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提示词_3_19_61

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_19_61

{"patientName":"Raghavan Srinivasan","Outpatient Medical Record":"Patient Basic Information:\nName: Raghavan Srinivasan\nDate of Birth: REDACTED\nDate of Visit: REDACTED\nPhysician: REDACTED\nChief Complaint:\nRecent hematuria, discomfort, and concerns regarding bladder and urinary tract health.\nHistory of Present Illness:\nMr. Raghavan Srinivasan presents for a follow-up visit concerning recent episodes of hematuria which began on 11/27. The patient reports a sensation of incomplete bladder emptying and a "pinching" sensation. Initial urinalysis and culture revealed a bacterial infection (Streptococcus) with no visible hematuria during the sample provided, yet the patient experienced visible hematuria at home. Antibiotics (cephalexin) were initiated but later changed based on urologist consultation to target the specific bacteria identified. Discomfort and suspected prostatitis were evaluated by a urologist.\nPast Medical History:\nType 2 Diabetes Mellitus\nHypertension\nDyslipidemia\nPersonal and Family History:\nNo relevant family history of urologic or nephrologic conditions reported.\nPhysical Examination:\nVital Signs: Blood pressure and glucose levels are managed within target ranges.\nAbdominal Examination: Non-tender with no palpable masses.\nDigital Rectal Examination (DRE) by urologist: No irregularities noted.\nAuxiliary Tests:\nRecent HbA1c: Improved to 7.3%.\nKidney function normal as evidenced by BUN and creatinine levels.\nDecreased cholesterol and triglyceride levels.\nUpcoming: CT scan with contrast and cystoscopy scheduled for further evaluation of hematuria etiology.\nDiagnosis and Assessment:\nDifferential diagnosis includes urinary tract infection (responding to antibiotic treatment), nephrolithiasis, or potential other urological etiologies, pending results of further diagnostic tests. Diabetes and hypertension management appears adequate with improved HbA1c and lipid profile.\nTreatment Plan:\n1. Completion of prescribed antibiotics for the identified bacteria.\n2. Compliance with current diabetes, hypertension, and dyslipidemia medications.\n3. Undergo recommended cystoscopy and CT scan for ruling out stones or structural irregularities in the urinary tract.\n4. Continue monitoring of symptoms and follow-up as needed.\n5. Patient reassured and advised to maintain hydration and report any new or worsening symptoms immediately.\nFollow-up:\nMr. Srinivasan will be in touch after the completion of the procedures with the urology reports for further discussion and interpretation. He will return for a routine follow-up in 3 months or sooner if indicated."}