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提示词_8_7_74

Instructions:

You are an experienced medical expert tasked with generating a standardized outpatient medical record in JSON format based on the conversation between the doctor and the patient. Your response must adhere to clinical outpatient documentation standards and provide a comprehensive and structured report. The output must be in JSON format as specified below and in English.

Prompt Template

{
  "visitSummary": "string",
  "subjective": "string",
  "objective": "string",
  "assessmentAndPlan": "string",
  "patientInstructions": "string",
  "transcriptSummary": "string",
  "patientName": "string",
  "patientBasicInformation": {
    "name": "string",
    "age": "string"

  }
}

Field Descriptions

  • visitSummary:

    • Provide a concise summary of the patient is visit in English. This should include key complaints, clinical findings, and the overall management plan.

  • subjective:

    • Document the patient is reported symptoms, chief complaint, and relevant personal, family, and past medical history as expressed during the consultation. Ensure the information is accurate and written in professional English.

  • objective:

    • Include detailed findings from the physical examination, vital signs, and results from any auxiliary examinations (e.g., laboratory tests or imaging studies). Present this information clearly and professionally in English.

  • assessmentAndPlan:

    • Record the clinical assessment, including the primary diagnosis, differential diagnoses, and the proposed treatment plan. This should cover prescribed medications, lifestyle recommendations, and any further diagnostic or therapeutic interventions. Write this section using formal medical terminology in English.

  • patientInstructions:

    • Summarize the instructions provided to the patient regarding treatment, lifestyle changes, follow-ups, or other relevant recommendations. The instructions should be clear and easy to understand in English.

  • transcriptSummary:

    • Provide a high-level summary of the dialogue or interaction between the doctor and the patient. Capture the key points discussed and outcomes in fluent English. Output the original fluent dialogue content with roles assigned.

  • patientName:

    • Include the name of the patient as mentioned in the conversation.

  • patientBasicInformation:

    • Include basic information about the patient, such as name and age.

Constraints

  • The output must be written entirely in English.
  • Follow professional medical documentation standards, ensuring clarity, accuracy, and relevance.
  • The JSON structure provided above is mandatory and must not be altered.
  • Use concise and formal language suitable for a medical record.
  • When a theme contains multiple related points, present them within a list format to ensure clarity and organization

病历_8_7_74

{
  "visitSummary": "The patient, Wang Lei, presented for an annual health check-up expressing concerns regarding his health status, particularly at the age of 40. He reported intermittent heartburn and acid reflux occurring about once or twice a week. A family history of gastrointestinal issues was noted, specifically his mother's severe gastric problems requiring annual endoscopies. The management plan includes lifestyle modifications, medication, and further diagnostic evaluations.",
  "subjective": "Patient reports a history of heartburn and occasional acid reflux, occurring approximately once or twice a week. He mentions that his mother has a history of severe gastrointestinal issues and requires annual endoscopies. The patient has previously treated an H. pylori infection, which alleviated some symptoms, but he still experiences acid reflux, occasionally exacerbated by stress or lack of sleep. He is concerned about his health at age 40 and inquires about necessary examinations.",
  "objective": "Physical examination reveals normal blood pressure. Blood sugar levels were previously recorded at 5.7 mmol/L; the patient monitors his blood sugar at home weekly. Sleep study shows no snoring and good sleep quality.",
  "assessmentAndPlan": "1. Likely diagnosis of gastroesophageal reflux disease (GERD) due to reported symptoms of heartburn and acid reflux. 2. Monitor lipid levels due to family history of hyperlipidemia. Treatment plan includes: a) Prescribe Omeprazole to alleviate acid reflux symptoms. b) Continue regular monitoring of blood sugar and lipid levels, with recommendations for fasting laboratory tests. c) Recommend a colonoscopy screening as males are advised to start this at age 45. d) Advise lifestyle modifications to reduce stress and maintain a regular sleep schedule, which may help improve gastrointestinal symptoms.",
  "patientInstructions": "1. Take Omeprazole as prescribed to manage acid reflux. 2. Continue monitoring your blood sugar and lipid levels regularly. 3. Schedule a colonoscopy screening around age 45. 4. Implement lifestyle changes to reduce stress and improve sleep habits.",
  "transcriptSummary": "Doctor: Good morning, Wang Lei. What brings you in today? \nPatient: I'm here for my annual check-up; I'm particularly concerned about my health now that I’m 40. \nDoctor: I see. Have you had any specific symptoms? \nPatient: Yes, I've been experiencing heartburn and occasional acid reflux about once or twice a week. \nDoctor: Any family history of gastrointestinal issues? \nPatient: Yes, my mother has severe stomach problems and needs regular endoscopies. \nDoctor: Understood. Let’s conduct a physical examination and discuss further tests. \nPatient: Thank you, Doctor.",
  "patientName": "Wang Lei",
  "patientBasicInformation": {
    "name": "Wang Lei",
    "age": "40"
  }
}