提示词_7_20_68
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
- The output must be JSON structure
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." }}"