样例方案
# 样例健康管理方案
基于客户及检查报告给出健管建议。能够筛选体检报告、病历等 脱敏数据 作为输入，并可结合 知识库 给出健管方案
# 输入：脱敏检查指标
根据检查结果给出健康管理方案+脱敏检查指标。详细见后。
# 输出：健康管理建议
根据体检报告结果，现制定以下健康管理方案：
一、紧急处理事项
- 消化系统问题：
- 立即预约消化内科就诊，处理上消化道内视镜发现的异物
- 胆囊结石建议每6个月复查腹部超声
二、营养与代谢管理
- 维生素D补充：
- 立即开始补充维生素D3 2000IU/日
- 3个月后复查25-羟基维生素D水平（目标＞30ng/mL）
- 体重管理：
- 当前BMI 26.01（超重），腰围87.7cm（超标）
- 制定减重目标：3个月内减重5%（约3.5kg）
- 每日热量控制：男性1800kcal/日，女性1500kcal/日
三、心血管风险管理
- 血脂管理：
- LDL 125mg/dl偏高，建议： • 减少饱和脂肪摄入 • 增加ω-3脂肪酸摄入 • 每日有氧运动30分钟
- 动脉硬化预防：
- 控制盐摄入＜6g/日（当前8.9g）
- 每周至少150分钟中等强度运动
四、血糖管理
- 监测：
- 空腹血糖100mg/dl（临界）
- HbA1c 5.6%（正常上限）
- 建议每周监测2次空腹血糖
- 干预：
- 低碳水化合物饮食（每日碳水化合物＜130g）
- 餐后步行20分钟
五、定期监测计划
- 3个月后复查：
- 肝功能
- 空腹血糖+HbA1c
- 维生素D水平
- 6个月后复查：
- 胆囊超声（结石监测）
- 颈动脉超声
- 糖代谢相关指标
六、疫苗接种建议
- 立即接种：
- 麻疹疫苗（抗体阴性）
- 腮腺炎疫苗（弱阳性）
- 考虑接种：
- 风疹疫苗（虽阳性但滴度偏低）
七、生活方式调整
- 饮食建议：
- 地中海饮食模式
- 每日蔬菜＞500g
- 限酒（男性＜25g/日乙醇）
- 运动处方：
- 每周运动计划： • 有氧运动：5次/周，30分钟/次 • 抗阻训练：2次/周
八、专科随访计划
- 消化内科：1个月内
- 内分泌科：3个月后（评估代谢状况）
- 心血管科：6个月后（动脉硬化评估）
九、监测指标阈值提醒 需警惕以下指标变化：
- ALT＞40U/L
- 空腹血糖＞110mg/dL
- LDL＞130mg/dL
- 胆囊结石症状发作
请严格执行本管理方案，建议使用健康管理APP记录每日饮食、运动和症状变化。有任何异常症状请及时就医。
# 完整输入内容：
根据检查结果给出健康管理方案：
{
"data": [
{
"item_code": "bloodType",
"item_name": "血型",
"item_value": "XX型 Rh(+)"
},
{
"item_code": "upperGastrointestinalEndoscopy",
"item_name": "上消化道内视镜检查",
"item_value": "发现异物，需到消化内科就诊"
},
{
"item_code": "vitaminD",
"item_name": "25-羟基维生素D",
"item_value": "低于20ng/mL，维生素D缺乏症"
},
{
"item_code": "weightAndWaist",
"item_name": "体重和腰围",
"item_value": "均超过标准值"
},
{
"item_code": "liverFunction",
"item_name": "肝功能检查",
"item_value": "轻度异常，需持续观察"
},
{
"item_code": "sugarMetabolism",
"item_name": "糖代谢异常",
"item_value": "疑有糖代谢异常，需持续观察"
},
{
"item_code": "freeTestosterone",
"item_name": "游离睾酮",
"item_value": "数值偏低，但男性更年期的可能性不高"
},
{
"item_code": "chestAbdominalCT",
"item_name": "胸部/腹部CT检查",
"item_value": "胆囊结石，需持续观察"
},
{
"item_code": "carotidUltrasound",
"item_name": "颈动脉超声波检查",
"item_value": "动脉硬化性改变，需控制饮食并适当运动"
},
{
"item_code": "abdominalUltrasound",
"item_name": "腹部超声波检查",
"item_value": "疑有胆囊息肉，需持续观察"
},
{
"item_code": "bloodTypeAB",
"item_name": "血型AB型Rh(+)",
"item_value": "AB型Rh(+)"
},
{
"item_code": "HBsAntibody",
"item_name": "HBs抗体检测",
"item_value": "阳性，可能是疾病已治愈或接种过疫苗"
},
{
"item_code": "rubellaAntibody",
"item_name": "风疹抗体检测",
"item_value": "阳性，建议接种疫苗"
},
{
"item_code": "measlesAntibody",
"item_name": "麻疹抗体检测",
"item_value": "阴性，建议接种疫苗"
},
{
"item_code": "mumpsAntibody",
"item_name": "腮腺炎抗体检测",
"item_value": "弱阳性，建议接种疫苗"
},
{
"item_code": "varicellaAntibody",
"item_name": "水痘带状疱疹抗体检测",
"item_value": "阳性"
},
{
"item_code": "saltIntake",
"item_name": "盐分摄入量",
"item_value": "高水平，建议减少食盐摄入量"
},
{
"item_code": "helicobacterPylori",
"item_name": "血清幽门螺旋杆菌检测",
"item_value": "阴性"
},
{
"item_code": "height",
"item_name": "身高",
"item_value": "165.4 cm"
},
{
"item_code": "weight",
"item_name": "体重",
"item_value": "71.2 kg"
},
{
"item_code": "bmi",
"item_name": "BMI",
"item_value": "26.01 kg/m²"
},
{
"item_code": "waistCircumference",
"item_name": "腰围",
"item_value": "87.7 cm"
},
{
"item_code": "visceralFatCT",
