提示词_5_2_30
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_2_30
Patient Basic Information
- Name: Patient's Name
- Gender: Unspecified
- Age: Unspecified
- Consultation Date: 2023-09-29
Chief Complaint
- Patient needs a medication prescription refill and assessment of blood pressure.
History of Present Illness
- Onset of symptoms: Patient mentions episodes of dizziness uncertain if caused by high blood pressure or hypoglycemia.
- Symptom description: Dizziness occurs suddenly and subsides with rest.
- Aggravating/Alleviating factors: Occurs occasionally, especially during work.
- Previous management: Patient takes measures to manage hypoglycemia and has checked blood sugar levels at home regularly, but not A1C.
- Additional context: Increased activity during Amazon Prime weeks; experiences normal blood sugar but uncertain about high blood pressure.
Past Medical History
- Type 2 diabetes, managed partly with insulin.
- Medication History: Insulin prescribed by the physician; no recent use of an oral hypoglycemic agent (second-degree dual flower).
Personal History
- Not specified.
Family History
- Not specified.
Physical Examination
- Vital signs: Blood pressure at home ranges from 110 to 138/85 mmHg; exact in-office measurement pending.
- Examination findings: Awaiting new blood pressure measurement.
Auxiliary Examinations
- A1C checks not regularly updated; last A1C was 7.
Diagnosis and Assessment
- Preliminary Diagnosis: Type 2 diabetes with well-controlled symptoms, suspect of possible hypertension.
- Differential Diagnosis: None provided.
Treatment Plan
- Medications: Prescription of insulin needles and additional insulin (unspecified type) to be sent to the Safeway pharmacy in Newcastle.
- Lifestyle Interventions: None specified.
- Further Examinations: Recommends a comprehensive blood test including A1C, liver function tests, and possible follow-up with a sleep specialist if sleep disturbances continue.
Notes:
- The patient will have a blood pressure check during the visit. If patients' blood pressure readings are consistently high at home or during office visits, starting antihypertensive medication may be considered.
- Recommends reserving anti-hypertensive medication for confirmed cases of hypertension rather than intermittent high readings.
- Eye examination for diabetic retinopathy is advised annually.
- A colonoscopy appointment is overdue and should be scheduled.
- Continues monitoring blood sugar levels at home, adjusting insulin dosage accordingly.