[ { "id": 1744, "text": "遂就诊于我院门诊行上消化道钡餐检查提示：右肺门结节及右肺上叶大叶性肺炎，胃蠕动减弱，血图分析提示hb 65g/L,今为求进一步诊治遂入我院入我科。", "event": [ { "core_name": "结节", "tendency": "", "character": [], "anatomy_list": [ "右肺门" ] }, { "core_name": "肺炎", "tendency": "", "character": [ "大叶性" ], "anatomy_list": [ "右肺上叶" ] }, { "core_name": "蠕动减弱", "tendency": "", "character": [], "anatomy_list": [ "胃" ] } ] }, { "id": 11, "text": "本次发病以来患者精神食欲稍差,大小便如常,睡眠较差,体重无明显下降。", "event": [ { "core_name": "精神", "tendency": "", "character": [ "稍差" ], "anatomy_list": [] }, { "core_name": "食欲", "tendency": "", "character": [ "稍差" ], "anatomy_list": [] }, { "core_name": "大小便", "tendency": "", "character": [ "正常" ], "anatomy_list": [] }, { "core_name": "睡眠", "tendency": "", "character": [ "较差" ], "anatomy_list": [] }, { "core_name": "体重下降", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [] } ] }, { "id": 295, "text": "患者本次发病以来，食欲正常， 神志清醒，精神尚可，睡眠尚可，大便正常，小便正常，近一年体重减少10kg。", "event": [ { "core_name": "食欲", "tendency": "", "character": [ "正常" ], "anatomy_list": [] }, { "core_name": "神志", "tendency": "", "character": [ "清醒" ], "anatomy_list": [] }, { "core_name": "精神", "tendency": "", "character": [ "尚可" ], "anatomy_list": [] }, { "core_name": "睡眠", "tendency": "", "character": [ "尚可" ], "anatomy_list": [] }, { "core_name": "大便", "tendency": "", "character": [ "正常" ], "anatomy_list": [] }, { "core_name": "小便", "tendency": "", "character": [ "正常" ], "anatomy_list": [] }, { "core_name": "体重减少", "tendency": "", "character": [], "anatomy_list": [] } ] }, { "id": 1605, "text": "2020-7-26于某医院某院区就诊，行电子阴道镜：宫颈癌？妇科彩超提示：宫颈处减弱回声，约7.6×4.0cm；宫腔内积液。", "event": [ { "core_name": "癌", "tendency": "不确定", "character": [], "anatomy_list": [ "宫颈" ] }, { "core_name": "回声", "tendency": "", "character": [ "减弱" ], "anatomy_list": [ "宫颈处" ] }, { "core_name": "积液", "tendency": "", "character": [], "anatomy_list": [ "宫腔内" ] } ] }, { "id": 1256, "text": "因患者需期末考试，故予以口服“雷贝拉唑钠肠溶片”治疗，现腹痛情况明显好转。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [ "明显好转" ], "anatomy_list": [ "腹" ] } ] }, { "id": 587, "text": "4.左膝关节退行性变。", "event": [ { "core_name": "病变", "tendency": "", "character": [ "退行性" ], "anatomy_list": [ "左膝关节" ] } ] }, { "id": 1408, "text": "院外经口饮食差，消瘦，静脉营养支持好转出院。", "event": [ { "core_name": "饮食", "tendency": "", "character": [ "差" ], "anatomy_list": [] }, { "core_name": "消瘦", "tendency": "", "character": [], "anatomy_list": [] } ] }, { "id": 1141, "text": "2016年4月8日患者无明显诱因出现阴道少许流血，每日用少量卫生纸即可，无明显臭味，2+日自净，未重视未处理。", "event": [ { "core_name": "出血", "tendency": "", "character": [ "少许" ], "anatomy_list": [ "阴道" ] }, { "core_name": "臭味", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [] } ] }, { "id": 1868, "text": "现入院行第四次化疗，故门诊以“直肠腺癌术后”收入住院。", "event": [ { "core_name": "腺癌", "tendency": "", "character": [ "术后" ], "anatomy_list": [ "直肠" ] } ] }, { "id": 350, "text": "患者既往月经规律，初潮年龄15岁，4/2525天，量中，无痛经，13年前自然绝经，绝经后无异常阴道流血及流液，无同房接触性出血，未行妇科检查。", "event": [ { "core_name": "月经", "tendency": "", "character": [ "规律", "量中" ], "anatomy_list": [] }, { "core_name": "痛经", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "出血", "tendency": "否定", "character": [ "异常", "绝经后" ], "anatomy_list": [ "阴道" ] }, { "core_name": "流液", "tendency": "否定", "character": [ "异常", "绝经后" ], "anatomy_list": [ "阴道" ] }, { "core_name": "出血", "tendency": "否定", "character": [ "同房接触性" ], "anatomy_list": [] } ] }, { "id": 1257, "text": "为求进一步治疗，昨日再次就诊于我院门诊，遂以“胃窦包块：间质瘤？”收入我科。", "event": [ { "core_name": "包块", "tendency": "", "character": [], "anatomy_list": [ "胃窦" ] }, { "core_name": "间质瘤", "tendency": "不确定", "character": [], "anatomy_list": [ "胃窦" ] } ] }, { "id": 1077, "text": "术后行静脉港置管辅助化疗治疗，方案为ec-t（吡柔比星+环磷酰胺序贯紫杉醇），共行5疗程，化疗后产生中度药物骨髓毒性反应，予以对症支持治疗；原始病灶位于右乳外上，簇状钙化灶，临床不能触及。现为继续化疗入院。", "event": [ { "core_name": "毒性反应", "tendency": "", "character": [ "化疗后", "中度" ], "anatomy_list": [ "骨髓" ] }, { "core_name": "病灶", "tendency": "", "character": [ "原始" ], "anatomy_list": [ "右乳外上" ] }, { "core_name": "钙化灶", "tendency": "", "character": [ "簇状", "不能触及" ], "anatomy_list": [ "右乳外上" ] } ] }, { "id": 324, "text": "院外患者无乳头溢液，无乳房胀痛等不适。", "event": [ { "core_name": "溢液", "tendency": "否定", "character": [], "anatomy_list": [ "乳头" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [ "胀痛" ], "anatomy_list": [ "乳房" ] } ] }, { "id": 1547, "text": "患者于入院前1+年无明显诱因出现双下肢乏力，活动后伴轻微疼痛，休息后双下肢疼痛可缓解，乏力稍缓解，无胸闷胸痛，无畏寒发热，无咳嗽咳痰，期间乏力程度无明显变化，患者未予重视，期间自服药物（具体不详），上述症状缓解不明显，今为求相应诊治，就诊于我院，门诊以“双下肢乏力待查”收入我科。", "event": [ { "core_name": "乏力", "tendency": "不确定", "character": [], "anatomy_list": [ "双下肢" ] }, { "core_name": "疼痛", "tendency": "", "character": [ "活动后", "轻微" ], "anatomy_list": [ "双下肢" ] }, { "core_name": "疼痛", "tendency": "", "character": [ "休息后可缓解" ], "anatomy_list": [ "双下肢" ] }, { "core_name": "乏力", "tendency": "", "character": [ "休息后稍缓解" ], "anatomy_list": [ "双下肢" ] }, { "core_name": "胸闷", "tendency": "否定", "character": [], "anatomy_list": [ "胸" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "胸" ] }, { "core_name": "畏寒", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "发热", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "咳嗽", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "乏力", "tendency": "", "character": [ "1期间程度无明显变化" ], "anatomy_list": [] }, { "core_name": "乏力", "tendency": "不确定", "character": [], "anatomy_list": [ "双下肢" ] } ] }, { "id": 530, "text": "左室整体收缩功能减低”，予以“呋塞米20mg利尿+西地兰0.2mg强心”处理，以“扩张性心肌病”收入我科。", "event": [ { "core_name": "收缩功能减低", "tendency": "", "character": [ "减低" ], "anatomy_list": [ "左室" ] }, { "core_name": "心肌病", "tendency": "", "character": [ "扩张性" ], "anatomy_list": [] } ] }, { "id": 812, "text": "近3年患者症状加重，痰由白色粘痰转为黄色脓痰，且伴劳力性胸闷、心悸、气促，约持续半分钟左右，活动后尤甚，休息后可逐渐缓解，偶伴双下肢凹陷性水肿，伴端坐呼吸，无夜间阵发性呼吸困难，既往在我科及呼吸科住院，被诊断为“1.慢性阻塞性肺疾病 慢性肺源性心脏病 心力衰竭；2.冠状动脉粥样硬化性心脏病 心房纤颤”患者院外一直口服“阿司匹林肠溶片、泰嘉、欣康、麝香保心丸、胺碘酮”等药物治疗（具体剂量不详）。", "event": [ { "core_name": "咳痰", "tendency": "", "character": [ "白色粘痰转为黄色脓痰" ], "anatomy_list": [] }, { "core_name": "胸闷", "tendency": "", "character": [ "劳力性", "活动后加重", "休息后可逐渐缓解" ], "anatomy_list": [ "胸" ] }, { "core_name": "心悸", "tendency": "", "character": [ "活动后加重", "休息后可逐渐缓解" ], "anatomy_list": [ "心" ] }, { "core_name": "气促", "tendency": "", "character": [ "活动后加重", "休息后可逐渐缓解" ], "anatomy_list": [] }, { "core_name": "水肿", "tendency": "", "character": [ "凹陷性", "偶伴" ], "anatomy_list": [ "双下肢" ] }, { "core_name": "端坐呼吸", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "呼吸困难", "tendency": "否定", "character": [ "夜间", "阵发性" ], "anatomy_list": [] }, { "core_name": "肺疾病", "tendency": "", "character": [ "慢性", "阻塞性" ], "anatomy_list": [ "肺" ] }, { "core_name": "心脏病", "tendency": "", "character": [ "慢性", "肺源性" ], "anatomy_list": [ "心脏" ] }, { "core_name": "心力衰竭", "tendency": "", "character": [], "anatomy_list": [ "心" ] }, { "core_name": "心脏病", "tendency": "", "character": [ "冠状动脉粥样硬化性" ], "anatomy_list": [ "心脏" ] }, { "core_name": "心房纤颤", "tendency": "", "character": [], "anatomy_list": [ "心房" ] } ] }, { "id": 1217, "text": "2016年12月患者因阴道大量流血急诊至某医院就诊，考虑“功血”，给予止血药止血治疗（具体治疗经过不详）后未进一步诊治，停药后阴道分泌物继续增多，呈暗红色，伴异味，伴同房后有少量阴道流血，呈鲜红色，量较少，持续两天后消失。", "event": [ { "core_name": "出血", "tendency": "", "character": [ "大量" ], "anatomy_list": [ "阴道" ] }, { "core_name": "功能失调性子宫出血", "tendency": "不确定", "character": [], "anatomy_list": [ "子宫" ] }, { "core_name": "阴道分泌物", "tendency": "", "character": [ "继续增多", "呈暗红色", "伴异味" ], "anatomy_list": [ "阴道" ] }, { "core_name": "出血", "tendency": "", "character": [ "同房后", "少量", "呈鲜红色", "量较少", "持续两天后消失" ], "anatomy_list": [ "阴道" ] } ] }, { "id": 263, "text": "患者此次患病以来，精神状态欠佳，小便正常，大便可疑黑便。", "event": [ { "core_name": "精神", "tendency": "", "character": [ "欠佳" ], "anatomy_list": [] }, { "core_name": "小便", "tendency": "", "character": [ "正常" ], "anatomy_list": [] }, { "core_name": "黑便", "tendency": "不确定", "character": [], "anatomy_list": [] } ] }, { "id": 982, "text": "2月前，患者结核门诊痰检结果示：发现抗酸杆菌（+）；结核rna恒温扩增检测：阴性，肺结核（活菌）核酸检测：阴性，结核分枝杆菌耐药性检测：利福平耐药未检出；咳嗽、咳痰较前加重，于我科住院治疗，完善相关检查，考虑诊断为“1.继发型肺结核 双肺 涂阳 培阳 复治 耐多药肺结核 2.肺部感染 3.败血症？4.营养不良 5.慢性乙肝携带者 6.慢性胃炎 7.电解质代谢紊乱 8.低蛋白血症 9.前列腺增生症 10.前列腺病变待查”，给予抗感染、止咳祛痰等治疗，患者症状好转出院。", "event": [ { "core_name": "结核", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "咳嗽", "tendency": "", "character": [ "加重" ], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "加重" ], "anatomy_list": [] }, { "core_name": "结核", "tendency": "不确定", "character": [ "继发性" ], "anatomy_list": [ "双肺" ] }, { "core_name": "结核", "tendency": "不确定", "character": [ "耐多药" ], "anatomy_list": [ "肺" ] }, { "core_name": "感染", "tendency": "不确定", "character": [], "anatomy_list": [ "肺部" ] }, { "core_name": "败血症", "tendency": "不确定", "character": [], "anatomy_list": [] }, { "core_name": "营养不良", "tendency": "不确定", "character": [], "anatomy_list": [ "肺部" ] }, { "core_name": "乙肝携带者", "tendency": "不确定", "character": [ "慢性", "乙型" ], "anatomy_list": [ "肝" ] }, { "core_name": "胃炎", "tendency": "不确定", "character": [ "慢性" ], "anatomy_list": [ "胃" ] }, { "core_name": "电解质代谢紊乱", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "低蛋白血症", "tendency": "不确定", "character": [], "anatomy_list": [] }, { "core_name": "增生症", "tendency": "不确定", "character": [], "anatomy_list": [ "前列腺" ] }, { "core_name": "病变", "tendency": "", "character": [], "anatomy_list": [ "前列腺" ] } ] }, { "id": 880, "text": "10+年前，患者发现血压增高，后多次测血压大于140/90mmHg，最高血压150+/？mmhg，偶服用药物治疗（美托洛尔缓释片、培哚普利），未规律监测血压，血压波动情况不详。", "event": [ { "core_name": "血压", "tendency": "", "character": [ "增高" ], "anatomy_list": [] }, { "core_name": "血压", "tendency": "", "character": [ "波动情况不详" ], "anatomy_list": [] } ] }, { "id": 972, "text": "12年前，患者无明显诱因出现咳嗽、咳痰，干咳为主，咳少量白色粘痰，痰不易咳出，伴胸闷、气促、呼吸困难，无咯血、胸痛，无腹痛、腹胀，无潮热、盗汗等不适。", "event": [ { "core_name": "咳嗽", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "咳嗽", "tendency": "", "character": [ "干性" ], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "少量", "白色", "粘性", "不易咳出" ], "anatomy_list": [] }, { "core_name": "胸闷", "tendency": "", "character": [], "anatomy_list": [ "胸" ] }, { "core_name": "气促", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "呼吸困难", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "咯血", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "胸" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "腹胀", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "潮热", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "盗汗", "tendency": "否定", "character": [], "anatomy_list": [] } ] }, { "id": 1270, "text": "11月前患者于我院诊断为“右肺鳞状细胞癌 ”，分别于2016-07-09日、2016-08-06日、2017-01-05、2017-02-15日行紫杉醇240mg d1+奥沙利铂230mg d2化疗4次，化疗过程中有头晕、头痛、呕吐、轻微腹泻等化疗反应，予以对症治疗后好转出院。", "event": [ { "core_name": "鳞癌", "tendency": "", "character": [], "anatomy_list": [ "右肺" ] }, { "core_name": "头晕", "tendency": "", "character": [], "anatomy_list": [ "头" ] }, { "core_name": "疼痛", "tendency": "", "character": [], "anatomy_list": [ "头" ] }, { "core_name": "呕吐", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "腹泻", "tendency": "", "character": [ "轻微" ], "anatomy_list": [] } ] }, { "id": 112, "text": "入院半月前，患者无明显诱因出现黑便，成形，量少，次数不详，伴上腹胀、反酸、烧心、呃逆，伴背部放射痛、身黄、尿黄，无厌油、恶心、呕吐、呕血、腹痛、腹泻、便血，无畏寒、发热，无心悸、气促、头晕，无黑曚、晕厥，无眼黄、身黄、尿黄等不适，患者自行购买“斯达舒、铝碳酸镁”服用2+天后未再黑便，上腹胀、反酸、烧心、呃逆有所好转；入院20小时前，患者无明显诱因再次出现黑便，先后解2次较多量成形黑便（具体不详）、2次较少量黑色稀便，伴上腹胀、反酸、烧心、呃逆、背部放射痛、身黄、尿黄，患者未予处理，入院3小时前出现呕咖啡色样物质1次，约500ml，含食物残渣，无鲜血、血凝块，并伴乏力、大汗、心慌、头昏、眼花，无厌油、腹痛、腹泻、便血，无畏寒、发热等不适，遂于我院急诊科就诊，急诊科查：血常规：血红蛋白浓度(hb)122g/L、红细胞计数(rbc)3.66*10^12/L、白细胞计数(wbc) 12.5*10^9/L 、中性粒细胞百分百 75.9%；肝功、电解质、凝血象未见明显异常；予以补液等处理后转入我科。", "event": [ { "core_name": "黑便", "tendency": "", "character": [ "成形", "量少", "次数不详" ], "anatomy_list": [] }, { "core_name": "腹胀", "tendency": "", "character": [], "anatomy_list": [ "上腹" ] }, { "core_name": "反酸", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "烧心", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "呃逆", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "", "character": [ "放射性" ], "anatomy_list": [ "背部" ] }, { "core_name": "黄染", "tendency": "", "character": [], "anatomy_list": [ "身" ] }, { "core_name": "尿黄", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "厌油", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "恶心", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "呕吐", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "呕血", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "腹泻", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "便血", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "畏寒", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "发热", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "心悸", "tendency": "否定", "character": [], "anatomy_list": [ "心" ] }, { "core_name": "气促", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "头晕", "tendency": "否定", "character": [], "anatomy_list": [ "头" ] }, { "core_name": "黒朦", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "晕厥", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "黄染", "tendency": "否定", "character": [], "anatomy_list": [ "眼" ] }, { "core_name": "黄染", "tendency": "否定", "character": [], "anatomy_list": [ "身" ] }, { "core_name": "尿黄", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "黑便", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "腹胀", "tendency": "", "character": [ "好转" ], "anatomy_list": [ "上腹" ] }, { "core_name": "反酸", "tendency": "", "character": [ "好转" ], "anatomy_list": [] }, { "core_name": "烧心", "tendency": "", "character": [ "好转" ], "anatomy_list": [ "心" ] }, { "core_name": "呃逆", "tendency": "", "character": [ "好转" ], "anatomy_list": [] }, { "core_name": "黑便", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "黑便", "tendency": "", "character": [ "较多量", "成形", "2次" ], "anatomy_list": [] }, { "core_name": "黑便", "tendency": "", "character": [ "少量", "稀便", "2次" ], "anatomy_list": [] }, { "core_name": "腹胀", "tendency": "", "character": [], "anatomy_list": [ "上腹" ] }, { "core_name": "反酸", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "烧心", "tendency": "", "character": [], "anatomy_list": [ "心" ] }, { "core_name": "呃逆", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "", "character": [ "放射性" ], "anatomy_list": [ "背部" ] }, { "core_name": "黄染", "tendency": "", "character": [], "anatomy_list": [ "身" ] }, { "core_name": "尿黄", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "呕吐", "tendency": "", "character": [ "咖啡色样", "含食物残渣", "无鲜血", "无血凝块" ], "anatomy_list": [] }, { "core_name": "乏力", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "出汗", "tendency": "", "character": [ "增多" ], "anatomy_list": [] }, { "core_name": "心慌", "tendency": "", "character": [], "anatomy_list": [ "心" ] }, { "core_name": "头昏", "tendency": "", "character": [], "anatomy_list": [ "头" ] }, { "core_name": "眼花", "tendency": "", "character": [], "anatomy_list": [ "眼" ] }, { "core_name": "厌油", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "腹泻", "tendency": "否定", "character": [], "anatomy_list": [ "腹部" ] }, { "core_name": "便血", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "畏寒", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "发热", "tendency": "否定", "character": [], "anatomy_list": [] } ] }, { "id": 1822, "text": "入院1+年前患者无明显诱因出现阴道不规律出血，为鲜红色，每次量少，伴血凝块，伴下腹隐痛，持续时间短，能忍受，无放射痛，无阴道阴道坠胀，无尿频、尿急、尿痛、血尿，无呕血、黑便，无头痛、头昏、乏力，无畏寒、发热，无明显体重下降，于我院行宫颈脱落细胞检查：鳞状细胞癌。", "event": [ { "core_name": "出血", "tendency": "", "character": [ "不规律", "鲜红色", "每次量少", "血凝块" ], "anatomy_list": [ "阴道" ] }, { "core_name": "疼痛", "tendency": "", "character": [ "隐痛", "持续时间短", "能忍受" ], "anatomy_list": [ "下腹" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [ "放射性" ], "anatomy_list": [] }, { "core_name": "坠胀", "tendency": "否定", "character": [], "anatomy_list": [ "阴道" ] }, { "core_name": "尿频", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "尿急", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "尿痛", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "血尿", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "呕血", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "黑便", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "头" ] }, { "core_name": "头昏", "tendency": "否定", "character": [], "anatomy_list": [ "头" ] }, { "core_name": "乏力", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "畏寒", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "发热", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "体重下降", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [] }, { "core_name": "鳞癌", "tendency": "", "character": [], "anatomy_list": [ "宫颈" ] } ] }, { "id": 339, "text": "患者 1+月 前无明显诱因下开始出现大便次数增多，由 1 次/天增加至 3-4 次/天， 伴便血 ， 便血与粪便混合 。", "event": [ { "core_name": "大便", "tendency": "", "character": [ "次数增多", "由 1 次/天增加至 3-4 次/天" ], "anatomy_list": [] }, { "core_name": "便血", "tendency": "", "character": [ "便血与粪便混合" ], "anatomy_list": [] } ] }, { "id": 1268, "text": "建议住院治疗，患者遂于今日入我院，门诊以“左肺门肿块待查”收入我科住院治疗。", "event": [ { "core_name": "肿块", "tendency": "不确定", "character": [], "anatomy_list": [ "左肺门" ] } ] }, { "id": 303, "text": "考虑患者肺癌术后复发，遂于2011-10-28在我科行左侧胸腔奈达铂100mg局部灌注化疗术＋多西他赛100mg全身静脉化疗，于2011-11-22行多西他赛100mg全身静脉化疗，于2011-11-23行胸腔穿刺抽液术+奈达铂100mg灌注术，2011-12-15行奈达铂100mg＋多西他赛80mg全身静脉化疗，2012-01-06行多西他赛100mg+奈达铂80mg全身静脉化疗，好转出院，此后患者多次复查未见明显转移病灶。", "event": [ { "core_name": "癌", "tendency": "不确定", "character": [ "术后复发" ], "anatomy_list": [ "肺" ] }, { "core_name": "病灶", "tendency": "否定", "character": [ "明显", "转移" ], "anatomy_list": [] } ] }, { "id": 746, "text": "病程中患者精神、饮食欠佳，小便正常，大便如上述，体重无明显下降。", "event": [ { "core_name": "精神", "tendency": "", "character": [ "欠佳" ], "anatomy_list": [] }, { "core_name": "进食", "tendency": "", "character": [ "欠佳" ], "anatomy_list": [] }, { "core_name": "小便", "tendency": "", "character": [ "正常" ], "anatomy_list": [] }, { "core_name": "大便", "tendency": "", "character": [ "正常" ], "anatomy_list": [] }, { "core_name": "体重下降", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [] } ] }, { "id": 1719, "text": "4天前到我院就诊行胸部ct检查提示“右肺下叶片块影并周围炎症改变”，今为明确诊治入院。", "event": [ { "core_name": "片块影", "tendency": "", "character": [], "anatomy_list": [ "右肺下" ] }, { "core_name": "炎症改变", "tendency": "", "character": [], "anatomy_list": [ "右肺下周围" ] } ] }, { "id": 770, "text": "患者未予重视，未作相关处理，遂到到我院门诊就诊，查血常规：血红蛋白50g/L;红细胞压积16.4%;上腹部彩超提示胆囊壁毛糙，胆囊息肉样变。", "event": [ { "core_name": "毛糙", "tendency": "", "character": [], "anatomy_list": [ "胆囊壁" ] }, { "core_name": "息肉样变", "tendency": "", "character": [], "anatomy_list": [ "胆囊" ] } ] }, { "id": 493, "text": "现患者无腹胀、呕吐，无发热、咳嗽、咳痰等不适，为行第1次曲妥珠单抗靶向化疗入院，门诊以“左乳癌术后第6次化疗后”收入我科。", "event": [ { "core_name": "腹胀", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "呕吐", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "发热", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "咳嗽", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "癌", "tendency": "", "character": [ "术后", "第6次化疗后" ], "anatomy_list": [ "左乳" ] } ] }, { "id": 1778, "text": "为求进一步诊治，于我院就诊，门诊以“黄疸原因待查”收治入科。", "event": [ { "core_name": "黄疸", "tendency": "不确定", "character": [], "anatomy_list": [] } ] }, { "id": 1122, "text": "随即分别于术后8天、术后1月、术后3月先后三次给予卡铂800mg腹腔灌注+紫杉醇210mg静脉滴注化疗,化疗过程中有恶心、呕吐等不适,复查示ii度骨髓抑制，予以升白细胞、止吐等对症处理后好转出院。", "event": [ { "core_name": "恶心", "tendency": "", "character": [ "化疗过程中" ], "anatomy_list": [] }, { "core_name": "呕吐", "tendency": "", "character": [ "化疗过程中" ], "anatomy_list": [] }, { "core_name": "骨髓抑制", "tendency": "", "character": [ "II度" ], "anatomy_list": [ "骨髓" ] } ] }, { "id": 2003, "text": "本次入院记录 患者于2月余前于某医院复查甲胎蛋白示：39.2ng/ml，无纳差、乏力、厌油，无眼黄、身黄，无反酸、嗳气等不适，未特殊治疗；1月前随访甲胎蛋白示：64.9ng/ml，3天前随访甲胎蛋白示：76.0ng/ml，遂于我院就诊，门诊以“原发性肝癌介入术后”收入我科。", "event": [ { "core_name": "纳差", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "乏力", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "厌油", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "黄染", "tendency": "否定", "character": [], "anatomy_list": [ "眼" ] }, { "core_name": "黄染", "tendency": "否定", "character": [], "anatomy_list": [ "身" ] }, { "core_name": "反酸", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "嗳气", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "癌", "tendency": "", "character": [ "介入术后", "原发性" ], "anatomy_list": [ "肝" ] } ] }, { "id": 717, "text": "门诊以“直肠癌术后”收治入院。", "event": [ { "core_name": "癌", "tendency": "", "character": [ "术后" ], "anatomy_list": [ "直肠" ] } ] }, { "id": 1002, "text": "进一步行腹部ct检查提示肝右叶前段稍低密度结节低密度结节影,大小约1.8×2.2cm,包膜完整,增强后明显强化,考虑肿瘤性病变,原发性小肝癌可能性大。", "event": [ { "core_name": "结节影", "tendency": "", "character": [ "稍低密度", "包膜完整", "增强后明显强化" ], "anatomy_list": [ "肝右叶前段" ] }, { "core_name": "病变", "tendency": "不确定", "character": [ "肿瘤性" ], "anatomy_list": [] }, { "core_name": "癌", "tendency": "不确定", "character": [ "原发性", "小" ], "anatomy_list": [ "肝" ] } ] }, { "id": 1973, "text": "患者本次发病以来，食欲正常神志清醒，精神欠佳，睡眠欠佳，大便如上述，小便正常，体重无明显变化。", "event": [ { "core_name": "食欲", "tendency": "", "character": [ "正常" ], "anatomy_list": [] }, { "core_name": "神志", "tendency": "", "character": [ "清醒" ], "anatomy_list": [] }, { "core_name": "精神", "tendency": "", "character": [ "欠佳" ], "anatomy_list": [] }, { "core_name": "睡眠", "tendency": "", "character": [ "欠佳" ], "anatomy_list": [] }, { "core_name": "大便", "tendency": "", "character": [ "正常" ], "anatomy_list": [] }, { "core_name": "小便", "tendency": "", "character": [ "正常" ], "anatomy_list": [] }, { "core_name": "体重改变", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [] } ] }, { "id": 1065, "text": "患者本次发病以来，食欲正常，神志清醒，精神尚可，睡眠尚可，大便如上诉，小便正常，体重无明显变化。", "event": [ { "core_name": "食欲", "tendency": "", "character": [ "正常" ], "anatomy_list": [] }, { "core_name": "神志", "tendency": "", "character": [ "清醒" ], "anatomy_list": [] }, { "core_name": "精神", "tendency": "", "character": [ "尚可" ], "anatomy_list": [] }, { "core_name": "睡眠", "tendency": "", "character": [ "尚可" ], "anatomy_list": [] }, { "core_name": "小便", "tendency": "", "character": [ "正常" ], "anatomy_list": [] }, { "core_name": "体重改变", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [] } ] }, { "id": 1700, "text": "入院前2年，患者无明显诱因下出现阵发性咳嗽，咳大量白色粘稠痰，痰易咳出，伴口干、冷汗，活动后感心累，症状于夜间加重，无发热、畏寒，无胸痛、咯血，遂就诊于我院，“胸部ct示：右肺上叶楔形致密影，右上肺不张；纤支镜示：右上叶开口被一菜花样新生物完全阻塞；病理诊断：右上叶开口小细胞性恶性肿瘤，倾向于低分化鳞癌”。", "event": [ { "core_name": "咳嗽", "tendency": "", "character": [ "阵发性" ], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "大量", "白色", "粘稠" ], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "易咳出" ], "anatomy_list": [] }, { "core_name": "口干", "tendency": "", "character": [], "anatomy_list": [ "口" ] }, { "core_name": "冷汗", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "心累", "tendency": "", "character": [ "活动后" ], "anatomy_list": [ "心" ] }, { "core_name": "发热", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "畏寒", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "胸" ] }, { "core_name": "咯血", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "致密影", "tendency": "", "character": [ "楔形" ], "anatomy_list": [ "右肺上叶" ] }, { "core_name": "肺不张", "tendency": "", "character": [], "anatomy_list": [ "右上肺" ] }, { "core_name": "新生物", "tendency": "", "character": [ "菜花样" ], "anatomy_list": [ "右上肺右上叶开口" ] }, { "core_name": "阻塞", "tendency": "", "character": [ "完全", "被新生物" ], "anatomy_list": [ "右上肺右上叶开口" ] }, { "core_name": "肿瘤", "tendency": "", "character": [ "小细胞性", "恶性" ], "anatomy_list": [ "右上肺右上叶开口" ] }, { "core_name": "鳞癌", "tendency": "不确定", "character": [ "低分化" ], "anatomy_list": [ "右上肺右上叶开口" ] } ] }, { "id": 1135, "text": "4、腹腔少量积液。", "event": [ { "core_name": "积液", "tendency": "", "character": [ "少量" ], "anatomy_list": [ "腹腔" ] } ] }, { "id": 909, "text": "患者于4+年前体检时行腹部彩超发现胆囊结石，未见报告，具体不详，患者自诉无腹痛、腹胀、腹泻等不适，故未予重视与治疗。", "event": [ { "core_name": "结石", "tendency": "", "character": [], "anatomy_list": [ "胆囊" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "腹胀", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "腹泻", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] } ] }, { "id": 81, "text": "遂来我院就诊，行麦默通穿刺活检后确诊为左乳浸润性癌。", "event": [ { "core_name": "癌", "tendency": "", "character": [ "浸润性" ], "anatomy_list": [ "左乳" ] } ] }, { "id": 327, "text": "患者1月前无明显诱因出现胀痛，表现为脐周阵发性胀痛，偶为窜气样疼痛，疼痛较重，不伴腰背部及肩部放射性疼痛，排气排便后稍缓解。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [ "胀痛" ], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "", "character": [ "胀痛", "阵发性", "偶为窜气样疼痛", "疼痛较重", "排气排便后稍缓解" ], "anatomy_list": [ "脐周" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [ "放射性" ], "anatomy_list": [ "腰背部", "肩部" ] } ] }, { "id": 1232, "text": "患者遂来我院急诊科查全腹ct：1、胃窦、十二指肠区条状高密度影，考虑术后改变可能。请结合临床。", "event": [ { "core_name": "密度影", "tendency": "", "character": [ "高", "条状" ], "anatomy_list": [ "胃窦", "十二指肠区" ] }, { "core_name": "术后改变", "tendency": "不确定", "character": [], "anatomy_list": [] } ] }, { "id": 1214, "text": "入院前3天，患者因剑突下隐痛及喉部梗阻感，就诊于某医院，于该院行“冠脉造影及右冠球囊扩张术”冠脉造影示：lm分叉处斑块，lad近段原支架内血流通畅，中段分叉后狭窄70%,中远段狭窄80%，lcx弥漫斑块，中段狭窄60%-70%，可见溃疡和瘤样扩张，远段细小，狭窄70%-80%,om远段狭窄80%，rca近段见原支架内再狭窄85%，中段原支架内血流通畅，中远段支架内可见内皮增生狭窄50%，于rca支架近段狭窄处行球囊扩张后，rac支架内血流通畅，timi血流3级。