提示词_5_5_33
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_5_33
Patient Basic Information
- Name: Jing An San
- Gender: Unspecified
- Age: Unspecified
- Consultation Date: Unspecified
Chief Complaint
- The patient reports experiencing increased anxiety and depressive symptoms over the past six months.
History of Present Illness
- Onset of symptoms: The patient reports that symptoms have been increasingly severe for the past six months but has had them intermittently for a few years.
- Symptom description: The patient describes anxiety attacks, lack of motivation, concerns about work performance, and thoughts of self-harm without specific plans.
- Aggravating/Alleviating factors: The patient indicates that work stress exacerbates his anxiety.
- Previous management: No medications taken or therapy underwent for anxiety or depression prior to this visit.
- Additional context: The patient mentions that sleep and appetite are not significantly affected.
Past Medical History
- No significant past medical conditions or surgeries reported.
- Medication History: The patient is not currently taking any medications.
Personal History
- Unspecified habits regarding smoking, alcohol consumption, diet, or exercise.
Family History
- No familial diseases or genetic predispositions mentioned.
Physical Examination
- Vital signs: Unspecified
- Examination findings: Normal general physical examination with no abnormalities noted during the standard check-up.
Auxiliary Examinations
- Blood tests for routine parameters including liver and renal function, cholesterol, blood sugar, neurotransmitter function, and hepatitis screening were recommended.
Diagnosis and Assessment
- Preliminary Diagnosis: Generalized anxiety disorder with depressive symptoms.
- Differential Diagnosis: Unspecified pending results from laboratory examinations.
Treatment Plan
- Medications: Prescribed Wellbutrin with dosage adjusted after two weeks based on patient response.
- Lifestyle Interventions: Recommended psychology/therapy consultations from PsychologyToday.com.
- Further Examinations: Laboratory tests on liver function, thyroid function, and complete blood panel. Follow-up scheduled for next week.
Notes
- The patient considered a suicide plan but has not made specific arrangements. He was advised to contact 911 or this office immediately if such thoughts recur.
- He was instructed to receive vaccinations for tetanus, flu, and COVID-19 booster, with the flu and tetanus vaccinations administered during the visit.
- Emphasized the importance of continuing medication even after feeling better and confirmed an appointment for next week to review lab results and treatment progress.