提示词_3_17_57
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_17_57
{"patientName":"Mei Hai Yang","plaintext":"Basic Information:\nPatient Name: Mei Hai Yang\nGender: Female\nAge: 88 years\nDate of Consultation: [Include Date]\nMedical Record No.: [Include Number]\nChief Complaint:\nMild knee pain\nHistory of Present Illness:\nThe patient reports intermittent knee pain and a history of slight swelling in the thigh. She has a notable history of manual labor which may have contributed to joint wear.\nPast Medical History:\nHypertension: Controlled with Telmisartan\nDyslipidemia: Controlled with Simvastatin\nNo known diabetes history\nNo other significant past medical history\nPersonal and Family History:\nNo family history of diabetes or other hereditary diseases reported.\nPhysical Examination:\nNo palpable tenderness or significant physical abnormalities in the knee area.\nAuxiliary Tests:\nKnee X-ray: Mild degenerative changes in bilateral knees, no fractures observed.\nBlood tests: Elevated cholesterol; fasting blood sugar at 6.4 mmol/L, slightly higher than previous measure of 6.2 mmol/L.\nDiagnosis and Assessment:\nBilateral knee osteoarthritis, mild\nSlight hyperglycemia\nDyslipidemia, controlled on medication\nTreatment Plan:\n1. Prescribed physical therapy (Phone: 425-202-6128 at Boost Physical Therapy, Crossroads Mall)\n2. Advised the patient to reduce the intake of carbohydrates, especially processed ones like noodles, mantou, and to increase protein intake such as eggs, tofu, and meat.\n3. Continue Telmisartan and Simvastatin for hypertension and lipid management.\n4. Monitor blood sugar levels, if hyperglycemia persists, consider initiation of oral hypoglycemic agents.\n5. Advise over-the-counter pain relief patches for immediate pain management as needed.\n6. Scheduling follow-up in 3 months to reassess blood sugar and cholesterol levels and adjust treatment plan accordingly.\nCompliance with Clinical Standards:\nThis medical record follows the standard U.S. outpatient format, incorporating necessary patient information and accurate medical terminology in diagnosis and treatment planning. Patient instructions and education provided related to their condition and management plan."}