提示词_5_9_37
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_9_37
{"patientName":"Wang Ming","Patient Basic Information":"Name : Wang Ming\nGender : Male\nAge : 33 years old\nConsultation Date : [YYYY-MM-DD]\n","Chief Complaint":"Follow-up consultation regarding high triglyceride levels.\n","History of Present Illness":"Onset of symptoms: Not specified, recent test result showing elevated triglycerides.\nSymptom description: Triglyceride levels increased to 500 mg/dL from 195 mg/dL over the course of a year.\nAggravating/Alleviating factors: Possible postprandial increase, suggesting a later diagnostic test during the day.\nPrevious management: None specified for triglycerides; however, antihistamines initiated for urticaria.\nAdditional context: Urticaria flare-ups suspected to be related to home environment; potential mite allergy considered.\n","Past Medical History":"Allergic rhinitis, diagnosed chestnut pollen sensitization.\nMedication History : Fexofenadine 180mg for urticaria.","Personal History":"No specific lifestyle habits discussed.","Family History":"Not mentioned.\n","Physical Examination":"Vital signs: Not recorded during this visit.\nExamination findings: No physical abnormalities mentioned.\n","Auxiliary Examinations":"Triglycerides: 500 mg/dL\nTotal cholesterol: Slight elevation noted at 214 mg/dL.\nLDL cholesterol: Within normal range.\nGlycated hemoglobin (HbA1c): Normal.\nRenal function (eGFR, serum creatinine): Normal.\n","Diagnosis and Assessment":"Preliminary Diagnosis : Hypertriglyceridemia.\nDifferential Diagnosis : Not specified in this visit. Follow-up blood test to verify triglyceride levels.\n","Treatment Plan":"1. Medications : Prescription for antihypertensive medication in case of persistent high triglyceride levels after retesting (post-fasting recommended).\n2. Lifestyle Interventions : Recommendation to consume high-quality protein, reduce fatty meat intake, and consider environmental controls for possible dust mite allergy (use of anti-mite bedding covers, frequently washing and heat-drying sheets).\n3. Further Examinations : Schedule a fasting blood test in January for triglyceride reevaluation.\n"}