"item_name": "内脏脂肪CT检查",
"item_value": "77.0 cm"
},
{
"item_code": "bloodPressure",
"item_name": "血压",
"item_value": "收缩期111 mmHg，扩张期74 mmHg"
},
{
"item_code": "hemoglobin",
"item_name": "血红蛋白量",
"item_value": "16.1 g/dl"
},
{
"item_code": "redBloodCellCount",
"item_name": "红血球数",
"item_value": "51.6 10/ul"
},
{
"item_code": "hematocrit",
"item_name": "血细胞积压",
"item_value": "47.1%"
},
{
"item_code": "plateletCount",
"item_name": "血小板数",
"item_value": "18.6 10/ul"
},
{
"item_code": "whiteBloodCellCount",
"item_name": "白血球数",
"item_value": "43 10/ul"
},
{
"item_code": "mcv",
"item_name": "MCV",
"item_value": "91 f"
},
{
"item_code": "mch",
"item_name": "MCH",
"item_value": "31.2 pg"
},
{
"item_code": "mchc",
"item_name": "MCHC",
"item_value": "34.2%"
},
{
"item_code": "neutrophils",
"item_name": "中性粒细胞",
"item_value": "42.7%"
},
{
"item_code": "eosinophils",
"item_name": "嗜酸性粒细胞",
"item_value": "0.9%"
},
{
"item_code": "basophils",
"item_name": "嗜碱性粒细胞",
"item_value": "0.7%"
},
{
"item_code": "monocytes",
"item_name": "单核细胞",
"item_value": "6.2%"
},
{
"item_code": "lymphocytes",
"item_name": "淋巴细胞",
"item_value": "49.5%"
},
{
"item_code": "totalProtein",
"item_name": "总蛋白",
"item_value": "7.3 g/dl"
},
{
"item_code": "albumin",
"item_name": "白蛋白",
"item_value": "4.5 g/dl"
},
{
"item_code": "agRatio",
"item_name": "A/G比",
"item_value": "1.6"
},
{
"item_code": "ast",
"item_name": "AST(GOT)",
"item_value": "17 U/l"
},
{
"item_code": "alt",
"item_name": "ALT(GPT)",
"item_value": "26 U/l"
},
{
"item_code": "ggt",
"item_name": "Y-GTP",
"item_value": "24 U/l"
},
{
"item_code": "alp",
"item_name": "ALP",
"item_value": "65 U/l"
},
{
"item_code": "totalBilirubin",
"item_name": "总胆红素",
"item_value": "1.41 mg/dl"
},
{
"item_code": "directBilirubin",
"item_name": "直接胆红素",
"item_value": "0.3 mg/dl"
},
{
"item_code": "ldh",
"item_name": "LDH",
"item_value": "133 U/l"
},
{
"item_code": "chE",
"item_name": "Ch-E",
"item_value": "390 U/l"
},
{
"item_code": "bloodAmylase",
"item_name": "血中淀粉酶",
"item_value": "103 U/l"
},
{
"item_code": "tsh",
"item_name": "TSH",
"item_value": "1.200 μIU/ml"
},
{
"item_code": "ft3",
"item_name": "FT3",
"item_value": "3.04 pg/ml"
},
{
"item_code": "ft4",
"item_name": "FT4",
"item_value": "1.37 ng/dl"
},
{
"item_code": "fastingBloodSugar",
"item_name": "空腹时血糖",
"item_value": "100 mg/dl"
},
{
"item_code": "fastingUrineSugar",
"item_name": "空腹时尿糖",
"item_value": "(-)"
},
{
"item_code": "hba1c",
"item_name": "HbA1c（NGSP）",
"item_value": "5.61%"
},
{
"item_code": "totalCholesterol",
"item_name": "总胆固醇",
"item_value": "205 mg/dl"
},
{
"item_code": "hdlCholesterol",
"item_name": "HDL胆固醇",
"item_value": "50 mg/dl"
},
{
"item_code": "nonHdlCholesterol",
"item_name": "non-HDL胆固醇",
"item_value": "155 mg/dl"
},
{
"item_code": "ldlCholesterol",
"item_name": "LDL胆固醇",
"item_value": "125 mg/dl"
},
{
"item_code": "triglycerides",
"item_name": "甘油三酯",
"item_value": "142 mg/dl"
},
{
"item_code": "crp",
"item_name": "CRP",
"item_value": "0.05 mg/dl"
},
{