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [ "隐痛" ], "anatomy_list": [ "剑突下" ] }, { "core_name": "梗阻感", "tendency": "", "character": [], "anatomy_list": [ "喉部" ] }, { "core_name": "斑块", "tendency": "", "character": [], "anatomy_list": [ "冠脉lm分叉处" ] }, { "core_name": "血流通畅", "tendency": "", "character": [ "原支架内" ], "anatomy_list": [ "冠脉lad近段" ] }, { "core_name": "狭窄", "tendency": "", "character": [ "70%" ], "anatomy_list": [ "冠脉lad中段分叉后" ] }, { "core_name": "狭窄", "tendency": "", "character": [ "80%" ], "anatomy_list": [ "冠脉lad中远段" ] }, { "core_name": "斑块", "tendency": "", "character": [ "弥漫" ], "anatomy_list": [ "冠脉lcx" ] }, { "core_name": "狭窄", "tendency": "", "character": [ "60%-70%" ], "anatomy_list": [ "冠脉lcx中段" ] }, { "core_name": "溃疡", "tendency": "", "character": [], "anatomy_list": [ "冠脉lcx中段" ] }, { "core_name": "扩张", "tendency": "", "character": [ "瘤样" ], "anatomy_list": [ "冠脉lcx中段" ] }, { "core_name": "狭窄", "tendency": "", "character": [ "70%-80%" ], "anatomy_list": [ "冠脉lcx远段" ] }, { "core_name": "细小", "tendency": "", "character": [], "anatomy_list": [ "冠脉lcx远段" ] }, { "core_name": "狭窄", "tendency": "", "character": [ "80%" ], "anatomy_list": [ "冠脉om远段" ] }, { "core_name": "再狭窄", "tendency": "", "character": [ "原支架内", "85%" ], "anatomy_list": [ "rca近段" ] }, { "core_name": "血流通畅", "tendency": "", "character": [ "原支架内" ], "anatomy_list": [ "rca中段" ] }, { "core_name": "增生狭窄", "tendency": "", "character": [ "支架内", "50%" ], "anatomy_list": [ "rca中远段内皮" ] }, { "core_name": "血流通畅", "tendency": "", "character": [ "支架内" ], "anatomy_list": [ "rca" ] }, { "core_name": "timi血流", "tendency": "", "character": [ "3级" ], "anatomy_list": [] } ] }, { "id": 1170, "text": "患者为求进一步诊治，遂来我科，以“胆囊结石、胆囊炎”收入我科。", "event": [ { "core_name": "结石", "tendency": "", "character": [], "anatomy_list": [ "胆囊" ] }, { "core_name": "胆囊炎", "tendency": "", "character": [], "anatomy_list": [ "胆囊" ] } ] }, { "id": 2051, "text": "于2011-09-13行超声胃镜检查并取活检术，术后病检提示：1、（十二指肠球部）送检粘膜下方见少许异型细胞团，恶性肿瘤可能；2、（胃体）息肉。", "event": [ { "core_name": "异形细胞团", "tendency": "", "character": [ "少许" ], "anatomy_list": [ "十二指肠球粘膜下方" ] }, { "core_name": "肿瘤", "tendency": "不确定", "character": [ "恶性" ], "anatomy_list": [ "十二指肠球粘膜下方" ] }, { "core_name": "息肉", "tendency": "", "character": [], "anatomy_list": [ "胃体" ] } ] }, { "id": 1161, "text": "三天前突然咳出10ml鲜血。", "event": [ { "core_name": "咳血", "tendency": "", "character": [ "突然", "10ml", "鲜血" ], "anatomy_list": [] } ] }, { "id": 1226, "text": "诊断为“宫颈神经内分泌癌iib期”，因病灶大，建议先行新辅助化疗，排除化疗禁忌症后于2017年06月16日、2017年7月8日行tp（紫杉醇240mg+奈达铂140mg）静脉化疗2周期，化疗过程顺利。", "event": [ { "core_name": "癌", "tendency": "", "character": [ "神经内分泌", "iib期" ], "anatomy_list": [ "宫颈" ] }, { "core_name": "病灶", "tendency": "", "character": [ "大" ], "anatomy_list": [] } ] }, { "id": 575, "text": "术后于某医院进一步检查，会诊某医院病理切片123456提示：（右卵巢）恶性肿瘤，根据免疫组化考虑恶性混合性生殖细胞瘤（无性细胞瘤合并卵黄囊瘤）。", "event": [ { "core_name": "肿瘤", "tendency": "", "character": [ "恶性" ], "anatomy_list": [ "右卵巢" ] }, { "core_name": "瘤", "tendency": "不确定", "character": [ "恶性", "混合性" ], "anatomy_list": [ "右卵巢", "生殖细胞" ] }, { "core_name": "瘤", "tendency": "不确定", "character": [ "无恶性细胞" ], "anatomy_list": [ "右卵巢" ] }, { "core_name": "瘤", "tendency": "不确定", "character": [ "卵黄囊" ], "anatomy_list": [ "右卵巢" ] } ] }, { "id": 1169, "text": "患者于当地医院就诊，行腹部彩超、ct等检查，患者家属自诉检查结果提示胆囊结石（未见报告单），予以输液治疗（具体不详），治疗后症状稍缓解。", "event": [ { "core_name": "结石", "tendency": "", "character": [], "anatomy_list": [ "胆囊" ] } ] }, { "id": 1448, "text": "2010年11月患者复查腹部ct见肝右前叶动脉期小结节灶，0.4cm，有强化，考虑肝癌，建议患者手术治疗。", "event": [ { "core_name": "结节灶", "tendency": "", "character": [ "小", "有强化", "动脉期" ], "anatomy_list": [ "肝右前叶" ] }, { "core_name": "癌", "tendency": "不确定", "character": [], "anatomy_list": [ "肝" ] } ] }, { "id": 1094, "text": "患者本次发病以来，食欲减退， 神志清醒，精神尚可，睡眠尚可，大便正常，小便正常，体重减少5Kg。", "event": [ { "core_name": "食欲", "tendency": "", "character": [ "减退" ], "anatomy_list": [] }, { "core_name": "神志", "tendency": "", "character": [ "清醒" ], "anatomy_list": [] }, { "core_name": "精神", "tendency": "", "character": [ "尚可" ], "anatomy_list": [] }, { "core_name": "睡眠", "tendency": "", "character": [ "尚可" ], "anatomy_list": [] }, { "core_name": "大便", "tendency": "", "character": [ "正常" ], "anatomy_list": [] }, { "core_name": "小便", "tendency": "", "character": [ "正常" ], "anatomy_list": [] }, { "core_name": "体重减轻", "tendency": "", "character": [], "anatomy_list": [] } ] }, { "id": 272, "text": "现患者为求进一步治疗就诊于我院，以“双下肢乏力”收入我科住院治疗。", "event": [ { "core_name": "乏力", "tendency": "", "character": [], "anatomy_list": [ "双下肢" ] } ] }, { "id": 1679, "text": "9天前，患者受凉后再次出现咳嗽咳痰症状加重，咳白色粘痰，易咯出，量不多；伴发热，有畏寒，无明显寒战，在外测得体温最高达39℃；伴呕吐，呕吐物为胃内容物，无咖啡色样物质；无反酸嗳气，无咯血胸痛，无左侧胸前区压榨感及左肩及左手臂内侧放射性疼痛等不适。", "event": [ { "core_name": "咳嗽", "tendency": "", "character": [ "受凉后加重" ], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "受凉后加重" ], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "白色", "粘", "易咯出", "量不多" ], "anatomy_list": [] }, { "core_name": "发热", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "畏寒", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "寒战", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [] }, { "core_name": "体温", "tendency": "", "character": [ "升高" ], "anatomy_list": [] }, { "core_name": "呕吐", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "呕吐", "tendency": "", "character": [ "呕吐物为胃内容物", "无咖啡色样物质" ], "anatomy_list": [] }, { "core_name": "返酸", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "嗳气", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "咯血", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "胸" ] }, { "core_name": "压榨感", "tendency": "否定", "character": [], "anatomy_list": [ "左侧胸前区" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [ "放射性" ], "anatomy_list": [ "左肩", "左手臂内侧" ] } ] }, { "id": 336, "text": "患病以来，患者精神、食欲、睡眠欠佳，大小便正常，近期体重无明显变化。", "event": [ { "core_name": "精神", "tendency": "", "character": [ "欠佳" ], "anatomy_list": [] }, { "core_name": "食欲", "tendency": "", "character": [ "欠佳" ], "anatomy_list": [] }, { "core_name": "睡眠", "tendency": "", "character": [ "欠佳" ], "anatomy_list": [] }, { "core_name": "大小便", "tendency": "", "character": [ "正常" ], "anatomy_list": [] }, { "core_name": "体重变化", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [] } ] }, { "id": 611, "text": "患者自起病以来，精神可，胃纳可，大便如常，小便如上述，体重未见明显下降。", "event": [ { "core_name": "精神", "tendency": "", "character": [ "可" ], "anatomy_list": [] }, { "core_name": "胃纳", "tendency": "", "character": [ "可" ], "anatomy_list": [ "胃" ] }, { "core_name": "大便", "tendency": "", "character": [ "如常" ], "anatomy_list": [] }, { "core_name": "小便", "tendency": "", "character": [ "如常" ], "anatomy_list": [] }, { "core_name": "体重下降", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [] } ] }, { "id": 260, "text": "无痛胃镜：1.十二指肠球部多发性溃疡多发性溃疡伴出血（a1期，forrestib）2.糜烂性胃炎（3级）3.食管隆起：组织外压？其他？可进一步超声胃镜检查。", "event": [ { "core_name": "溃疡", "tendency": "", "character": [ "多发性", "1期", "forrestib" ], "anatomy_list": [ "十二指肠球部" ] }, { "core_name": "出血", "tendency": "", "character": [], "anatomy_list": [ "十二指肠球部" ] }, { "core_name": "胃炎", "tendency": "", "character": [ "糜烂性", "3级" ], "anatomy_list": [ "胃" ] }, { "core_name": "隆起", "tendency": "", "character": [], "anatomy_list": [ "食管" ] } ] }, { "id": 458, "text": "4.双肾肾周少许絮状渗出，双肾多发小囊肿。", "event": [ { "core_name": "渗出", "tendency": "", "character": [ "少许", "絮状" ], "anatomy_list": [ "双肾周" ] }, { "core_name": "囊肿", "tendency": "", "character": [ "多发", "小" ], "anatomy_list": [ "双肾" ] } ] }, { "id": 1869, "text": "患者自发病以来，精神稍差，食欲稍差，睡眠欠佳，大便如常，小便如常，体重无明显变化。", "event": [ { "core_name": "精神", "tendency": "", "character": [ "稍差" ], "anatomy_list": [] }, { "core_name": "食欲", "tendency": "", "character": [ "稍差" ], "anatomy_list": [] }, { "core_name": "睡眠", "tendency": "", "character": [ "欠佳" ], "anatomy_list": [] }, { "core_name": "大便", "tendency": "", "character": [ "正常" ], "anatomy_list": [] }, { "core_name": "小便", "tendency": "", "character": [ "如常" ], "anatomy_list": [] }, { "core_name": "体重改变", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [] } ] }, { "id": 841, "text": "2月前前患者于我院体检查甲状腺彩超提示“甲状腺右叶异常回声，ti-rads4a类，建议穿刺活检”，甲功及甲功抗体未见异常。", "event": [ { "core_name": "异常回声", "tendency": "", "character": [ "ti-rads4a类" ], "anatomy_list": [ "甲状腺右叶" ] }, { "core_name": "甲状腺功能异常", "tendency": "否定", "character": [], "anatomy_list": [ "甲状腺" ] }, { "core_name": "甲状腺功能抗体异常", "tendency": "否定", "character": [], "anatomy_list": [ "甲状腺" ] } ] }, { "id": 1963, "text": "2015年因“直肠癌”于“某医院”手术治疗，术中输血（具体血型及量不详），无输血反应，术后正规化疗，目前大便正常。", "event": [ { "core_name": "癌", "tendency": "", "character": [], "anatomy_list": [ "直肠" ] }, { "core_name": "输血反应", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "大便", "tendency": "", "character": [ "正常" ], "anatomy_list": [] } ] }, { "id": 1148, "text": "无畏寒发热、无头痛头晕、无恶心、无腹胀腹痛、无呼吸困难、无咳嗽咳痰、无声音嘶哑。", "event": [ { "core_name": "畏寒", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "发热", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "头" ] }, { "core_name": "头晕", "tendency": "否定", "character": [], "anatomy_list": [ "头" ] }, { "core_name": "恶心", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "腹胀", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "呼吸困难", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "咳嗽", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "声音嘶哑", "tendency": "否定", "character": [], "anatomy_list": [] } ] }, { "id": 1238, "text": "入院前1月，患者无明显诱因开始出现腹胀，呈持续性，与进食及体位无关，伴剑突下隐痛，尚可忍受，伴四肢乏力（能坚持日常工作），大便次数增多，约6-7次/天，为黄色稀糊状便，无身黄、尿黄等不适。", "event": [ { "core_name": "腹胀", "tendency": "", "character": [ "持续性", "与进食及体位无关" ], "anatomy_list": [ "腹" ] }, { "core_name": "疼痛", "tendency": "", "character": [ "隐痛", "尚可忍受" ], "anatomy_list": [ "剑突下" ] }, { "core_name": "乏力", "tendency": "", "character": [ "能坚持日常工作" ], "anatomy_list": [ "四肢" ] }, { "core_name": "大便", "tendency": "", "character": [ "次数增多", "约6-7次/天", "黄色稀糊状" ], "anatomy_list": [] }, { "core_name": "黄染", "tendency": "否定", "character": [], "anatomy_list": [ "身" ] }, { "core_name": "尿黄", "tendency": "否定", "character": [], "anatomy_list": [] } ] }, { "id": 1685, "text": "患者患病以来，精神、食欲、睡眠可，大小便正常，体重无明显下降。", "event": [ { "core_name": "精神", "tendency": "", "character": [ "可" ], "anatomy_list": [] }, { "core_name": "食欲", "tendency": "", "character": [ "可" ], "anatomy_list": [] }, { "core_name": "睡眠", "tendency": "", "character": [ "可" ], "anatomy_list": [] }, { "core_name": "大小便", "tendency": "", "character": [ "正常" ], "anatomy_list": [] }, { "core_name": "体重下降", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [] } ] }, { "id": 586, "text": "3.左腓骨上段骨折。", "event": [ { "core_name": "骨折", "tendency": "", "character": [], "anatomy_list": [ "左腓骨上段" ] } ] }, { "id": 1945, "text": "患者遂于某医院就诊，行胸部ct检查提示双肺炎症，考虑肺部感染，予以抗炎等对症支持治疗后复查ct提示脊柱阴影，后行胸椎mri：所示多个胸椎椎体及椎弓多发异常信号伴椎体周围多软组织影及胸10椎体压缩性骨折，考虑：1）转移瘤？2）多发性骨髓瘤？，后患者就诊于某医院行免疫球蛋白八项：免疫球蛋白轻链lambda 9460.00mg/dl，免疫球蛋白g 101.00g/L。", "event": [ { "core_name": "炎症", "tendency": "", "character": [], "anatomy_list": [ "双肺" ] }, { "core_name": "感染", "tendency": "不确定", "character": [], "anatomy_list": [ "肺部" ] }, { "core_name": "阴影", "tendency": "", "character": [], "anatomy_list": [ "脊柱" ] }, { "core_name": "异常信号", "tendency": "", "character": [ "多个", "多发" ], "anatomy_list": [ "胸椎椎体", "椎弓" ] }, { "core_name": "软组织影", "tendency": "", "character": [ "多" ], "anatomy_list": [ "胸椎体周围" ] }, { "core_name": "骨折", "tendency": "", "character": [ "压缩性" ], "anatomy_list": [ "胸椎T10椎体" ] }, { "core_name": "瘤", "tendency": "不确定", "character": [ "转移" ], "anatomy_list": [] }, { "core_name": "瘤", "tendency": "不确定", "character": [ "多发性" ], "anatomy_list": [ "骨髓" ] } ] }, { "id": 475, "text": "现为求进一步诊治，前来我院，门诊以“高血压、心功能不全”收住院。", "event": [ { "core_name": "高血压", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "心功能不全", "tendency": "", "character": [], "anatomy_list": [ "心" ] } ] }, { "id": 1163, "text": "入院前3月，患者无明显诱因出现心悸、胸闷，活动后或夜间加重，每次持续时间约20-30秒，休息后可自行缓解，伴头昏、胸背部背部隐痛不适，无左肩及左上肢放射痛，无夜间阵发性呼吸困难及端坐呼吸，无浮肿、少尿，无畏寒、发热、头痛，无恶心、呕吐，无腹痛、腹泻。", "event": [ { "core_name": "心悸", "tendency": "", "character": [ "活动后或夜间加重", "每次持续时间约20-29秒", "休息后可自行缓解" ], "anatomy_list": [ "心" ] }, { "core_name": "胸闷", "tendency": "", "character": [ "活动后或夜间加重", "每次持续时间约20-30秒", "休息后可自行缓解" ], "anatomy_list": [ "胸" ] }, { "core_name": "头昏", "tendency": "", "character": [], "anatomy_list": [ "头" ] }, { "core_name": "疼痛", "tendency": "", "character": [ "隐痛" ], "anatomy_list": [ "胸部", "背部" ] }, { "core_name": "胸背部不适", "tendency": "", "character": [], "anatomy_list": [ "胸部", "背部" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [ "放射性" ], "anatomy_list": [ "左肩", "左上肢" ] }, { "core_name": "呼吸困难", "tendency": "否定", "character": [ "夜间", "阵发性" ], "anatomy_list": [] }, { "core_name": "端坐呼吸", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "浮肿", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "少尿", "tendency": "否定", "character": [], "anatomy_list": [ "左肩", "左上肢" ] }, { "core_name": "畏寒", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "发热", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "头" ] }, { "core_name": "恶心", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "呕吐", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "腹泻", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] } ] }, { "id": 1083, "text": "患者本次发病以来，食欲一般，神志清醒，精神尚可，睡眠尚可，大便如常，小便如上述，体重无明显变化。", "event": [ { "core_name": "食欲", "tendency": "", "character": [ "一般" ], "anatomy_list": [] }, { "core_name": "神志", "tendency": "", "character": [ "清醒" ], "anatomy_list": [] }, { "core_name": "精神", "tendency": "", "character": [ "尚可" ], "anatomy_list": [] }, { "core_name": "睡眠", "tendency": "", "character": [ "尚可" ], "anatomy_list": [] }, { "core_name": "大便", "tendency": "", "character": [ "如常" ], "anatomy_list": [] }, { "core_name": "小便", "tendency": "", "character": [ "如常" ], "anatomy_list": [] }, { "core_name": "体重改变", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [] } ] }, { "id": 645, "text": "第五次化疗妇科彩超提示：子宫肌层不均质，以右前壁为着，内见27*28*30mm的混合回声区，边界欠清楚，其内大部分为无回声，少部分为中低回声，cdfi：无回声区区内见丰富血流信号，ri：0.44。", "event": [ { "core_name": "不均质", "tendency": "", "character": [ "肌层" ], "anatomy_list": [ "子宫", "子宫右前壁" ] }, { "core_name": "混合回声区", "tendency": "", "character": [ "混合", "边界欠清楚", "其内大部分为无回声", "少部分为中低回声" ], "anatomy_list": [ "子宫" ] }, { "core_name": "血流信号", "tendency": "", "character": [ "丰富", "无回声区内" ], "anatomy_list": [ "子宫" ] } ] }, { "id": 698, "text": "患者同时行取环术，给予妇乐片独一味胶囊治疗，患者阴道流液症状好转，今患者为进一步治疗入我院，门诊以“子宫内膜癌”收入我科住院治疗。", "event": [ { "core_name": "流液", "tendency": "", "character": [ "好转" ], "anatomy_list": [ "阴道" ] }, { "core_name": "癌", "tendency": "", "character": [], "anatomy_list": [ "子宫内膜" ] } ] }, { "id": 1772, "text": "术中见：肿块大小约1.8x1.5cm，术后病理检查回报：）：（左乳）浸润性癌，非特殊类型，iii级8分。", "event": [ { "core_name": "肿块", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "癌", "tendency": "", "character": [ "浸润性", "非特殊类型", "iii级8分" ], "anatomy_list": [ "左乳" ] } ] }, { "id": 939, "text": "于2018-6-11行颅内占位病变切除术，术后病检示：（左侧顶叶占位）转移性腺癌，结合免疫组化，考虑肺部来源，免疫组化：ck7+、p40-、p63-、ttf-1+、napsin-a+、ki67约40%、ck20-、ck+、cga-、syn-、cd56-。未进一步治疗。", "event": [ { "core_name": "占位", "tendency": "", "character": [], "anatomy_list": [ "左侧顶叶" ] }, { "core_name": "腺癌", "tendency": "", "character": [ "转移性" ], "anatomy_list": [ "左侧顶叶" ] } ] }, { "id": 1661, "text": "于2017-03-14行第四次化疗，予以吡柔比星 110mg ivgtt qd d1-3+维a酸 10mg po tid d1-14+亚砷酸10mg ivgtt qd d1-14进行化疗，辅以碱化尿液、水化、增强免疫力、减轻胃肠道反应、升白细胞、血小板等对症治疗后，好转出院；2017-4-17行第五次化疗，予以亚砷酸 10mg 维持治疗，并先后两次予以阿糖胞苷50mg+地塞米松磷酸钠10mg+甲氨蝶呤15mg鞘内注射化疗，化疗期间及化疗后未诉特殊不适。患者现拟行第6次维持巩固化疗入院。", "event": [ { "core_name": "胃肠反应", "tendency": "", "character": [ "减轻" ], "anatomy_list": [ "胃", "肠" ] } ] }, { "id": 1739, "text": "6月23日复查骨髓细胞形态学“一、骨髓象原始粒细胞3%；二、外周血涂片淋巴细胞及单核细胞比例略增高，偶见幼粒，成熟红细胞大小不等，血小板成簇、散在少见，可见巨大血小板三、细胞化学染色mpo：正常，细胞外铁：++++细胞内铁：72%，环铁占36%；意见：1.粒、红二系可见轻度病态造血2.细胞外铁：++++，细胞内铁占72%，其中环铁占36%”，免疫分型“可见粒系前体细胞发育发育异常”，血常规“白细胞数目1.09*10^9/L↓，血红蛋白55g/l↓，血小板数目22*10^9/L↓，中性粒细胞数目0.61*10^9/L↓”。", "event": [ { "core_name": "淋巴细胞及单核细胞增高", "tendency": "", "character": [ "增高" ], "anatomy_list": [ "淋巴细胞", "单核细胞" ] }, { "core_name": "大小不等", "tendency": "", "character": [ "幼粒", "成熟红细胞", "偶见" ], "anatomy_list": [] }, { "core_name": "血小板", "tendency": "", "character": [ "成簇", "散在少见" ], "anatomy_list": [] }, { "core_name": "病态造血", "tendency": "", "character": [ "粒、红二系" ], "anatomy_list": [] }, { "core_name": "发育异常", "tendency": "", "character": [ "" ], "anatomy_list": [] } ] }, { "id": 836, "text": "患者6月前因“发现左乳包块伴点状钙化3小时”入院，入院后完善相关检查后行左乳包块麦默通活检术+术中冰冻，术后病理示：（左乳）浸润性癌。", "event": [ { "core_name": "包块", "tendency": "", "character": [], "anatomy_list": [ "左乳" ] }, { "core_name": "钙化", "tendency": "", "character": [ "点状" ], "anatomy_list": [ "左乳" ] }, { "core_name": "癌", "tendency": "", "character": [ "浸润性" ], "anatomy_list": [ "左乳" ] } ] }, { "id": 1912, "text": "入院前1+年，患者受凉后出现咳嗽、咳痰，咳白色泡沫样痰，无咯血、喘息及呼吸困难，偶有上腹部不适，反酸、嗳气等症状，遂到我院就诊，胸部ct提示：左肺下叶肿块伴远端阻塞性炎症、支气管阻塞性痰栓形成，多系肿瘤，建议纤维支气管镜活检；双肺尘肺。", "event": [ { "core_name": "咳嗽", "tendency": "", "character": [ "受凉后" ], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "受凉后" ], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "白色", "泡沫样" ], "anatomy_list": [] }, { "core_name": "咯血", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "气喘", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "呼吸困难", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "上腹部不适", "tendency": "", "character": [ "偶有" ], "anatomy_list": [ "上腹部" ] }, { "core_name": "反酸", "tendency": "", "character": [ "偶有" ], "anatomy_list": [] }, { "core_name": "嗳气", "tendency": "", "character": [ "偶有" ], "anatomy_list": [] }, { "core_name": "肿块", "tendency": "", "character": [], "anatomy_list": [ "左肺下叶" ] }, { "core_name": "炎症", "tendency": "", "character": [ "阻塞性" ], "anatomy_list": [ "左肺下叶远端" ] }, { "core_name": "痰栓", "tendency": "", "character": [ "阻塞性" ], "anatomy_list": [ "支气管" ] }, { "core_name": "肿瘤", "tendency": "", "character": [], "anatomy_list": [ "支气管" ] }, { "core_name": "尘肺", "tendency": "", "character": [], "anatomy_list": [ "双肺" ] } ] }, { "id": 1841, "text": "患者于2天前无明显诱因感右侧胸痛加重，为诊治，于今日来我院门诊就诊，门诊医师以“咳嗽、胸痛”收入院治疗。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [ "加重" ], "anatomy_list": [ "右侧胸" ] }, { "core_name": "咳嗽", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "", "character": [], "anatomy_list": [ "胸" ] } ] }, { "id": 1521, "text": "出院后间断有咳嗽、咳痰，为白色泡沫痰，偶晨起有痰中少量血丝，否认潮热、盗汗。", "event": [ { "core_name": "咳嗽", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "白色", "泡沫痰" ], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "偶晨起", "少量", "血丝" ], "anatomy_list": [] }, { "core_name": "潮热", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "盗汗", "tendency": "否定", "character": [], "anatomy_list": [] } ] }, { "id": 1104, "text": "术后患者于肝胆胸外科化疗，分别于2017-01-06起给予tp方案（药物方案：紫杉醇180mg d1，顺铂100mg2）化疗3周期，于2017-04-18起给予tp方案化疗2周期（药物：紫杉醇150mg d1，顺铂100mg2）,2017-5-23给予tp（化疗药物：紫杉醇180mg d1，顺铂100mg2）方案化疗1周期，共计6周期，患者无明显化疗毒副反应及骨髓抑制。", "event": [ { "core_name": "化疗毒副反应", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [] }, { "core_name": "骨髓抑制", "tendency": "否定", "character": [], "anatomy_list": [ "骨髓" ] } ] }, { "id": 671, "text": "于全麻下行“右侧乳腺癌改良根治术”，术后病检示：浸润性导管癌，腋窝有5个淋巴结转移。", "event": [ { "core_name": "导管癌", "tendency": "", "character": [ "浸润性" ], "anatomy_list": [] }, { "core_name": "癌", "tendency": "", "character": [ "转移" ], "anatomy_list": [ "腋窝淋巴结" ] } ] }, { "id": 1654, "text": "后患者反复发热不适（体温不详），伴畏寒，无寒战，伴咳嗽、咳痰，咳少量白色粘液痰，咽喉部疼痛、全身肌肉酸痛不适，伴乏力、活动后心累气促不适，遂于我科住院治疗。", "event": [ { "core_name": "发热", "tendency": "", "character": [ "反复", "体温不详" ], "anatomy_list": [] }, { "core_name": "畏寒", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "寒颤", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "咳嗽", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "少量", "白色", "粘液" ], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "", "character": [], "anatomy_list": [ "咽喉部" ] }, { "core_name": "疼痛", "tendency": "", "character": [ "酸痛" ], "anatomy_list": [ "全身肌肉" ] }, { "core_name": "全身肌肉不适", "tendency": "", "character": [], "anatomy_list": [ "全身肌肉" ] }, { "core_name": "乏力", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "心累", "tendency": "", "character": [ "活动后" ], "anatomy_list": [ "心" ] }, { "core_name": "气促", "tendency": "", "character": [ "活动后" ], "anatomy_list": [] } ] }, { "id": 122, "text": "患者目前无咳嗽，无肝区疼痛，有胸壁疼痛。", "event": [ { "core_name": "咳嗽", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "肝区" ] }, { "core_name": "疼痛", "tendency": "", "character": [], "anatomy_list": [ "胸壁" ] } ] }, { "id": 1625, "text": "考虑肿瘤残存可能，因患者宫腔节育环取出困难无法行盆腔mri检查，建议行活检进一步明确，根据病理结果评估后续化疗或手术治疗方案。", "event": [ { "core_name": "肿瘤", "tendency": "不确定", "character": [ "残存" ], "anatomy_list": [] } ] }, { "id": 95, "text": "8月初，患者于当地诊所就诊，给予药物治疗（具体不详），阴道流血量稍有减少，后再次出现阴道流血量多。", "event": [ { "core_name": "出血", "tendency": "", "character": [ "量稍有减少" ], "anatomy_list": [ "阴道" ] }, { "core_name": "出血", "tendency": "", "character": [ "再次出现", "量多" ], "anatomy_list": [ "阴道" ] } ] }, { "id": 331, "text": "腹部立卧位片示：1、考虑肠梗阻2、右侧尿路双j管置入术后表现。", "event": [ { "core_name": "梗阻", "tendency": "不确定", "character": [], "anatomy_list": [ "肠" ] } ] }, { "id": 1989, "text": "至某医院就诊，查：“血常规：血红蛋白偏低”（具体不详），予输液（具体不详）后仍有解暗红血便2次，量共约100g。", "event": [ { "core_name": "血便", "tendency": "", "character": [ "暗红色" ], "anatomy_list": [] }, { "core_name": "血红蛋白", "tendency": "", "character": [ "偏低" ], "anatomy_list": [] } ] }, { "id": 1328, "text": "曾连续数年以上发作，每次发作均在 3月 以上，诊断为”慢性支气管炎”。", "event": [ { "core_name": "支气管炎", "tendency": "", "character": [ "慢性" ], "anatomy_list": [ "支气管" ] } ] }, { "id": 1290, "text": "于2018-02-06行左侧髂骨放射治疗，放疗剂量ptv(30G,10f),放疗期间患者诉左髂骨疼痛不适，期间予以抗溶骨治疗及止痛药物治疗后好转出院。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [ "放疗期间" ], "anatomy_list": [ "左髂骨" ] } ] }, { "id": 1349, "text": "2天前，患者ptcd管无引流液，无明显腹痛、腹胀，无恶心、呕吐，无反酸、嗳气，无畏寒、发热，无胸闷、胸痛等特殊不适，予以生理盐水冲洗ptcd管后仍无明显引流液流出，现患者为求进一步诊治于我院就诊，门诊以“胆管癌术后复发，第一次免疫治疗后”收住我科。", "event": [ { "core_name": "引流液", "tendency": "否定", "character": [ "ptcd管" ], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [ "腹" ] }, { "core_name": "腹胀", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [ "腹" ] }, { "core_name": "恶心", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "呕吐", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "反酸", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "嗳气", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "畏寒", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "发热", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "胸闷", "tendency": "否定", "character": [], "anatomy_list": [ "胸" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "胸" ] }, { "core_name": "引流液", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "癌", "tendency": "", "character": [ "术后", "复发" ], "anatomy_list": [ "胆管" ] } ] }, { "id": 1950, "text": "mri提示前列腺侵犯膀胱，于2018年12月3日在局麻下行经直肠前列腺穿刺活检术，术后病检提示：前列腺腺癌gleason评分最高为4+5=9分，骨扫描提示为l5存在放射性浓聚，考虑肿瘤转移可能。", "event": [ { "core_name": "癌", "tendency": "", "character": [ "侵犯膀胱" ], "anatomy_list": [ "前列腺" ] }, { "core_name": "腺癌", "tendency": "", "character": [ "gleason评分最高为4+5=9分" ], "anatomy_list": [ "前列腺" ] }, { "core_name": "浓聚", "tendency": "不确定", "character": [ "放射性" ], "anatomy_list": [ "骨" ] }, { "core_name": "肿瘤", "tendency": "不确定", "character": [ "转移" ], "anatomy_list": [] } ] }, { "id": 1024, "text": "入院前9+月，患者无明显诱因出现阴道不规则出血，为淡红色，每次量少，遂于我院妇科门诊行上腹部+妇科超声提示肿瘤复发转移，2017.12.01-2018.01.15给予宫颈癌复发病灶放射治疗（预防区50G/25f/5w，病灶区60G/30f/6w），放疗过程顺利；院外无特殊不适。", "event": [ { "core_name": "出血", "tendency": "", "character": [ "不规则", "淡红色", "每次量少" ], "anatomy_list": [ "阴道" ] }, { "core_name": "肿瘤", "tendency": "", "character": [ "复发", "转移" ], "anatomy_list": [] } ] }, { "id": 75, "text": "现仍偶诉左髋关节疼痛，活动时明显，轻压痛，行走时可见轻微跛行，无红肿，无进行性加重，其他关节未见明显异常及畸形，偶有咳嗽，无咳痰、流涕，无发热，无头痛、呕吐，无腹痛、腹胀，无胸闷、胸痛，活动量未见明显减少。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [ "活动时明显", "轻压痛", "无进行性加重" ], "anatomy_list": [ "左髋关节" ] }, { "core_name": "跛行", "tendency": "", "character": [ "行走时可见", "轻微" ], "anatomy_list": [] }, { "core_name": "红肿", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "畸形", "tendency": "否定", "character": [], "anatomy_list": [ "其他关节" ] }, { "core_name": "咳嗽", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "流涕", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "发热", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "头" ] }, { "core_name": "呕吐", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "腹胀", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "胸闷", "tendency": "否定", "character": [], "anatomy_list": [ "胸" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "胸" ] }, { "core_name": "活动量减少", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [] } ] }, { "id": 1211, "text": "8.腹膜后淋巴结显示。", "event": [ { "core_name": "显示", "tendency": "", "character": [], "anatomy_list": [ "腹膜后淋巴结" ] } ] }, { "id": 1683, "text": "患者恢复顺利，无特殊不适，切口甲级愈合，治愈拆线出院。", "event": [ { "core_name": "切口", "tendency": "", "character": [ "甲级愈合" ], "anatomy_list": [] } ] }, { "id": 1826, "text": "5天前患者无明显诱因出现每次进食后恶心、呕吐，呕吐物为胃内容物，非喷射性，伴反酸、嗳气、腹胀、腹痛，伴少尿，无肛门停止排气，无腹痛、腹泻，无胸闷、心前区压榨感，无胸痛、咯血，为进一步治疗入院，呼120入我院，以\"呕吐原因待查：肠梗阻？肾功能不全？