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
{"patientName":"","Outpatient Medical Record":"Basic Information\nPatient: Mr. Mingyang Huai\nAge: 33\nGender: Male\nVisit Purpose: Follow-up\nChief Complaint\nPersistently elevated triglycerides from previous test.\nChronic urticaria lasting for several months.\nHistory of Present Illness\nMr. 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.\nComplains of chronic urticaria that has persisted for several months, with symptoms flaring up most acutely when in the domicile.\nPast Medical History\nNo significant past medical conditions were reported.\nNo history of diabetes or other metabolic disorders.\nPersonal and Family History\nDenies history of allergies apart from the present condition.\nPhysical Examination\nVital signs were within normal limits.\nNo other physical abnormalities noted during the visit.\nAuxiliary Tests\nLaboratory reports show elevated triglycerides at 500 mg/dL but normal blood glucose levels. No renal or liver function abnormalities were noted.\nHemoglobin A1c levels were also within normal range, ruling out diabetes.\nAntihistamine skin eradication test: Positive for common allergens, including dust mites. Negative for pet dander.\nDiagnosis and Assessment\n1. Hypertriglyceridemia, etiology to be further investigated, potentially related to non-fasting state during the last laboratory test.\n2. Chronic urticaria, likely driven by domestic allergen exposure.\nTreatment Plan\n1. Rechecking triglyceride levels in a fasting state in January to confirm if hypertriglyceridemia is persisting.\n2. If elevated triglycerides persist, initiating lipid-lowering pharmacotherapy will be considered.\n3. Providing a prescription for an antihistamine for chronic urticaria relief - switched to Fexofenadine from previous medication for improved response.\n4. Recommendation to assess the home for dust mite presence and consider anti-dust mite bedding covers and regular laundering with heat drying.\n5. Advising the patient to obtain a flu vaccine for the upcoming flu season. The vaccine was administered during the visit.\n6. Advising a diet focusing on high-quality proteins and reduced red meat intake as part of lipid management.\nPrescription Provided:\nAntihistamine prescription (Fexofenadine).\n\nPatient Education and Follow-up\nImportance of a fasting blood test for accurate lipid panel results.\nShould return for follow-up testing in January with fasting blood work.\nAdvised to obtain dust mite covers for bedding and to continue current dietary adjustments. Return to clinic for additional evaluation if symptoms persist or worsen."}