提示词_3_7_45
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_7_45
{"patientName":"** Liang Wang","Sure, below is the patient's outpatient record based on the diagnostic conversation:":"## Outpatient Medical Record","Basic Information":"Patient Name: Liang Wang\nGender: Male\nAge: 40\nDate of Visit: [Insert Date]","Chief Complaint":"Annual physical examination.","History of Present Illness":"Patient reports past COVID-19 infection, with symptoms resolving rapidly after medication. Expresses interest in receiving current flu and COVID-19 booster vaccines.\nPresents concern due to recent increase in heartburn episodes, approximately every one to two weeks. Symptoms not directly correlated with food intake and usually resolve without medication.\nRecent history of constipation, noted to have become more frequent after a previous episode of rectal bleeding diagnosed as hemorrhoids.","Past Medical History":"History of H. Pylori infection, previously treated.\nElevated blood glucose levels, monitoring with no significant changes.\nDiet includes adequate fluid intake.\nDiscusses history of cutaneous lipomas without significant change in size or tenderness.","Personal and Family History":"Family history of gastric issues in mother, including gastritis and esophageal thickening as precursors to potential malignancy.","Physical Examination":"Vital signs: WNL (within normal limits)\nFocused examination of the abdomen and cutaneous tissues for lipomas: WNL\nCardiovascular and respiratory examination: WNL","Auxiliary Tests":"Ordered standard blood tests, including CBC, lipid profile, liver, and renal function tests.\nUrea Breath Test for H. Pylori redisposition.","Diagnosis and Assessment":"Reflux esophagitis may be contributing to heartburn episodes.\nConstipation with no alarming features thus far; monitoring trends.\nElevated blood glucose levels, aligned with previous records.","Treatment Plan":"Medications: Recommend trial of Omeprazole for symptomatic relief of heartburn.\nVaccinations: Administered influenza and COVID-19 booster vaccines.\nInvestigations: Schedule further GI assessments dependent on breath test results and persistence of constipation symptoms.\nFollow-Up: Review of test results and symptomatology in one week; arrange specialist referral if necessary.\n\nPlease note: this medical record should be appended to the patient's existing records and thoroughly reviewed during subsequent visits."}