宫颈鳞癌放化疗后伴腹腔广泛转移（iv期）\"收入我科。", "event": [ { "core_name": "恶心", "tendency": "", "character": [ "进食后" ], "anatomy_list": [] }, { "core_name": "呕吐", "tendency": "", "character": [ "进食后" ], "anatomy_list": [] }, { "core_name": "呕吐", "tendency": "", "character": [ "非喷射性", "呕吐物为胃内容物" ], "anatomy_list": [] }, { "core_name": "反酸", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "嗳气", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "腹胀", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "少尿", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "排气", "tendency": "否定", "character": [ "停止" ], "anatomy_list": [ "肛门" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "腹泻", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "胸闷", "tendency": "否定", "character": [], "anatomy_list": [ "胸" ] }, { "core_name": "压榨感", "tendency": "否定", "character": [], "anatomy_list": [ "心前区" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "胸" ] }, { "core_name": "咯血", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "呕吐", "tendency": "不确定", "character": [], "anatomy_list": [] }, { "core_name": "梗阻", "tendency": "不确定", "character": [], "anatomy_list": [ "肠" ] }, { "core_name": "肾功能不全", "tendency": "不确定", "character": [], "anatomy_list": [ "肾" ] }, { "core_name": "鳞癌", "tendency": "不确定", "character": [ "放化疗后", "iv期" ], "anatomy_list": [ "宫颈" ] }, { "core_name": "鳞癌", "tendency": "不确定", "character": [ "iv期", "广泛转移" ], "anatomy_list": [ "腹腔" ] } ] }, { "id": 1804, "text": "伤后他人送患者到“某医院”住院治疗3天，行头颅ct提示左颞骨及颧弓骨折、左小腿x片提示左腓骨中段骨折（未见报告），予以左小腿石膏托制动、甘露醇脱水降颅压、奥拉西坦营养神经、奥美拉唑抑酸护胃及补液对症等治疗，患者自觉头晕头痛症状好转不明显，近两日出现阵时恶心伴视物旋转，伴返酸，无呕吐。", "event": [ { "core_name": "骨折", "tendency": "", "character": [], "anatomy_list": [ "左颞骨", "左颧弓" ] }, { "core_name": "骨折", "tendency": "", "character": [], "anatomy_list": [ "左腓骨中段" ] }, { "core_name": "头晕", "tendency": "", "character": [ "好转不明显" ], "anatomy_list": [ "头" ] }, { "core_name": "疼痛", "tendency": "", "character": [ "好转不明显" ], "anatomy_list": [ "头" ] }, { "core_name": "恶心", "tendency": "", "character": [ "阵时" ], "anatomy_list": [] }, { "core_name": "视物旋转", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "返酸", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "呕吐", "tendency": "否定", "character": [], "anatomy_list": [] } ] }, { "id": 271, "text": "无潮热、盗汗，无咳嗽、咳痰，无胸闷、气促，无呼吸困难，无大小便失禁等。", "event": [ { "core_name": "潮热", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "盗汗", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "咳嗽", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "胸闷", "tendency": "否定", "character": [], "anatomy_list": [ "胸" ] }, { "core_name": "气促", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "呼吸困难", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "大小便", "tendency": "否定", "character": [ "失禁" ], "anatomy_list": [] } ] }, { "id": 102, "text": "患者目前未诉头昏、头痛、咳嗽、咳痰、发热、畏寒、恶心、呕吐等不适，门诊以“残胃癌术后第3次化疗”收入我科。", "event": [ { "core_name": "头昏", "tendency": "否定", "character": [], "anatomy_list": [ "头" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "头" ] }, { "core_name": "咳嗽", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "发热", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "畏寒", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "恶心", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "呕吐", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "癌", "tendency": "", "character": [ "残胃", "术后" ], "anatomy_list": [ "胃" ] } ] }, { "id": 559, "text": "无头晕、心慌。", "event": [ { "core_name": "头晕", "tendency": "否定", "character": [], "anatomy_list": [ "头" ] }, { "core_name": "心慌", "tendency": "否定", "character": [], "anatomy_list": [ "心" ] } ] }, { "id": 1829, "text": "入院前2月，患者上述症状加重，稍运动后就感到下腹部刺痛，伴尿痛，仍无其他特殊症状。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [ "稍运动后", "刺痛" ], "anatomy_list": [ "下腹部" ] }, { "core_name": "尿痛", "tendency": "", "character": [], "anatomy_list": [] } ] }, { "id": 177, "text": "2019-2开始吃艾坦，2019-4开始口服奥拉帕尼（盗版的），2019-10开始腰背部疼痛（未予重视）。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [], "anatomy_list": [ "腰背部" ] } ] }, { "id": 1017, "text": "20余年前患者无明显诱因出现右耳流脓，伴听觉减退，约数年发作一次，无眩晕、耳鸣，无头晕、头痛、无恶心、呕吐，无咳嗽、咳痰。", "event": [ { "core_name": "流脓", "tendency": "", "character": [], "anatomy_list": [ "右耳" ] }, { "core_name": "听觉减退", "tendency": "", "character": [ "约数年发作一次" ], "anatomy_list": [] }, { "core_name": "眩晕", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "耳鸣", "tendency": "否定", "character": [], "anatomy_list": [ "耳" ] }, { "core_name": "头晕", "tendency": "否定", "character": [], "anatomy_list": [ "头" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "头" ] }, { "core_name": "恶心", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "呕吐", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "咳嗽", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "否定", "character": [], "anatomy_list": [] } ] }, { "id": 990, "text": "3天前患者无明显诱因出现喘累、胸闷，常于活动后出现，伴咳嗽、咳痰，咳白色泡沫痰，伴恶心、干呕，伴声嘶，伴乏力，无头晕、头痛，无胸痛，无腹胀、腹泻，无寒战、发热等不适，遂就诊于我院，门诊以“肺ca”收入我科。", "event": [ { "core_name": "喘累", "tendency": "", "character": [ "常于活动后出现" ], "anatomy_list": [] }, { "core_name": "胸闷", "tendency": "", "character": [ "常于活动后出现" ], "anatomy_list": [ "胸" ] }, { "core_name": "咳嗽", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "白色", "泡沫痰" ], "anatomy_list": [] }, { "core_name": "恶心", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "干呕", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "声嘶", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "乏力", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "头晕", "tendency": "否定", "character": [], "anatomy_list": [ "头" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "头" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "胸" ] }, { "core_name": "腹胀", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "腹泻", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "寒颤", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "发热", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "癌", "tendency": "", "character": [], "anatomy_list": [ "肺" ] } ] }, { "id": 1873, "text": "考虑“肠梗阻”，现为求进一步治疗来我院收入我科。", "event": [ { "core_name": "梗阻", "tendency": "不确定", "character": [], "anatomy_list": [ "肠" ] } ] }, { "id": 739, "text": "9月前患者再次于打麻将过程中突发意识丧失，家属诉患者发病过程有双目凝视、四肢抽搐、小便失禁，持续约1分1分钟左右，意识恢复后出现恶心、呕吐，呕出淡黄色胃内容物，休息后逐渐缓解。", "event": [ { "core_name": "意识丧失", "tendency": "", "character": [ "打麻将过程中", "突发" ], "anatomy_list": [] }, { "core_name": "凝视", "tendency": "", "character": [], "anatomy_list": [ "双目" ] }, { "core_name": "抽搐", "tendency": "", "character": [], "anatomy_list": [ "四肢" ] }, { "core_name": "小便", "tendency": "", "character": [ "失禁" ], "anatomy_list": [] }, { "core_name": "恶心", "tendency": "", "character": [ "意识恢复后" ], "anatomy_list": [] }, { "core_name": "呕吐", "tendency": "", "character": [ "意识恢复后", "呕出淡黄色胃内容物", "休息后逐渐缓解" ], "anatomy_list": [] } ] }, { "id": 1767, "text": "术后病检示：右乳外上象限非特殊性浸润性癌，中分化。", "event": [ { "core_name": "癌", "tendency": "", "character": [ "非特殊性", "中分化", "浸润性" ], "anatomy_list": [ "右乳外上象限" ] } ] }, { "id": 1694, "text": "患者入院前1周无明显诱因出现尿频,日间约10次，夜间约4次，每次尿量中等，伴尿痛及双侧腰痛，伴排尿费力，多需用力咳嗽后排尿。", "event": [ { "core_name": "尿频", "tendency": "", "character": [ "尿量中等" ], "anatomy_list": [] }, { "core_name": "尿痛", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "", "character": [], "anatomy_list": [ "双侧腰部" ] }, { "core_name": "排尿费力", "tendency": "", "character": [ "多需用力咳嗽" ], "anatomy_list": [] } ] }, { "id": 1439, "text": "于2018-06-13行ct引导下经皮肺穿刺活检，冰冻病理提示（123456）：（右上）肺穿刺组织考虑鳞癌。", "event": [ { "core_name": "鳞癌", "tendency": "不确定", "character": [], "anatomy_list": [ "右上肺" ] } ] }, { "id": 1880, "text": "2+年前，患者无明显诱因出现四肢肢端麻木，偶有头昏，伴烦渴、多饮、多尿，无胸闷、心累、气促，无腹泻、腹痛，无间歇性跛行，无静息痛，无下肢皮温改变，无下肢水肿，无关节活动障碍，患者于某医院就诊，予以调整降糖方案为门冬胰岛素30早餐前24u，晚餐前24u腹部皮下注射控制血糖，平素监测空腹指血糖波动在11-12mm12mmol/L，患者未重视，未进一步治疗，患者感口干、多饮症状加重时自行调整胰岛素剂量。", "event": [ { "core_name": "麻木", "tendency": "", "character": [], "anatomy_list": [ "四肢肢端" ] }, { "core_name": "头昏", "tendency": "", "character": [ "偶有" ], "anatomy_list": [ "头" ] }, { "core_name": "烦渴", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "多饮", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "多尿", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "胸闷", "tendency": "否定", "character": [], "anatomy_list": [ "胸" ] }, { "core_name": "心累", "tendency": "否定", "character": [], "anatomy_list": [ "心" ] }, { "core_name": "气促", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "腹泻", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "跛行", "tendency": "否定", "character": [ "间歇性" ], "anatomy_list": [] }, { "core_name": "静息痛", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "皮温改变", "tendency": "否定", "character": [], "anatomy_list": [ "下肢" ] }, { "core_name": "水肿", "tendency": "否定", "character": [], "anatomy_list": [ "下肢" ] }, { "core_name": "活动障碍", "tendency": "否定", "character": [], "anatomy_list": [ "关节" ] }, { "core_name": "口干", "tendency": "", "character": [ "加重" ], "anatomy_list": [ "口" ] }, { "core_name": "多饮", "tendency": "", "character": [ "加重" ], "anatomy_list": [] } ] }, { "id": 2054, "text": "患者本次发病以来，食欲减退， 神志清醒，精神尚可，睡眠尚可，大便正常，小便正常，体重减少约10Kg。", "event": [ { "core_name": "食欲", "tendency": "", "character": [ "减退" ], "anatomy_list": [] }, { "core_name": "神志", "tendency": "", "character": [ "清醒" ], "anatomy_list": [] }, { "core_name": "精神", "tendency": "", "character": [ "尚可" ], "anatomy_list": [] }, { "core_name": "睡眠", "tendency": "", "character": [ "尚可" ], "anatomy_list": [] }, { "core_name": "大便", "tendency": "", "character": [ "正常" ], "anatomy_list": [] }, { "core_name": "小便", "tendency": "", "character": [ "正常" ], "anatomy_list": [] }, { "core_name": "体重减少", "tendency": "", "character": [], "anatomy_list": [] } ] }, { "id": 310, "text": "患者15天前，患者因\"尿频、尿急、尿痛及排尿困难1+年，加重伴腰背部胀痛不适1月 \"到某医院就诊，行泌尿系彩超提示：“1.左输尿管上段扩张伴腔内低回声：肿瘤？2.前列腺增大、回声粗细不均，血供丰富；3.左肾积水；4.膀胱壁增厚、粗糙。", "event": [ { "core_name": "尿频", "tendency": "", "character": [ "加重" ], "anatomy_list": [] }, { "core_name": "尿急", "tendency": "", "character": [ "加重" ], "anatomy_list": [] }, { "core_name": "尿痛", "tendency": "", "character": [ "加重" ], "anatomy_list": [] }, { "core_name": "排尿困难", "tendency": "", "character": [ "加重" ], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "", "character": [ "胀痛" ], "anatomy_list": [ "腰背部" ] }, { "core_name": "扩张", "tendency": "", "character": [], "anatomy_list": [ "左输尿管上段" ] }, { "core_name": "回声", "tendency": "", "character": [ "低" ], "anatomy_list": [ "左输尿管上段腔内" ] }, { "core_name": "肿瘤", "tendency": "不确定", "character": [], "anatomy_list": [] }, { "core_name": "增大", "tendency": "", "character": [], "anatomy_list": [ "前列腺" ] }, { "core_name": "回声", "tendency": "", "character": [ "粗细不均" ], "anatomy_list": [ "前列腺" ] }, { "core_name": "血供丰富", "tendency": "", "character": [], "anatomy_list": [ "前列腺" ] }, { "core_name": "积水", "tendency": "", "character": [], "anatomy_list": [ "左肾" ] }, { "core_name": "增厚", "tendency": "", "character": [], "anatomy_list": [ "膀胱壁" ] }, { "core_name": "粗糙", "tendency": "", "character": [], "anatomy_list": [ "膀胱壁" ] } ] }, { "id": 1489, "text": "患者本次发病以来，食欲减退， 神志清醒，精神欠佳，睡眠欠佳，大便正常，小便正常，体重减少（具体不详）。", "event": [ { "core_name": "食欲", "tendency": "", "character": [ "减退" ], "anatomy_list": [] }, { "core_name": "神志", "tendency": "", "character": [ "清醒" ], "anatomy_list": [] }, { "core_name": "精神", "tendency": "", "character": [ "欠佳" ], "anatomy_list": [] }, { "core_name": "睡眠", "tendency": "", "character": [ "欠佳" ], "anatomy_list": [] }, { "core_name": "大便", "tendency": "", "character": [ "正常" ], "anatomy_list": [] }, { "core_name": "小便", "tendency": "", "character": [ "正常" ], "anatomy_list": [] }, { "core_name": "体重减轻", "tendency": "", "character": [], "anatomy_list": [] } ] }, { "id": 733, "text": "5天前，患者无明显诱因再次出现头昏、乏力，伴活动后气促，休息数分钟后能缓解，今日到我院门诊复查血常规：血红蛋白51g/l，要求输血纠正贫血来院，我科以“重度贫血、白血病”收住入院。", "event": [ { "core_name": "头昏", "tendency": "", "character": [], "anatomy_list": [ "头" ] }, { "core_name": "乏力", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "气促", "tendency": "", "character": [ "活动后", "休息数分钟后能缓解" ], "anatomy_list": [] }, { "core_name": "贫血", "tendency": "", "character": [ "重度" ], "anatomy_list": [] }, { "core_name": "白血病", "tendency": "", "character": [], "anatomy_list": [] } ] }, { "id": 1014, "text": "我院急诊全麻下行“腹腔镜探查术+脾部分切除术+左侧黄体囊肿剥除术”，手术顺利，术后予抗生素抗感染、抑酸护胃、护肝、止痛、止吐、解痉、消肿、雾化等治疗，术后病理提示（123456）：左侧卵巢黄体囊肿符合出血、囊性变。", "event": [ { "core_name": "囊肿", "tendency": "", "character": [ "出血" ], "anatomy_list": [ "左侧卵巢黄体" ] }, { "core_name": "囊肿", "tendency": "", "character": [ "囊性变" ], "anatomy_list": [ "左侧卵巢黄体" ] } ] }, { "id": 738, "text": "4年前于“某医院”就诊，家属诉考虑“脑供血不足”（未见报告及病历），具体治疗不详，出院后症状无明显改善。", "event": [ { "core_name": "供血不足", "tendency": "不确定", "character": [], "anatomy_list": [ "脑" ] } ] }, { "id": 796, "text": "患者于入院前２月余因“反复畏寒、寒战半年，再发伴肝功异常１０余天”入我院，于2012-3-27在局麻下行ercp，见乳头肿大，尖端周围明显新生物，触之易出血，并取活检5块，送病检提示：十二指肠乳头管状绒毛状腺瘤，局灶腺体轻度不典型增生。", "event": [ { "core_name": "畏寒", "tendency": "", "character": [ "反复" ], "anatomy_list": [] }, { "core_name": "寒颤", "tendency": "", "character": [ "反复" ], "anatomy_list": [] }, { "core_name": "肝功能异常", "tendency": "", "character": [], "anatomy_list": [ "肝" ] }, { "core_name": "肿大", "tendency": "", "character": [], "anatomy_list": [ "乳头" ] }, { "core_name": "新生物", "tendency": "", "character": [ "明显", "触之易出血" ], "anatomy_list": [ "乳头周围" ] }, { "core_name": "腺瘤", "tendency": "", "character": [ "管状", "绒毛状" ], "anatomy_list": [ "十二指肠乳头" ] }, { "core_name": "增生", "tendency": "", "character": [ "局灶", "非典型性", "轻度" ], "anatomy_list": [ "腺体" ] } ] }, { "id": 844, "text": "未规律监测血糖，现自服“二甲双胍缓释片500mg早上、1000mg中午、晚上”控制血糖，血糖控制情况不详。", "event": [ { "core_name": "血糖", "tendency": "", "character": [ "控制情况不详" ], "anatomy_list": [] } ] }, { "id": 805, "text": "2、胸12、腰1椎体新近压缩性骨折。", "event": [ { "core_name": "骨折", "tendency": "", "character": [ "新近", "压缩性" ], "anatomy_list": [ "胸12、腰1椎体" ] } ] }, { "id": 1763, "text": "（左腋窝）淋巴结见癌转移（2/39）。", "event": [ { "core_name": "癌", "tendency": "", "character": [ "转移" ], "anatomy_list": [ "左腋窝淋巴结" ] } ] }, { "id": 1167, "text": "院外未进行特殊治疗，患者为防止病情进一步加重，遂于今日来我院就诊，门诊以“冠心病”收住入院。", "event": [ { "core_name": "心脏病", "tendency": "", "character": [ "硬化性", "粥样" ], "anatomy_list": [ "冠状动脉", "心脏" ] } ] }, { "id": 1146, "text": "入院前24天完成肿瘤术后第3次化疗，出院后无特殊不适，现按疗程入院行下一疗程化疗，门诊以“肿瘤化疗”收入院，现患儿精神反应可，无发热、咳嗽，进食可。", "event": [ { "core_name": "精神反应", "tendency": "", "character": [ "可" ], "anatomy_list": [] }, { "core_name": "发热", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "咳嗽", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "进食", "tendency": "", "character": [ "可" ], "anatomy_list": [] } ] }, { "id": 759, "text": "2018-2-15患者因“发热3天”入院，完善胸部ct提示：与2018年2月2日胸部ct比较：1.右下肺肺门占位，考虑肿瘤伴阻塞性肺炎，肿块较前变化不大。", "event": [ { "core_name": "发热", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "占位", "tendency": "", "character": [], "anatomy_list": [ "右下肺门" ] }, { "core_name": "肿瘤", "tendency": "不确定", "character": [], "anatomy_list": [ "右下肺门" ] }, { "core_name": "肺炎", "tendency": "不确定", "character": [ "阻塞性" ], "anatomy_list": [ "肺" ] }, { "core_name": "肿块", "tendency": "", "character": [ "较前变化不大" ], "anatomy_list": [ "右下肺门" ] } ] }, { "id": 860, "text": "入院前半天解1次黑色糊状便，诉量较多，具体不详，伴恶心，感中上腹上腹部不适，伴心悸、乏力表现，在外口服1粒云南白药胶囊治疗无缓解。", "event": [ { "core_name": "大便", "tendency": "", "character": [ "黑色", "糊状", "量较多" ], "anatomy_list": [] }, { "core_name": "恶心", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "不适", "tendency": "", "character": [], "anatomy_list": [ "中上腹部" ] }, { "core_name": "心悸", "tendency": "", "character": [], "anatomy_list": [ "心" ] }, { "core_name": "乏力", "tendency": "", "character": [], "anatomy_list": [] } ] }, { "id": 837, "text": "遂于术后行1次新辅助化疗，并于2017-06-02在全麻下行左腋窝前哨淋巴结活检术+术中冰冻+左乳癌改良根治术，术后病理示：（左乳）浸润性导管癌（Ⅱ级，7分）病检术后之乳腺根治标本（原病变参见17-8223号），残腔内见少许癌残留，皮肤、基底、乳头未见癌累及。", "event": [ { "core_name": "导管癌", "tendency": "", "character": [ "浸润性", "Ⅱ级", "7分" ], "anatomy_list": [ "左乳" ] }, { "core_name": "癌", "tendency": "", "character": [ "残腔内", "少许", "残留" ], "anatomy_list": [] }, { "core_name": "癌", "tendency": "否定", "character": [ "累及" ], "anatomy_list": [ "乳头" ] }, { "core_name": "癌", "tendency": "否定", "character": [ "累及" ], "anatomy_list": [ "乳房皮肤" ] }, { "core_name": "癌", "tendency": "否定", "character": [ "累及" ], "anatomy_list": [ "乳房基底" ] } ] }, { "id": 1520, "text": "近2年前患者咳嗽时痰中带血丝，为鲜红色血丝，病情加重时咯鲜红色血痰，伴喘累、心悸，多次我院住院诊断为“慢阻肺急性发作 冠心病 快速心房纤颤 支气管扩张”，给予抗感染、解痉、控制心室率等内科治疗好转出院。", "event": [ { "core_name": "咳嗽", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "鲜红色血丝" ], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "病情加重时", "鲜红色", "血痰" ], "anatomy_list": [] }, { "core_name": "喘累", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "心悸", "tendency": "", "character": [], "anatomy_list": [ "心" ] }, { "core_name": "肺疾病", "tendency": "", "character": [ "急性发作", "慢性", "阻塞性" ], "anatomy_list": [ "肺" ] }, { "core_name": "冠心病", "tendency": "", "character": [], "anatomy_list": [ "心" ] }, { "core_name": "心房纤颤", "tendency": "", "character": [ "快速" ], "anatomy_list": [ "心房" ] }, { "core_name": "扩张", "tendency": "", "character": [], "anatomy_list": [ "支气管" ] } ] }, { "id": 1638, "text": "患者发病以来，神志 清晰，精神可，胃纳可，大便如常，小便如常，体重未见明显下降。", "event": [ { "core_name": "神志", "tendency": "", "character": [ "清" ], "anatomy_list": [] }, { "core_name": "精神", "tendency": "", "character": [ "可" ], "anatomy_list": [] }, { "core_name": "胃纳", "tendency": "", "character": [ "可" ], "anatomy_list": [ "胃" ] }, { "core_name": "大便", "tendency": "", "character": [ "如常" ], "anatomy_list": [] }, { "core_name": "排尿", "tendency": "", "character": [ "如常" ], "anatomy_list": [] }, { "core_name": "体重下降", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [] } ] }, { "id": 975, "text": "患者遂至“某医院”就诊，自诉完善检查后诊断：继发性肺结核 涂（+）初治、结核性胸膜炎，予以抗结核治疗（具体不详）后好转出院，院外继续口服结核药物1+年，自觉症状好转，复查痰抗酸杆菌阴性，遂自行停用抗结核药物。", "event": [ { "core_name": "结核", "tendency": "", "character": [ "继发性", "初治" ], "anatomy_list": [ "肺" ] }, { "core_name": "胸膜炎", "tendency": "", "character": [ "结核性" ], "anatomy_list": [ "胸膜" ] } ] }, { "id": 1569, "text": "患者起病以来，精神尚可，食欲较差，大便稀黄，3-5次/天，小便量如常，体重无明显变化。", "event": [ { "core_name": "精神", "tendency": "", "character": [ "尚可" ], "anatomy_list": [] }, { "core_name": "食欲", "tendency": "", "character": [ "较差" ], "anatomy_list": [] }, { "core_name": "大便", "tendency": "", "character": [ "稀黄" ], "anatomy_list": [] }, { "core_name": "小便", "tendency": "", "character": [ "量如常" ], "anatomy_list": [] }, { "core_name": "体重改变", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [] } ] }, { "id": 2011, "text": "5年前开始到“某医院”就诊，诊断为“慢性阻塞性肺病”，予以“舒利迭50/500ug、噻托溴铵”吸入治疗，患者坚持用药，平时症状控制可。", "event": [ { "core_name": "肺病", "tendency": "", "character": [ "慢性", "阻塞性" ], "anatomy_list": [ "肺" ] } ] }, { "id": 935, "text": "患者病程中反复眼红、近7年来患者视力明显下降，反复腮腺炎，近1年来发作频率增加，脱发较明显，有鼻干，双下肢远端内侧反复出现皮下结节30余年，无光过敏，无晨僵、无眼干、无耳痛、耳鸣，无反复口腔溃疡，无牙齿片状脱落，无猖獗齿，无咀嚼疼痛、乏力，无关节疼痛，无手指遇冷后变白变紫又变红现象等。", "event": [ { "core_name": "眼红", "tendency": "", "character": [ "反复" ], "anatomy_list": [ "眼" ] }, { "core_name": "视力下降", "tendency": "", "character": [ "明显" ], "anatomy_list": [] }, { "core_name": "腮腺炎", "tendency": "", "character": [ "反复" ], "anatomy_list": [ "腮腺" ] }, { "core_name": "脱发", "tendency": "", "character": [ "较明显" ], "anatomy_list": [] }, { "core_name": "鼻干", "tendency": "", "character": [], "anatomy_list": [ "鼻" ] }, { "core_name": "结节", "tendency": "", "character": [ "反复", "皮下" ], "anatomy_list": [ "双下肢远端内侧" ] }, { "core_name": "过敏", "tendency": "否定", "character": [ "光" ], "anatomy_list": [] }, { "core_name": "晨僵", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "眼干", "tendency": "否定", "character": [], "anatomy_list": [ "眼" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "耳" ] }, { "core_name": "耳鸣", "tendency": "否定", "character": [], "anatomy_list": [ "耳" ] }, { "core_name": "溃疡", "tendency": "否定", "character": [ "反复" ], "anatomy_list": [ "口腔" ] }, { "core_name": "脱落", "tendency": "否定", "character": [ "片状" ], "anatomy_list": [ "牙齿" ] }, { "core_name": "猖獗齿", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "否定", "character": [ "咀嚼" ], "anatomy_list": [] }, { "core_name": "乏力", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "关节" ] }, { "core_name": "变白", "tendency": "否定", "character": [ "遇冷后" ], "anatomy_list": [ "手指" ] }, { "core_name": "变紫", "tendency": "否定", "character": [ "遇冷后" ], "anatomy_list": [ "手指" ] }, { "core_name": "变红", "tendency": "否定", "character": [ "遇冷后" ], "anatomy_list": [ "手指" ] } ] }, { "id": 1749, "text": "患者2月余前因乏力、纳差于我我院就诊，行腹部mr发现肝占位性病变，遂于2016-10-11于我院行“胆囊切除术+中肝癌切除术”，术后予以抑酸，保肝，止血，抗感染，止吐，营养支持，改善微循环等治疗，术后病理示：1、（肝中叶）癌，低分化胆管细胞癌。", "event": [ { "core_name": "乏力", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "纳差", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "病变", "tendency": "", "character": [ "占位性" ], "anatomy_list": [ "肝" ] }, { "core_name": "癌", "tendency": "", "character": [], "anatomy_list": [ "肝中叶" ] }, { "core_name": "癌", "tendency": "", "character": [ "低分化" ], "anatomy_list": [ "胆管细胞" ] } ] }, { "id": 1958, "text": "入院前7天患者无明显诱因出现鼻出血，成滴流出，出血量较多（具体不详），自诉血液由前鼻孔和口腔内流出，自行指压鼻部缓解，期间无晕厥、咳嗽、呕血、黑便，无恶性、呕吐，无头昏、头痛、眩晕等症状，无鼻阻、发热、咳嗽、咳痰、听力下降，无咯血、胸痛，无潮热、盗汗、全身乏力、食欲减退等。未因重视而就医。", "event": [ { "core_name": "出血", "tendency": "", "character": [ "成滴流出", "量较" ], "anatomy_list": [ "鼻" ] }, { "core_name": "血液流出", "tendency": "", "character": [], "anatomy_list": [ "前鼻孔", "口腔" ] }, { "core_name": "晕厥", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "咳嗽", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "呕血", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "黑便", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "恶心", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "呕吐", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "头昏", "tendency": "否定", "character": [], "anatomy_list": [ "头" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "头" ] }, { "core_name": "眩晕", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "鼻塞", "tendency": "否定", "character": [], "anatomy_list": [ "鼻" ] }, { "core_name": "发热", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "咳嗽", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "听力下降", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "咯血", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "胸" ] }, { "core_name": "潮热", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "盗汗", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "乏力", "tendency": "否定", "character": [], "anatomy_list": [ "全身" ] }, { "core_name": "食欲减退", "tendency": "否定", "character": [], "anatomy_list": [] } ] }, { "id": 2004, "text": "入院前2月，患者体检时发现右乳无痛性包块，约拇指指头大小，质韧，边界欠清，活动度尚可，无压痛，局部皮肤无红肿；乳头无溢血、溢液等；为求进一步治疗，就诊于我科，完善相关辅助检查，于2016-11-18日在全麻下行右乳包块切除+术中冰冻术，术中冰冻提示提示为恶性，遂行右乳癌改良根治术，术后病理诊断（123456）：1.（右乳）癌，70%为浸润性癌，非特殊类型，Ⅰ级5分（导管内癌成份占30%）；30%为粘液癌成份。", "event": [ { "core_name": "包块", "tendency": "", "character": [ "无痛性", "约拇指指头大小", "质韧", "边界欠清", "活动度尚可", "无压痛" ], "anatomy_list": [ "右乳" ] }, { "core_name": "红肿", "tendency": "否定", "character": [ "局部" ], "anatomy_list": [ "皮肤" ] }, { "core_name": "溢血", "tendency": "否定", "character": [], "anatomy_list": [ "乳头" ] }, { "core_name": "溢液", "tendency": "否定", "character": [], "anatomy_list": [ "乳头" ] }, { "core_name": "包块", "tendency": "", "character": [ "恶性" ], "anatomy_list": [] }, { "core_name": "癌", "tendency": "", "character": [], "anatomy_list": [ "右乳" ] }, { "core_name": "癌", "tendency": "", "character": [ "浸润性", "非特殊类型", "Ⅰ级5分" ], "anatomy_list": [ "右乳" ] }, { "core_name": "癌", "tendency": "", "character": [ "导管内" ], "anatomy_list": [ "右乳" ] }, { "core_name": "癌", "tendency": "", "character": [ "粘液" ], "anatomy_list": [ "右乳" ] } ] }, { "id": 593, "text": "2周前患者复查胃镜：食管至胃底胃体ca化疗后、慢性萎缩性胃炎。", "event": [ { "core_name": "癌", "tendency": "", "character": [ "化疗后" ], "anatomy_list": [ "食管至胃底胃体" ] }, { "core_name": "胃炎", "tendency": "", "character": [ "慢性", "萎缩性" ], "anatomy_list": [ "胃" ] } ] }, { "id": 314, "text": "1+月前，患者无明显诱因出现阴道少许血性分泌物，无阴道阴道流液，伴尿频、尿痛、下腹部及腰骶部坠胀，无尿急、尿血及排尿困难，无腹痛腹泻，自行于某医院就诊，给予输液治疗（具体不详），尿频尿痛好转，阴道流血持续5天自行停止。", "event": [ { "core_name": "分泌物", "tendency": "", "character": [ "血性", "少许" ], "anatomy_list": [ "阴道" ] }, { "core_name": "流液", "tendency": "否定", "character": [], "anatomy_list": [ "阴道" ] }, { "core_name": "尿频", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "尿痛", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "坠胀", "tendency": "", "character": [], "anatomy_list": [ "下腹部", "腰骶部" ] }, { "core_name": "尿急", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "尿血", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "排尿困难", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "腹泻", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "尿频", "tendency": "", "character": [ "好转" ], "anatomy_list": [] }, { "core_name": "尿痛", "tendency": "", "character": [ "好转" ], "anatomy_list": [] }, { "core_name": "出血", "tendency": "", "character": [ "持续5天自行停止" ], "anatomy_list": [ "阴道" ] } ] }, { "id": 696, "text": "患者为求进一步治疗，遂于2016-5-16入我院就诊，电子阴道镜检查示：宫颈i度糜烂，薄的醋酸白色上皮；tct:轻度炎症，未见上皮内病变或恶性细胞，妇科彩超示：1.宫腔内偏强回声，子宫内膜ca待排，建议进一步检查。", "event": [ { "core_name": "糜烂", "tendency": "", "character": [ "i度" ], "anatomy_list": [ "宫颈" ] }, { "core_name": "醋酸白色上皮", "tendency": "", "character": [ "薄的" ], "anatomy_list": [] }, { "core_name": "炎症", "tendency": "", "character": [ "轻度" ], "anatomy_list": [ "宫颈" ] }, { "core_name": "病变", "tendency": "否定", "character": [], "anatomy_list": [ "上皮内", "恶性细胞" ] }, { "core_name": "回声", "tendency": "", "character": [ "偏强" ], "anatomy_list": [ "宫腔内" ] }, { "core_name": "癌", "tendency": "不确定", "character": [], "anatomy_list": [ "子宫内膜" ] } ] }, { "id": 2045, "text": "患者自发病以来，精神差，食欲差，睡眠可，大便如常，小便如常，体重无明显变化。", "event": [ { "core_name": "精神", "tendency": "", "character": [ "差" ], "anatomy_list": [] }, { "core_name": "食欲", "tendency": "", "character": [ "差" ], "anatomy_list": [] }, { "core_name": "睡眠", "tendency": "", "character": [ "可 " ], "anatomy_list": [] }, { "core_name": "大便", "tendency": "", "character": [ "如常" ], "anatomy_list": [] }, { "core_name": "小便", "tendency": "", "character": [ "如常" ], "anatomy_list": [] }, { "core_name": "体重改变", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [] } ] }, { "id": 1994, "text": "子宫平滑肌瘤伴玻变。", "event": [ { "core_name": "肌瘤", "tendency": "", "character": [], "anatomy_list": [ "子宫平滑肌" ] }, { "core_name": "玻变", "tendency": "", "character": [], "anatomy_list": [ "子宫平滑肌" ] } ] }, { "id": 621, "text": "入院前6+月，患者无明显诱因出现性生活后阴道流血，量少，色鲜红，不伴疼痛，可自行停止，患者未引起重视，未正规检查及诊治。", "event": [ { "core_name": "出血", "tendency": "", "character": [ "性生活后", "量少", "色鲜红", "不伴疼痛", "可自行停止" ], "anatomy_list": [ "阴道" ] } ] }, { "id": 1320, "text": "后口服依西美坦至2018年5月，患者无明显诱因出现咳嗽，我院门诊查胸部ct提示：肺内、右肺门、肝脏多发转移可能。", "event": [ { "core_name": "咳嗽", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "癌", "tendency": "不确定", "character": [ "多发", "转移" ], "anatomy_list": [ "肺内", "右肺门", "肝脏" ] } ] }, { "id": 1953, "text": "半月前，患者家属发现患者皮肤黄染，尿色加深，无厌油，无恶心、呕吐，无纳差，诉双下肢乏力，无腹胀、腹痛、腹泻，无反酸、嗳气，无呕血、黑便，无牙龈出血，无畏寒及发热，无咳嗽、咳痰，无头昏、头痛，无酱油色尿，无皮肤瘙痒，自诉大便颜色变浅，黄白色，患者及家属为求进一步诊治就诊于我院，急诊以“黄疸待查”收治入院。", "event": [ { "core_name": "黄染", "tendency": "", "character": [], "anatomy_list": [ "皮肤" ] }, { "core_name": "小便", "tendency": "", "character": [ "色加深" ], "anatomy_list": [] }, { "core_name": "厌油", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "恶心", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "呕吐", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "纳差", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "乏力", "tendency": "否定", "character": [], "anatomy_list": [ "双下肢" ] }, { "core_name": "腹胀", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "腹泻", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "返酸", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "嗳气", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "呕血", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "黑便", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "出血", "tendency": "否定", "character": [], "anatomy_list": [ "牙龈" ] }, { "core_name": "畏寒", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "发热", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "咳嗽", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "头昏", "tendency": "否定", "character": [], "anatomy_list": [ "头" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "头" ] }, { "core_name": "小便", "tendency": "否定", "character": [ "酱油色" ], "anatomy_list": [] }, { "core_name": "瘙痒", "tendency": "否定", "character": [], "anatomy_list": [ "皮肤" ] }, { "core_name": "大便", "tendency": "", "character": [ "颜色变浅", "黄白色" ], "anatomy_list": [] }, { "core_name": "黄疸", "tendency": "", "character": [], "anatomy_list": [] } ] }, { "id": 248, "text": "腹部彩超示：肝脏实性占位：ca? 