提示词_5_3_31
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_3_31
{"patientName":"Ritu Singh","Patient Basic Information":"Name : Ritu Singh\nGender : Female\nAge : Unspecified\nConsultation Date : 2021-XX-XX (Date unspecified in conversation)","Chief Complaint":"Muscle pain, numbness in hands and feet, tingling, and stiffness in calf muscles.","History of Present Illness":"Onset of symptoms: Symptoms started after initial diagnosis of Crohn's disease.\nSymptom description: Muscle pain in various areas, numbness in hands and feet, tingling and pins-and-needles sensations, stiffness in calf muscles, particularly worsens with specific movements like cooking. The skin has also been feeling quite sensitive, with a burning sensation and the appearance of a rash.\nAggravating/Alleviating factors: Symptoms worsen after prolonged sitting or certain movements.\nPrevious management: Started SkyRizi infusions (2 infusions so far) for Crohn's disease.\nAdditional context: Symptoms were present before starting Crohn's treatment but seem to have worsened after it.","Past Medical History":"Diagnosed with Crohn's disease. No prior family doctor before the diagnosis.\nMedication History : SkyRizi infusions for Crohn's disease.","Personal History":"[No lifestyle habits discussed].","Family History":"[Not mentioned].","Physical Examination":"Vital signs: [Not discussed].\nExamination findings: [Not conducted during the visit].","Auxiliary Examinations":"Colonoscopy: Performed (details not specified).\nRoutine Lab Work: Hemoglobin and MCV normal, ferritin level normal, serum iron normal, TIBC normal, but iron saturation is low at 8%.","Diagnosis and Assessment":"Preliminary Diagnosis : Peripheral neuropathy possibly linked to Crohn's disease or medication side effect.\nDifferential Diagnosis : Rheumatologic issues, peripheral neuropathy, enthesitis, spondyloarthritis.","Treatment Plan":"1. Medications :\n- None prescribed during this visit.\n2. Lifestyle Interventions :\n- Not discussed.\n3. Further Examinations :\n- Referral to rheumatology.\n- Lab tests to check Vitamin B12, Folate, Vitamin D, Thyroid function, and Hepatitis screening.","Notes":"Referral to a rheumatologist to rule out autoimmune or rheumatologic issues possibly related to Crohn's disease.\nAwaiting results from ordered laboratory tests. Follow-up appointment scheduled for next Monday."}