnosis. However, CT scan or MRI of the pancreas may be considered if insulinoma is suspected.
诊断 (zhěn duàn) Diagnosis:
Hypoglycemia (confirmed by blood glucose level)
Underlying cause of hypoglycemia (if identified) – e.g., diabetes type 1, type 2, medication-induced
Severity of hypoglycemia (based on symptoms and blood glucose level)
治疗方案 (zhì liáo fāng àn) Treatment Plan:
Immediate treatment (if needed):
Oral glucose (if conscious)
Intravenous glucose (if unconscious or unable to swallow)
Long-term management:
Diet modifications (consistent meal schedule, balanced carbohydrate intake)
Medication adjustments (insulin dosage or type of medication) – if applicable
Patient education on hypoglycemia prevention and self-management
预后 (yù hòu) Prognosis:
Discuss the outlook based on the underlying cause, severity of hypoglycemia, and adherence to treatment plan.
With proper management, most cases of hypoglycemia can be well-controlled and prevent complications.
健康指导 (jiàn kāng zhǐ dào) Patient Education:
Importance of following a regular meal plan and healthy diet
Recognizing and avoiding triggers for hypoglycemia
Proper monitoring of blood glucose levels (if applicable)
Carrying and using a glucagon emergency kit (if at risk for severe hypoglycemia)
Importance of medication adherence (if prescribed)
Importance of communicating with healthcare providers about any changes in symptoms or medication needs
下次随访 (xià cì suí fǎng) Next Follow-up:
Schedule for the next appointment depends on the severity and frequency of hypoglycemic episodes.
Regular follow-up is essential to monitor blood sugar control, adjust treatment as needed, and provide ongoing education and support.