。", "event": [ { "core_name": "占位", "tendency": "", "character": [ "实性" ], "anatomy_list": [ "肝脏" ] }, { "core_name": "癌", "tendency": "不确定", "character": [], "anatomy_list": [ "肝" ] } ] }, { "id": 1338, "text": "于2019年3月11日在全麻下行“右半肝切除+门静脉切开取栓+胆囊切除术+肝内胆管空肠吻合+t管引流术”，术后病理检查提示为“病检结果已回<肝脏>低分化癌，结合形态及免疫组化，符合低分化胆管细胞癌。<胆管下端冰冻>送检组织中见个别不典型细胞。", "event": [ { "core_name": "癌", "tendency": "", "character": [ "低分化" ], "anatomy_list": [ "肝脏" ] }, { "core_name": "癌", "tendency": "", "character": [ "低分化" ], "anatomy_list": [ "胆管", "细胞" ] } ] }, { "id": 1008, "text": "免疫结果为右半结肠非霍奇金氏淋巴瘤（弥漫大b细胞型）。", "event": [ { "core_name": "瘤", "tendency": "", "character": [ "弥漫性", "大B细胞" ], "anatomy_list": [ "右半结肠", "淋巴" ] }, { "core_name": "瘤", "tendency": "", "character": [ "非霍奇金氏" ], "anatomy_list": [ "右半结肠", "淋巴" ] } ] }, { "id": 1462, "text": "病程中患者存在飞蚊症，视近物模糊，但无烦渴多饮，无肢端发麻等不适。", "event": [ { "core_name": "飞蚊症", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "视物模糊", "tendency": "", "character": [ "近物" ], "anatomy_list": [] }, { "core_name": "烦渴", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "多饮", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "发麻", "tendency": "否定", "character": [], "anatomy_list": [ "肢端" ] } ] }, { "id": 710, "text": "术后每月定期复查，血清ca125持续升高，he4、ca153、ca199、cea均未见异常，2017-9-13（某医院）pet-ct：卵巢癌术后，腹膜后及右侧髂血管血管旁多发淋巴结转移，右肺上叶转移，左髂骨髂骨骨骨转移，后出现左侧腰骶部持续性胀痛，2017-9-15ca-125785u/ml，考虑“卵巢癌术后化疗后复发”，于2017-9-16开始予以“tc方案”（紫杉醇+卡铂）静脉化疗，治疗期间ca125缓慢下降，2018-1-8第6次化疗前复查ca-12568.1u/ml，更改为“奥沙利铂+多西他赛”静脉化疗1次，2018-1-30复查ca-12560.8u/ml，第二周期化疗结束后ca125仍未降至正常，后逐渐升高，2018-8-8ca-1251129u/ml，后拒绝检查，失访4月。", "event": [ { "core_name": "血清ca125", "tendency": "", "character": [ "持续升高" ], "anatomy_list": [] }, { "core_name": "he4", "tendency": "否定", "character": [ "异常" ], "anatomy_list": [] }, { "core_name": "ca153", "tendency": "否定", "character": [ "异常" ], "anatomy_list": [] }, { "core_name": "ca199", "tendency": "否定", "character": [ "异常" ], "anatomy_list": [] }, { "core_name": "cea", "tendency": "否定", "character": [ "异常" ], "anatomy_list": [] }, { "core_name": "癌", "tendency": "", "character": [ "术后" ], "anatomy_list": [ "卵巢" ] }, { "core_name": "转移", "tendency": "", "character": [ "多发性" ], "anatomy_list": [ "腹膜后淋巴结", "右侧髂血管旁淋巴结" ] }, { "core_name": "转移", "tendency": "", "character": [], "anatomy_list": [ "右肺上叶" ] }, { "core_name": "转移", "tendency": "", "character": [], "anatomy_list": [ "左髂骨" ] }, { "core_name": "疼痛", "tendency": "", "character": [ "持续性", "胀痛" ], "anatomy_list": [ "左侧腰骶部" ] }, { "core_name": "癌", "tendency": "不确定", "character": [], "anatomy_list": [ "卵巢" ] }, { "core_name": "ca125", "tendency": "", "character": [ "治疗期间", "缓慢下降" ], "anatomy_list": [] }, { "core_name": "ca125", "tendency": "否定", "character": [ "第二周期化疗结束后", "降至正常" ], "anatomy_list": [] } ] }, { "id": 397, "text": "伴腹胀 ， 伴恶心、呕吐,呕吐物为胃内容物 ， 发病 以来肛门未排气排便。", "event": [ { "core_name": "腹胀", "tendency": "", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "恶心", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "呕吐", "tendency": "", "character": [ "呕吐物为胃内容物" ], "anatomy_list": [] }, { "core_name": "排气", "tendency": "否定", "character": [], "anatomy_list": [ "肛门" ] }, { "core_name": "排便", "tendency": "否定", "character": [], "anatomy_list": [ "肛门" ] } ] }, { "id": 1690, "text": "入院前1年余，患者无明显诱因出现双眼视力逐渐下降，偶感眼痒、流泪，无眼痛、眼胀、眼卡，无畏光、分泌物增多，无视物遮挡、变形、黑影漂浮，无头痛、恶心等不适，患者未予重视及特殊治疗。", "event": [ { "core_name": "视力下降", "tendency": "", "character": [ "逐渐" ], "anatomy_list": [ "双眼" ] }, { "core_name": "眼痒", "tendency": "", "character": [ "偶感" ], "anatomy_list": [ "眼" ] }, { "core_name": "流泪", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "眼痛", "tendency": "否定", "character": [], "anatomy_list": [ "眼" ] }, { "core_name": "眼胀", "tendency": "否定", "character": [], "anatomy_list": [ "眼" ] }, { "core_name": "眼卡", "tendency": "否定", "character": [], "anatomy_list": [ "眼" ] }, { "core_name": "畏光", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "分泌物", "tendency": "否定", "character": [ "增多" ], "anatomy_list": [] }, { "core_name": "视物遮挡", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "视物变形", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "黑影漂浮", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "头痛", "tendency": "否定", "character": [], "anatomy_list": [ "头" ] }, { "core_name": "恶心", "tendency": "否定", "character": [], "anatomy_list": [] } ] }, { "id": 1493, "text": "入院前6月，患者无明显诱因出现咯血，表现为痰中带血，伴咳嗽、咳白痰，偶伴头晕，无畏寒、发热，无恶心、呕吐，无头痛，无意识不清，无呼吸困难，无胸闷、心悸，无心前区压榨感，无腹痛、腹泻。", "event": [ { "core_name": "咯血", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "带血" ], "anatomy_list": [] }, { "core_name": "咳嗽", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "白色" ], "anatomy_list": [] }, { "core_name": "头晕", "tendency": "", "character": [], "anatomy_list": [ "头" ] }, { "core_name": "畏寒", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "发热", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "恶心", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "呕吐", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "头" ] }, { "core_name": "意识不清", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "呼吸困难", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "胸闷", "tendency": "否定", "character": [], "anatomy_list": [ "胸" ] }, { "core_name": "心悸", "tendency": "否定", "character": [], "anatomy_list": [ "心" ] }, { "core_name": "压榨感", "tendency": "否定", "character": [], "anatomy_list": [ "心前区" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "腹泻", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] } ] }, { "id": 1293, "text": "入院前3天，患者肛门少量排气排便，伴腹痛腹胀，呈持续性胀痛不适，阵发性加重，无放射痛及牵涉痛，伴恶心，无呕吐，无畏寒发热，无便血、腹泻，无头昏、头痛；无心慌、胸闷；无嗳气、呃逆等不适，患者自觉腹痛不缓解，为求进一步诊治，遂到我院就医，门诊以“不完全性肠梗阻”收入我科进一步治疗。", "event": [ { "core_name": "排气", "tendency": "", "character": [ "少量" ], "anatomy_list": [ "肛门" ] }, { "core_name": "排便", "tendency": "", "character": [ "少量" ], "anatomy_list": [ "肛门" ] }, { "core_name": "疼痛", "tendency": "", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "腹胀", "tendency": "", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "疼痛", "tendency": "", "character": [ "胀痛", "持续性", "阵发性加重", "无放射痛及牵涉痛" ], "anatomy_list": [ "腹" ] }, { "core_name": "恶心", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "呕吐", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "畏寒", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "发热", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "便血", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "腹泻", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "头昏", "tendency": "否定", "character": [], "anatomy_list": [ "头" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "头" ] }, { "core_name": "心慌", "tendency": "否定", "character": [], "anatomy_list": [ "心" ] }, { "core_name": "胸闷", "tendency": "否定", "character": [], "anatomy_list": [ "胸" ] }, { "core_name": "嗳气", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "呃逆", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "否定", "character": [ "缓解" ], "anatomy_list": [ "腹" ] }, { "core_name": "梗阻", "tendency": "", "character": [ "不完全性" ], "anatomy_list": [ "肠" ] } ] }, { "id": 781, "text": "入院2+小时 前 ，患者无明显诱因出现头晕，伴视物旋转，平卧时缓解，坐起时加重，伴恶心、呕吐胃内容物，量及次数具体不详，无咖啡色样物质，无喷射性呕吐；伴耳鸣，无耳胀、听力下降；无外耳道疱疹，无鼻唇沟变浅，无饮水呛咳、吞咽困难、肢体麻木、肢体无力；无发热、畏寒、寒战等不适。", "event": [ { "core_name": "头晕", "tendency": "", "character": [ "坐起时加重", "平卧时缓解" ], "anatomy_list": [ "头" ] }, { "core_name": "视物旋转", "tendency": "", "character": [ "坐起时加重", "平卧时缓解" ], "anatomy_list": [] }, { "core_name": "恶心", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "呕吐", "tendency": "", "character": [ "胃内容物", "量及次数具体不详", "无咖啡色样物质" ], "anatomy_list": [] }, { "core_name": "呕吐", "tendency": "否定", "character": [ "喷射性" ], "anatomy_list": [] }, { "core_name": "耳鸣", "tendency": "", "character": [], "anatomy_list": [ "耳" ] }, { "core_name": "耳胀", "tendency": "否定", "character": [], "anatomy_list": [ "耳" ] }, { "core_name": "听力下降", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "疱疹", "tendency": "否定", "character": [], "anatomy_list": [ "外耳道" ] }, { "core_name": "变浅", "tendency": "否定", "character": [ "变浅" ], "anatomy_list": [ "鼻唇沟" ] }, { "core_name": "呛咳", "tendency": "否定", "character": [ "饮水" ], "anatomy_list": [] }, { "core_name": "吞咽困难", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "麻木", "tendency": "否定", "character": [], "anatomy_list": [ "肢体" ] }, { "core_name": "无力", "tendency": "否定", "character": [], "anatomy_list": [ "肢体" ] }, { "core_name": "发热", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "畏寒", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "寒颤", "tendency": "否定", "character": [], "anatomy_list": [] } ] }, { "id": 656, "text": "患者遂致某医院就诊，门诊行乳腺彩超检查，提示：双乳多发囊肿，部分囊内透声较差，考虑出血可能性大。", "event": [ { "core_name": "囊肿", "tendency": "", "character": [ "多发", "部分囊内透声较差" ], "anatomy_list": [ "双乳" ] }, { "core_name": "出血", "tendency": "不确定", "character": [], "anatomy_list": [ "双乳囊内" ] } ] }, { "id": 712, "text": "2020-4-23ca-1254247u/ml，全腹ct提示：右肺多发结节影，腹腔及腹膜后多发淋巴结多发淋巴结转移，双侧骶翼骨考转移，脊柱mr提示：腰1椎体、腰55椎体骶棘、所示骶骨及左侧髂骨异常信号，考虑转移改变，腹腔后增多软组织影，肿大淋巴结，建议联合靶向治疗，患者拒绝，2020-4-26予以“卡培他滨”治疗，2020-5-16ca-1253697u/ml，2020-5-18予以“伊立替康+卡培他滨”治疗，2020-6-10ca-1253967u/ml。", "event": [ { "core_name": "结节影", "tendency": "", "character": [ "多发" ], "anatomy_list": [ "右肺" ] }, { "core_name": "转移", "tendency": "", "character": [ "多发" ], "anatomy_list": [ "腹腔淋巴结", "腹腔后淋巴结" ] }, { "core_name": "转移", "tendency": "不确定", "character": [], "anatomy_list": [ "双侧骶翼骨" ] }, { "core_name": "异常信号", "tendency": "", "character": [], "anatomy_list": [ "腰1椎体", "腰5椎体骶棘", "骶骨", "左侧髂骨" ] }, { "core_name": "转移改变", "tendency": "不确定", "character": [], "anatomy_list": [] }, { "core_name": "软组织影", "tendency": "", "character": [ "增多" ], "anatomy_list": [ "腹腔后" ] }, { "core_name": "肿大", "tendency": "", "character": [], "anatomy_list": [ "腹腔后淋巴结" ] } ] }, { "id": 913, "text": "25年前，患者在玩耍时右侧腕部及手指不慎被化学物质（具体化学物质名称不详）烧伤（腕部及手部变现不详），当即患者疼痛难忍，哭闹不止，神志清楚，患者家属自行未做任何处理，立即将患者送到某一诊所进行治疗，予以换药、补液、抗感染等常规治疗，伤口愈合后皮肤覆盖创面，但疤痕形成，严重影响腕部及手指功能，在医生建议下行腕部及手指功能康复锻炼（具体治疗过程不详）后，右手小指瘢痕挛缩明显，功能受到影响，其余四指恢复良好，腕部活动有轻微受限，疤痕明显。", "event": [ { "core_name": "烧伤", "tendency": "", "character": [ "化学物质" ], "anatomy_list": [ "右侧腕部" ] }, { "core_name": "烧伤", "tendency": "", "character": [ "化学物质" ], "anatomy_list": [ "手指" ] }, { "core_name": "疼痛", "tendency": "", "character": [ "难忍" ], "anatomy_list": [ "右侧腕部" ] }, { "core_name": "疼痛", "tendency": "", "character": [ "难忍" ], "anatomy_list": [ "手指" ] }, { "core_name": "哭闹不止", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "神志", "tendency": "", "character": [ "清楚" ], "anatomy_list": [] }, { "core_name": "疤痕形成", "tendency": "", "character": [ "严重影响腕部及手指功能" ], "anatomy_list": [] }, { "core_name": "瘢痕", "tendency": "", "character": [ "挛缩明显" ], "anatomy_list": [ "右手小指" ] }, { "core_name": "功能受到影响", "tendency": "", "character": [], "anatomy_list": [ "右手小指" ] }, { "core_name": "活动受限", "tendency": "", "character": [ "轻微" ], "anatomy_list": [ "腕部" ] }, { "core_name": "疤痕", "tendency": "", "character": [ "明显" ], "anatomy_list": [] } ] }, { "id": 1864, "text": "患者本次发病以来，食欲正常，神志清醒，精神尚可，睡眠可，大便正常，小便正常，体重无明显变化。", "event": [ { "core_name": "食欲", "tendency": "", "character": [ "正常" ], "anatomy_list": [] }, { "core_name": "神志", "tendency": "", "character": [ "清醒" ], "anatomy_list": [] }, { "core_name": "精神", "tendency": "", "character": [ "尚可" ], "anatomy_list": [] }, { "core_name": "睡眠", "tendency": "", "character": [ "可" ], "anatomy_list": [] }, { "core_name": "大便", "tendency": "", "character": [ "正常" ], "anatomy_list": [] }, { "core_name": "小便", "tendency": "", "character": [ "正常" ], "anatomy_list": [] }, { "core_name": "体重改变", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [] } ] }, { "id": 94, "text": "月经结束4天后，阴道再次出现流血，持续至今，量多。", "event": [ { "core_name": "出血", "tendency": "", "character": [ "再次", "持续至今", "量多" ], "anatomy_list": [ "阴道" ] } ] }, { "id": 468, "text": "故急诊以“腹痛待查：卵巢黄体囊肿破裂？异位妊娠？”收入我科。", "event": [ { "core_name": "疼痛", "tendency": "不确定", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "囊肿破裂", "tendency": "不确定", "character": [], "anatomy_list": [ "卵巢黄体" ] }, { "core_name": "异位妊娠", "tendency": "不确定", "character": [], "anatomy_list": [ "卵巢黄体" ] } ] }, { "id": 142, "text": "患者长期排尿困难，夜尿增多，3+月前于i某医院行前列腺穿刺活检，病检结果回示：前列腺腺癌，患者未予特殊处理。", "event": [ { "core_name": "排尿困难", "tendency": "", "character": [ "长期" ], "anatomy_list": [] }, { "core_name": "夜尿增多", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "腺癌", "tendency": "", "character": [], "anatomy_list": [ "前列腺" ] } ] }, { "id": 434, "text": "现患者无肝区疼痛、骨关节关节疼痛等，今为行第8疗程化疗入院。", "event": [ { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "肝区" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "骨关节" ] } ] }, { "id": 1774, "text": "患病以来，精神、睡眠、食欲可，二便正常，体重无明显减轻", "event": [ { "core_name": "精神", "tendency": "", "character": [ "可" ], "anatomy_list": [] }, { "core_name": "睡眠", "tendency": "", "character": [ "可" ], "anatomy_list": [] }, { "core_name": "食欲", "tendency": "", "character": [ "可" ], "anatomy_list": [] }, { "core_name": "大小便", "tendency": "", "character": [ "正常" ], "anatomy_list": [] }, { "core_name": "体重减轻", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [] } ] }, { "id": 1634, "text": "”诊断为降结肠癌，于2013.8.23日行腹腔镜辅助下左结肠切除术+放射性粒子植入术，术后恢复好，病理类型（左半结肠）溃疡型中分化管状乳头状腺癌，浸及肠壁全层，脉管、神经未见癌侵犯，两切端未见癌累及，淋巴结见癌转移（7/12）），分期t3、n2、m0。", "event": [ { "core_name": "癌", "tendency": "", "character": [], "anatomy_list": [ "降结肠" ] }, { "core_name": "腺癌", "tendency": "", "character": [ "溃疡型", "中分化", "管状", "乳头状" ], "anatomy_list": [ "左半结肠" ] }, { "core_name": "癌", "tendency": "否定", "character": [ "侵犯" ], "anatomy_list": [ "脉管", "神经" ] }, { "core_name": "癌", "tendency": "", "character": [ "浸及" ], "anatomy_list": [ "肠壁全层" ] }, { "core_name": "癌", "tendency": "否定", "character": [ "累及" ], "anatomy_list": [ "两切端" ] }, { "core_name": "癌", "tendency": "", "character": [ "转移", "分期t3、n2、m0" ], "anatomy_list": [ "淋巴结" ] } ] }, { "id": 1115, "text": "患者自起病以来，精神可，胃纳可，大便次数增多，尿频，体重未见明显下降。", "event": [ { "core_name": "精神", "tendency": "", "character": [ "可" ], "anatomy_list": [] }, { "core_name": "胃纳", "tendency": "", "character": [ "可" ], "anatomy_list": [ "胃" ] }, { "core_name": "大便", "tendency": "", "character": [ "次数增多" ], "anatomy_list": [] }, { "core_name": "尿频", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "体重", "tendency": "", "character": [ "无明显下降" ], "anatomy_list": [] } ] }, { "id": 45, "text": "今日患者为求进一步治疗来我院就诊,门诊以“盆腔包块待查”收治入院。", "event": [ { "core_name": "包块", "tendency": "不确定", "character": [], "anatomy_list": [ "盆腔" ] } ] }, { "id": 116, "text": "遂患者为求进一步诊疗于我科住院，我科予以讨论后患者病情后，于2017-06-11、2017-07-04、2017-07-26、2017-08-21、2017-09-25予以5次tac方案化疗，于2017-08-24在全麻下行右乳癌改良根治术，手术顺利，术后标本送常规病检(2017-08-29):<右乳>浸润性癌，非特殊类型，Ⅱ级7分。", "event": [ { "core_name": "癌", "tendency": "", "character": [ "浸润性", "非特殊类型", "Ⅱ级7分" ], "anatomy_list": [ "右乳" ] } ] }, { "id": 1209, "text": "6.子宫腔积液。", "event": [ { "core_name": "积液", "tendency": "", "character": [], "anatomy_list": [ "子宫腔" ] } ] }, { "id": 1179, "text": "诊断慢性髓细胞白血病明确，遂予以国产伊马替尼400mg每日一次口服治疗，前期血象控制尚可，2014年9月底开始多次复查血常规提示白细胞逐渐升高，但脾脏逐渐缩小，患者未定期复查骨穿及调整药物。", "event": [ { "core_name": "白血病", "tendency": "", "character": [ "慢性" ], "anatomy_list": [ "髓细胞" ] }, { "core_name": "白细胞升高", "tendency": "", "character": [ "逐渐" ], "anatomy_list": [ "白细胞" ] }, { "core_name": "脾脏缩小", "tendency": "", "character": [ "逐渐" ], "anatomy_list": [ "脾脏" ] } ] }, { "id": 668, "text": "病程中患者无夜间阵发性呼吸困难，无咯粉红色泡沫痰，无双下肢水肿。", "event": [ { "core_name": "呼吸困难", "tendency": "否定", "character": [ "夜间", "阵发性" ], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "否定", "character": [ "粉红色", "泡沫痰" ], "anatomy_list": [] }, { "core_name": "水肿", "tendency": "否定", "character": [], "anatomy_list": [ "双下肢" ] } ] }, { "id": 1942, "text": "于2018.03.07予以tp方案姑息性化疗；化疗药物（紫杉醇 210mg；顺铂 120mg），胸部ct提示肿瘤处于pd，于2018.05.05更换为dp方案化疗，化疗药物总量（多西他赛 120mg；顺铂120mg），化疗期间无特殊不适，化疗后无骨髓抑制，今为求下周期化疗入院，以\"肺鳞癌伴骨转移\"收入我科。", "event": [ { "core_name": "肿瘤", "tendency": "", "character": [ "处于pd" ], "anatomy_list": [] }, { "core_name": "骨髓抑制", "tendency": "否定", "character": [ "化疗后" ], "anatomy_list": [ "骨髓" ] }, { "core_name": "鳞癌", "tendency": "", "character": [], "anatomy_list": [ "肺" ] }, { "core_name": "鳞癌", "tendency": "", "character": [ "转移" ], "anatomy_list": [ "骨" ] } ] }, { "id": 92, "text": "患者平素月经规则，初潮14岁，周期17天，经期8-9天，量中等，色鲜红，无痛经，血凝块较少，既往白带正常。", "event": [ { "core_name": "月经", "tendency": "", "character": [ "规则" ], "anatomy_list": [] }, { "core_name": "痛经", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "经量", "tendency": "", "character": [ "中等" ], "anatomy_list": [] }, { "core_name": "月经", "tendency": "", "character": [ "色鲜红" ], "anatomy_list": [] }, { "core_name": "血凝块", "tendency": "", "character": [ "较少" ], "anatomy_list": [] }, { "core_name": "白带", "tendency": "", "character": [ "正常" ], "anatomy_list": [] } ] }, { "id": 50, "text": "予以保肝、增强抵抗力等治疗,于2016-3-2行fc方案化疗；今为行化疗于我院就诊,门诊以“慢性淋巴细胞白血病/小淋巴细胞性淋巴瘤 binet b期”收治入院。", "event": [ { "core_name": "白血病", "tendency": "", "character": [ "慢性" ], "anatomy_list": [ "淋巴细胞" ] }, { "core_name": "瘤", "tendency": "", "character": [ "小淋巴细胞性", "binet b期" ], "anatomy_list": [ "淋巴" ] } ] }, { "id": 1102, "text": "患者偶有咳嗽，无活动后心累、气促，无胸闷、胸痛、咯血、呼吸困难，无潮热、盗汗、疲乏、消瘦，无畏寒、发热。", "event": [ { "core_name": "咳嗽", "tendency": "", "character": [ "偶有" ], "anatomy_list": [] }, { "core_name": "气促", "tendency": "否定", "character": [ "活动后" ], "anatomy_list": [] }, { "core_name": "心累", "tendency": "否定", "character": [ "活动后" ], "anatomy_list": [ "心" ] }, { "core_name": "胸闷", "tendency": "否定", "character": [], "anatomy_list": [ "胸" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "胸" ] }, { "core_name": "咯血", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "呼吸困难", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "潮热", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "盗汗", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "疲乏", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "消瘦", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "畏寒", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "发热", "tendency": "否定", "character": [], "anatomy_list": [] } ] }, { "id": 311, "text": "”遂进一步行前列腺穿刺病检提示：“前列腺癌”全身ect提示：“全身骨显影未见明显异常。", "event": [ { "core_name": "癌", "tendency": "", "character": [], "anatomy_list": [ "前列腺" ] }, { "core_name": "骨显影异常", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [ "全身" ] } ] }, { "id": 22, "text": "患者目前诉术区皮肤麻木及轻微刺痛,诉指端皮肤麻木麻木不适,无头晕、乏力等,今日为行放疗就诊于我科门诊,门诊以“乳腺癌 术后化疗后”收入院。", "event": [ { "core_name": "麻木", "tendency": "", "character": [], "anatomy_list": [ "术区皮肤" ] }, { "core_name": "疼痛", "tendency": "", "character": [ "轻微", "刺痛" ], "anatomy_list": [ "术区皮肤" ] }, { "core_name": "麻木", "tendency": "", "character": [], "anatomy_list": [ "指端皮肤" ] }, { "core_name": "麻木不适", "tendency": "", "character": [], "anatomy_list": [ "指端皮肤" ] }, { "core_name": "头晕", "tendency": "否定", "character": [], "anatomy_list": [ "头" ] }, { "core_name": "乏力", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "癌", "tendency": "", "character": [ "术后", "化疗后" ], "anatomy_list": [ "乳腺" ] } ] }, { "id": 31, "text": "入院2天余,患者于当地医院就诊（具体诊断不详）,患者自诉予以“青霉素”治疗后声嘶未见明显好转,后出现阵发性多汗,量多,昼夜无明显变化。", "event": [ { "core_name": "声嘶", "tendency": "否定", "character": [ "明显好转" ], "anatomy_list": [] }, { "core_name": "出汗", "tendency": "", "character": [ "阵发性", "多", "量多", "昼夜无明显变化" ], "anatomy_list": [] } ] }, { "id": 1575, "text": "今日拟行下一周期化疗来院，遂以“直肠癌术后化疗后”收入住院治疗。", "event": [ { "core_name": "癌", "tendency": "", "character": [ "术后化疗后" ], "anatomy_list": [ "直肠" ] } ] }, { "id": 1140, "text": "患者绝经17年，既往月经规律，量中，无痛经。", "event": [ { "core_name": "绝经", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "月经", "tendency": "", "character": [ "规律", "量中" ], "anatomy_list": [] }, { "core_name": "痛经", "tendency": "否定", "character": [], "anatomy_list": [] } ] }, { "id": 1359, "text": "入院前1+月，患者无明显诱因出现左侧胸痛，为持续性胀痛，以咳嗽及深吸气时明显，伴咳嗽，为刺激性干咳，无咳痰，无胸闷、咯血、呼吸困难，无潮热、盗汗、疲乏、消瘦，无畏寒、发热等不适。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [ "持续性", "胀痛", "咳嗽及深吸气时明显" ], "anatomy_list": [ "左侧胸" ] }, { "core_name": "咳嗽", "tendency": "", "character": [ "刺激性干咳" ], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "胸闷", "tendency": "否定", "character": [], "anatomy_list": [ "胸" ] }, { "core_name": "咯血", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "呼吸困难", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "潮热", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "盗汗", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "疲乏", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "消瘦", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "畏寒", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "发热", "tendency": "否定", "character": [], "anatomy_list": [] } ] }, { "id": 1292, "text": "患病以来，精神、睡眠欠佳，食欲尚可，大小便正常，否认近期体重明显减轻。", "event": [ { "core_name": "精神", "tendency": "", "character": [ "欠佳" ], "anatomy_list": [] }, { "core_name": "睡眠", "tendency": "", "character": [ "欠佳" ], "anatomy_list": [] }, { "core_name": "食欲", "tendency": "", "character": [ "尚可" ], "anatomy_list": [] }, { "core_name": "大便", "tendency": "", "character": [ "正常" ], "anatomy_list": [] }, { "core_name": "小便", "tendency": "", "character": [ "正常" ], "anatomy_list": [] }, { "core_name": "体重减轻", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [] } ] }, { "id": 227, "text": "患者于1月前无明显原因出现活动后气促，休息后可稍缓解，无发热，无咳嗽、咳痰，无胸痛、咯血、呼吸困难，无心悸、咯粉红色泡沫痰、夜间阵发性呼吸困难，无腹痛腹泻。", "event": [ { "core_name": "气促", "tendency": "", "character": [ "活动后", "休息后稍缓解" ], "anatomy_list": [] }, { "core_name": "发热", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "咳嗽", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "胸" ] }, { "core_name": "咯血", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "呼吸困难", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "心悸", "tendency": "否定", "character": [], "anatomy_list": [ "心" ] }, { "core_name": "咳痰", "tendency": "否定", "character": [ "粉红色", "泡沫" ], "anatomy_list": [] }, { "core_name": "呼吸困难", "tendency": "否定", "character": [ "夜间", "阵发性" ], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "腹泻", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] } ] }, { "id": 1412, "text": "患者因“左卵巢鳞状细胞癌”于2016.10.01行了经腹双侧附件切除术+盆腹腔淋巴结清扫术+大网膜切除术+阑尾切除术，术程顺利，术后予以抗炎、对症治疗，病检结果回示：直肠表面结节：低分化鳞状细胞癌；右卵巢有低分化鳞状细胞癌；回盲部肿瘤肿瘤结节：低分化鳞状细胞癌；大网膜扪及两个癌结节。", "event": [ { "core_name": "鳞癌", "tendency": "", "character": [], "anatomy_list": [ "左卵巢" ] }, { "core_name": "结节", "tendency": "", "character": [], "anatomy_list": [ "直肠表面" ] }, { "core_name": "鳞癌", "tendency": "", "character": [ "低分化" ], "anatomy_list": [ "直肠" ] }, { "core_name": "鳞癌", "tendency": "", "character": [ "低分化" ], "anatomy_list": [ "右卵巢" ] }, { "core_name": "结节", "tendency": "", "character": [ "肿瘤" ], "anatomy_list": [ "回盲部" ] }, { "core_name": "鳞癌", "tendency": "", "character": [ "低分化" ], "anatomy_list": [ "回盲部", "鳞状细胞" ] }, { "core_name": "结节", "tendency": "", "character": [ "两个", "癌" ], "anatomy_list": [ "大网膜" ] } ] }, { "id": 1677, "text": "此后患者病情反复，尤其秋冬季节交替时症状加重，并逐渐出现活动后喘累，无夜间端坐呼吸及咯粉红色泡沫痰。", "event": [ { "core_name": "喘累", "tendency": "", "character": [ "活动后" ], "anatomy_list": [] }, { "core_name": "端坐呼吸", "tendency": "否定", "character": [ "夜间" ], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "否定", "character": [ "粉红色", "泡沫" ], "anatomy_list": [] } ] }, { "id": 1899, "text": "2.右侧第四肋骨后支骨骨质破坏，伴周围软组织软组织块块影，建议进一步结合穿刺活检检查。", "event": [ { "core_name": "骨质破坏", "tendency": "", "character": [], "anatomy_list": [ "右侧第四肋骨后支骨" ] }, { "core_name": "块影", "tendency": "", "character": [], "anatomy_list": [ "周围软组织" ] } ] }, { "id": 1337, "text": "患者9月余前因“身黄、尿黄16日”入院，于我院诊断为：肝门部胆管癌。", "event": [ { "core_name": "黄染", "tendency": "", "character": [], "anatomy_list": [ "身" ] }, { "core_name": "尿黄", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "癌", "tendency": "", "character": [], "anatomy_list": [ "肝门", "胆管" ] } ] }, { "id": 821, "text": "化疗前予以昂丹司琼止吐，补液等对症治疗，顺利完成前两次化疗，化疗过程中无恶心、呕吐、畏寒、发热、腹泻、黑便等不适。", "event": [ { "core_name": "恶心", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "呕吐", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "畏寒", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "发热", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "腹泻", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "黑便", "tendency": "否定", "character": [], "anatomy_list": [] } ] }, { "id": 1361, "text": "于2016-09-18在某医院完善经彩超引导下左肺实性肿物穿刺活检术，术后病检：（左肺）非小细胞癌，建议做免疫组化进一步分型。", "event": [ { "core_name": "肿物", "tendency": "", "character": [ "实性" ], "anatomy_list": [ "左肺" ] }, { "core_name": "癌", "tendency": "", "character": [], "anatomy_list": [ "左肺", "非小细胞" ] } ] }, { "id": 26, "text": "患者本次发病以来,食欲正常, 神志清醒,精神尚可,睡眠尚可,大便正常,小便正常,体重无明显变化。", "event": [ { "core_name": "食欲", "tendency": "", "character": [ "正常" ], "anatomy_list": [] }, { "core_name": "神志", "tendency": "", "character": [ "清醒" ], "anatomy_list": [] }, { "core_name": "精神", "tendency": "", "character": [ "尚可" ], "anatomy_list": [] }, { "core_name": "睡眠", "tendency": "", "character": [ "尚可" ], "anatomy_list": [] }, { "core_name": "大便", "tendency": "", "character": [ "正常" ], "anatomy_list": [] }, { "core_name": "小便", "tendency": "", "character": [ "正常" ], "anatomy_list": [] }, { "core_name": "体重变化", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [] } ] }, { "id": 113, "text": "7天前，患者无诱因出现腰部疼痛，为持续性胀痛，久卧后加重，坐立可稍缓解，翻身起床时疼痛加重，安静休息部分缓解；无头痛、头晕，无心慌、胸闷，间断性咳嗽，无咯血，无腹痛、腹胀及便血，无双下肢疼痛麻木；到我院就诊，门诊行腰椎mri检查提示：胸腰椎多椎体异常信号改变，考虑骨转移转移性肿瘤，故收治入院。