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提示词_3_2_40

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

  1. Analyze and summarize the medical record from the diagnostic conversation.
  2. Organize the record according to U.S. outpatient standards, ensuring accuracy and professionalism.
  3. 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

  1. Deep understanding of human diseases and medical knowledge.
  2. Ability to articulate complex medical concepts clearly in standard medical record formats.
  3. Proficiency in interpreting diagnostic results and clinical information to create concise yet comprehensive records.

Workflow

  1. Assess the patient’s health condition through dialogue.
  2. Interactively analyze and confirm the patient’s symptoms and medical history.
  3. Record the medical history, examination findings, and comprehensive clinical situation.
  4. Review, refine, and finalize the diagnosis and treatment plan in a standardized format.

notes

  • English in your output

病历_3_2_40

{"patientName":"Mr. Zhong","Here's the medical record based on the diagnostic conversation:":"\nBASIC INFORMATION:\nPatient Name: Mr. Zhong\nDate of Visit: [Insert Date]\nReason for Visit: Routine follow-up for diabetes management\n\nCHIEF COMPLAINT:\nPatient requests renewed prescriptions for insulin and pen needles, as well as further evaluation due to recent symptoms of dizziness which may be associated with blood pressure fluctuations.\n\nHISTORY OF PRESENT ILLNESS:\nMr. Zhong is a known type 2 diabetes mellitus (T2DM) patient on insulin therapy. He also experiences occasional dizziness and suspects it might be related to either low blood sugar levels or hypertension. Although he regularly monitors blood glucose, he finds it challenging to reliably measure glucose levels due to professional constraints. The Patient states that his condition fluctuates but feels controlled with current medication.\n\nPAST MEDICAL HISTORY:\nType 2 Diabetes Mellitus\nPrevious A1c recorded at 7%\nNo history of retinopathy or neuropathy\nNo documented allergies or specific cardiovascular conditions reported.\n\nPERSONAL AND FAMILY HISTORY:\nNo mention of significant family history related to diabetes or heart disease. Mr. Zhong works as a truck driver with irregular work hours.\n\nPHYSICAL EXAMINATION:\nBlood Pressure: [Pending measurement, anticipate potential hypertension]\nOthers: Unremarkable at the time of the examination.\n\nAUXILIARY TESTS:\nHbA1c, lipid panel, liver function tests, renal function tests, and urine microalbumin to be ordered for comprehensive evaluation.\nReferral for a routine eye examination by an ophthalmologist to monitor for diabetic retinopathy.\nColonoscopy is recommended given that the patient has reached an age requiring this surveillance.\n\nDIAGNOSIS AND ASSESSMENT:\nType 2 Diabetes Mellitus, slightly elevated A1c levels.\nPotential hypertension requiring monitoring and further assessment.\nNeed for evaluation of possible causes of dizziness and potential revision of diabetes management plan.\n\nTREATMENT PLAN:\n1. Renew prescriptions for the following:\n- Insulin\n- Pen needles\n2. Schedule follow-up for blood pressure measurement and consider antihypertensive medication if consistently elevated.\n3. Encourage patient to continue monitoring blood glucose levels and maintain a record for review during next visit.\n4. Advise scheduling a colonoscopy and eye examination.\n5. Educate the patient about lifestyle modifications to aid in managing both blood pressure and blood glucose levels.\n\nFOLLOW-UP:\nThe patient will be contacted following the lab results, and a follow-up appointment will be scheduled to discuss outcomes and further adjustments to the treatment plan if necessary.\n\nThis record adheres to standard outpatient documentation practices."}