의료 보고서 요약기

입력

의료 보고서 내용

Comprehensive Metabolic Panel and Lipid Panel. Glucose 142 mg/dL (H), HbA1c 6.8% (H), Total Cholesterol 232 mg/dL (H), LDL 158 mg/dL (H), HDL 41 mg/dL, Triglycerides 180 mg/dL (H), eGFR 88, ALT 30, AST 28. Sodium, potassium, and creatinine within normal limits.

보고서 유형

실험실 결과 / 혈액 검사

요약 대상

환자 (간단한 언어)

요약 심도

표준 (발견 + 맥락)

구체적 중점 영역 (선택)

cholesterol levels, blood sugar

출력 (발췌)

Your Results in Plain Language

Blood sugar: Your fasting glucose (142) and HbA1c (6.8%) are a bit high, which suggests prediabetes or early diabetes. The HbA1c reflects your average over the past 3 months.

Cholesterol: Your LDL ('bad' cholesterol) at 158 and total cholesterol at 232 are above the healthy range, while HDL ('good' cholesterol) is on the low side.

Good news: Your kidney and liver values look normal. Please discuss diet, activity, and next steps with your doctor.

입력

의료 보고서 내용

Discharge summary: Patient admitted for community-acquired pneumonia, treated with IV ceftriaxone and azithromycin, transitioned to oral amoxicillin-clavulanate. Afebrile for 48 hours, oxygen saturation 96% on room air at discharge. Follow-up with PCP in 7 days. Continue inhaler as prescribed. Activity as tolerated.

보고서 유형

퇴원 요약

요약 대상

돌보는 사람 / 가족

요약 심도

간결하게 (주요 발견만)

구체적 중점 영역 (선택)

medications, follow-up

출력 (발췌)

Caregiver Summary

Why they were in the hospital: A lung infection (pneumonia), now improving.

What to do at home:
- Give the oral antibiotic (amoxicillin-clavulanate) exactly as prescribed until finished.
- Continue the prescribed inhaler.
- Let them rest but encourage light activity as they feel able.

Important: Book a follow-up with their primary doctor within 7 days. Call the doctor if fever, worsening cough, or breathing trouble returns.

입력

의료 보고서 내용

MRI of the lumbar spine without contrast. Findings: L4-L5 disc desiccation with a 4mm posterior disc protrusion causing mild central canal stenosis and bilateral lateral recess narrowing. L5-S1 mild facet arthropathy. No acute fracture. Conus medullaris normal. Mild multilevel degenerative changes consistent with age.

보고서 유형

영상 (엑스레이, MRI, CT, 초음파)

요약 대상

의료 제공자

요약 심도

상세 (전체 해석)

구체적 중점 영역 (선택)

출력 (발췌)

Impression Summary (Provider)

Key finding: L4-L5 disc desiccation with 4mm posterior protrusion producing mild central canal stenosis and bilateral lateral recess narrowing - the likely correlate for radicular symptoms if present.

Secondary: L5-S1 mild facet arthropathy; multilevel age-related degenerative change.

Reassuring: No acute fracture, normal conus medullaris.

Clinical note: Findings are mild; recommend correlating with exam before considering injection or surgical referral.