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [ "持续性胀痛", "久卧后加重", "坐立可稍缓解", "翻身起床时疼痛加重", "安静休息部分缓解" ], "anatomy_list": [ "腰部" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "头" ] }, { "core_name": "头晕", "tendency": "否定", "character": [], "anatomy_list": [ "头" ] }, { "core_name": "心慌", "tendency": "否定", "character": [], "anatomy_list": [ "心" ] }, { "core_name": "胸闷", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "咳嗽", "tendency": "否定", "character": [ "间断性" ], "anatomy_list": [] }, { "core_name": "咯血", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "腹胀", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "便血", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "双下肢" ] }, { "core_name": "麻木", "tendency": "否定", "character": [], "anatomy_list": [ "双下肢" ] }, { "core_name": "信号改变", "tendency": "", "character": [ "异常" ], "anatomy_list": [ "胸椎椎体", "腰椎椎体" ] }, { "core_name": "肿瘤", "tendency": "不确定", "character": [ "转移性" ], "anatomy_list": [ "骨组织" ] } ] }, { "id": 1858, "text": "术后予以补液、止血、抗感染、对症支持、伤口换药等处理，病情恢复顺利，无特殊不适，切口愈合良好，好转出院。", "event": [ { "core_name": "切口", "tendency": "", "character": [ "愈合良好" ], "anatomy_list": [] } ] }, { "id": 1010, "text": "患者于2020-08-12乘坐公交车突发左下腹部下腹部疼痛疼痛不适，呈持续性胀痛，后逐渐出现头晕、心慌、乏力等不适，面色逐渐苍白，伴晕厥4次，晕厥时无意识，旁人可唤醒，无头痛，无恶心、呕吐等不适，无明显肛门坠胀，无阴道阴道流血、流液，急诊我院行全腹部ct平扫显示：1、肝实质内散在低密度影，建议增强扫描进一步明确。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [ "突发" ], "anatomy_list": [ "左下腹部" ] }, { "core_name": "疼痛", "tendency": "", "character": [ "持续性", "胀痛" ], "anatomy_list": [ "左下腹部" ] }, { "core_name": "头晕", "tendency": "", "character": [], "anatomy_list": [ "头" ] }, { "core_name": "心慌", "tendency": "", "character": [], "anatomy_list": [ "心" ] }, { "core_name": "疲劳", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "苍白", "tendency": "", "character": [ "面色" ], "anatomy_list": [] }, { "core_name": "晕厥", "tendency": "", "character": [ "无意识", "旁人可唤醒", "4次" ], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "头" ] }, { "core_name": "恶心", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "呕吐", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "坠胀", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [ "肛门" ] }, { "core_name": "出血", "tendency": "否定", "character": [], "anatomy_list": [ "阴道" ] }, { "core_name": "流液", "tendency": "否定", "character": [], "anatomy_list": [ "阴道" ] }, { "core_name": "密度影", "tendency": "", "character": [ "散在", "低" ], "anatomy_list": [ "肝实质内" ] } ] }, { "id": 976, "text": "5年前，患者无明显诱因再次出现咳嗽、咳痰，干咳为主，无咯血、胸痛，无胸闷、气促等不适，患者至当地疾控中心就诊，完善检查后考虑结核复发，再次予以抗结核治疗（具体药物及疗程不详）。", "event": [ { "core_name": "咳嗽", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "咳嗽", "tendency": "", "character": [ "干" ], "anatomy_list": [] }, { "core_name": "咯血", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "胸" ] }, { "core_name": "胸闷", "tendency": "否定", "character": [], "anatomy_list": [ "胸" ] }, { "core_name": "气促", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "结核", "tendency": "不确定", "character": [ "复发" ], "anatomy_list": [] } ] }, { "id": 776, "text": "2017-4-7患者因“咯血1月余”到我院门诊就诊，行胸部ct：右肺上叶占位，考虑周围型肺癌，纵膈及右肺门淋巴结肿大。", "event": [ { "core_name": "咯血", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "占位", "tendency": "", "character": [], "anatomy_list": [ "右肺上叶" ] }, { "core_name": "癌", "tendency": "不确定", "character": [ "周围型" ], "anatomy_list": [ "肺" ] }, { "core_name": "肿大", "tendency": "", "character": [], "anatomy_list": [ "纵膈淋巴结", "右肺门淋巴结" ] } ] }, { "id": 834, "text": "入院前1月患者无明显诱因再次出现感呼吸困难，咳嗽，痰中带血，于2019年12月6日某医院住院，行ct提示甲状软骨水平-气管分叉水平气管壁不均匀增厚 ，局部呈结节样凸向腔内，部分向腔外突出，管腔不同程度变窄，最窄处位于甲状腺水平，双肺散在散在结节较前增多增大。", "event": [ { "core_name": "呼吸困难", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "咳嗽", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "带血" ], "anatomy_list": [] }, { "core_name": "增厚", "tendency": "", "character": [ "不均匀" ], "anatomy_list": [ "甲状软骨水平气管壁" ] }, { "core_name": "增厚", "tendency": "", "character": [ "不均匀" ], "anatomy_list": [ "气管分叉水平气管壁" ] }, { "core_name": "突出", "tendency": "", "character": [ "结节样", "局部", "凸向腔内", "部分向腔外突出" ], "anatomy_list": [ "气管" ] }, { "core_name": "变窄", "tendency": "", "character": [ "不同程度", "最窄处位于甲状腺水平" ], "anatomy_list": [ "管腔" ] }, { "core_name": "结节", "tendency": "", "character": [ "增大", "增多", "散在" ], "anatomy_list": [ "双肺" ] } ] }, { "id": 584, "text": "入院前3小时，驾驶摩托车被其他车辆撞伤，当时受伤时机制不详，伤后即感左小腿膝部疼痛，呈持续性疼痛，伴创面渗血；左足足背拇指开放性伤口，伤口出血，具体出血量不详，伤后无昏迷，可回忆受伤经过，不伴头晕、头痛、心慌、气促、胸闷、胸痛、腹痛、大小便失禁、恶心、呕吐、腹痛、腹胀等，急送入我院就诊，急诊行x线片示：放射检查： 1.左尺桡骨中下段未见异常。", "event": [ { "core_name": "撞伤", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "受伤", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "", "character": [ "持续性" ], "anatomy_list": [ "左小腿", "膝部" ] }, { "core_name": "渗血", "tendency": "", "character": [], "anatomy_list": [ "创面" ] }, { "core_name": "伤口", "tendency": "", "character": [ "开放性", "出血", "具体出血量不详" ], "anatomy_list": [ "左足背", "拇指" ] }, { "core_name": "昏迷", "tendency": "否定", "character": [ "伤后" ], "anatomy_list": [] }, { "core_name": "受伤", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "头晕", "tendency": "否定", "character": [], "anatomy_list": [ "头" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "头" ] }, { "core_name": "心慌", "tendency": "否定", "character": [], "anatomy_list": [ "心" ] }, { "core_name": "气促", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "胸闷", "tendency": "否定", "character": [], "anatomy_list": [ "胸" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "胸" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "大小便", "tendency": "否定", "character": [ "失禁" ], "anatomy_list": [] }, { "core_name": "恶心", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "呕吐", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "腹胀", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "异常", "tendency": "否定", "character": [], "anatomy_list": [ "尺桡骨中段下段" ] } ] }, { "id": 409, "text": "双肺门肺门及纵隔淋巴结显示，fdg代谢增高，倾向反应性增生。", "event": [ { "core_name": "fdg", "tendency": "", "character": [ "代谢增高" ], "anatomy_list": [] }, { "core_name": "增生", "tendency": "不确定", "character": [ "反应性" ], "anatomy_list": [ "双肺门淋巴结", "纵隔淋巴结" ] } ] }, { "id": 461, "text": "3.原l4-l5椎体右侧放射性浓聚灶较前无明显变化，考虑良性病变。", "event": [ { "core_name": "浓聚灶", "tendency": "", "character": [ "放射性", "较前无明显变化" ], "anatomy_list": [ "L4-L5椎体右侧" ] }, { "core_name": "病变", "tendency": "不确定", "character": [ "良性" ], "anatomy_list": [ "L4-L5椎体右侧" ] } ] }, { "id": 1689, "text": "患者自患病以来，精神、饮食、睡眠可，大小便未见明显异常，体重无明显增减。", "event": [ { "core_name": "精神", "tendency": "", "character": [ "可" ], "anatomy_list": [] }, { "core_name": "进食", "tendency": "", "character": [ "可" ], "anatomy_list": [] }, { "core_name": "睡眠", "tendency": "", "character": [ "可" ], "anatomy_list": [] }, { "core_name": "大小便异常", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [] }, { "core_name": "体重改变", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [] } ] }, { "id": 39, "text": "1月前上述症状复发,咳嗽,咳白色泡沫痰,每天痰量约40ml,伴活动后气促、心悸,伴胸痛不适,持续几分钟能自行缓解,无心前区压榨感,无畏寒及寒战,无发热,无咽喉疼痛,无头昏及头痛,无恶心及呕吐,无腹胀及腹痛。", "event": [ { "core_name": "咳嗽", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "白色", "泡沫痰" ], "anatomy_list": [] }, { "core_name": "气促", "tendency": "", "character": [ "活动后" ], "anatomy_list": [] }, { "core_name": "心悸", "tendency": "", "character": [ "活动后" ], "anatomy_list": [ "心" ] }, { "core_name": "疼痛", "tendency": "", "character": [ "持续几分钟能自行缓解" ], "anatomy_list": [ "胸部" ] }, { "core_name": "压榨感", "tendency": "否定", "character": [], "anatomy_list": [ "心前区" ] }, { "core_name": "畏寒", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "寒颤", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "发热", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "咽", "喉" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "头" ] }, { "core_name": "头昏", "tendency": "否定", "character": [], "anatomy_list": [ "头" ] }, { "core_name": "恶心", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "呕吐", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "腹胀", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] } ] }, { "id": 1266, "text": "入院前1+月，患者无明显诱因再次出现咳嗽、咳痰，为白色泡沫痰，量多，不易咳出，且偶感头晕，感进食梗阻、胸部胀痛，伴背部牵涉痛，食欲明显降低，无发热、畏寒，无头痛，无恶心、呕吐，无胸痛、心前区压榨感，无腹胀、腹痛、腹泻等不适，遂于我院胃肠外科门诊就诊，行上消化道钡餐检查（2018-3-19，我院）示：1.食管中下段外压性改变，考虑左肺门肿块所致，请结合ct检查。", "event": [ { "core_name": "咳嗽", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "白色", "泡沫痰", "量多", "不易咳出" ], "anatomy_list": [] }, { "core_name": "头晕", "tendency": "", "character": [ "偶感" ], "anatomy_list": [ "头" ] }, { "core_name": "进食", "tendency": "", "character": [ "梗阻" ], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "", "character": [ "胀痛" ], "anatomy_list": [ "胸部" ] }, { "core_name": "疼痛", "tendency": "", "character": [ "牵涉痛" ], "anatomy_list": [ "背部" ] }, { "core_name": "食欲", "tendency": "", "character": [ "明显降低" ], "anatomy_list": [] }, { "core_name": "发热", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "畏寒", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "头" ] }, { "core_name": "恶心", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "呕吐", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "胸" ] }, { "core_name": "压榨感", "tendency": "否定", "character": [], "anatomy_list": [ "心前区" ] }, { "core_name": "腹胀", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "腹泻", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "改变", "tendency": "", "character": [ "外压性" ], "anatomy_list": [ "食管中下段" ] }, { "core_name": "肿块", "tendency": "不确定", "character": [], "anatomy_list": [ "左肺门" ] } ] }, { "id": 445, "text": "为进一步诊治，拟“慢性阻塞性肺疾病急性发作伴肺部感染”收入院", "event": [ { "core_name": "肺疾病", "tendency": "", "character": [ "慢性", "阻塞性", "急性发作" ], "anatomy_list": [ "肺部" ] }, { "core_name": "感染", "tendency": "", "character": [], "anatomy_list": [ "肺部" ] } ] }, { "id": 1887, "text": "入院前1+月，患者因右眼红痛3月到我院就诊，诊断为右眼角膜溃疡穿孔，双眼白内障术后，冠心病，并在我科住院治疗，住院后完善相关检查并给予抗炎治疗后，右眼角膜溃疡无明显好转，给予行右眼结膜瓣遮盖术，术后患者眼痛症状明显缓解，后患者因右侧腹股沟疝转入我院普外科治疗，患者出院后自觉右眼渐出现疼痛，并逐渐加重，患者及其家属为求进一步诊治，再次来我院就诊，经检查诊断为右眼角膜溃疡术后，建议住院治疗，遂于今日收住院。", "event": [ { "core_name": "右眼红", "tendency": "", "character": [], "anatomy_list": [ "右眼" ] }, { "core_name": "疼痛", "tendency": "", "character": [], "anatomy_list": [ "右眼" ] }, { "core_name": "穿孔", "tendency": "", "character": [ "溃疡" ], "anatomy_list": [ "右眼角膜" ] }, { "core_name": "白内障", "tendency": "", "character": [ "术后" ], "anatomy_list": [ "双眼" ] }, { "core_name": "冠心病", "tendency": "", "character": [], "anatomy_list": [ "心" ] }, { "core_name": "溃疡", "tendency": "否定", "character": [ "明显好转" ], "anatomy_list": [ "右眼角膜" ] }, { "core_name": "疼痛", "tendency": "", "character": [ "明显缓解" ], "anatomy_list": [ "眼" ] }, { "core_name": "疝", "tendency": "", "character": [], "anatomy_list": [ "右侧腹股沟" ] }, { "core_name": "疼痛", "tendency": "", "character": [ "逐渐加重" ], "anatomy_list": [ "右眼" ] }, { "core_name": "溃疡", "tendency": "", "character": [ "术后" ], "anatomy_list": [ "右眼角膜" ] } ] }, { "id": 1063, "text": "发现血糖升高5年，既往诊断“2型糖尿病”明确，现予“格列齐特”控制血糖尚可，具体数值不详。", "event": [ { "core_name": "血糖", "tendency": "", "character": [ "升高" ], "anatomy_list": [] }, { "core_name": "糖尿病", "tendency": "", "character": [ "2型" ], "anatomy_list": [] }, { "core_name": "血糖", "tendency": "", "character": [ "控制尚可" ], "anatomy_list": [] } ] }, { "id": 1401, "text": "病程中患者月经无改变，无痛经，无头晕、心慌，无尿频、尿急、肛门坠胀等不适。", "event": [ { "core_name": "月经", "tendency": "否定", "character": [ "改变" ], "anatomy_list": [] }, { "core_name": "痛经", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "头晕", "tendency": "否定", "character": [], "anatomy_list": [ "头" ] }, { "core_name": "心慌", "tendency": "否定", "character": [], "anatomy_list": [ "心" ] }, { "core_name": "尿频", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "尿急", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "坠胀", "tendency": "否定", "character": [], "anatomy_list": [ "肛门" ] } ] }, { "id": 160, "text": "患“高脂血症”1+年，未规范性用药。", "event": [ { "core_name": "高脂血症", "tendency": "", "character": [], "anatomy_list": [] } ] }, { "id": 354, "text": "腋窝淋巴结转移1/12。", "event": [ { "core_name": "转移", "tendency": "", "character": [], "anatomy_list": [ "腋窝淋巴结" ] } ] }, { "id": 246, "text": "患者于入院前1月余无明显诱因出现厌油伴食欲下降、恶心，无返酸、嗳气、呕吐、呕血，无腹痛、腹胀、腹泻、黑便，无发热、寒战，无头晕、头痛，患者未予重视，未行任何处理。", "event": [ { "core_name": "厌油", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "食欲", "tendency": "", "character": [ "下降" ], "anatomy_list": [] }, { "core_name": "恶心", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "返酸", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "嗳气", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "呕吐", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "呕血", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "腹胀", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "腹泻", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "黑便", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "发热", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "寒颤", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "头晕", "tendency": "否定", "character": [], "anatomy_list": [ "头" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "头" ] } ] }, { "id": 649, "text": "患者自起病以来，精神较萎，胃纳较差，大便如常，小便如常，体重未见明显下降。", "event": [ { "core_name": "精神", "tendency": "", "character": [ "较萎" ], "anatomy_list": [] }, { "core_name": "胃纳", "tendency": "", "character": [ "较差" ], "anatomy_list": [ "胃" ] }, { "core_name": "大便", "tendency": "", "character": [ "如常" ], "anatomy_list": [] }, { "core_name": "小便", "tendency": "", "character": [ "如常" ], "anatomy_list": [] }, { "core_name": "体重下降", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [] } ] }, { "id": 1341, "text": "<癌栓袋>见癌组织。", "event": [ { "core_name": "癌组织", "tendency": "", "character": [], "anatomy_list": [ "癌栓袋" ] } ] }, { "id": 1302, "text": "放疗后患者诉偶有咳嗽不适，以夜间平卧时明显，考虑放射性食管炎，给予口服“雷贝拉唑”抑酸护胃治疗后好转出院。", "event": [ { "core_name": "咳嗽", "tendency": "", "character": [ "夜间平卧时明显", "放疗后", "偶有" ], "anatomy_list": [] }, { "core_name": "食管炎", "tendency": "不确定", "character": [ "放射性" ], "anatomy_list": [ "食管" ] } ] }, { "id": 1050, "text": "今日门诊以“乳癌术后化疗”收入我科。", "event": [ { "core_name": "癌", "tendency": "", "character": [ "术后化疗" ], "anatomy_list": [ "乳" ] } ] }, { "id": 301, "text": "其后于我科行卡铂0.45g1+足叶乙甙0.15g1-3方案化疗６周期，化疗过程中患者无明显恶心、呕吐等胃肠道反应，咳嗽等症状明显好转，患者定期在我院复查，均无明显进展。", "event": [ { "core_name": "恶心", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [] }, { "core_name": "呕吐", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [] }, { "core_name": "胃肠道反应", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [ "胃肠道" ] }, { "core_name": "咳嗽", "tendency": "", "character": [ "明显好转" ], "anatomy_list": [] } ] }, { "id": 402, "text": "术后患者行3疗程辅助化疗，方案为ec-t（表柔比星+环磷酰胺序贯多西他赛），化疗过程顺利，未出现药物骨髓毒性反应，现患者为第四次化疗入院。", "event": [ { "core_name": "毒性反应", "tendency": "否定", "character": [ "药物" ], "anatomy_list": [ "骨髓" ] } ] }, { "id": 846, "text": "患者6+月前因“阵发性腹痛，伴肛门停止排气、排便2天”入院。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [ "阵发性" ], "anatomy_list": [ "腹" ] }, { "core_name": "排气", "tendency": "", "character": [ "停止" ], "anatomy_list": [ "肛门" ] }, { "core_name": "排便", "tendency": "", "character": [ "停止2天" ], "anatomy_list": [ "肛门" ] } ] }, { "id": 2016, "text": "患者本次发病以来，食欲减退，神志清醒，精神欠佳，睡眠欠佳，大便5日未解，小便正常，体重减少约1kg。", "event": [ { "core_name": "食欲", "tendency": "", "character": [ "减退" ], "anatomy_list": [] }, { "core_name": "神志", "tendency": "", "character": [ "清醒" ], "anatomy_list": [] }, { "core_name": "精神", "tendency": "", "character": [ "欠佳" ], "anatomy_list": [] }, { "core_name": "睡眠", "tendency": "", "character": [ "欠佳" ], "anatomy_list": [] }, { "core_name": "大便", "tendency": "", "character": [ "5日未解" ], "anatomy_list": [] }, { "core_name": "小便", "tendency": "", "character": [ "正常" ], "anatomy_list": [] }, { "core_name": "体重减轻", "tendency": "", "character": [], "anatomy_list": [] } ] }, { "id": 1348, "text": "1月余前患者无明显诱因出现乏力、纳差，无明显腹痛、腹胀，无反酸、嗳气，无心悸、气促，入我院后予以保肝治疗后好转，并于2019年11月26日、2019年12月18日输注信迪利单抗200mg，输注过程顺利，未诉特殊不适。", "event": [ { "core_name": "乏力", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "纳差", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [ "腹" ] }, { "core_name": "腹胀", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [ "腹" ] }, { "core_name": "反酸", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "嗳气", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "心悸", "tendency": "否定", "character": [], "anatomy_list": [ "心" ] }, { "core_name": "气促", "tendency": "否定", "character": [], "anatomy_list": [] } ] }, { "id": 86, "text": "入院前10+月，患者无明显诱因出现活动后心累气促，伴全身乏力，自觉日常活动轻微受限，无头昏、眼花及耳鸣，无畏寒、发热，无咳嗽、咳痰、咯血，无胸闷、心悸及心前区压榨感，无腹痛、呕血及黑便，无皮肤瘀点瘀点及瘀斑，无牙龈出血，无黄染，无肝掌及蜘蛛痣，患者于我院心血管内科住院治疗，查血常规：白细胞数2.46*10^9/L↓红细胞数2.73*10^12/L↓;血红蛋白60g/L↓;血小板数75*10^9/L↓，患者拒绝行骨髓穿刺及输血治疗，给予对症治疗后出院，之后患者上述症状加重，活动后心累气促，日常活动受影响，无咳嗽咳痰，无畏寒发热，无牙龈出血，全身未见瘀斑瘀点，无头晕头痛，无阵发性呼吸困难，查血常规提示：血红蛋白46g/L↓，我院输血等对症治疗后好转出院，患者于某医院就诊，行骨髓穿刺结果考虑mds-raeb2,骨髓活检考虑mds，未治疗；6+月前，患者再次出现活动后心累气促及乏力症状加重，表现为快走时心累气促，休息后缓解，日常活动轻度受限，予以抗感染、输血治疗，并于2018年11月29号给予输注地西他滨25mg1-5全身化疗，化疗后出现iii度骨髓抑制，予以升白、升血小板治疗后纠正。", "event": [ { "core_name": "心累", "tendency": "", "character": [ "活动后" ], "anatomy_list": [ "心" ] }, { "core_name": "气促", "tendency": "", "character": [ "活动后" ], "anatomy_list": [] }, { "core_name": "乏力", "tendency": "", "character": [], "anatomy_list": [ "全身" ] }, { "core_name": "活动受限", "tendency": "", "character": [ "轻微", "日常" ], "anatomy_list": [] }, { "core_name": "头昏", "tendency": "否定", "character": [], "anatomy_list": [ "头" ] }, { "core_name": "眼花", "tendency": "否定", "character": [ "模糊" ], "anatomy_list": [ "眼" ] }, { "core_name": "耳鸣", "tendency": "否定", "character": [], "anatomy_list": [ "耳" ] }, { "core_name": "畏寒", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "发热", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "咳嗽", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "咯血", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "胸闷", "tendency": "否定", "character": [], "anatomy_list": [ "胸" ] }, { "core_name": "心悸", "tendency": "否定", "character": [], "anatomy_list": [ "心" ] }, { "core_name": "压榨感", "tendency": "否定", "character": [], "anatomy_list": [ "心前区" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "呕血", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "黑便", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "瘀点", "tendency": "否定", "character": [], "anatomy_list": [ "皮肤" ] }, { "core_name": "瘀斑", "tendency": "否定", "character": [], "anatomy_list": [ "皮肤" ] }, { "core_name": "出血", "tendency": "否定", "character": [], "anatomy_list": [ "牙龈" ] }, { "core_name": "黄染", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "肝掌", "tendency": "否定", "character": [], "anatomy_list": [ "掌" ] }, { "core_name": "蜘蛛痣", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "心累", "tendency": "", "character": [ "活动后" ], "anatomy_list": [ "心" ] }, { "core_name": "气促", "tendency": "", "character": [ "活动后" ], "anatomy_list": [] }, { "core_name": "活动受限", "tendency": "", "character": [ "日常" ], "anatomy_list": [] }, { "core_name": "咳嗽", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "畏寒", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "发热", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "出血", "tendency": "否定", "character": [], "anatomy_list": [ "牙龈" ] }, { "core_name": "瘀斑", "tendency": "否定", "character": [], "anatomy_list": [ "全身" ] }, { "core_name": "瘀点", "tendency": "否定", "character": [], "anatomy_list": [ "全身" ] }, { "core_name": "头晕", "tendency": "否定", "character": [], "anatomy_list": [ "头" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "头" ] }, { "core_name": "呼吸困难", "tendency": "否定", "character": [ "阵发性" ], "anatomy_list": [] }, { "core_name": "mds-raeb2", "tendency": "不确定", "character": [], "anatomy_list": [ "骨髓" ] }, { "core_name": "mds", "tendency": "不确定", "character": [], "anatomy_list": [] }, { "core_name": "心累", "tendency": "", "character": [ "活动后", "症状加重" ], "anatomy_list": [ "心" ] }, { "core_name": "气促", "tendency": "", "character": [ "活动后", "症状加重" ], "anatomy_list": [] }, { "core_name": "乏力", "tendency": "", "character": [ "活动后", "症状加重" ], "anatomy_list": [] }, { "core_name": "心累", "tendency": "", "character": [ "快走时", "休息后缓解" ], "anatomy_list": [ "心" ] }, { "core_name": "气促", "tendency": "", "character": [ "快走时", "休息后缓解" ], "anatomy_list": [] }, { "core_name": "活动受限", "tendency": "", "character": [ "日常", "轻度" ], "anatomy_list": [] }, { "core_name": "骨髓抑制", "tendency": "", "character": [ "iii度" ], "anatomy_list": [ "骨髓" ] } ] }, { "id": 1322, "text": "排除穿刺禁忌后给予胸腔穿刺引流，并在纤维支气管镜下取肺部占位行病理活检示：免疫组化：gcdfp-15（-），gata-3（+），ck（+），ck8（+），her-2（1+），pr小灶（+），er小灶（+）。", "event": [ { "core_name": "病变", "tendency": "", "character": [ "占位" ], "anatomy_list": [ "肺部" ] } ] }, { "id": 384, "text": "为进一步治疗，今日以\" 肺癌化疗后 \"收入我科。", "event": [ { "core_name": "癌", "tendency": "", "character": [ "化疗后" ], "anatomy_list": [ "肺" ] } ] }, { "id": 115, "text": "患者因“发现右乳一包快2+月”，于我院门诊行乳腺活检术，术后病理检查结果回报“<右乳>乳腺癌”。", "event": [ { "core_name": "包块", "tendency": "", "character": [], "anatomy_list": [ "右乳" ] }, { "core_name": "癌", "tendency": "", "character": [], "anatomy_list": [ "右乳乳腺" ] } ] }, { "id": 413, "text": "患者于2012年4月23日我院行左乳房乳癌改良根治术＋前哨淋巴结活检术，术后病理提示：前哨淋巴结未见癌转移，已行１次术前辅助化疗，7次术后辅助化疗，化疗方案为吡柔比星＋环磷酰胺＋多西他赛（ＡＣＴ）。", "event": [ { "core_name": "癌", "tendency": "否定", "character": [ "转移" ], "anatomy_list": [ "前哨淋巴结" ] } ] }, { "id": 992, "text": "1年前出现反复腰背痛，尤以t2-4、t7椎体，t8椎体严重，无放射，平卧位稍缓解，疼痛由间断性逐渐发展为持续性。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [ "反复", "尤以t2-4、t7、t8椎体严重", "平卧位稍缓解" ], "anatomy_list": [ "腰", "背" ] }, { "core_name": "疼痛", "tendency": "", "character": [ "放射性" ], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "", "character": [ "由间断性逐渐发展为持续" ], "anatomy_list": [ "腰", "背" ] } ] }, { "id": 287, "text": "2月前患者无明显诱因出现胸痛，为双侧胸部隐痛，呈持续性，程度轻，咳嗽及翻身时加重，休息后缓解，否认与深呼吸、进食、活动有关，偶有咳嗽、咽干、晨起流涕，为白色粘涕，无发热、潮热、盗汗，无咳痰、咯血、咽痛、肌肉酸痛，无胸闷、心悸、喘累，无反酸、烧心、嗳气，无皮肤皮疹、红肿等不适。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [], "anatomy_list": [ "胸" ] }, { "core_name": "疼痛", "tendency": "", "character": [ "隐痛", "呈持续性", "程度轻", "咳嗽及翻身时加重", "休息后缓解", "否认与深呼吸、进食、活动有关" ], "anatomy_list": [ "双侧胸部" ] }, { "core_name": "咳嗽", "tendency": "", "character": [ "偶有" ], "anatomy_list": [] }, { "core_name": "咽干", "tendency": "", "character": [ "偶有" ], "anatomy_list": [] }, { "core_name": "流涕", "tendency": "", "character": [ "晨起", "白色粘涕" ], "anatomy_list": [] }, { "core_name": "发热", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "潮热", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "盗汗", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "咯血", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "咽" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [ "酸痛" ], "anatomy_list": [ "肌肉" ] }, { "core_name": "胸闷", "tendency": "否定", "character": [], "anatomy_list": [ "胸" ] }, { "core_name": "心悸", "tendency": "否定", "character": [], "anatomy_list": [ "心" ] }, { "core_name": "喘累", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "反酸", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "烧心", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "嗳气", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "皮疹", "tendency": "否定", "character": [], "anatomy_list": [ "皮肤" ] }, { "core_name": "红肿", "tendency": "否定", "character": [], "anatomy_list": [ "皮肤" ] } ] }, { "id": 230, "text": "为进一步诊治，遂于我院就诊，门诊拟“胸腔积液原因待查”收入住院。", "event": [ { "core_name": "积液", "tendency": "不确定", "character": [], "anatomy_list": [ "胸腔" ] } ] }, { "id": 1602, "text": "入院前半天，患者无明显诱因症状复发加重，伴胸口紧缩感，伴腰部及双下肢游走性疼痛，伴咳嗽咳黑灰色粘液痰（未见到痰液），无恶心呕吐，无头昏头痛，无黑曚晕厥，无胸痛，无腹痛腹胀，无四肢乏力等不适，遂送入我院治疗，门诊以“心力衰竭\"收入我科。", "event": [ { "core_name": "紧缩感", "tendency": "", "character": [], "anatomy_list": [ "胸口" ] }, { "core_name": "疼痛", "tendency": "", "character": [ "游走性" ], "anatomy_list": [ "腰部", "双下肢" ] }, { "core_name": "咳嗽", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "粘液", "黑灰色" ], "anatomy_list": [] }, { "core_name": "恶心", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "呕吐", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "头昏", "tendency": "否定", "character": [], "anatomy_list": [ "头" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "头" ] }, { "core_name": "黒朦", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "晕厥", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "胸" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "腹胀", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "乏力", "tendency": "否定", "character": [], "anatomy_list": [ "四肢" ] }, { "core_name": "心力衰竭", "tendency": "", "character": [], "anatomy_list": [ "心" ] } ] }, { "id": 351, "text": "6天前患者于我院行妇科彩超发现子宫左前方见大小约156×92mm的异常无回声区,边界清,形态规则,无回声区区内透声好,cdfi:其内部及周边可探及血流信号。", "event": [ { "core_name": "回声区", "tendency": "", "character": [ "异常", "无", "边界清", "形态规则", "无回声区内透声好" ], "anatomy_list": [ "子宫左前方" ] }, { "core_name": "血流信号", "tendency": "", "character": [], "anatomy_list": [ "内部及周边" ] } ] }, { "id": 1934, "text": "2017-4-12某医院pet-ct示：1、结肠术后改变，未见明确复发征象，吻合口上方、下方右侧腰大肌旁及腹腔第1212、16组多发淋巴结转移。", "event": [ { "core_name": "术后改变", "tendency": "", "character": [], "anatomy_list": [ "结肠" ] }, { "core_name": "转移", "tendency": "", "character": [ "多发" ], "anatomy_list": [ "吻合口上方、下方右侧腰大肌旁腹腔1212、16组淋巴结" ] } ] }, { "id": 1267, "text": "2.