病历_7_20_68
"{ "Patient Basic Information": { "Name": "Kelvin Corzami", "Gender": "Male", "Age": "Unspecified", "Consultation Date": "YYYY-MM-DD" }, "Chief Complaint": "Headache, neck stiffness, and fever for the past three days.", "History of Present Illness": { "Onset of symptoms": "Started approximately three days ago, on a Tuesday.", "Symptom description": "Bad headaches, neck stiffness, feeling of brain pressure and knocking, worse with head and eye movement.", "Aggravating/Alleviating factors": "Symptoms seem to be alleviated with Excedrin and hot water treatments.", "Previous management": "Patient took Excedrin and was feeling better. Tylenol was also used initially for headaches and fever control.", "Additional context": "Symptoms include light coughing and phlegm production starting on the day of consultation." }, "Past Medical History": { "Gallbladder removal by Dr. Kim; post-surgery pain resolved after several weeks.", "Medication History": [ { "Name": "Excedrin", "Dosage": "Unspecified", "Frequency": "As needed for headaches" }, { "Name": "Tylenol (Acetaminophen)", "Dosage": "Unspecified", "Frequency": "As needed" } ] }, "Personal History": "Unspecified.", "Family History": "Unspecified.", "Physical Examination": { "Vital signs": "Unspecified.", "Examination findings": "No signs of meningitis. No swelling or significant tenderness in the joints observed." }, "Auxiliary Examinations": "Unspecified.", "Diagnosis and Assessment": { "Preliminary Diagnosis": "Viral infection presenting with fever, headache, neck stiffness, and mild respiratory symptoms.", "Differential Diagnosis": "Meningitis, ruled out upon examination." }, "Treatment Plan": { "Medications": [ { "Name": "Tylenol", "Dosage": "Unspecified", "Instructions": "To be taken as needed for pain and fever." } ], "Lifestyle Interventions": "Increase fluid intake and ensure plenty of rest.", "Further Examinations": "None specified at this time." }}"