"item_code": "rf",
"item_name": "RF",
"item_value": "3 IU/ml"
},
{
"item_code": "urineSpecificGravity",
"item_name": "尿比重",
"item_value": "1.020"
},
{
"item_code": "urinePh",
"item_name": "尿pH",
"item_value": "6.5"
},
{
"item_code": "urineProtein",
"item_name": "尿蛋白",
"item_value": "(-)"
},
{
"item_code": "urineBlood",
"item_name": "尿潜血",
"item_value": "(-)"
},
{
"item_code": "urineUrobilinogen",
"item_name": "尿胆原",
"item_value": "(±)"
},
{
"item_code": "urineKetones",
"item_name": "尿酮体",
"item_value": "(-)"
},
{
"item_code": "urineRedBloodCells",
"item_name": "尿红血球",
"item_value": "0-4 /HPF"
},
{
"item_code": "urineWhiteBloodCells",
"item_name": "尿白血球",
"item_value": "<1 /HPF"
},
{
"item_code": "urineEpithelialCells",
"item_name": "尿上皮细胞",
"item_value": "<1 /HPF"
},
{
"item_code": "creatinine",
"item_name": "肌酸酐",
"item_value": "0.98 mg/dl"
},
{
"item_code": "bloodUreaNitrogen",
"item_name": "尿氮素",
"item_value": "21.6 mg/dl"
},
{
"item_code": "egfr",
"item_name": "eGFR",
"item_value": "65 ml/min"
},
{
"item_code": "uricAcid",
"item_name": "尿酸",
"item_value": "5.5 mg/dl"
},
{
"item_code": "sodium",
"item_name": "钠",
"item_value": "142 mEq/l"
},
{
"item_code": "potassium",
"item_name": "钾",
"item_value": "4.1 mEq/l"
},
{
"item_code": "chloride",
"item_name": "氯",
"item_value": "107 mEq/l"
},
{
"item_code": "calcium",
"item_name": "钙",
"item_value": "9.7 mg/dl"
},
{
"item_code": "correctedCalcium",
"item_name": "校正钙",
"item_value": "9.7 mg/dl"
},
{
"item_code": "magnesium",
"item_name": "镁",
"item_value": "2.2 mg/dl"
},
{
"item_code": "phosphorus",
"item_name": "磷",
"item_value": "3.4 mg/dl"
},
{
"item_code": "hbsAntigen",
"item_name": "HBs抗原",
"item_value": "(-)"
},
{
"item_code": "hbsAntibody",
"item_name": "HBs抗体",
"item_value": "(+)"
},
{
"item_code": "hcvAntibody",
"item_name": "HCV抗体",
"item_value": "(-)"
},
{
"item_code": "rubellaAntibodyValue",
"item_name": "风疹抗体值",
"item_value": "8.0"
},
{
"item_code": "measlesAntibodyValue",
"item_name": "麻疹抗体值",
"item_value": "1.3"
},
{
"item_code": "mumpsAntibodyValue",
"item_name": "腮腺炎抗体值",
"item_value": "3.9"
},
{
"item_code": "varicellaAntibodyValue",
"item_name": "水痘抗体值",
"item_value": "100.5"
},
{
"item_code": "afp",
"item_name": "AFP",
"item_value": "4.1 ng/ml"
},
{
"item_code": "ca19_9",
"item_name": "CA19-9",
"item_value": "26.5 U/ml"
},
{
"item_code": "cea",
"item_name": "CEA",
"item_value": "3.2 ng/ml"
},
{
"item_code": "pivka_ii",
"item_name": "PIVKA-II",
"item_value": "0 mAU/ml"
},
{
"item_code": "psa",
"item_name": "PSA",
"item_value": "0.97 ng/ml"
},
{
"item_code": "elastase1",
"item_name": "弹性蛋白酶1",
"item_value": "80 ng/ml"
},
{
"item_code": "serumIron",
"item_name": "血清铁",
"item_value": "149 ug/dl"
},
{
"item_code": "ferritin",
"item_name": "铁蛋白",
"item_value": "25.0~250.0 ng/ml"
},
{
"item_code": "homocysteine",
"item_name": "高半胱氨酸",
"item_value": "5.1~11.7 nmol/ml"
},
{
"item_code": "ck",
"item_name": "CK（CPK）",
"item_value": "50.0~210.0 U/l"
},
{
"item_code": "nt_probnp",
"item_name": "NT-proBNP",