胃窦炎征象。", "event": [ { "core_name": "胃窦炎", "tendency": "", "character": [], "anatomy_list": [ "胃窦" ] } ] }, { "id": 994, "text": "7月前，患者行相关检查，ct、ect均提示转移性骨肿瘤，并来我院行化疗，上一次化疗时间为2013.5.25,化疗方案为长春瑞滨+洛铂,患者为行相关检查来我院，门诊以“左乳癌术后”收治入院。", "event": [ { "core_name": "肿瘤", "tendency": "", "character": [ "转移性" ], "anatomy_list": [ "骨" ] }, { "core_name": "癌", "tendency": "", "character": [ "术后" ], "anatomy_list": [ "左乳" ] } ] }, { "id": 954, "text": "患者现为求进一步诊治，急诊拟“消化道出血”收住入院。", "event": [ { "core_name": "出血", "tendency": "", "character": [], "anatomy_list": [ "消化道" ] } ] }, { "id": 241, "text": "1+月前患者症状较前加重，并出现腰背部疼痛伴双下肢大腿后外侧胀痛，平卧位或侧卧位疼痛加重，端坐位或站立位疼痛减轻。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [ "平卧位或侧卧位疼痛加重，端坐位或站立位疼痛减轻" ], "anatomy_list": [ "腰背部" ] }, { "core_name": "胀痛", "tendency": "", "character": [ "平卧位或侧卧位疼痛加重，端坐位或站立位疼痛减轻" ], "anatomy_list": [ "双下肢大腿后外侧" ] } ] }, { "id": 1578, "text": "期间每年行常规体检，查宫颈刮片等未见明显异常。", "event": [ { "core_name": "异常", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [ "宫颈" ] } ] }, { "id": 924, "text": "建议ctu检查，盆腔少量积液。", "event": [ { "core_name": "积液", "tendency": "", "character": [ "少量" ], "anatomy_list": [ "盆腔" ] } ] }, { "id": 1806, "text": "3天来患者精神食欲及睡眠差，大小便正常，体重无明显减轻。", "event": [ { "core_name": "精神", "tendency": "", "character": [ "差" ], "anatomy_list": [] }, { "core_name": "食欲", "tendency": "", "character": [ "差" ], "anatomy_list": [] }, { "core_name": "睡眠", "tendency": "", "character": [ "差" ], "anatomy_list": [] }, { "core_name": "大小便", "tendency": "", "character": [ "正常" ], "anatomy_list": [] }, { "core_name": "体重减轻", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [] } ] }, { "id": 870, "text": "入院前8年，患者无明显诱因出现双侧第一跖趾关节关节疼痛，伴发热、发红、关节肿痛，至当地医院就诊，考虑“痛风”，予以“秋水仙碱”口服后关节疼痛疼痛缓解，后未规律服药。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [], "anatomy_list": [ "双侧第1跖趾关节" ] }, { "core_name": "发热", "tendency": "", "character": [], "anatomy_list": [ "双侧第1跖趾关节" ] }, { "core_name": "发红", "tendency": "", "character": [], "anatomy_list": [ "双侧第1跖趾关节" ] }, { "core_name": "肿痛", "tendency": "", "character": [], "anatomy_list": [ "双侧第1跖趾关节" ] }, { "core_name": "痛风", "tendency": "不确定", "character": [], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "", "character": [ "缓解" ], "anatomy_list": [ "关节" ] } ] }, { "id": 1825, "text": "10+天前患者再次出现喘累，活动后气促，伴腹胀，入院后予以胸腔、腹腔穿刺置管引流后稍好转，复查腹部ct见腹腔内肿瘤广泛转移，予以对症治疗后出院。", "event": [ { "core_name": "喘累", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "气促", "tendency": "", "character": [ "活动后" ], "anatomy_list": [] }, { "core_name": "腹胀", "tendency": "", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "肿瘤", "tendency": "", "character": [ "广泛转移" ], "anatomy_list": [ "腹腔内" ] } ] }, { "id": 630, "text": "患者平素无同房出血，无异常阴道流血、流液，于8月前于我院行妇科检查宫颈hpv16型阳性，宫颈tct未见上皮内病变及恶性病变，嘱其门诊随访。", "event": [ { "core_name": "出血", "tendency": "否定", "character": [ "同房后" ], "anatomy_list": [] }, { "core_name": "出血", "tendency": "否定", "character": [ "异常" ], "anatomy_list": [ "阴道" ] }, { "core_name": "宫颈hpv16型", "tendency": "", "character": [ "阳性" ], "anatomy_list": [] }, { "core_name": "流液", "tendency": "否定", "character": [ "异常" ], "anatomy_list": [ "阴道" ] }, { "core_name": "病变", "tendency": "否定", "character": [ "上皮内" ], "anatomy_list": [ "宫颈" ] }, { "core_name": "病变", "tendency": "否定", "character": [ "恶性" ], "anatomy_list": [ "宫颈" ] } ] }, { "id": 1828, "text": "入院前1+年，患者劳累后出现下腹部刺痛刺痛感，伴尿痛，患者无尿频、尿急，肉眼血尿，无腰部疼痛，无恶心、呕吐，无腹胀、腹泻、便秘等，无头晕、头痛，无胸闷、胸痛、心悸、气促，无寒战、发热等不适，患者未予重视，未予处理。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [ "劳累后", "刺痛" ], "anatomy_list": [ "下腹部" ] }, { "core_name": "尿痛", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "尿频", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "尿急", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "血尿", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "腰部" ] }, { "core_name": "恶心", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "呕吐", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "腹胀", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "腹泻", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "便秘", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "头晕", "tendency": "否定", "character": [], "anatomy_list": [ "头" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "头" ] }, { "core_name": "胸闷", "tendency": "否定", "character": [], "anatomy_list": [ "胸" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "胸" ] }, { "core_name": "心悸", "tendency": "否定", "character": [], "anatomy_list": [ "心" ] }, { "core_name": "气促", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "寒颤", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "发热", "tendency": "否定", "character": [], "anatomy_list": [] } ] }, { "id": 1925, "text": "患者急性腹膜炎经消化疾病中心会诊后建议行手术治疗，患者拒绝并要求保守治疗，经对症保守治疗后病情好转自动出院。", "event": [ { "core_name": "腹膜炎", "tendency": "", "character": [ "急性" ], "anatomy_list": [ "腹膜" ] } ] }, { "id": 1155, "text": "急诊以“抽搐待查”收入我科住院治疗。", "event": [ { "core_name": "抽搐", "tendency": "不确定", "character": [], "anatomy_list": [] } ] }, { "id": 218, "text": "为求进一步诊治，门诊以“左肺鳞癌”收入我科。", "event": [ { "core_name": "鳞癌", "tendency": "", "character": [], "anatomy_list": [ "左肺" ] } ] }, { "id": 1759, "text": "2.肝内钙化灶。", "event": [ { "core_name": "钙化灶", "tendency": "", "character": [], "anatomy_list": [ "肝内" ] } ] }, { "id": 1386, "text": "气促，无心慌、心悸等。", "event": [ { "core_name": "气促", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "心慌", "tendency": "否定", "character": [], "anatomy_list": [ "心" ] }, { "core_name": "心悸", "tendency": "否定", "character": [], "anatomy_list": [ "心" ] } ] }, { "id": 182, "text": "双肺散在散在结节，考虑转移瘤可能。", "event": [ { "core_name": "结节", "tendency": "", "character": [ "散在" ], "anatomy_list": [ "双肺" ] }, { "core_name": "瘤", "tendency": "不确定", "character": [ "转移" ], "anatomy_list": [] } ] }, { "id": 119, "text": "于2017-09-02行tac方案化疗治疗，化疗过程中予以抗过敏、护胃、止吐、对症等治疗，今日为行术后第3次化疗，遂来我科就诊，门诊以“右乳癌术后第2次化疗后”收入我科。", "event": [ { "core_name": "癌", "tendency": "", "character": [ "术后", "第2次化疗后" ], "anatomy_list": [ "右乳" ] } ] }, { "id": 1447, "text": "78月前（2010年10月），患者因乳腺癌术后放化疗后复查示afp异常升高（85.77IU/ml），腹部彩超未见明显异常占位。", "event": [ { "core_name": "占位", "tendency": "否定", "character": [ "明显异常" ], "anatomy_list": [] } ] }, { "id": 484, "text": "患者于2020年10月22日至我院呼吸科就诊，行纤支镜检查活检病理报告：（气管中段）淋巴组织增生性病变，结合临床资料、内镜所见及免疫表型，符合低级别淋巴瘤，倾向黏膜相关淋巴组织结外边缘区淋巴瘤（maltoma）。", "event": [ { "core_name": "病变", "tendency": "", "character": [ "增生性" ], "anatomy_list": [ "气管中段淋巴组织" ] }, { "core_name": "瘤", "tendency": "", "character": [ "低级别" ], "anatomy_list": [ "淋巴" ] }, { "core_name": "瘤", "tendency": "不确定", "character": [ "黏膜相关" ], "anatomy_list": [ "淋巴组织结外边缘区", "淋巴" ] } ] }, { "id": 224, "text": "给予对症治疗后，患者当日即前往某医院就诊，行肠镜及病检提示：降结肠新生物伴狭窄，管状-绒毛状腺瘤，横结肠及降结肠交界区肠壁不均匀增厚，结肠癌？侵犯胃壁；腹盆腔积液，腹膜网膜肠系膜增厚模糊，转移待排，肝左外叶姐姐，不典型血管瘤？转移？。", "event": [ { "core_name": "新生物", "tendency": "", "character": [], "anatomy_list": [ "降结肠" ] }, { "core_name": "狭窄", "tendency": "", "character": [], "anatomy_list": [ "降结肠" ] }, { "core_name": "腺瘤", "tendency": "", "character": [ "管状-绒毛状" ], "anatomy_list": [] }, { "core_name": "增厚", "tendency": "", "character": [ "不均匀" ], "anatomy_list": [ "横结肠及降结肠交界区肠壁" ] }, { "core_name": "癌", "tendency": "不确定", "character": [], "anatomy_list": [ "结肠" ] }, { "core_name": "侵犯", "tendency": "", "character": [], "anatomy_list": [ "胃壁" ] }, { "core_name": "积液", "tendency": "", "character": [], "anatomy_list": [ "腹", "盆腔" ] }, { "core_name": "增厚模糊", "tendency": "", "character": [], "anatomy_list": [ "腹膜", "肠系膜", "网膜" ] }, { "core_name": "转移", "tendency": "不确定", "character": [], "anatomy_list": [] }, { "core_name": "结节", "tendency": "", "character": [], "anatomy_list": [ "肝左外叶" ] }, { "core_name": "血管瘤", "tendency": "不确定", "character": [ "不典型" ], "anatomy_list": [] }, { "core_name": "转移", "tendency": "不确定", "character": [], "anatomy_list": [] } ] }, { "id": 29, "text": "入院1年前因“发现尿量减少4月,皮肤瘙痒20天”收入我科,考虑“继发性甲状旁腺功能亢进”,予以纠正贫血、降磷补钙、规律透析等治疗后,症状好转出院,出院后于当地医院规律透析治疗,规律透析（周二、周四、周六）,未规律监测肌酐,偶查肌酐,值约1000umol/L。", "event": [ { "core_name": "尿量", "tendency": "", "character": [ "减少" ], "anatomy_list": [] }, { "core_name": "瘙痒", "tendency": "", "character": [], "anatomy_list": [ "皮肤" ] }, { "core_name": "甲状旁腺功能亢进", "tendency": "不确定", "character": [ "继发性" ], "anatomy_list": [ "甲状旁腺" ] } ] }, { "id": 713, "text": "2020-8-3he4348.90pmol/l↑，ca-1252579.0u/ml↑，于8-4、8-5在我科住院予以免疫细胞治疗（“pd1-t细胞生物制剂”），输注后有轻微恶心、反胃、乏力、食欲减退等不适，停药后症状逐渐消失，现每日口服“盐酸羟考酮缓释片（10mg）”予以镇痛治疗，目前觉左侧腰骶部及左下肢疼痛、麻木较前加重，休息时不能向左侧平躺，无头晕、头痛、心慌、心悸、腹痛、腹胀等不适，小便正常，大便干燥，2~3日1次，此次要求行第二次免疫细胞治疗，门诊以“卵巢高级别浆液性癌iiic期术后化疗后复发伴骨、肺、盆腔、腹腔淋巴结转移”收入我科。", "event": [ { "core_name": "恶心", "tendency": "", "character": [ "输注后", "轻微" ], "anatomy_list": [] }, { "core_name": "反胃", "tendency": "", "character": [ "输注后" ], "anatomy_list": [] }, { "core_name": "乏力", "tendency": "", "character": [ "输注后" ], "anatomy_list": [] }, { "core_name": "食欲", "tendency": "", "character": [ "输注后", "减退" ], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "", "character": [ "加重", "休息时不能向左侧平躺" ], "anatomy_list": [ "左侧腰骶部", "左下肢" ] }, { "core_name": "麻木", "tendency": "", "character": [ "加重", "休息时不能向左侧平躺" ], "anatomy_list": [ "左侧腰骶部", "左下肢" ] }, { "core_name": "头晕", "tendency": "否定", "character": [], "anatomy_list": [ "头" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "头" ] }, { "core_name": "心慌", "tendency": "否定", "character": [], "anatomy_list": [ "心" ] }, { "core_name": "心悸", "tendency": "否定", "character": [], "anatomy_list": [ "心" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "腹胀", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "小便", "tendency": "", "character": [ "正常" ], "anatomy_list": [] }, { "core_name": "大便", "tendency": "", "character": [ "结干", "2~3日1次" ], "anatomy_list": [] }, { "core_name": "癌", "tendency": "", "character": [ "高级别", "浆液性", "术后", "化疗后", "复发", "iiic期" ], "anatomy_list": [ "卵巢" ] }, { "core_name": "癌", "tendency": "", "character": [ "转移" ], "anatomy_list": [ "骨", "肺", "盆腔", "腹腔淋巴结" ] } ] }, { "id": 507, "text": "此后，吞咽困难进行性加重，进食半流质、流质饮食仍感梗阻,于2017年10月06日到我院行胃镜提示食管癌，病检：鳞状细胞癌。", "event": [ { "core_name": "吞咽困难", "tendency": "", "character": [ "进行性加重" ], "anatomy_list": [] }, { "core_name": "梗阻", "tendency": "", "character": [ "半流质、流质食物" ], "anatomy_list": [] }, { "core_name": "癌", "tendency": "", "character": [], "anatomy_list": [ "食管" ] }, { "core_name": "鳞癌", "tendency": "", "character": [], "anatomy_list": [] } ] }, { "id": 903, "text": "1天前，患儿出现右下肢疼痛，不能下地行走，不伴咳嗽，无进行性消瘦渐明显，不伴潮热盗汗。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [], "anatomy_list": [ "右下肢" ] }, { "core_name": "下地行走", "tendency": "", "character": [ "不能" ], "anatomy_list": [] }, { "core_name": "咳嗽", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "消瘦", "tendency": "否定", "character": [ "进行性", "明显" ], "anatomy_list": [] }, { "core_name": "潮热", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "盗汗", "tendency": "否定", "character": [], "anatomy_list": [] } ] }, { "id": 1645, "text": "入院前1年，患者无明显诱因出现上腹胀痛，呈阵发性发作，进食后加重，无恶心、呕吐、反酸、嗳气，无咳嗽、咳痰、气促、胸闷，患者诉服药后好转（具体不详）。患者上腹胀痛反复出现，患者服药后均能控制。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [ "阵发性", "胀痛", "进食后加重" ], "anatomy_list": [ "上腹" ] }, { "core_name": "恶心", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "呕吐", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "返酸", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "嗳气", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "咳嗽", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "气促", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "胸闷", "tendency": "否定", "character": [], "anatomy_list": [ "胸" ] }, { "core_name": "疼痛", "tendency": "", "character": [ "胀痛", "反复出现" ], "anatomy_list": [ "上腹" ] } ] }, { "id": 1906, "text": "5.甲状腺密度减低，fdg代谢增高，建议超声检查。", "event": [ { "core_name": "甲状腺密度", "tendency": "", "character": [ "减低" ], "anatomy_list": [ "甲状腺" ] }, { "core_name": "fdg代谢", "tendency": "", "character": [ "增高" ], "anatomy_list": [] } ] }, { "id": 512, "text": "建议1月后返院复查及行放化疗等综合治疗，此次患者为行放化疗来我院，遂以“食管癌术后”收入住院治疗。", "event": [ { "core_name": "癌", "tendency": "", "character": [ "术后" ], "anatomy_list": [ "食管" ] } ] }, { "id": 1929, "text": "患者本次发病以来，食欲正常，神志清醒，精神尚可，睡眠尚可，大便次数增多，进食油腻食物后解大便频繁，小便正常，体重无明显变化。", "event": [ { "core_name": "食欲", "tendency": "", "character": [ "正常" ], "anatomy_list": [] }, { "core_name": "神志", "tendency": "", "character": [ "清醒" ], "anatomy_list": [] }, { "core_name": "精神", "tendency": "", "character": [ "尚可" ], "anatomy_list": [] }, { "core_name": "睡眠", "tendency": "", "character": [ "尚可" ], "anatomy_list": [] }, { "core_name": "大便", "tendency": "", "character": [ "次数增多" ], "anatomy_list": [] }, { "core_name": "大便", "tendency": "", "character": [ "频繁", "进食油腻食物" ], "anatomy_list": [] }, { "core_name": "小便", "tendency": "", "character": [ "正常" ], "anatomy_list": [] }, { "core_name": "体重改变", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [] } ] }, { "id": 638, "text": "（肠周）淋巴结未见癌转移（0/15）。", "event": [ { "core_name": "癌", "tendency": "否定", "character": [ "转移" ], "anatomy_list": [ "肠周淋巴结" ] } ] }, { "id": 1021, "text": "2.头皮表皮囊肿”收治入院，进一步处理。", "event": [ { "core_name": "囊肿", "tendency": "", "character": [ "表皮" ], "anatomy_list": [ "头皮" ] } ] }, { "id": 1305, "text": "患者于入院前20+年因受凉后出现咳嗽、咳痰，为少量白色粘液痰，不伴喘息，无咯血，无胸闷、胸痛，无潮热、盗汗等症状，经口服感冒药后症状好转。", "event": [ { "core_name": "咳嗽", "tendency": "", "character": [ "受凉" ], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "受凉", "少量", "白色", "粘液" ], "anatomy_list": [] }, { "core_name": "喘息", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "咯血", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "胸闷", "tendency": "否定", "character": [], "anatomy_list": [ "胸" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "胸" ] }, { "core_name": "潮热", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "盗汗", "tendency": "否定", "character": [], "anatomy_list": [] } ] }, { "id": 1702, "text": "1天前，患者出现痰中带血，量不多，无发热、畏寒，无胸痛，无声音嘶哑，无吞咽困难，无关节疼痛，为求进一步诊治，收住入院。", "event": [ { "core_name": "咳痰", "tendency": "", "character": [ "带血", "量不多" ], "anatomy_list": [] }, { "core_name": "发热", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "畏寒", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "胸" ] }, { "core_name": "声音嘶哑", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "吞咽困难", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "关节" ] } ] }, { "id": 1081, "text": "2月前患者因排尿困难，遂到我院就诊，予以膀胱造瘘，术后予以抗感染及对症支持治疗，术后患者恢复可。", "event": [ { "core_name": "排尿困难", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "恢复", "tendency": "", "character": [ "可" ], "anatomy_list": [] } ] }, { "id": 1076, "text": "患者于入院3个多月前（2016.01.28）因确诊“右乳浸润癌”在全麻下行右乳癌改良根治术；术后病理诊断：右乳浸润性导管癌，腋窝淋巴结转移（0/14）；免疫组化：er（+++）60%pr（++）40%cerbb-2（－） ki-6767个细胞（+）。", "event": [ { "core_name": "浸润癌", "tendency": "", "character": [], "anatomy_list": [ "右乳" ] }, { "core_name": "导管癌", "tendency": "", "character": [ "浸润性" ], "anatomy_list": [ "右乳" ] }, { "core_name": "转移", "tendency": "", "character": [], "anatomy_list": [ "腋窝淋巴结" ] } ] }, { "id": 1630, "text": "1天前患者头昏明显再发，视物模糊，有轻度头痛，伴双上肢远端麻木，颈部活动障碍，活动时有心累，胸闷症状，无心前区疼痛。", "event": [ { "core_name": "头昏", "tendency": "", "character": [ "明显再发" ], "anatomy_list": [ "头" ] }, { "core_name": "视物模糊", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "", "character": [ "轻度" ], "anatomy_list": [ "头" ] }, { "core_name": "麻木", "tendency": "", "character": [], "anatomy_list": [ "双上肢远端" ] }, { "core_name": "活动障碍", "tendency": "", "character": [], "anatomy_list": [ "颈部" ] }, { "core_name": "心累", "tendency": "", "character": [ "活动时" ], "anatomy_list": [] }, { "core_name": "胸闷", "tendency": "", "character": [ "活动时" ], "anatomy_list": [ "胸" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "心前区" ] } ] }, { "id": 793, "text": "入院前6天，患者再次因受凉后出现喘累较前加重，喜高枕卧位，活动耐量急剧降低，无明显咳嗽、咳痰，伴纳差、全身乏力，无发热、畏寒，无意识障碍、黑朦，无胸痛、咯血，无呕吐、腹痛，双下肢无水肿，在外予对症治疗后病情无明显缓解，随急呼“120”来我院，急诊科予以静滴“多索茶碱”后，以“慢性阻塞性肺病伴急性加重”收入我科住院治疗。", "event": [ { "core_name": "喘累", "tendency": "", "character": [ "受凉后", "较前加重" ], "anatomy_list": [] }, { "core_name": "活动耐量", "tendency": "", "character": [ "急剧降低" ], "anatomy_list": [] }, { "core_name": "咳嗽", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "纳差", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "乏力", "tendency": "", "character": [], "anatomy_list": [ "全身" ] }, { "core_name": "发热", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "畏寒", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "意识障碍", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "黑朦", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "胸" ] }, { "core_name": "咯血", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "呕吐", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "水肿", "tendency": "否定", "character": [], "anatomy_list": [ "双下肢" ] }, { "core_name": "肺病", "tendency": "", "character": [ "慢性", "阻塞性", "急性加重" ], "anatomy_list": [ "肺" ] } ] }, { "id": 176, "text": "2周期化疗后复查腹膜后病变体积稍前减小。", "event": [ { "core_name": "病变", "tendency": "", "character": [ "体积稍前减小" ], "anatomy_list": [ "腹膜后" ] } ] }, { "id": 1710, "text": "胸部ct见双肺感染、双侧胸腔积液、肩胛骨及骨性胸廓多发低密度影，符合多发性骨髓瘤。", "event": [ { "core_name": "感染", "tendency": "", "character": [], "anatomy_list": [ "双肺" ] }, { "core_name": "积液", "tendency": "", "character": [], "anatomy_list": [ "双侧胸腔" ] }, { "core_name": "密度影", "tendency": "", "character": [ "多发", "低" ], "anatomy_list": [ "骨性胸廓", "肩胛骨" ] }, { "core_name": "瘤", "tendency": "", "character": [ "多发性" ], "anatomy_list": [ "骨髓" ] } ] }, { "id": 1126, "text": "2015年1月患者再出现右腹隐痛，无恶心、呕吐，无腹胀、阴道流血，复查ca-125 55.20U/ml ，胸腹部ct提示：1.卵巢癌术后复查， 腹膜后及肠系膜多发淋巴结显示增大，与2014.4.22对比有所增大、增多；余无明显变化。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [ "隐痛" ], "anatomy_list": [ "右腹" ] }, { "core_name": "恶心", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "呕吐", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "腹胀", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "出血", "tendency": "否定", "character": [], "anatomy_list": [ "阴道" ] }, { "core_name": "癌", "tendency": "", "character": [ "术后" ], "anatomy_list": [ "卵巢" ] }, { "core_name": "增大", "tendency": "", "character": [ "增多" ], "anatomy_list": [ "腹膜后淋巴结", "肠系膜淋巴结" ] } ] }, { "id": 505, "text": "离院后患儿无发热、咳嗽，无进行性面色苍白，无皮肤瘀斑瘀点及鼻衄、牙龈出血；精神食欲一般，睡眠好；大小便正常。", "event": [ { "core_name": "发热", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "咳嗽", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "面色苍白", "tendency": "否定", "character": [ "进行性" ], "anatomy_list": [ "面" ] }, { "core_name": "瘀斑", "tendency": "否定", "character": [], "anatomy_list": [ "皮肤" ] }, { "core_name": "瘀点", "tendency": "否定", "character": [], "anatomy_list": [ "皮肤" ] }, { "core_name": "鼻衄", "tendency": "否定", "character": [], "anatomy_list": [ "鼻" ] }, { "core_name": "出血", "tendency": "否定", "character": [], "anatomy_list": [ "牙龈" ] }, { "core_name": "精神", "tendency": "", "character": [ "一般" ], "anatomy_list": [] }, { "core_name": "食欲", "tendency": "", "character": [ "一般" ], "anatomy_list": [] }, { "core_name": "睡眠", "tendency": "", "character": [ "好" ], "anatomy_list": [] }, { "core_name": "大小便", "tendency": "", "character": [ "正常" ], "anatomy_list": [] } ] }, { "id": 236, "text": "今患者为求进一步治疗来我院门诊，门诊以“糖尿病”收治入院。", "event": [ { "core_name": "糖尿病", "tendency": "", "character": [], "anatomy_list": [] } ] }, { "id": 622, "text": "后患者上诉症状反复发作，均为每次同房后阴道无痛性流少量鲜红色血液，性质同前，均不伴畏寒、发热、尿频、尿急、尿痛，无白带异常，无血凝块，无外阴瘙痒等不适，患者自觉病情严重，为求进一步治疗遂于2019-03-26于我院门诊就诊，电子阴道镜检查示：宫颈ca？厚的醋酸白上皮，进一步完善病检提示：（宫颈）鳞状细胞癌。", "event": [ { "core_name": "出血", "tendency": "", "character": [ "无痛性", "同房后", "少量", "鲜红色" ], "anatomy_list": [ "阴道" ] }, { "core_name": "畏寒", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "发热", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "尿频", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "尿急", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "尿痛", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "白带", "tendency": "否定", "character": [ "异常" ], "anatomy_list": [] }, { "core_name": "血凝块", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "瘙痒", "tendency": "否定", "character": [], "anatomy_list": [ "外阴" ] }, { "core_name": "癌", "tendency": "不确定", "character": [], "anatomy_list": [ "宫颈" ] }, { "core_name": "醋酸白上皮", "tendency": "", "character": [ "厚的" ], "anatomy_list": [] }, { "core_name": "鳞癌", "tendency": "", "character": [], "anatomy_list": [ "宫颈" ] } ] }, { "id": 923, "text": "完善腹部ct：双肾、双侧输尿管输尿管积水，双侧输尿管上段管壁增厚。", "event": [ { "core_name": "积水", "tendency": "", "character": [], "anatomy_list": [ "双肾" ] }, { "core_name": "积水", "tendency": "", "character": [], "anatomy_list": [ "双侧输尿管" ] }, { "core_name": "增厚", "tendency": "", "character": [ "管壁" ], "anatomy_list": [ "双侧输尿管上段" ] } ] }, { "id": 1061, "text": "近5日患者未排大便，自觉腹胀，反酸，嗳气加重，来我院门诊以“肠梗阻”收入我科。", "event": [ { "core_name": "大便", "tendency": "", "character": [ "未排", "近5日" ], "anatomy_list": [] }, { "core_name": "腹胀", "tendency": "", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "反酸", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "嗳气", "tendency": "", "character": [ "加重" ], "anatomy_list": [] }, { "core_name": "梗阻", "tendency": "", "character": [], "anatomy_list": [ "肠" ] } ] }, { "id": 1325, "text": "2019-1-2患者入院复查ct评估提示疾病进展，积极给予胸腔穿刺引流，给于il-2胸腔灌注控制胸水，于2019-1-7、2019-1-28、2019-2-28：贝伐珠单抗300mg1+卡培他滨口服早2片，晚3片d1-14治疗3次，治疗过程顺利，2019-2-26完善胸部+腹部ct：肝肺转移转移灶稍增多，结合患者cea、ca125较前降低，患者呼吸困难等症状较前好转，评估患者病情稳定，可继续按原方案治疗。", "event": [ { "core_name": "胸水", "tendency": "", "character": [], "anatomy_list": [ "胸" ] }, { "core_name": "转移灶", "tendency": "", "character": [ "稍增多" ], "anatomy_list": [ "肝", "肺" ] }, { "core_name": "呼吸困难", "tendency": "", "character": [ "较前好转" ], "anatomy_list": [] } ] }, { "id": 1965, "text": "患者患病以来精神一般，食欲可，长期睡眠差，大小便正常，近期无明显体重减轻。", "event": [ { "core_name": "精神", "tendency": "", "character": [ "一般" ], "anatomy_list": [] }, { "core_name": "食欲", "tendency": "", "character": [ "可" ], "anatomy_list": [] }, { "core_name": "睡眠", "tendency": "", "character": [ "差" ], "anatomy_list": [] }, { "core_name": "大小便", "tendency": "", "character": [ "正常" ], "anatomy_list": [] }, { "core_name": "体重减轻", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [] } ] }, { "id": 1430, "text": "入院前1年余，患者因血尿外院诊断为“左侧输尿管尿路上皮癌，膀胱高级别乳头状尿路上皮癌”就诊于我院。", "event": [ { "core_name": "血尿", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "癌", "tendency": "", "character": [], "anatomy_list": [ "左侧输尿管", "尿路上皮" ] }, { "core_name": "癌", "tendency": "", "character": [ "高级别", "乳头状" ], "anatomy_list": [ "膀胱", "尿路上皮" ] } ] }, { "id": 85, "text": "术后予以tp（多西他赛+洛铂）化疗+赫赛汀靶向治疗，过程顺利，化疗后产生中度药物骨髓反应及胃肠道反应，予以对症处理。", "event": [ { "core_name": "药物骨髓反应", "tendency": "", "character": [ "化疗后", "中度" ], "anatomy_list": [ "骨髓" ] }, { "core_name": "胃肠道反应", "tendency": "", "character": [ "化疗后" ], "anatomy_list": [ "胃肠道" ] } ] }, { "id": 1725, "text": "入院前4+月患儿因“发热、贫血、骨痛”在我院住院治疗，经micm分型诊断为急性前b淋巴细胞淋巴细胞白血病l2型(e2a/pbx1阳性，中危) ，至今已经完成vdlp、cat诱导缓解化疗，第1-4次hd-mtx、间期治疗1-8周第1次静脉化疗。", "event": [ { "core_name": "发热", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "贫血", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "", "character": [], "anatomy_list": [ "骨" ] }, { "core_name": "白血病", "tendency": "", "character": [ "急性", "前B淋巴细胞", "l2型", "e2a/pbx1阳性", "中危" ], "anatomy_list": [] } ] }, { "id": 1854, "text": "”于我科住院治疗，完善相关检查，诊断为“1.直肠腺癌（pT2n0M0）；2.慢支炎、肺气肿；3.完全性右束支传导阻滞；4.左肾囊肿”，于2016年2月6日在全麻下行腹腔镜下直肠癌根治术（dixon）。", "event": [ { "core_name": "腺癌", "tendency": "", "character": [ "pT2n0M0" ], "anatomy_list": [ "直肠" ] }, { "core_name": "支气管炎", "tendency": "", "character": [ "慢性" ], "anatomy_list": [ "支气管" ] }, { "core_name": "肺气肿", "tendency": "", "character": [], "anatomy_list": [ "肺" ] }, { "core_name": "传导阻滞", "tendency": "", "character": [ "完全性" ], "anatomy_list": [ "右束支" ] }, { "core_name": "囊肿", "tendency": "", "character": [], "anatomy_list": [ "左肾" ] } ] }, { "id": 725, "text": "2012年12月初在我科复查，脑胸部及骨未见明显转移，腹部ct提示直肠癌术后吻合口肠壁稍增厚。", "event": [ { "core_name": "转移", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [ "脑", "胸部", "骨" ] }, { "core_name": "癌", "tendency": "", "character": [ "术后" ], "anatomy_list": [ "直肠" ] }, { "core_name": "增厚", "tendency": "", "character": [ "稍" ], "anatomy_list": [ "吻合口肠壁" ] } ] }, { "id": 515, "text": "不伴发热、畏寒、寒战、头昏、头痛、胸闷、心悸、胸痛、反酸、嗳气、恶心、呕吐、腹痛、腹胀、腹泻、黑便。", "event": [ { "core_name": "发热", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "畏寒", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "寒颤", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "头昏", "tendency": "否定", "character": [], "anatomy_list": [ "头" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "头" ] }, { "core_name": "胸闷", "tendency": "否定", "character": [], "anatomy_list": [ "胸" ] }, { "core_name": "心悸", "tendency": "否定", "character": [], "anatomy_list": [ "心" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "胸" ] }, { "core_name": "反酸", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "嗳气", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "恶心", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "呕吐", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "腹胀", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "腹泻", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "黑便", "tendency": "否定", "character": [], "anatomy_list": [] } ] }, { "id": 1644, "text": "术后于2016-10-22、2016-11-23、2016-12-15、2017-01-06行ec方案化疗4次，于2017-01-30、2017-02-23、2017-03-17、2017-04-07行th方案化疗4次，从2017-04-28开始至今连续行13次靶向治疗，每次靶向治疗间隔21天左右，过程顺利，患者未诉特殊不适，无畏寒、发热，偶有咳嗽、咳痰，无头晕、头痛，无恶心、呕吐；患者今日为求第14次靶向治疗，遂入我院，门诊以“左乳癌术后第13次靶向治疗后”收入我科住院治疗。", "event": [ { "core_name": "畏寒", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "发热", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "咳嗽", "tendency": "", "character": [ "偶有" ], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "偶有" ], "anatomy_list": [] }, { "core_name": "头晕", "tendency": "否定", "character": [], "anatomy_list": [ "头" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "头" ] }, { "core_name": "恶心", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "呕吐", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "癌", "tendency": "", "character": [ "术后", "第13次靶向治疗后" ], "anatomy_list": [ "左乳" ] } ] }, { "id": 1798, "text": "来我院就诊，诊断为“冠心病？”