提示词_5_1_29
Instructions:
You are an experienced medical expert tasked with generating a standardized outpatient medical record in English based on the conversation between the doctor and the patient. Follow clinical outpatient record standards and ensure accuracy by using professional medical terminology. Adhere to the following sections for organizing the information.
Patient Basic Information
- Name: [Patient's Name]
- Gender: [Male/Female/Unspecified]
- Age: [Patient's Age/Unspecified]
- Consultation Date: [YYYY-MM-DD]
Chief Complaint
- [Summarize the patient's main discomfort or reason for consultation in one sentence.]
History of Present Illness
- Onset of symptoms: [Duration of symptoms or onset description].
- Symptom description: [Details about the current symptoms].
- Aggravating/Alleviating factors: [Factors that worsen or improve the symptoms].
- Previous management: [Treatments tried or actions taken].
- Additional context: [Any other relevant details mentioned].
Past Medical History
- [Summarize relevant past medical conditions, hospitalizations, surgeries, or chronic illnesses.]
- Medication History: [List current medications, including dosage and frequency.]
Personal History
- [Lifestyle habits such as smoking, alcohol consumption, diet, or exercise.]
Family History
- [Relevant familial diseases or genetic predispositions.]
Physical Examination
- Vital signs: [Blood pressure, pulse, temperature, respiratory rate, etc.]
- Examination findings: [Describe observed clinical signs or abnormalities.]
Auxiliary Examinations
- [Summarize any laboratory tests, imaging, or diagnostic tools mentioned, with results.]
Diagnosis and Assessment
- Preliminary Diagnosis: [Professional assessment and likely diagnosis based on the conversation.]
- Differential Diagnosis: [Other conditions considered, if relevant.]
Treatment Plan
- Medications: [Prescribed medications, dosage, and instructions.]
- Lifestyle Interventions: [Diet, exercise, or other recommended changes.]
- Further Examinations: [Recommended tests, imaging, or referrals.]
Notes:
- Use concise language, maintaining professionalism and clarity.
- Ensure all clinical information is accurate and based on the provided dialogue.
- Follow standardized formats for readability and completeness.
- English in your output
病历_5_1_29
{"patientName":"Unspecified","# Outpatient Medical Record":"","Patient Basic Information":"Name : Unspecified\nGender : Unspecified\nAge : Unspecified\nConsultation Date : YYYY-MM-DD\n","Chief Complaint":"Patient complains of joint pain which varies in intensity and location.\n","History of Present Illness":"Onset of symptoms: Fluctuating frequency over the last few years.\nSymptom description: Pain mainly in fingers and knees, variable in intensity, sometimes managed with ibuprofen (Aleve).\nAggravating/Alleviating factors: Symptoms alleviate with ibuprofen, no clear aggravating factors.\nPrevious management: Use of ibuprofen on an as-needed basis.\nAdditional context: Recently started cholesterol-lowering medication which may have increased the frequency of pain.\n","Past Medical History":"Blood sugar levels: Increased marginally from 6.0 to 6.2 over one year.\nMedication History : Cholesterol-lowering medication, dosage unspecified.","Personal History":"Smoking: About one pack per day.\nDiet: Reducing carb intake, primarily consuming proteins.\nExercise: Unspecified.","Family History":"Unspecified\n","Physical Examination":"Vital signs: Blood Pressure: 136/92 mmHg\nExamination findings: No joint swelling, normal joint mobility, pain in fingers and knees.\n","Auxiliary Examinations":"Blood sugar: Increased slightly, specific values not provided.\nUric acid levels: Normal.\nLiver and kidney function: Normal\nCholesterol: Improved from 237 to 151, LDL cholesterol improved from 252 to 79.\n","Diagnosis and Assessment":"Preliminary Diagnosis : Non-Inflammatory Osteoarthritis\nDifferential Diagnosis : Rheumatoid Arthritis, Gout, Tendinitis\n","Treatment Plan":"1. Medications : Continue cholesterol-lowering medication; Advise Ibuprofen 3 tablets as needed for pain, not to exceed 6 tablets per day.\n2. Lifestyle Interventions : Recommend smoking cessation, continue a protein-rich diet, and reduce carb intake.\n3. Further Examinations : Suggest colonoscopy to screen for other conditions.\n","Additional Notes":"Patient education on the impact of smoking on cardiovascular and joint health.\nEncouraged the patient to investigate the compatibility of their blood glucose monitoring device with provided test strips."}