"item_value": "22 pg/ml"
},
{
"item_code": "vitaminDLevel",
"item_name": "维生素D",
"item_value": "13.9 ng/ml"
},
{
"item_code": "saltIntakeLevel",
"item_name": "盐分摄取量",
"item_value": "8.9 g/day"
},
{
"item_code": "rightEyeVision",
"item_name": "右眼视力",
"item_value": "0.40（裸眼）"
},
{
"item_code": "leftEyeVision",
"item_name": "左眼视力",
"item_value": "0.80（裸眼）"
},
{
"item_code": "eyePressureRight",
"item_name": "右眼眼压",
"item_value": "13 mmHg"
},
{
"item_code": "eyePressureLeft",
"item_name": "左眼眼压",
"item_value": "16 mmHg"
},
{
"item_code": "fundusFindings",
"item_name": "眼底所见",
"item_value": "无异常"
},
{
"item_code": "hearing1000Hz",
"item_name": "1000Hz听力检查",
"item_value": "右：无所见/左：无所见"
},
{
"item_code": "hearing4000Hz",
"item_name": "4000Hz听力检查",
"item_value": "右：无所见/左：无所见"
},
{
"item_code": "ecg",
"item_name": "心电图",
"item_value": "轻度异常，窦性心动过缓"
},
{
"item_code": "abiRight",
"item_name": "右ABI",
"item_value": "1.20"
},
{
"item_code": "abiLeft",
"item_name": "左ABI",
"item_value": "1.21"
},
{
"item_code": "pwvRight",
"item_name": "右PWV",
"item_value": "1212 cm/s"
},
{
"item_code": "pwvLeft",
"item_name": "左PWV",
"item_value": "1173 cm/s"
},
{
"item_code": "chestXRay",
"item_name": "胸部X光",
"item_value": ""
},
{
"item_code": "lungFunction",
"item_name": "肺功能",
"item_value": ""
},
{
"item_code": "upperGastrointestinal",
"item_name": "上消化道",
"item_value": "内镜检查/无活检"
},
{
"item_code": "lowerGastrointestinal",
"item_name": "下消化道",
"item_value": "便潜血第1天(-)，第2天(-)"
},
{
"item_code": "boneDensity",
"item_name": "骨密度",
"item_value": "DEXA法：0.792 g/cm²"
},
{
"item_code": "headCT",
"item_name": "头部CT",
"item_value": ""
},
{
"item_code": "chestAbdominalCTFindings",
"item_name": "胸部/腹部CT所见",
"item_value": "瘢痕（双肺），肝囊泡，胆囊结石"
},
{
"item_code": "carotidUltrasoundFindings",
"item_name": "颈动脉超声波所见",
"item_value": "双侧颈动脉动脉硬化性改变"
},
{
"item_code": "thyroidUltrasound",
"item_name": "甲状腺超声波",
"item_value": "无异常"
},
{
"item_code": "heartUltrasound",
"item_name": "心脏超声波",
"item_value": ""
},
{
"item_code": "abdominalUltrasoundFindings",
"item_name": "腹部超声波所见",
"item_value": "胆囊泡疑似胆囊息肉"
},
{
"item_code": "headMRIMRA",
"item_name": "头部MRI/MRA",
"item_value": "白质病变（轻度），双侧水晶体术后"
},
{
"item_code": "upperAbdomenMRI",
"item_name": "上腹部MRI",
"item_value": ""
},
{
"item_code": "pelvisMRI",
"item_name": "盆骨MRI",
"item_value": ""
},
{
"item_code": "breastUltrasound",
"item_name": "乳腺超声波",
"item_value": ""
},
{
"item_code": "breastXRay",
"item_name": "乳腺X光",
"item_value": "3D钼靶"
},
{
"item_code": "gynecologicalExam",
"item_name": "妇科检查",
"item_value": ""
},
{
"item_code": "cervicalCytology",
"item_name": "宫颈细胞学检查",
"item_value": ""
},
{
"item_code": "hpvTest",
"item_name": "人乳头瘤病毒检测",
"item_value": ""
},
{
"item_code": "vaginalUltrasound",
"item_name": "阴道超声波",
"item_value": ""
},
{
"item_code": "metabolicSyndrome",
"item_name": "代谢综合征判定",
"item_value": "不符合"
},
{
"item_code": "healthGuidance",
"item_name": "保健指导水平",
"item_value": "动机支持"
}
],
"schema": {
"item_code": "编码",
"item_name": "项目",
"item_value": "结果"
}
}