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提示词_3_13_56

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_13_56

{"patientName":"Timothy Beall","## Outpatient Medical Record":"","Basic Information:":"Patient Name: Timothy Beall\nDate of Birth: [DOB]\nGender: Male\nDate of Visit: December [Date], 2023","Chief Complaint:":"Follow-up for physical examination and lab results.","History of Present Illness:":"Patient is a [#]-year-old male who was previously seen by Dr. Cindy. Recent lab results show an elevated cholesterol level, particularly LDL. The patient has a history of high cholesterol and has experimented with various statins, resulting in severe myopathy. Diet changes since the summer include increased intake of fattier meats.","Past Medical History:":"High cholesterol with previous adverse reactions to statins.\nHistory of anemia earlier this year.\nTaking Lexapro for anxiety.\nUsing Propranolol PRN for anxiety episodes.\nUsing Zaleplon PRN for sleep initiation issues.","Personal and Family History:":"No significant family history reported in this session.","Physical Examination:":"Patient is alert, oriented, and cooperative. Vital signs are within normal parameters, with a recent blood pressure check being good. BMI and other physical exam components are within the normal range.","Auxiliary Tests:":"1. Lipid Panel:\n- Total Cholesterol: [Current Level] (High)\n- LDL: [Current Level] mg/dL (High)\n- HDL, Triglycerides: [Within normal limits]\n2. Liver Enzymes: ALT decreased from earlier levels this year.\n3. Complete Metabolic Panel: All values within normal range, excluding increased cholesterol.\n4. Hepatitis Panel: Immune to Hepatitis A, non-immune to Hepatitis B, Hepatitis C not present.\n5. Vitamin D: Low levels detected.","Diagnosis and Assessment:":"1. Hyperlipidemia, primarily elevated LDL.\n2. Anemia, resolved with elevated hemoglobin and hematocrit levels.\n3. Deficiency of Vitamin D.\n4. Non-immune status to Hepatitis B.\n5. Strong negative for H. pylori.","Treatment Plan:":"1. Dietary Modifications: Initiate a low-fat diet with lean meats.\n2. F/U: Recheck cholesterol levels and hepatic panel in 3 months.\n3. Vaccinations:\n- Administer 1st dose of Hepatitis B vaccine today, with the 2nd dose scheduled in one month.\n- Recommend Shingles vaccine for when the patient turns 50.\n4. Vitamin D Supplementation: Patient advised to resume Vitamin D supplementation and maintain sun exposure for natural synthesis.\n5. Medication Management: Continue Lexapro and Propranolol as previously prescribed. Reinforce selective use of Zaleplon.","Physician:":"Dr. Z\nNote: Please schedule follow-up in three months to reassess cholesterol and administer the second dose of the Hepatitis B vaccine."}