病历_8_5_70
{
"visitSummary": "The patient presents with worsening anxiety and depressive symptoms impacting daily life and work. Initial diagnosis includes anxiety disorder and depression, requiring further assessment and treatment.",
"subjective": "The patient reports increased anxiety and depression over the past six months, with thoughts that 'it would be better not to be in this world,' although there is no specific plan for self-harm. He notes that these emotional issues have affected his work performance, leading to decreased concentration despite completing projects. The patient has not received specialized psychological treatment previously, and his anxiety and depression have not been this severe before.",
"objective": "Physical examination reveals the following: General condition appears stable with no significant health issues detected. Neurological examination shows alertness and good eye movement coordination. Cardiopulmonary examination demonstrates normal heart rate and respiration, with no abnormal heart or lung sounds noted.",
"assessmentAndPlan": "Preliminary diagnosis includes: 1. Anxiety disorder 2. Depression (pending further evaluation). The patient's emotional state significantly affects daily life and work, necessitating psychological intervention and pharmacotherapy. Treatment plan includes: 1. Medication: Prescribe anxiolytics, with follow-up on effectiveness during the next visit. 2. Psychological therapy: Recommend the patient seek evaluation and treatment from a psychologist or psychiatrist. 3. Vaccination: Arrange for tetanus and flu vaccinations, with COVID-19 vaccination to be determined later. 4. Follow-up: Advise the patient to return for a follow-up appointment in one week to monitor medication effects and emotional changes.",
"patientInstructions": "The patient should maintain communication with family and friends and seek help promptly. If emotional distress worsens or self-harming thoughts arise, he should seek medical attention immediately.",
"transcriptSummary": "Doctor: 'What brings you in today?' Patient: 'I've been feeling more anxious and depressed lately, it's affecting my work.' Doctor: 'Tell me more about your feelings.' Patient: 'It's been really hard, and I've had thoughts that it might be better if I wasn't here, but I don't have any specific plans.' Doctor: 'I see. Let's discuss some treatment options and support for you.'",
"patientName": "静安",
"patientBasicInformation": {
"name": "静安",
"age": "Not specified"
}
}