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提示词_3_12_52

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_12_52

{"patientName":"[Redacted]","plaintext":"Basic Information:\nPatient Name: [Redacted]\nSex: [Redacted]\nAge: [Redacted]\nDate: [Current Date]\nChief Complaint:\nDevelopment of new blisters on the body following recent treatment for known condition.\nHistory of Present Illness:\nThe patient reports the appearance of new blisters on the designated skin areas. These new occurrences developed approximately 4-5 days after previous consultation, during which similar vesicular eruptions were almost completely healed. The patient has recently been exposed to potential climatic changes and is scheduled to travel internationally next week, seeking advice on medication continuation or modifications.\nPast Medical History:\nKnown history of HSV-2 related blisters.\nRecently completed a 10-day course of Acyclovir 1000mg once daily.\nPersonal and Family History:\nNo significant family medical history disclosed in relation to this condition.\nRecent exposure to possible triggers due to travel plans.\nPhysical Examination:\nInspection of affected areas reveals presence of new vesicular eruptions. These formations are consistent with previously documented findings and suggest localized viral dissemination. Noted cluster in areas previously affected. Some central lesions have resolved, but peripheral vesicles are newly encountered.\nAuxiliary Tests:\nNot indicated at this time, based on history and physical examination findings.\nDiagnosis and Assessment:\nRecurrent HSV-2 vesicular outbreaks, likely due to the extension of previous infection. The patient exhibits a pattern characteristic of viral infections showcasing replication in adjacent dermal tissues, following a latency period.\nTreatment Plan:\nPrescribed Acyclovir 500mg, to be taken twice daily for a further 5 to 7 days. The patient is advised to start treatment promptly upon noticing the reoccurrence of vesicular lesions.\nA prescription refill is provided for an additional 10-day course as a precaution for potential future outbreaks, particularly relevant with upcoming travel plans.\nThe patient should resume another full 5-day course if new lesions present, ensuring the initiation of treatment within 72 hours of lesion onset for optimal efficacy.\nAdvised to refrain from intimate contact until all lesions are healed, to avoid transmission risks.\nPatient Education:\nExplained the nature of HSV-2 outbreaks and the possibility of reoccurrence despite effective initial treatment due to latency periods.\nHighlighted the importance of prompt treatment at the signs of new lesions.\nEnsured patient understands the potential triggers and the need for vigilance while traveling.\nSignature:\n[Doctor's Name], [Medical Qualifications]"}