提示词_3_5_43
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_5_43
{"patientName":"","Outpatient Medical Record":"Basic Information:\nPatient: Jing An Shan (景安山), Male\nVisited: Dr. Jia\nChief Complaint:\nRoutine health check-up with complaints of anxiety and depression over the past 6 months.\nHistory of Present Illness:\nMr. Jing An Shan has experienced increasing anxiety and depression over the last six months, occasionally impairing his work as a software engineer due to high stress levels. He reports intermittent thoughts of self-harm but denies any concrete plans. The patient mentioned waking up feeling anxious, particularly when thinking about work and deadlines.\nPast Medical History:\nNo history of significant surgeries or current medications.\nPersonal and Family History:\nNot discussed in detail.\nPhysical Examination:\nEars: Normal\nThroat: Normal\nLungs: Clear to auscultation\nAbdomen: Soft, non-tender\nAuxiliary Tests:\nRoutine blood work including CBC, liver and kidney function, cholesterol levels, glucose levels, and thyroid function.\nScreening for Hepatitis B, Hepatitis C, and HIV.\nDiagnosis and Assessment:\nGeneralized Anxiety Disorder (GAD)\nMajor Depressive Disorder (MDD), without psychotic features\nDifferential diagnosis includes thyroid dysfunction; confirmation pending lab results.\nTreatment Plan:\nPrescription of Bupropion for anxiety and depression management. Initial dose to be adjusted after two weeks.\nReferral to Psychology Today for finding a counselor/psychologist.\nRecommendation for a follow-up appointment next week after lab results.\nAdministration of Tetanus (Td) vaccine and Influenza (fluer vaccination recommended.\nCOVID-19 booster to be scheduled at a later time.\nPatient Advice and Liaisons:\nPatient is advised to seek immediate help by calling 911 if experiencing thoughts of self-harm.\nEncouraged to communicate feelings of distress with family, significant others, or medical professionals.\nReview and Plan:\nFollow-up appointment is scheduled for next week post-lab results to assess progress and update the treatment plan accordingly."}