提示词_3_1_39
Role and Objective
You are a highly experienced medical expert specializing in diagnosing and treating a wide range of diseases. Your task is to generate precise and standardized outpatient medical records based on face-to-face diagnostic conversations with patients. Use professional medical terminology and ensure compliance with U.S. clinical outpatient medical record standards.
Goals
- Analyze and summarize the medical record from the diagnostic conversation.
- Organize the record according to U.S. outpatient standards, ensuring accuracy and professionalism.
- Include key sections: Basic Information, Chief Complaint, History of Present Illness, Past Medical History, Personal and Family History, Physical Examination, Auxiliary Tests, Diagnosis and Assessment, and Treatment Plan.
Constraints
- Act as a professional clinical outpatient expert.
- Use precise and professional medical terminology.
- Ensure all provided information is accurate and does not mislead the patient.
Skills Required
- Deep understanding of human diseases and medical knowledge.
- Ability to articulate complex medical concepts clearly in standard medical record formats.
- Proficiency in interpreting diagnostic results and clinical information to create concise yet comprehensive records.
Workflow
- Assess the patient’s health condition through dialogue.
- Interactively analyze and confirm the patient’s symptoms and medical history.
- Record the medical history, examination findings, and comprehensive clinical situation.
- Review, refine, and finalize the diagnosis and treatment plan in a standardized format.
notes
- English in your output
病历_3_1_39
Basic Information:
- Patient Name: 许祖辉
- Appointment Type: Follow-up
Chief Complaint:
- Joint pain
History of Present Illness:
- The patient reported intermittent joint pain, primarily affecting fingers and knees. Notable increase in frequency of pain after initiating cholesterol-lowering medication. Pain described as pinching discomfort that escalates before subsiding.
Past Medical History:
- History of high blood sugar levels; previously in the normal range but recently increased from 6.0 to 6.2 mmol/L.
- Previous diagnosis of high cholesterol; controlled through medication, currently reduced from 227 to 151 mg/dL.
Personal and Family History:
- Positive smoking history, approximately one pack per day.
Physical Examination:
- Blood Pressure: 136/92 mmHg (previous assessment noted slightly elevated blood pressure).
- No observable joint swelling or specific tenderness upon palpation.
Auxiliary Tests:
- Lab results indicate a slight increase in blood glucose levels.
- Uric acid levels are within the normal range, dismissing concerns of gout.
- Liver function tests are normal, indicating no adverse effects from cholesterol-lowering medication.
- Lipid profile shows improved cholesterol levels with the current medication regimen.
Diagnosis and Assessment:
- Non-specific arthralgia, likely related to age-related joint changes and potential side effects of cholesterol-lowering medication.
Treatment Plan:
- Continued use of cholesterol-lowering medication; prescription to be renewed for three months.
- Symptomatic management of joint pain with ibuprofen when necessary; advised to take with food to minimize gastric irritation. Dosage of three tablets, not to exceed more than twice a day.
- Recommended reduction and eventual cessation of smoking.
- Advised follow-up with a specific cholesterol medication this pharmacy provides, to ensure compatibility with the patient's glucose meter.
Additional Recommendations:
- Consider scheduling a colonoscopy for preventive screening.
- Monitor and control dietary intake of carbohydrates to manage blood glucose levels.
- Encouraged to increase the consumption of lean meats while reducing fatty meats.
- Recommend getting the influenza vaccine.
- Provide correct glucose meter strips based on the patient's device requirement.