提示词_5_21_66
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_21_66
Based on the conversation, here is the standardized outpatient medical record:
Patient Basic Information
- Name: Unspecified
- Gender: Unspecified
- Age: Unspecified
- Consultation Date: 2021-11-XX
Chief Complaint
- The patient reports persistent weight loss.
History of Present Illness
- Onset of symptoms: Ongoing for a while.
- Symptom description: The patient feels they are losing weight despite regular food intake.
- Aggravating/Alleviating factors: None specified.
- Previous management: Monitoring food intake and routine exercises.
- Additional context: The patient engaged in consistent running, approximately 100-110 miles monthly.
Past Medical History
- History of high cholesterol requiring medication that the patient discontinued.
- Previous injury involving a fall with chest pain. Underwent CT, results normal.
- Medication History: Unspecified cholesterol medication (discontinued).
Personal History
- Regular exercise, specifically morning runs.
- No reported smoking.
- No influenza vaccine last year.
Family History
- No familial colon cancer.
- Relatives with diabetes.
Physical Examination
- Vital signs: Blood pressure checked, within normal range.
- Examination findings: No abnormalities in the examination of the eyes, ears, and throat. Regular heartbeat and breathing. Abdomen non-tender. No swelling of the thyroid.
Auxiliary Examinations
- No auxiliary examinations mentioned.
Diagnosis and Assessment
- Preliminary Diagnosis: Weight loss, potentially due to high metabolic rate or exercise level.
- Differential Diagnosis: Consideration of cholesterol levels and diabetes.
Treatment Plan
- Medications: Check cholesterol levels; consider resuming medication if necessary.
- Lifestyle Interventions: Monitor diet and weight, rule out excessive exercise as cause of weight loss.
- Further Examinations: Recommend colonoscopy for colorectal cancer screening, considering age and skip in yearly tests.
Notes:
- The patient is advised to schedule a colonoscopy, especially since the last test was performed in April.
- Pneumococcal vaccine is suggested for individuals aged 50 and above.
- Routine blood work, thyroid, and cholesterol profile tests to be conducted.