提示词_3_9_47
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_9_47
Outpatient Medical Record
Basic Information
- Patient: Mr. Mingyang Huai
- Age: 33
- Gender: Male
- Visit Purpose: Follow-up
Chief Complaint
- Persistently elevated triglycerides from previous test.
- Chronic urticaria lasting for several months.
History of Present Illness
- Mr. Huai reported a triglyceride level increase to 500 mg/dL from a previous level of 195 mg/dL upon re-testing, raising concerns about potential factors influencing this spike.
- Complains of chronic urticaria that has persisted for several months, with symptoms flaring up most acutely when in the domicile.
Past Medical History
- No significant past medical conditions were reported.
- No history of diabetes or other metabolic disorders.
Personal and Family History
- Denies history of allergies apart from the present condition.
Physical Examination
- Vital signs were within normal limits.
- No other physical abnormalities noted during the visit.
Auxiliary Tests
- Laboratory reports show elevated triglycerides at 500 mg/dL but normal blood glucose levels. No renal or liver function abnormalities were noted.
- Hemoglobin A1c levels were also within normal range, ruling out diabetes.
- Antihistamine skin eradication test: Positive for common allergens, including dust mites. Negative for pet dander.
Diagnosis and Assessment
- Hypertriglyceridemia, etiology to be further investigated, potentially related to non-fasting state during the last laboratory test.
- Chronic urticaria, likely driven by domestic allergen exposure.
Treatment Plan
- Rechecking triglyceride levels in a fasting state in January to confirm if hypertriglyceridemia is persisting.
- If elevated triglycerides persist, initiating lipid-lowering pharmacotherapy will be considered.
- Providing a prescription for an antihistamine for chronic urticaria relief - switched to Fexofenadine from previous medication for improved response.
- Recommendation to assess the home for dust mite presence and consider anti-dust mite bedding covers and regular laundering with heat drying.
- Advising the patient to obtain a flu vaccine for the upcoming flu season. The vaccine was administered during the visit.
- Advising a diet focusing on high-quality proteins and reduced red meat intake as part of lipid management.
Prescription Provided:
- Antihistamine prescription (Fexofenadine).
Patient Education and Follow-up
- Importance of a fasting blood test for accurate lipid panel results.
- Should return for follow-up testing in January with fasting blood work.
- Advised to obtain dust mite covers for bedding and to continue current dietary adjustments. Return to clinic for additional evaluation if symptoms persist or worsen.