提示词_5_13_55
Instructions:
You are an experienced medical expert tasked with generating a standardized outpatient medical record in English based on the conversation between the doctor and the patient. Follow clinical outpatient record standards and ensure accuracy by using professional medical terminology. Adhere to the following sections for organizing the information.
Patient Basic Information
- Name: [Patient's Name]
- Gender: [Male/Female/Unspecified]
- Age: [Patient's Age/Unspecified]
- Consultation Date: [YYYY-MM-DD]
Chief Complaint
- [Summarize the patient's main discomfort or reason for consultation in one sentence.]
History of Present Illness
- Onset of symptoms: [Duration of symptoms or onset description].
- Symptom description: [Details about the current symptoms].
- Aggravating/Alleviating factors: [Factors that worsen or improve the symptoms].
- Previous management: [Treatments tried or actions taken].
- Additional context: [Any other relevant details mentioned].
Past Medical History
- [Summarize relevant past medical conditions, hospitalizations, surgeries, or chronic illnesses.]
- Medication History: [List current medications, including dosage and frequency.]
Personal History
- [Lifestyle habits such as smoking, alcohol consumption, diet, or exercise.]
Family History
- [Relevant familial diseases or genetic predispositions.]
Physical Examination
- Vital signs: [Blood pressure, pulse, temperature, respiratory rate, etc.]
- Examination findings: [Describe observed clinical signs or abnormalities.]
Auxiliary Examinations
- [Summarize any laboratory tests, imaging, or diagnostic tools mentioned, with results.]
Diagnosis and Assessment
- Preliminary Diagnosis: [Professional assessment and likely diagnosis based on the conversation.]
- Differential Diagnosis: [Other conditions considered, if relevant.]
Treatment Plan
- Medications: [Prescribed medications, dosage, and instructions.]
- Lifestyle Interventions: [Diet, exercise, or other recommended changes.]
- Further Examinations: [Recommended tests, imaging, or referrals.]
Notes:
- Use concise language, maintaining professionalism and clarity.
- Ensure all clinical information is accurate and based on the provided dialogue.
- Follow standardized formats for readability and completeness.
- English in your output
病历_5_13_55
{"patientName":"Timothy Bellocte","Patient Basic Information":"Name : Timothy Bellocte\nGender : Male\nAge : Unspecified\nConsultation Date : 2023-09-25\n","Chief Complaint":"Follow-up appointment for physical examination and review of recent laboratory report.\n","History of Present Illness":"Onset of symptoms: Reviewed during the consultation.\nSymptom description: Variation in cholesterol levels noted over the past year.\nAggravating/Alleviating factors: Potentially aggravated by dietary habits, particularly increased consumption of fatty meats.\nPrevious management: Previous cholesterol management medications tried but discontinued due to severe muscle pain.\nAdditional context: Recent colonoscopy in July - results normal.\n","Past Medical History":"History of high cholesterol.\nPrevious borderline anemia corrected with Testosterone Replacement Therapy (TRT).\nMedication History :\n- Propranolol (as needed for anxiety)\n- Lexapro (daily since this year)\n- Zaloplon (as needed for insomnia)","Personal History":"Mentioned diet changes contributing to fluctuating cholesterol levels.\nAttempts to manage anxiety and sleep issues medically.","Family History":"His spouse had H. pylori infection, treated successfully.\n","Physical Examination":"Vital signs: Blood pressure rechecked and found to be within normal limits.\nExamination findings: Not elaborated in the conversation.\n","Auxiliary Examinations":"Hepatitis Panel: Positive immunity for Hepatitis A, non-immune for Hepatitis B, and negative for Hepatitis C.\nBlood Profile: Hemoglobin, white blood cells, and platelets within normal ranges. AST levels have decreased since earlier in the year.\nMetabolic Panel: Normal sugar, kidney function, electrolytes, and liver enzymes.\nLipid Profile: Elevated cholesterol and LDL levels.\nVitamin D: Low level noted.\nH. pylori Test: Negative.\n","Diagnosis and Assessment":"Preliminary Diagnosis : Hypercholesterolemia and Vitamin D deficiency.\nDifferential Diagnosis : Unnecessary due to lack of complex symptoms for differential considerations.\n","Treatment Plan":"1. Medications :\n- Hepatitis B vaccine, first dose today and a second dose one month later.\n2. Lifestyle Interventions :\n- Low-fat diet, reduce fatty meats, and increase lean protein consumption.\n- Recommends sunlight exposure to increase Vitamin D levels.\n3. Further Examinations :\n- Lipid profile recheck in 3 months to monitor cholesterol levels.\n- Blood pressure monitoring due to historical inconsistencies.\n- Shingles vaccine recommended upon reaching 50 years of age.\n"}