提示词_5_4_32
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_4_32
Patient Basic Information
- Name: Mr. Ji Yibo
- Gender: Male
- Age: Unspecified
- Consultation Date: [YYYY-MM-DD] (Date unspecified in the conversation)
Chief Complaint
- Persistent elevation in triglyceride levels despite medication.
History of Present Illness
- Onset of symptoms: Symptoms have been present for an unspecified duration; however, the patient has been under treatment for three months.
- Symptom description: Elevated triglyceride levels, which remain around 200 mg/dL despite treatment. The patient previously felt discomfort in the hepatic region but has not experienced this recently.
- Aggravating/Alleviating factors: Symptom improvement after adjusting medication.
- Previous management: Reduction in lipid medications from higher dosages to 10 mg has been effective. The patient has also been prescribed fenofibrate.
- Additional context: The patient's ALT level was slightly elevated previously but is now normal. Other liver function tests were also normal.
Past Medical History
- No significant past medical conditions, hospitalizations, or surgeries were mentioned.
- Medication History: Fenofibrate (dosage unspecified), with previous use of lipid-lowering medications.
Personal History
- Not mentioned.
Family History
- Not mentioned.
Physical Examination
- Vital signs: Not mentioned.
- Examination findings: No discomfort or significant clinical abnormalities observed in recent visits.
Auxiliary Examinations
- Liver function tests previously showed elevated ALT levels, now resolved to normal.
Diagnosis and Assessment
- Preliminary Diagnosis: Hypertriglyceridemia, likely hereditary considering the persistence despite lifestyle modifications and treatment.
- Differential Diagnosis: None provided.
Treatment Plan
- Medications: Discontinuation of unspecified lipid-lowering medication (previously at 10 mg) and continued use of fenofibrate. Introduction of omega-3 fatty acids (fish oil) to aid in reducing triglyceride levels.
- Lifestyle Interventions: Not specified.
- Further Examinations: Follow-up in three months with a lipid panel check before the visit.