，建议患者冠脉造影明确诊断，患者及家属表示拒绝，予以改善循环、对症等治疗好转。", "event": [ { "core_name": "冠心病", "tendency": "不确定", "character": [], "anatomy_list": [ "心" ] } ] }, { "id": 1545, "text": "结合患者本次复查及病检：考虑直肠癌局部复发及远处转移。", "event": [ { "core_name": "癌", "tendency": "不确定", "character": [ "局部", "复发", "远处转移" ], "anatomy_list": [ "直肠" ] } ] }, { "id": 21, "text": "化疗期间患者未复查乳腺彩超、胸部影像学及颅脑检查及骨ect,每2周期化疗后均复查腹部彩超,未见肝脏转移等。", "event": [ { "core_name": "转移", "tendency": "否定", "character": [], "anatomy_list": [ "肝脏" ] } ] }, { "id": 981, "text": "经治疗后，患者咳嗽稍好转。", "event": [ { "core_name": "咳嗽", "tendency": "", "character": [ "稍好转" ], "anatomy_list": [] } ] }, { "id": 1528, "text": "2020-11-3术后病理（123456）：右肺上叶前段结节黏液腺癌，癌周肺组织部分腺泡腔萎陷、肺泡隔增宽，间质纤维组织增生，肺切缘无癌，支气管切缘切缘无癌；第1111组组淋巴结可见癌转移(1/1)，第10组淋巴结可见癌转移(2/2)，第2.4组淋巴结可见癌转移(5/5)，第3a组淋巴结可见癌转移(3/3)，第1111组组淋巴结未见癌转移（0/5）,第77组组淋巴结未见癌转移（0/14）,第8.9组淋巴结可见癌转移(1/3)；右肺上叶肺组织弥漫出血、肺间质慢性炎，未见癌组织，肺切缘无癌，支气管切缘切缘无癌。", "event": [ { "core_name": "腺癌", "tendency": "", "character": [ "粘液", "结节" ], "anatomy_list": [ "右肺上叶前段" ] }, { "core_name": "萎陷", "tendency": "", "character": [], "anatomy_list": [ "癌周肺组织部分腺泡腔" ] }, { "core_name": "增宽", "tendency": "", "character": [], "anatomy_list": [ "肺泡隔" ] }, { "core_name": "增生", "tendency": "", "character": [], "anatomy_list": [ "间质纤维组织" ] }, { "core_name": "癌", "tendency": "否定", "character": [], "anatomy_list": [ "肺切缘" ] }, { "core_name": "癌", "tendency": "否定", "character": [], "anatomy_list": [ "支气管切缘" ] }, { "core_name": "癌", "tendency": "", "character": [ "转移" ], "anatomy_list": [ "1111组淋巴结" ] }, { "core_name": "癌", "tendency": "", "character": [ "转移" ], "anatomy_list": [ "2.4组淋巴结" ] }, { "core_name": "癌", "tendency": "", "character": [ "转移" ], "anatomy_list": [ "3a组淋巴结" ] }, { "core_name": "癌", "tendency": "", "character": [ "转移" ], "anatomy_list": [ "10组淋巴结" ] }, { "core_name": "癌", "tendency": "否定", "character": [ "转移" ], "anatomy_list": [ "1111组组淋巴结" ] }, { "core_name": "癌", "tendency": "否定", "character": [ "转移" ], "anatomy_list": [ "第77组淋巴结" ] }, { "core_name": "癌", "tendency": "", "character": [ "转移" ], "anatomy_list": [ "第8.9组淋巴结" ] }, { "core_name": "出血", "tendency": "", "character": [ "弥漫" ], "anatomy_list": [ "右肺上叶", "肺组织" ] }, { "core_name": "肺间质炎", "tendency": "", "character": [ "慢性" ], "anatomy_list": [ "肺间质" ] }, { "core_name": "癌", "tendency": "否定", "character": [], "anatomy_list": [ "肺切缘" ] }, { "core_name": "癌", "tendency": "否定", "character": [], "anatomy_list": [ "支气管切缘" ] } ] }, { "id": 1261, "text": "2.双肺气肿。", "event": [ { "core_name": "肺气肿", "tendency": "", "character": [], "anatomy_list": [ "双肺" ] } ] }, { "id": 1810, "text": "支气管切缘及肺切缘未见癌累及。", "event": [ { "core_name": "癌", "tendency": "否定", "character": [ "累及" ], "anatomy_list": [ "支气管切缘", "肺切缘" ] } ] }, { "id": 699, "text": "患病以来，精神、食欲及睡眠可，大小便正常，体重下降约2.5Kg。", "event": [ { "core_name": "精神", "tendency": "", "character": [ "可" ], "anatomy_list": [] }, { "core_name": "食欲", "tendency": "", "character": [ "正常" ], "anatomy_list": [] }, { "core_name": "睡眠质量", "tendency": "", "character": [ "可" ], "anatomy_list": [] }, { "core_name": "大小便", "tendency": "", "character": [ "正常" ], "anatomy_list": [] }, { "core_name": "体重下降", "tendency": "", "character": [], "anatomy_list": [] } ] }, { "id": 1150, "text": "患者自患病以来，精神正常，饮食吞咽困难，流质为主，小大便正常，体重无明显变化。", "event": [ { "core_name": "精神", "tendency": "", "character": [ "正常" ], "anatomy_list": [] }, { "core_name": "吞咽困难", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "小便", "tendency": "", "character": [ "正常" ], "anatomy_list": [] }, { "core_name": "大便", "tendency": "", "character": [ "正常" ], "anatomy_list": [] }, { "core_name": "体重", "tendency": "", "character": [ "无明显变化" ], "anatomy_list": [] } ] }, { "id": 626, "text": "3年前患者上述症状发作后伴活动后喘累。", "event": [ { "core_name": "喘累", "tendency": "", "character": [ "活动后" ], "anatomy_list": [] } ] }, { "id": 1688, "text": "今日患者及家属为求进一步治疗就诊于我院，门诊以“腰椎盘突出症；腰55椎血管瘤”收入我科住院治疗。", "event": [ { "core_name": "突出症", "tendency": "", "character": [], "anatomy_list": [ "腰椎盘" ] }, { "core_name": "瘤", "tendency": "", "character": [ "血管" ], "anatomy_list": [ "腰5椎" ] } ] }, { "id": 1970, "text": "拇指伴有针刺感。", "event": [ { "core_name": "针刺感", "tendency": "", "character": [], "anatomy_list": [ "拇指" ] } ] }, { "id": 1917, "text": "在我科行两周期“紫杉醇210mg+奈达铂110mg”化疗后，复查ct(256层)(123456):右侧枕叶结节，考虑转移性肿瘤；左下肺门区占位性病变，考虑肺癌伴左肺下叶阻塞性肺不张；左肺门淋巴结肿大；左侧胸腔积液；右肺上叶局部肺气肿（小叶中心型）；右肺细小结节，尘肺？；右肺上叶及斜裂结节，转移性肿瘤可能；肝脏右叶结节，考虑转移性肿瘤；肝右叶大片低强化区，考虑脂肪变性；右肾占位性病变，考虑转移性肿瘤可能性大；左肾小结石；左侧肾上腺结节，考虑转移性肿瘤。", "event": [ { "core_name": "结节", "tendency": "", "character": [], "anatomy_list": [ "右侧枕叶" ] }, { "core_name": "肿瘤", "tendency": "不确定", "character": [ "转移性" ], "anatomy_list": [ "右侧枕叶" ] }, { "core_name": "病变", "tendency": "", "character": [ "占位性" ], "anatomy_list": [ "左下肺1区" ] }, { "core_name": "癌", "tendency": "", "character": [], "anatomy_list": [ "肺" ] }, { "core_name": "肺不张", "tendency": "", "character": [ "阻塞性" ], "anatomy_list": [ "左肺下叶" ] }, { "core_name": "肿大", "tendency": "", "character": [], "anatomy_list": [ "左肺门淋巴结" ] }, { "core_name": "积液", "tendency": "", "character": [], "anatomy_list": [ "左侧胸腔" ] }, { "core_name": "肺气肿", "tendency": "", "character": [ "小叶中心型", "局部" ], "anatomy_list": [ "右肺上叶" ] }, { "core_name": "结节", "tendency": "", "character": [ "细小" ], "anatomy_list": [ "右肺" ] }, { "core_name": "尘肺", "tendency": "不确定", "character": [], "anatomy_list": [ "右肺" ] }, { "core_name": "结节", "tendency": "", "character": [], "anatomy_list": [ "右肺上叶", "右肺上叶斜裂" ] }, { "core_name": "肿瘤", "tendency": "不确定", "character": [ "转移性" ], "anatomy_list": [ "右肺上叶", "右肺上叶斜裂" ] }, { "core_name": "结节", "tendency": "", "character": [], "anatomy_list": [ "肝脏右叶" ] }, { "core_name": "肿瘤", "tendency": "不确定", "character": [ "转移性" ], "anatomy_list": [ "肝脏右叶" ] }, { "core_name": "低强化区", "tendency": "", "character": [ "大片" ], "anatomy_list": [ "肝脏右叶" ] }, { "core_name": "脂肪变性", "tendency": "", "character": [], "anatomy_list": [ "肝脏右叶" ] }, { "core_name": "病变", "tendency": "", "character": [ "占位性" ], "anatomy_list": [ "右肾" ] }, { "core_name": "肿瘤", "tendency": "不确定", "character": [ "转移性" ], "anatomy_list": [ "右肾" ] }, { "core_name": "结石", "tendency": "", "character": [ "小" ], "anatomy_list": [ "左肾" ] }, { "core_name": "结节", "tendency": "", "character": [], "anatomy_list": [ "左侧肾上腺" ] }, { "core_name": "肿瘤", "tendency": "不确定", "character": [ "转移性" ], "anatomy_list": [] } ] }, { "id": 1684, "text": "于2014年7月19日行第1次化疗，方案：奥沙利铂+雷替曲塞,化疗期间无发热咳嗽，无恶心、呕吐，无腹痛腹泻等不适。", "event": [ { "core_name": "发热", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "咳嗽", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "恶心", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "呕吐", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "腹泻", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] } ] }, { "id": 243, "text": "再次就诊于肛肠外科，行肛门指检（2016-06-22）未发现明显异常，复查盆腔ct（我院，2016-06-22）提示：盆腔未见明显异常。", "event": [ { "core_name": "异常", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [] }, { "core_name": "异常", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [ "盆腔" ] } ] }, { "id": 503, "text": "患者自起病以来，精神略差，胃纳较差，大便如常，小便如常，近2月体重下降6kg。", "event": [ { "core_name": "精神", "tendency": "", "character": [ "略差" ], "anatomy_list": [] }, { "core_name": "胃纳", "tendency": "", "character": [ "较差" ], "anatomy_list": [ "胃" ] }, { "core_name": "大便", "tendency": "", "character": [ "如常" ], "anatomy_list": [] }, { "core_name": "小便", "tendency": "", "character": [ "如常" ], "anatomy_list": [] }, { "core_name": "体重下降", "tendency": "", "character": [], "anatomy_list": [] } ] }, { "id": 1563, "text": "自发现以来，包块无明显增大，无咳嗽，气急，无全身黄染，无乳头流脓，溢液，无红肿，皮肤无橘皮样改变等。院外未行特殊诊治。", "event": [ { "core_name": "包块", "tendency": "否定", "character": [ "明显增大" ], "anatomy_list": [] }, { "core_name": "咳嗽", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "气促", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "黄染", "tendency": "否定", "character": [], "anatomy_list": [ "全身" ] }, { "core_name": "流脓", "tendency": "否定", "character": [], "anatomy_list": [ "乳头" ] }, { "core_name": "溢液", "tendency": "否定", "character": [], "anatomy_list": [ "乳头" ] }, { "core_name": "红肿", "tendency": "否定", "character": [], "anatomy_list": [ "乳头" ] }, { "core_name": "改变", "tendency": "否定", "character": [ "橘皮样" ], "anatomy_list": [ "皮肤" ] } ] }, { "id": 2017, "text": "术后病检回示：病理号2123456:\"直、乙交界\"中分化腺癌，侵及深肌层；两切端未见癌累及；脂肪组织中未发现明显肿大淋巴结。", "event": [ { "core_name": "腺癌", "tendency": "", "character": [ "中分化" ], "anatomy_list": [ "直、乙交界" ] }, { "core_name": "腺癌", "tendency": "", "character": [ "侵及" ], "anatomy_list": [ "深肌层" ] }, { "core_name": "癌", "tendency": "否定", "character": [ "累及" ], "anatomy_list": [ "两切端" ] }, { "core_name": "肿大", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [ "脂肪组织淋巴结" ] } ] }, { "id": 1153, "text": "入院前4小时，患者无明显诱因突发意识丧失、呼之不应，伴面色苍白、口唇发绀，双目向上凝视、牙关紧闭、口吐白沫、四肢抽搐、小便失禁，持续约5分5分钟后肢体抽搐渐停止，持续约20分20分钟后患者意识逐渐恢复，醒后不能回忆发作时情况，伴头痛，以额部胀痛为主，伴头昏、视物模糊，无视物旋转，无恶心、呕吐，无耳鸣、听力下降，无心慌、心累、心前区不适，无肢体活动障碍。", "event": [ { "core_name": "意识丧失", "tendency": "", "character": [ "突发" ], "anatomy_list": [] }, { "core_name": "呼之不应", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "面色苍白", "tendency": "", "character": [], "anatomy_list": [ "面" ] }, { "core_name": "发绀", "tendency": "", "character": [], "anatomy_list": [ "口唇" ] }, { "core_name": "凝视", "tendency": "", "character": [ "向上" ], "anatomy_list": [ "双目" ] }, { "core_name": "牙关紧闭", "tendency": "", "character": [], "anatomy_list": [ "牙" ] }, { "core_name": "口吐白沫", "tendency": "", "character": [], "anatomy_list": [ "口" ] }, { "core_name": "抽搐", "tendency": "", "character": [], "anatomy_list": [ "四肢" ] }, { "core_name": "小便", "tendency": "", "character": [ "失禁" ], "anatomy_list": [] }, { "core_name": "抽搐", "tendency": "否定", "character": [], "anatomy_list": [ "肢体" ] }, { "core_name": "意识恢复", "tendency": "", "character": [ "醒后不能回忆发作时情况" ], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "", "character": [ "胀痛为主" ], "anatomy_list": [ "头", "额部" ] }, { "core_name": "头昏", "tendency": "", "character": [], "anatomy_list": [ "头" ] }, { "core_name": "视物模糊", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "视物旋转", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "恶心", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "呕吐", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "耳鸣", "tendency": "否定", "character": [], "anatomy_list": [ "耳" ] }, { "core_name": "听力下降", "tendency": "否定", "character": [], "anatomy_list": [ "耳" ] }, { "core_name": "心悸", "tendency": "否定", "character": [], "anatomy_list": [ "心" ] }, { "core_name": "心前区不适", "tendency": "否定", "character": [], "anatomy_list": [ "心前区" ] }, { "core_name": "心累", "tendency": "否定", "character": [], "anatomy_list": [ "心" ] }, { "core_name": "活动障碍", "tendency": "否定", "character": [], "anatomy_list": [ "肢体" ] } ] }, { "id": 1134, "text": "3、双肾多发囊肿。", "event": [ { "core_name": "囊肿", "tendency": "", "character": [ "多发" ], "anatomy_list": [ "双肾" ] } ] }, { "id": 1859, "text": "现患者无恶心、呕吐、腹痛、腹胀、便血等表现，遵医嘱于今日至我院行直肠癌术后第一次化疗。", "event": [ { "core_name": "恶心", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "呕吐", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "腹胀", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "便血", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "癌", "tendency": "", "character": [ "术后第一次化" ], "anatomy_list": [ "直肠" ] } ] }, { "id": 881, "text": "发现血糖升高4月，现予以瑞格列奈1mg降糖治疗，监测血糖波动在：9.5-13mm13mmol/l之间。", "event": [ { "core_name": "血糖", "tendency": "", "character": [ "升高" ], "anatomy_list": [] }, { "core_name": "血糖", "tendency": "", "character": [ "波动" ], "anatomy_list": [] } ] }, { "id": 820, "text": "入院前4个月，患者因“胃癌”，在某医院行“胃癌根治术”（具体术式及术中情况不详），术后诊断为胃贲门贲门中低分化腺癌 t4n3M，术后恢复好。", "event": [ { "core_name": "癌", "tendency": "", "character": [], "anatomy_list": [ "胃" ] }, { "core_name": "腺癌", "tendency": "", "character": [ "中低分化", "t4n3M" ], "anatomy_list": [ "胃贲门" ] } ] }, { "id": 1823, "text": "遂于某医院完善相关检查诊断：宫颈鳞癌iiib期，因无手术指征，2017年6月8日行体外照射（具体不详），放疗后患者阴道流血停止，放疗后行5周期化疗（具体化疗方案及剂量不详），化疗期间无明显化疗副反应，化疗后出现骨髓抑制（具体不详），予以“重组人粒细胞刺激因子”治疗后骨髓抑制好转。", "event": [ { "core_name": "鳞癌", "tendency": "", "character": [ "iiib期" ], "anatomy_list": [ "宫颈" ] }, { "core_name": "出血", "tendency": "", "character": [ "停止", "放疗后" ], "anatomy_list": [ "阴道" ] }, { "core_name": "骨髓抑制", "tendency": "", "character": [ "化疗后" ], "anatomy_list": [ "骨髓" ] }, { "core_name": "骨髓抑制", "tendency": "", "character": [ "治疗后好转" ], "anatomy_list": [ "骨髓" ] }, { "core_name": "副反应", "tendency": "否定", "character": [ "化疗期间" ], "anatomy_list": [] } ] }, { "id": 1576, "text": "患者自发病以来，精神可，食欲可，睡眠可，大便2-3次/日，小便如常，体重无明显变化。", "event": [ { "core_name": "精神", "tendency": "", "character": [ "可" ], "anatomy_list": [] }, { "core_name": "食欲", "tendency": "", "character": [ "可" ], "anatomy_list": [] }, { "core_name": "睡眠", "tendency": "", "character": [ "可" ], "anatomy_list": [] }, { "core_name": "大便", "tendency": "", "character": [ "2-3次/日" ], "anatomy_list": [] }, { "core_name": "小便", "tendency": "", "character": [ "如常" ], "anatomy_list": [] }, { "core_name": "体重改变", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [] } ] }, { "id": 1346, "text": "2+月前患者患者无明显诱因出现全身皮肤及巩膜黄染，伴发热，最高高体温38.5℃，伴小便深黄，量尚可，大便颜色正常，全身皮肤瘙痒，伴有纳差、乏力、闷油，无明显腹痛、腹胀，无恶心、呕吐，无呕血、黑便，患者于某医院就诊，予以输注“多烯磷脂酰胆碱+谷胱甘肽”保肝治疗后无明显好转，其后于我院就诊，入院后完善ct考虑诊断为：胆管癌术后复发。", "event": [ { "core_name": "黄染", "tendency": "", "character": [], "anatomy_list": [ "巩膜" ] }, { "core_name": "黄染", "tendency": "", "character": [], "anatomy_list": [ "全身皮肤" ] }, { "core_name": "发热", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "小便", "tendency": "", "character": [ "深黄" ], "anatomy_list": [] }, { "core_name": "大便", "tendency": "", "character": [ "颜色正常" ], "anatomy_list": [] }, { "core_name": "瘙痒", "tendency": "", "character": [], "anatomy_list": [ "全身皮肤" ] }, { "core_name": "纳差", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "乏力", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "闷油", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [ "腹" ] }, { "core_name": "腹胀", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [ "腹" ] }, { "core_name": "恶心", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "呕吐", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "呕血", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "黑便", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "癌", "tendency": "不确定", "character": [ "术后", "复发" ], "anatomy_list": [ "胆管" ] } ] }, { "id": 639, "text": "术后予以予以禁食水、补液、抗感染等对症支持治疗，术后第1010天，期间患者反复发热，最高高体温40摄氏度，患者血培养提示格兰阳性球菌感染，血象提示感染征象高。", "event": [ { "core_name": "发热", "tendency": "", "character": [ "反复" ], "anatomy_list": [] }, { "core_name": "体温", "tendency": "", "character": [ "升高" ], "anatomy_list": [] }, { "core_name": "感染", "tendency": "", "character": [ "格兰阳性球菌" ], "anatomy_list": [] }, { "core_name": "感染", "tendency": "", "character": [ "征象高" ], "anatomy_list": [] } ] }, { "id": 1649, "text": "无寒战高热，无心慌胸闷，无呼吸困难，无四肢乏力。", "event": [ { "core_name": "寒颤", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "发热", "tendency": "否定", "character": [ "高" ], "anatomy_list": [] }, { "core_name": "心慌", "tendency": "否定", "character": [], "anatomy_list": [ "心" ] }, { "core_name": "胸闷", "tendency": "否定", "character": [], "anatomy_list": [ "胸" ] }, { "core_name": "呼吸困难", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "乏力", "tendency": "否定", "character": [], "anatomy_list": [ "四肢" ] } ] }, { "id": 1948, "text": "确诊为多发性骨髓瘤（igg/lambda）型，分别于2016-3-22、2016-04-26、2016-5-24、2016-6-22以vadt方案联合化疗，过程顺利，现患者为巩固化疗入院。", "event": [ { "core_name": "瘤", "tendency": "", "character": [ "多发性", "（igg/lambda）型" ], "anatomy_list": [ "骨髓" ] } ] }, { "id": 1552, "text": "后患者感上述包块进行性长大，遂于2014年8月到我院门诊就诊，行左颈淋巴结穿刺提示\"符合淋巴结转移鳞癌\"。", "event": [ { "core_name": "包块", "tendency": "", "character": [ "进行性长大" ], "anatomy_list": [] }, { "core_name": "鳞癌", "tendency": "", "character": [ "转移" ], "anatomy_list": [ "淋巴结" ] } ] }, { "id": 2043, "text": "患者白血病复发，建议上级医院就诊，患者家属拒绝上级医院就诊，患者左侧胸壁包块及阴茎部位赘生物，破溃，建议穿刺活检，患者家属拒绝，患者发热伴干咳，胸痛，最高高体温40℃，考虑肺部感染，口腔涂片：涂片找g菌查见;涂片找真菌查见;痰中找霉菌查见;g+球菌查见.", "event": [ { "core_name": "白血病", "tendency": "", "character": [ "复发" ], "anatomy_list": [] }, { "core_name": "包块", "tendency": "", "character": [], "anatomy_list": [ "左侧胸壁" ] }, { "core_name": "赘生物", "tendency": "", "character": [], "anatomy_list": [ "阴茎" ] }, { "core_name": "破溃", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "发热", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "咳嗽", "tendency": "", "character": [ "干" ], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "", "character": [], "anatomy_list": [ "胸" ] }, { "core_name": "体温", "tendency": "", "character": [ "升高" ], "anatomy_list": [] }, { "core_name": "感染", "tendency": "不确定", "character": [], "anatomy_list": [ "肺部" ] } ] }, { "id": 1637, "text": "肠镜示：盲肠息肉。", "event": [ { "core_name": "息肉", "tendency": "", "character": [], "anatomy_list": [ "盲肠" ] } ] }, { "id": 405, "text": "患者遂转诊我院肛肠科，行乙状结肠镜见直肠下段半环状包块，3*2.5cm大小，表面凹凸不平，糜烂出血，质硬，边界不清。", "event": [ { "core_name": "包块", "tendency": "", "character": [ "环状", "表面凹凸不平", "糜烂出血", "质硬", "边界不清" ], "anatomy_list": [ "直肠下段" ] } ] }, { "id": 80, "text": "遂于我院急诊就诊，行双乳彩超提示：1.左乳腺低回声肿块伴钙化；2.左侧腋窝淋巴结显影。", "event": [ { "core_name": "肿块", "tendency": "", "character": [ "低回声" ], "anatomy_list": [ "左乳腺" ] }, { "core_name": "钙化", "tendency": "", "character": [], "anatomy_list": [ "左乳腺" ] }, { "core_name": "显影", "tendency": "", "character": [], "anatomy_list": [ "左侧腋窝淋巴结" ] } ] }, { "id": 1336, "text": "患者1天前出现纳差不适，食欲下降2/3，无恶心、呕吐，无反酸、嗳气，无乏力，无腹痛、腹胀、腹泻，无尿频、尿急、尿痛，无黑便、便血，无肛门停止排便排气，伴咳嗽、咳痰，白色泡沫痰，无呼吸困难、喘累不适，今日至我院门诊完善腹部彩超提示：胆囊结石，为行进一步检查及治疗入院，以“消化不良、胆囊结石”收住院。", "event": [ { "core_name": "纳差", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "食欲", "tendency": "", "character": [ "下降" ], "anatomy_list": [] }, { "core_name": "恶心", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "呕吐", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "反酸", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "嗳气", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "乏力", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "腹胀", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "腹泻", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "尿频", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "尿急", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "尿痛", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "黑便", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "便血", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "排便", "tendency": "否定", "character": [ "停止" ], "anatomy_list": [ "肛门" ] }, { "core_name": "排气", "tendency": "否定", "character": [ "停止" ], "anatomy_list": [ "肛门" ] }, { "core_name": "咳嗽", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "白色", "泡沫痰" ], "anatomy_list": [] }, { "core_name": "呼吸困难", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "喘累不适", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "结石", "tendency": "", "character": [], "anatomy_list": [ "胆囊" ] }, { "core_name": "消化不良", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "结石", "tendency": "", "character": [], "anatomy_list": [ "胆囊" ] } ] }, { "id": 951, "text": "入院前3天患者无明显出现黑便不适，为黑色不成形大便，量约80g，仍有嗳气、上腹胀不适，不伴有头晕、心悸、出冷汗等不适。", "event": [ { "core_name": "黑便", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "大便", "tendency": "", "character": [ "黑色", "不成形" ], "anatomy_list": [] }, { "core_name": "嗳气", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "腹胀", "tendency": "", "character": [], "anatomy_list": [ "上腹" ] }, { "core_name": "头晕", "tendency": "否定", "character": [], "anatomy_list": [ "头" ] }, { "core_name": "心悸", "tendency": "否定", "character": [], "anatomy_list": [ "心" ] }, { "core_name": "出冷汗", "tendency": "否定", "character": [], "anatomy_list": [] } ] }, { "id": 576, "text": "今为进一步诊治到我院门诊诊治，门诊以“卵巢癌术后第二次化疗” 收入我科住院治疗。", "event": [ { "core_name": "癌", "tendency": "", "character": [ "术后", "第二次化疗" ], "anatomy_list": [ "卵巢" ] } ] }, { "id": 1627, "text": "今患者为进一步治疗于我院就诊，门诊以“宫颈恶性肿瘤”收入我科。", "event": [ { "core_name": "肿瘤", "tendency": "", "character": [ "恶性" ], "anatomy_list": [ "宫颈" ] } ] }, { "id": 838, "text": "腋窝淋巴结未见癌转移（0/16）。", "event": [ { "core_name": "癌", "tendency": "否定", "character": [ "转移" ], "anatomy_list": [ "腋窝淋巴结" ] } ] }, { "id": 588, "text": "患者入院前5+年，无明显诱因出现进食后梗咽感，进食固体食物及半流质食物明显，无恶心、呕吐、反酸，不伴呕血、黑便。", "event": [ { "core_name": "哽噎感", "tendency": "", "character": [ "进食后", "进食固体食物明显", "进食半流质食物明显" ], "anatomy_list": [] }, { "core_name": "恶心", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "呕吐", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "反酸", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "呕血", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "黑便", "tendency": "否定", "character": [], "anatomy_list": [] } ] }, { "id": 594, "text": "胸腹部ct：1、胃贲门癌：较2018-2-5片比较，贲门处软组织影较前无明显变化。", "event": [ { "core_name": "癌", "tendency": "", "character": [], "anatomy_list": [ "胃贲门" ] }, { "core_name": "软组织影", "tendency": "", "character": [ "较前无明显变化" ], "anatomy_list": [ "贲门" ] } ] }, { "id": 517, "text": "2天前患者感左侧腹痛，咳嗽时明显。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [ "咳嗽时明显" ], "anatomy_list": [ "左侧腹" ] } ] }, { "id": 603, "text": "肺动脉瓣关闭不全（轻度）。", "event": [ { "core_name": "关闭不全", "tendency": "", "character": [ "轻度" ], "anatomy_list": [ "肺动脉瓣" ] } ] }, { "id": 896, "text": "入院前1+年患者无明显诱因出现双下肢水肿，伴颜面浮肿，伴泡沫尿及尿量减少，无恶心、呕吐，无胸闷、气促，无腹痛、腹泻，患者诉自服药物后无效，遂在我院住院检查：尿微量白蛋白定量 >3000mg/L，总胆固醇 6.36mmol/l、肌酐 118.8 μmol/l、白蛋白 28.5g/l,诊断肾病综合征，予以利尿、抗凝、纠正蛋白等治疗，建议患者到上级医院行肾脏穿刺但患者拒绝。", "event": [ { "core_name": "水肿", "tendency": "", "character": [], "anatomy_list": [ "双下肢" ] }, { "core_name": "浮肿", "tendency": "", "character": [], "anatomy_list": [ "颜面" ] }, { "core_name": "泡沫尿", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "小便", "tendency": "", "character": [ "量减少" ], "anatomy_list": [] }, { "core_name": "恶心", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "呕吐", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "胸闷", "tendency": "否定", "character": [], "anatomy_list": [ "胸" ] }, { "core_name": "气促", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "腹泻", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "肾病综合征", "tendency": "", "character": [], "anatomy_list": [ "肾" ] } ] }, { "id": 1918, "text": "疗效评价pr，经医疗组内讨论后行第三周期tp方案化疗，化疗期间患者未诉特殊不适，患者好转出院，出院后反复发热、咳嗽、咳痰，今日患者诉行走时伴头晕、心累，无胸闷、胸痛，无腹痛、腹泻等，随来我院就诊，我科以“肺癌”收入治疗。", "event": [ { "core_name": "发热", "tendency": "", "character": [ "反复" ], "anatomy_list": [] }, { "core_name": "咳嗽", "tendency": "", "character": [ "反复" ], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "反复" ], "anatomy_list": [] }, { "core_name": "头晕", "tendency": "", "character": [ "行走时" ], "anatomy_list": [ "头" ] }, { "core_name": "心累", "tendency": "", "character": [ "行走时" ], "anatomy_list": [ "心" ] }, { "core_name": "胸闷", "tendency": "否定", "character": [], "anatomy_list": [ "胸" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "胸" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "腹泻", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "癌", "tendency": "", "character": [], "anatomy_list": [ "肺" ] } ] }, { "id": 1142, "text": "5月27日再次出现阴道流血，量少，无下腹及腰骶部疼痛疼痛不适，无发热、无头晕、晕厥、乏力，无尿频尿急、无尿痛，无腹泻，遂于某医院就诊，诊刮病检提示：子宫颈管恶性肿瘤；子宫腔恶性肿瘤，建议行免疫组化检查，明确病变性质及组织类型。", "event": [ { "core_name": "出血", "tendency": "", "character": [ "量少" ], "anatomy_list": [ "阴道" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "下腹", "腰骶部" ] }, { "core_name": "发热", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "头晕", "tendency": "否定", "character": [], "anatomy_list": [ "头" ] }, { "core_name": "晕厥", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "乏力", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "尿频", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "尿急", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "尿痛", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "腹泻", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "肿瘤", "tendency": "", "character": [ "恶性" ], "anatomy_list": [ "子宫颈管" ] }, { "core_name": "肿瘤", "tendency": "", "character": [ "恶性" ], "anatomy_list": [ "子宫腔" ] } ] }, { "id": 899, "text": "入院前1+周患者感双下肢水肿加重，伴咳嗽喘累明显，夜间不能平卧，伴咳嗽咳痰，痰呈白色粘痰，否认有痰中带血，伴呼吸困难气促，否认意识障碍、大小便失禁、视物旋转、胸闷、胸痛、恶心、呕吐、腹胀、腹痛、黑便等不适，来院复诊透析，门诊以“尿毒症、肺癌”收入我科住院治疗。", "event": [ { "core_name": "水肿", "tendency": "", "character": [ "加重" ], "anatomy_list": [ "双下肢" ] }, { "core_name": "咳嗽", "tendency": "", "character": [ "明显", "夜间", "夜间不能平卧" ], "anatomy_list": [] }, { "core_name": "喘累", "tendency": "", "character": [ "明显", "夜间", "夜间不能平卧" ], "anatomy_list": [] }, { "core_name": "咳嗽", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "白色", "粘性" ], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "否定", "character": [ "带血" ], "anatomy_list": [] }, { "core_name": "呼吸困难", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "气促", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "意识障碍", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "大小便", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "视物旋转", "tendency": "否定", "character": [ "旋转" ], "anatomy_list": [] }, { "core_name": "胸闷", "tendency": "否定", "character": [], "anatomy_list": [ "胸" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "胸" ] }, { "core_name": "恶心", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "呕吐", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "腹胀", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "黑便", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "尿毒症", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "癌", "tendency": "", "character": [], "anatomy_list": [ "肺" ] } ] }, { "id": 883, "text": "于2020-03就诊于某医学检查中心，完善腹部彩超提示肝内占位性病变，进一步完善上腹部ct提示肝内多发占位性病变，并考虑腹腔内淋巴结转移及肺内多发转移（具体报告未见）。", "event": [ { "core_name": "病变", "tendency": "", "character": [ "占位性" ], "anatomy_list": [ "肝内" ] }, { "core_name": "病变", "tendency": "", "character": [ "多发", "占位性" ], "anatomy_list": [ "肝内" ] }, { "core_name": "转移", "tendency": "不确定", "character": [], "anatomy_list": [ "腹腔内淋巴结" ] }, { "core_name": "转移", "tendency": "不确定", "character": [ "多发" ], "anatomy_list": [ "肺内" ] } ] }, { "id": 1079, "text": "今入我院就诊，门诊以“痛风”收治入院。", "event": [ { "core_name": "痛风", "tendency": "", "character": [], "anatomy_list": [] } ] }, { "id": 677, "text": "2.右肺中叶及下叶炎症，建议治疗后短期复查”予以比阿培南、他唑仙抗感染，2017-1-15复查胸部ct示“1.双肺气肿；右肺中叶及下叶炎症，与（2017.1.5）ct平扫相比右下叶下叶炎症较前稍增加；其余改变同前，建议抗炎后短期复查”。", "event": [ { "core_name": "炎症", "tendency": "", "character": [], "anatomy_list": [ "右肺中叶及下叶" ] }, { "core_name": "肺气肿", "tendency": "", "character": [], "anatomy_list": [ "双肺" ] }, { "core_name": "炎症", "tendency": "", "character": [], "anatomy_list": [ "右肺中叶及下叶" ] }, { "core_name": "炎症", "tendency": "", "character": [ "较前稍增加" ], "anatomy_list": [ "右肺中叶及下叶" ] } ] }, { "id": 78, "text": "入院前10月余，患者无明显诱因出现左乳疼痛，疼痛较剧，无法忍受。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [ "较剧", "无法忍受" ], "anatomy_list": [ "左乳" ] } ] }, { "id": 931, "text": "期间患者仍反复出现皮肤瘙痒症状。", "event": [ { "core_name": "皮肤瘙痒", "tendency": "", "character": [ "反复出现" ], "anatomy_list": [] } ] }, { "id": 1128, "text": "化疗后肿瘤标志物较前下降，遂于2015-06-15予以紫杉醇脂质体180mg ivgtt d1+奈达铂40mg d1－2化疗，2015-07-13入院复查提示病情稳定，于2015-07-21采用原方案行第3周期化疗，化疗后出现轻度胃肠道反应，后好转出院，院外一般情况可，进食可，现为行下一周期化疗，门诊以“卵巢癌”收住我科。", "event": [ { "core_name": "肿瘤标志物", "tendency": "", "character": [ "较前下降" ], "anatomy_list": [] }, { "core_name": "胃肠道反应", "tendency": "", "character": [ "轻度" ], "anatomy_list": [ "胃肠道" ] }, { "core_name": "进食", "tendency": "", "character": [ "可" ], "anatomy_list": [] }, { "core_name": "癌", "tendency": "", "character": [], "anatomy_list": [ "卵巢" ] } ] }, { "id": 756, "text": "4.部分胸椎内高密度影请随访复查。", "event": [ { "core_name": "密度影", "tendency": "", "character": [ "高" ], "anatomy_list": [ "部分胸椎内" ] } ] }, { "id": 1111, "text": "今日患者拟行化疗来院，遂以“右肺癌术后化疗后复发复发伴颈部淋巴结转移放疗后”收入我科。", "event": [ { "core_name": "复发", "tendency": "", "character": [ "术后", "化疗后" ], "anatomy_list": [ "右肺" ] }, { "core_name": "转移", "tendency": "", "character": [ "放疗后" ], "anatomy_list": [ "颈部", "淋巴结" ] } ] }, { "id": 1181, "text": "2018年5月25日某医院血常规提示：白细胞总数163.41×109/l，红细胞计数4.74×1012/l，血红蛋白128g/L，血小板262×109/l；骨穿提示：慢性髓细胞白血病（慢性期）；患者继续予以伊马替尼400mg维持治疗，血常规提示白细胞长长期处于升高状态。", "event": [ { "core_name": "白血病", "tendency": "", "character": [ "慢性", "髓细胞", "慢性期" ], "anatomy_list": [ "髓细胞" ] }, { "core_name": "白细胞升高", "tendency": "", "character": [ "长期" ], "anatomy_list": [ "白细胞" ] } ] }, { "id": 462, "text": "4.双手小关节、双侧膝关节良性病变较前无明显变化。", "event": [ { "core_name": "病变", "tendency": "", "character": [ "良性", "较前无明显变化" ], "anatomy_list": [ "双手小关节", "双侧膝关节" ] } ] }, { "id": 247, "text": "后患者于洗澡时摸到右下腹包块，遂就诊于某医院，行腹部增强ct示：肝内多发团块状高密度影，最大者直径约12cm，增强扫描动脉期呈不均匀明显强化，考虑为肝癌并肝内转移可能性大。", "event": [ { "core_name": "包块", "tendency": "", "character": [], "anatomy_list": [ "右下腹" ] }, { "core_name": "密度影", "tendency": "", "character": [ "高", "多发", "团块状", "最大者直径约12cm" ], "anatomy_list": [ "肝内" ] }, { "core_name": "强化", "tendency": "", "character": [ "增强扫描", "动脉期呈不均匀", "明显" ], "anatomy_list": [] }, { "core_name": "癌", "tendency": "不确定", "character": [], "anatomy_list": [ "肝" ] }, { "core_name": "转移", "tendency": "不确定", "character": [], "anatomy_list": [ "肝内" ] } ] }, { "id": 930, "text": "入院前7年，患者无明显诱因出现皮肤瘙痒，主要表现在双手前臂尺侧及下腹部，搔抓后可呈风团样，每次服用“湿毒清胶囊“10余天后可明显缓解，缓解后可留有色素沉着，患者未重视，未进行正规治疗。", "event": [ { "core_name": "瘙痒", "tendency": "", "character": [ "搔抓后可呈风团样" ], "anatomy_list": [ "双前臂尺侧皮肤" ] }, { "core_name": "瘙痒", "tendency": "", "character": [ "搔抓后可呈风团样" ], "anatomy_list": [ "下腹部皮肤" ] }, { "core_name": "色素沉着", "tendency": "", "character": [ "缓解后" ], "anatomy_list": [] } ] }, { "id": 966, "text": "20天前患者因胸痛加重，行pet- ct提示右胸膜转移转移灶，遂到某医院就诊，于2016-4-26至2016-5-10行伽马刀治疗，治疗右肺右胸膜病灶，以50%等剂量曲线包绕，边缘单次剂量400cgy，总剂量4000cgy，过程顺利，未诉不适。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [ "加重" ], "anatomy_list": [ "胸" ] }, { "core_name": "转移灶", "tendency": "", "character": [], "anatomy_list": [ "右胸膜" ] }, { "core_name": "病灶", "tendency": "", "character": [], "anatomy_list": [ "右肺" ] }, { "core_name": "病灶", "tendency": "", "character": [], "anatomy_list": [ "右肺胸膜" ] } ] }, { "id": 1326, "text": "与患者及家属沟通后于2019-4-23至今更换方案为哌柏西利125mg*21d+氟维司群500mg30d,患者于3天前出现头晕伴呕吐，不伴发热寒战等不适，现患者为行进一步治疗，故来我科。", "event": [ { "core_name": "头晕", "tendency": "", "character": [], "anatomy_list": [ "头" ] }, { "core_name": "呕吐", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "发热", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "寒颤", "tendency": "否定", "character": [], "anatomy_list": [] } ] }, { "id": 1773, "text": "乳头未见累及，腋窝淋巴结见癌转移（4/11），免疫组化：er(-),pr(-)，her-2(+),ki676730%，术后予tec方案化疗，化疗后无不良反应，今患者为行第2次化疗入我科住院治疗，门诊以“左乳癌术后，第1次化疗后”。", "event": [ { "core_name": "累及", "tendency": "否定", "character": [], "anatomy_list": [ "乳头" ] }, { "core_name": "癌", "tendency": "", "character": [ "转移" ], "anatomy_list": [ "腋窝淋巴结" ] }, { "core_name": "不良反应", "tendency": "否定", "character": [ "化疗后" ], "anatomy_list": [] }, { "core_name": "癌", "tendency": "", "character": [ "术后", "第1次化疗后" ], "anatomy_list": [ "左乳" ] } ] }, { "id": 1058, "text": "到某医院查：“胃镜：慢性胃窦炎，腹部ct：未见明显异常”，予“雷贝拉唑、莫沙必利”等治疗后可好转，但症状反复。", "event": [ { "core_name": "胃窦炎", "tendency": "", "character": [ "慢性" ], "anatomy_list": [ "胃窦" ] } ] }, { "id": 1465, "text": "诊断为“冠状动脉粥样硬化性心脏病”，术后规律冠心病二级预防治疗（阿托伐他汀钙片、硫酸氢氯吡格雷），于3天前因“咯血”停用硫酸氢氯吡格雷，病灶中偶有心前区不适及间断双下肢水肿。", "event": [ { "core_name": "心脏病", "tendency": "", "character": [ "粥样", "硬化性" ], "anatomy_list": [ "冠状动脉", "心脏" ] }, { "core_name": "咯血", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "病灶", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "心前区不适", "tendency": "", "character": [], "anatomy_list": [ "心前区" ] }, { "core_name": "水肿", "tendency": "", "character": [ "间断" ], "anatomy_list": [ "双下肢" ] } ] }, { "id": 96, "text": "病程中伴有头晕、乏力症状，无头痛、腹痛及腹胀等。", "event": [ { "core_name": "头晕", "tendency": "", "character": [], "anatomy_list": [ "头" ] }, { "core_name": "乏力", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "头" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "腹胀", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] } ] }, { "id": 215, "text": "随后于我科住院，完善腹部彩超（2020-3-31）：左肾结石；右肾结晶沉着。", "event": [ { "core_name": "结石", "tendency": "", "character": [], "anatomy_list": [ "左肾" ] }, { "core_name": "结晶", "tendency": "", "character": [ "沉着" ], "anatomy_list": [ "右肾" ] } ] }, { "id": 9, "text": "近半年来患者反复感咳嗽气喘,长期在我院及某医院就诊,患者逐渐有心累并下肢浮肿,间断服用利尿剂。", "event": [ { "core_name": "咳嗽", "tendency": "", "character": [ "反复" ], "anatomy_list": [] }, { "core_name": "气喘", "tendency": "", "character": [ "反复" ], "anatomy_list": [] }, { "core_name": "浮肿", "tendency": "", "character": [ "逐渐" ], "anatomy_list": [ "下肢" ] }, { "core_name": "心累", "tendency": "", "character": [ "逐渐" ], "anatomy_list": [ "心" ] } ] }, { "id": 309, "text": "术后予以抗感染、祛痰、雾化等对症支持治疗，拔除胸引管后出院，患者现诉无咳嗽咳痰、胸痛胸闷气促、头痛头晕、骨痛、心慌等不适，今患者为行化疗就诊于我院门诊，并以“右肺恶性肿瘤术后”收入我科。", "event": [ { "core_name": "咳嗽", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "胸" ] }, { "core_name": "胸闷", "tendency": "否定", "character": [], "anatomy_list": [ "胸" ] }, { "core_name": "气促", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "头" ] }, { "core_name": "头晕", "tendency": "否定", "character": [], "anatomy_list": [ "头" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "骨" ] }, { "core_name": "心慌", "tendency": "否定", "character": [], "anatomy_list": [ "心" ] }, { "core_name": "肿瘤", "tendency": "", "character": [ "术后", "恶性" ], "anatomy_list": [ "右肺" ] } ] }, { "id": 940, "text": "2019-6-6于我院复查胸腹部ct示：1、胸部与2018-11-6片比较：右肺上叶病灶略有增大，周围肺叶更明显。", "event": [ { "core_name": "病灶", "tendency": "", "character": [ "略有增大" ], "anatomy_list": [ "右肺上叶" ] }, { "core_name": "病灶", "tendency": "", "character": [ "更明显" ], "anatomy_list": [ "周围肺叶" ] } ] }, { "id": 147, "text": "今患者为求进一步治疗，遂至我院，门诊以“左侧输尿管支架置入术后，泌尿系结核，糖尿病”收入我科住院治疗。", "event": [ { "core_name": "结核", "tendency": "", "character": [], "anatomy_list": [ "泌尿系" ] }, { "core_name": "糖尿病", "tendency": "", "character": [], "anatomy_list": [] } ] }, { "id": 548, "text": "院外患者仍咳嗽、咳痰，伴右侧胸闷，伴乏力、活动后喘累，自服止咳药物后症状无明显缓解，遂入住我科，行ect（2014-10-29）未见明显骨转移，与患者家属沟通后，同意化疗，遂于2014-11-05、2014-11-29、2014-12-24、2015-01-21行“奈达铂100mg d1+吉西他滨1200mg d1、8”方案化疗4周期，化疗后，患者自觉咳嗽、胸闷、活动后喘累明显好转，于2015-01-09复查胸部增强ct提示右肺占位较化疗前明显缩小，于2015-02-07我院门诊复查血常规提示：白细胞 1.85×109/l，中性粒细胞 0.94×109/l，血小板 34×109/l。", "event": [ { "core_name": "咳嗽", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "胸闷", "tendency": "", "character": [ "右侧" ], "anatomy_list": [ "胸" ] }, { "core_name": "乏力", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "喘累", "tendency": "", "character": [ "活动后" ], "anatomy_list": [] }, { "core_name": "转移", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [ "骨组织" ] }, { "core_name": "咳嗽", "tendency": "", "character": [ "明显好转" ], "anatomy_list": [] }, { "core_name": "胸闷", "tendency": "", "character": [ "明显好转" ], "anatomy_list": [ "胸" ] }, { "core_name": "喘累", "tendency": "", "character": [ "活动后", "明显好转" ], "anatomy_list": [] }, { "core_name": "占位", "tendency": "", "character": [ "明显", "缩小", "较化疗前" ], "anatomy_list": [ "右肺" ] } ] }, { "id": 2060, "text": "患者本次发病以来，食欲正常,神志清醒，精神尚可，睡眠尚可，大便正常，小便正常，体重无明显变化。", "event": [ { "core_name": "食欲", "tendency": "", "character": [ "正常" ], "anatomy_list": [] }, { "core_name": "神志", "tendency": "", "character": [ "清醒" ], "anatomy_list": [] }, { "core_name": "精神", "tendency": "", "character": [ "尚可" ], "anatomy_list": [] }, { "core_name": "睡眠", "tendency": "", "character": [ "尚可" ], "anatomy_list": [] }, { "core_name": "大便", "tendency": "", "character": [ "正常" ], "anatomy_list": [] }, { "core_name": "小便", "tendency": "", "character": [ "正常" ], "anatomy_list": [] }, { "core_name": "体重改变", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [] } ] }, { "id": 701, "text": "7天前，患者感上腹胀程度较前加重，遂就诊于当地某诊所，给予输液治疗（具体不详），症状无好转，患者为求进一步诊治，就诊于我院，门诊以“上腹胀待查”收入我科住院治疗。", "event": [ { "core_name": "腹胀", "tendency": "", "character": [ "较前加重" ], "anatomy_list": [ "上腹" ] }, { "core_name": "腹胀", "tendency": "", "character": [], "anatomy_list": [ "上腹" ] } ] }, { "id": 1068, "text": "遂于某医院就诊，行浅表淋巴结彩超示：左侧腹股沟腹股沟区淋巴结淋巴结增大，行左侧腹股沟淋巴结腹股沟淋巴结活检示：（左侧腹股沟）淋巴结 弥漫大b细胞淋巴瘤。", "event": [ { "core_name": "增大", "tendency": "", "character": [], "anatomy_list": [ "左侧腹股沟区淋巴结" ] }, { "core_name": "瘤", "tendency": "", "character": [ "弥漫" ], "anatomy_list": [ "左侧腹股沟淋巴结", "大B细胞" ] } ] }, { "id": 532, "text": "患者20余年前无明显诱因出现口干、多饮、多尿，每日饮食量及尿量不详，伴夜尿增多，至某医院测血糖12.7mmol/L，给予口服药治疗（具体方案不详），未规律监测血糖。", "event": [ { "core_name": "口干", "tendency": "", "character": [], "anatomy_list": [ "口" ] }, { "core_name": "多饮", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "多尿", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "饮食量", "tendency": "", "character": [ "每日", "不详" ], "anatomy_list": [] }, { "core_name": "尿量", "tendency": "", "character": [ "每日", "不详" ], "anatomy_list": [] }, { "core_name": "排尿", "tendency": "", "character": [ "夜间", "增多" ], "anatomy_list": [] } ] }, { "id": 326, "text": "现患者为求进一步诊治遂入我院，门诊以“左乳包块待查”收入我科。", "event": [ { "core_name": "包块", "tendency": "不确定", "character": [], "anatomy_list": [ "左乳" ] } ] }, { "id": 1980, "text": "患者本次发病以来，食欲正常， 神志清醒，精神尚可，睡眠尚可，大便正常，小便正常，近7月体重减轻约5kg。", "event": [ { "core_name": "食欲", "tendency": "", "character": [ "正常" ], "anatomy_list": [] }, { "core_name": "神志", "tendency": "", "character": [ "清醒" ], "anatomy_list": [] }, { "core_name": "精神", "tendency": "", "character": [ "尚可" ], "anatomy_list": [] }, { "core_name": "睡眠", "tendency": "", "character": [ "尚可" ], "anatomy_list": [] }, { "core_name": "大便", "tendency": "", "character": [ "正常" ], "anatomy_list": [] }, { "core_name": "小便", "tendency": "", "character": [ "正常" ], "anatomy_list": [] }, { "core_name": "体重减轻", "tendency": "", "character": [], "anatomy_list": [] } ] }, { "id": 1299, "text": "患者无声嘶、呼吸困难，无畏寒、发热，无恶心、呕吐，无心悸、食欲亢进、大汗淋漓等不适，3天前于我院门诊就诊，完善彩超提示：（2018-06-15）甲状腺双侧低回声结节，建议穿刺活检；今患者为进一步治疗，遂来我院就诊，门诊以“双侧甲状腺甲状腺包块待查？”收入我科住院治疗。", "event": [ { "core_name": "声嘶", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "呼吸困难", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "畏寒", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "发热", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "恶心", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "呕吐", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "心悸", "tendency": "否定", "character": [], "anatomy_list": [ "心" ] }, { "core_name": "食欲", "tendency": "否定", "character": [ "亢进" ], "anatomy_list": [] }, { "core_name": "出汗", "tendency": "否定", "character": [ "大汗" ], "anatomy_list": [] }, { "core_name": "结节", "tendency": "", "character": [ "低回声" ], "anatomy_list": [ "甲状腺双侧" ] }, { "core_name": "包块", "tendency": "不确定", "character": [], "anatomy_list": [ "双侧甲状腺" ] } ] }, { "id": 258, "text": "腹部不适与进食、活动、体位无明显关系，无肩背部放射痛。", "event": [ { "core_name": "腹部不适", "tendency": "", "character": [ "与进食、活动、体位无明显关系" ], "anatomy_list": [ "腹部" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [ "放射性" ], "anatomy_list": [ "肩", "背部" ] } ] }, { "id": 706, "text": "今患者为求进一步治疗，来我院，门诊以“心律失常”收入我科。", "event": [ { "core_name": "心律失常", "tendency": "", "character": [], "anatomy_list": [ "心" ] } ] }, { "id": 765, "text": "基因检测（胸水）：egfr基因为T790M和19-del突变，b-raf基因、met基因、ros1基因、alk基因均为阴性。", "event": [ { "core_name": "胸水", "tendency": "", "character": [], "anatomy_list": [ "胸" ] } ] }, { "id": 1730, "text": "为进一步明确诊治血象改变原因遂就诊血液科，查心电图正常，骨髓“增生性贫血骨髓象”，骨髓活检未见异常，诊断“骨髓增生异常综合征（ms-rcmd）”，给予“利可君、维生素b6、维生素b4、生血宝合剂、骨化三醇、复方皂凡丸、胸腺肽”等药物治疗，血小板曾恢复正常，血色素有所提升。", "event": [ { "core_name": "血象", "tendency": "不确定", "character": [ "改变" ], "anatomy_list": [] }, { "core_name": "骨髓象", "tendency": "", "character": [ "增生性", "贫血" ], "anatomy_list": [ "骨髓" ] }, { "core_name": "骨髓增生异常综合征", "tendency": "", "character": [], "anatomy_list": [ "骨髓" ] } ] }, { "id": 1967, "text": "无呕血、粘液脓血便。", "event": [ { "core_name": "呕血", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "大便", "tendency": "否定", "character": [ "粘液", "血", "脓" ], "anatomy_list": [] } ] }, { "id": 1380, "text": "2.右肺中叶内侧段、下叶背段、左肺上叶尖后段、下叶后基底段纤维化灶。", "event": [ { "core_name": "纤维化灶", "tendency": "", "character": [], "anatomy_list": [ "右肺中叶内侧段、下叶背段", "左肺上叶尖后段、下叶后基底段" ] } ] }, { "id": 1952, "text": "、给予患者曲普瑞林3.75mg每月1次+比卡鲁胺50mg内分泌治疗、唑来膦酸抑制骨破坏以及多西他赛化疗，治疗后患者夜尿增多症状明显好转，今为求第三周期化疗于我院就诊，门诊以\"前列腺癌伴骨转移\"收住入院.", "event": [ { "core_name": "夜尿增多", "tendency": "", "character": [ "治疗后", "明显好转" ], "anatomy_list": [] }, { "core_name": "癌", "tendency": "", "character": [], "anatomy_list": [ "前列腺" ] }, { "core_name": "癌", "tendency": "", "character": [ "转移" ], "anatomy_list": [ "骨" ] } ] }, { "id": 1525, "text": "病程中患者精神、饮食稍差，大便干燥，小便口服利尿剂尚可，体重无明显下降。", "event": [ { "core_name": "精神", "tendency": "", "character": [ "稍差" ], "anatomy_list": [] }, { "core_name": "饮食", "tendency": "", "character": [ "稍差" ], "anatomy_list": [] }, { "core_name": "大便", "tendency": "", "character": [ "干燥" ], "anatomy_list": [] }, { "core_name": "小便", "tendency": "", "character": [ "口服利尿剂尚可" ], "anatomy_list": [] }, { "core_name": "体重下降", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [] } ] }, { "id": 1360, "text": "遂于2016-08-26在某卫生院完善胸部ct：1.左肺类圆形软组织密度影，建议进一步确诊；2.慢支改变；3.左侧胸膜肥厚伴钙化。", "event": [ { "core_name": "密度影", "tendency": "不确定", "character": [ "类圆形", "软组织" ], "anatomy_list": [ "左肺" ] }, { "core_name": "支气管炎", "tendency": "", "character": [ "慢性" ], "anatomy_list": [ "支气管" ] }, { "core_name": "钙化", "tendency": "", "character": [], "anatomy_list": [ "左侧胸膜" ] }, { "core_name": "肥厚", "tendency": "", "character": [], "anatomy_list": [ "左侧胸膜" ] } ] }, { "id": 722, "text": "术后恢复可，遂行第1周期化疗（奥沙利铂150mg d1）,化疗中出现严重消化道反应，无骨髓抑制，经对症处理后好转。", "event": [ { "core_name": "消化道反应", "tendency": "", "character": [ "严重" ], "anatomy_list": [ "消化道" ] }, { "core_name": "骨髓抑制", "tendency": "否定", "character": [], "anatomy_list": [ "骨髓" ] } ] }, { "id": 511, "text": "术后患者诉进食梗阻感较术前好转，无特殊不适。", "event": [ { "core_name": "梗阻感", "tendency": "", "character": [ "进食", "较术前好转" ], "anatomy_list": [] } ] }, { "id": 506, "text": "入院 2+月 前，不明原因出现进食干性食物时吞咽梗阻，常在进食过多、过快时发生，进食半流质及流质食物无梗阻，无胸骨后疼痛，无饮水呛咳、烧心、泛酸、嗳气，无胸闷及心前区压榨感，未予重视及诊治。", "event": [ { "core_name": "吞咽梗阻", "tendency": "", "character": [ "进食干性食物时", "进食过多、过快时发生" ], "anatomy_list": [] }, { "core_name": "梗阻", "tendency": "否定", "character": [ "进食半流质及流质食物" ], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "胸骨后" ] }, { "core_name": "呛咳", "tendency": "否定", "character": [ "饮水" ], "anatomy_list": [] }, { "core_name": "烧心", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "泛酸", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "嗳气", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "胸闷", "tendency": "否定", "character": [], "anatomy_list": [ "胸" ] }, { "core_name": "压榨感", "tendency": "否定", "character": [], "anatomy_list": [ "心前区" ] } ] }, { "id": 262, "text": "门诊以“胃溃疡”收入我科。", "event": [ { "core_name": "溃疡", "tendency": "", "character": [], "anatomy_list": [ "胃" ] } ] }, { "id": 562, "text": "今为求进一步诊治来我院，门诊以“腹痛待查”收治入院。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [], "anatomy_list": [ "腹" ] } ] }, { "id": 1370, "text": "入院前1+月，患者单位体检时查血常规提示白细胞升高（不详），无畏寒、发热，无头昏、乏力，无耳鸣，无视力障碍，无鼻塞、流涕，无头痛、呕吐及意识障碍，无咽痛、咳嗽、咳痰，无皮下瘀斑、瘀点，无牙龈出血，无关节疼痛，无呕血、黑便、便血，无腹痛、腹泻，无肛周疼痛，无尿频、尿急、尿痛及肉眼血尿等，在某医院查骨髓涂片、骨髓活检、流式检测等检查后诊断为慢性粒细胞白血病（未见报告），院外口服羟基脲2片、bid治疗，患者今日为求进一步诊治来院，我科以“慢性粒细胞白细胞”收住入院。", "event": [ { "core_name": "白细胞升高", "tendency": "", "character": [], "anatomy_list": [ "白细胞" ] }, { "core_name": "畏寒", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "发热", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "头昏", "tendency": "否定", "character": [], "anatomy_list": [ "头" ] }, { "core_name": "乏力", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "耳鸣", "tendency": "否定", "character": [], "anatomy_list": [ "耳" ] }, { "core_name": "视力障碍", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "鼻塞", "tendency": "否定", "character": [], "anatomy_list": [ "鼻" ] }, { "core_name": "流涕", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "头" ] }, { "core_name": "呕吐", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "意识障碍", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "咽" ] }, { "core_name": "咳嗽", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "瘀斑", "tendency": "否定", "character": [], "anatomy_list": [ "皮下" ] }, { "core_name": "瘀点", "tendency": "否定", "character": [], "anatomy_list": [ "皮下" ] }, { "core_name": "出血", "tendency": "否定", "character": [], "anatomy_list": [ "牙龈" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "关节" ] }, { "core_name": "呕血", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "黑便", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "便血", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "腹泻", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "肛周" ] }, { "core_name": "尿频", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "尿急", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "尿痛", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "血尿", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "白血病", "tendency": "", "character": [ "慢性" ], "anatomy_list": [ "粒细胞" ] } ] }, { "id": 1715, "text": "入院前5天，患者无意中发现左侧乳房乳房包块，包块如“豌豆”大小，无明显疼痛感，无乳头溢脓、渗液、出血，无乳房表面皮肤发红、皲裂、皱褶，遂来我院就诊，查乳腺彩超提示：左乳腺异常回声，bi-rads4b类，为求进一步诊治，门诊以“乳房肿块”收入我科。", "event": [ { "core_name": "包块", "tendency": "", "character": [ "豌豆大小", "无明显疼痛感" ], "anatomy_list": [ "左侧乳房" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [ "左侧乳房" ] }, { "core_name": "溢脓", "tendency": "否定", "character": [], "anatomy_list": [ "乳头" ] }, { "core_name": "渗液", "tendency": "否定", "character": [], "anatomy_list": [ "乳头" ] }, { "core_name": "出血", "tendency": "否定", "character": [], "anatomy_list": [ "乳头" ] }, { "core_name": "发红", "tendency": "否定", "character": [], "anatomy_list": [ "乳房表面皮肤" ] }, { "core_name": "皲裂", "tendency": "否定", "character": [], "anatomy_list": [ "乳房表面皮肤" ] }, { "core_name": "皱褶", "tendency": "否定", "character": [], "anatomy_list": [ "乳房表面皮肤" ] }, { "core_name": "异常回声", "tendency": "", "character": [ "bi-rads4b类" ], "anatomy_list": [ "左乳腺" ] }, { "core_name": "肿块", "tendency": "", "character": [], "anatomy_list": [ "乳房" ] } ] }, { "id": 1287, "text": "今为求进一步放疗，以“宫颈癌”收入我科住院治疗。", "event": [ { "core_name": "癌", "tendency": "", "character": [], "anatomy_list": [ "宫颈" ] } ] }, { "id": 481, "text": "2020年1月包块增大，至某医院就诊，行口腔包块切除，嘱患者观察颈部包块。", "event": [ { "core_name": "包块增大", "tendency": "", "character": [ "增大" ], "anatomy_list": [] }, { "core_name": "包块", "tendency": "", "character": [], "anatomy_list": [ "颈部" ] } ] }, { "id": 889, "text": "患者本次发病以来，食欲正常，神志清醒，精神尚可，睡眠尚可，大小便如上所述，体重无明显变化。", "event": [ { "core_name": "食欲", "tendency": "", "character": [ "正常" ], "anatomy_list": [] }, { "core_name": "神志", "tendency": "", "character": [ "清醒" ], "anatomy_list": [] }, { "core_name": "精神", "tendency": "", "character": [ "尚可" ], "anatomy_list": [] }, { "core_name": "睡眠", "tendency": "", "character": [ "尚可" ], "anatomy_list": [] }, { "core_name": "体重改变", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [] } ] }, { "id": 1509, "text": "入院前1+月，患者无明显出现左侧下肢部疼痛，为持续性胀痛，久坐、久站后加重，卧位休息可缓解，腰骶部疼痛反复发作，以左大腿后侧后外侧、小腿后侧，为进一步诊疗，遂来我院就诊，行腰椎ct提示：腰椎退行性变；腰44椎体i°滑脱，腰1椎体向后右侧移位，腰33椎体向左移位，椎间盘变性，腰11/2、3/4、4/5、腰5/骶1椎间盘膨出。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [ "为持续性胀痛", "久坐久站后加重", "卧位休息可缓解" ], "anatomy_list": [ "左侧下肢" ] }, { "core_name": "疼痛", "tendency": "", "character": [ "反复发作" ], "anatomy_list": [ "腰骶部" ] }, { "core_name": "病变", "tendency": "", "character": [ "退行性" ], "anatomy_list": [ "腰椎" ] }, { "core_name": "滑脱", "tendency": "", "character": [ "i°" ], "anatomy_list": [ "腰L4椎体" ] }, { "core_name": "移位", "tendency": "", "character": [ "向后右侧" ], "anatomy_list": [ "腰L1椎体" ] }, { "core_name": "移位", "tendency": "", "character": [ "向左" ], "anatomy_list": [ "腰L3椎体" ] }, { "core_name": "变性", "tendency": "", "character": [ "向左" ], "anatomy_list": [ "腰3椎体", "椎间盘" ] }, { "core_name": "膨出", "tendency": "", "character": [], "anatomy_list": [ "腰1/2、3/4、4/5、腰5/骶1椎间盘" ] } ] }, { "id": 1983, "text": "入院前8小时，患者在夜间洗澡受凉后突然出现头晕，呈持续性，体位变化时头晕加重，伴恶心、呕吐非血性胃内容物，伴畏寒、寒战，偶有心前区不适感，患者不能准确描述是否有视物旋转，无耳鸣、耳聋，无发热、咳嗽、咳痰，无意识障碍、肢体活动障碍、肢体抽搐、大小便失禁。患者未予以重视及处理。", "event": [ { "core_name": "头晕", "tendency": "", "character": [ "持续性", "夜间洗澡受凉后" ], "anatomy_list": [ "头" ] }, { "core_name": "头晕", "tendency": "", "character": [ "体位变化时加重" ], "anatomy_list": [ "头" ] }, { "core_name": "恶心", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "呕吐", "tendency": "", "character": [ "非血性胃内容物" ], "anatomy_list": [] }, { "core_name": "畏寒", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "寒颤", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "心前区不适感", "tendency": "", "character": [ "偶有" ], "anatomy_list": [ "心前区" ] }, { "core_name": "视物旋转", "tendency": "不确定", "character": [], "anatomy_list": [] }, { "core_name": "耳鸣", "tendency": "否定", "character": [], "anatomy_list": [ "耳" ] }, { "core_name": "耳聋", "tendency": "否定", "character": [], "anatomy_list": [ "耳" ] }, { "core_name": "发热", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "咳嗽", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "意识障碍", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "活动障碍", "tendency": "", "character": [], "anatomy_list": [ "肢体" ] }, { "core_name": "抽搐", "tendency": "", "character": [], "anatomy_list": [ "肢体" ] }, { "core_name": "大小便失禁", "tendency": "", "character": [ "失禁" ], "anatomy_list": [] } ] }, { "id": 907, "text": "病后精神尚可，食欲好，小便正常，大便正常。", "event": [ { "core_name": "精神", "tendency": "", "character": [ "尚可" ], "anatomy_list": [] }, { "core_name": "食欲", "tendency": "", "character": [ "好" ], "anatomy_list": [] }, { "core_name": "小便", "tendency": "", "character": [ "正常" ], "anatomy_list": [] }, { "core_name": "大便", "tendency": "", "character": [ "正常" ], "anatomy_list": [] } ] }, { "id": 685, "text": "遂至某医院行petct检查提示：胸腺瘤，恶性可能性较大（未见报告）；于2016-11-03在全麻下行胸腔镜下纵隔肿瘤切除术+心包部分切除术，术中见胸膜腔腔内广泛粘连，无明显积液，手术顺利，标本送病检（病理号123456）提示：胸腺鳞状细胞癌；术后好转出院，偶有咳嗽、头昏，无明显胸闷、呼吸困难，无咯血，无畏寒、发热，无恶心呕吐，无腹胀、腹泻等症状；现患者为行第一次化疗，遂至我院就诊，门诊以“胸腺癌术后”收入我科住院治疗。", "event": [ { "core_name": "瘤", "tendency": "不确定", "character": [ "恶性" ], "anatomy_list": [ "胸腺" ] }, { "core_name": "粘连", "tendency": "", "character": [ "广泛" ], "anatomy_list": [ "胸膜腔内" ] }, { "core_name": "积液", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [ "胸膜腔内" ] }, { "core_name": "鳞癌", "tendency": "", "character": [], "anatomy_list": [ "胸腺" ] }, { "core_name": "咳嗽", "tendency": "", "character": [ "偶有" ], "anatomy_list": [] }, { "core_name": "头昏", "tendency": "", "character": [ "偶有" ], "anatomy_list": [ "头" ] }, { "core_name": "胸闷", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [ "胸" ] }, { "core_name": "呼吸困难", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [] }, { "core_name": "咯血", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "畏寒", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "发热", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "恶心", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "呕吐", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "腹胀", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "腹泻", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "癌", "tendency": "", "character": [ "术后" ], "anatomy_list": [ "胸腺" ] } ] }, { "id": 735, "text": "入院前10天，患者受凉后出现咳嗽、咳痰，为白色泡沫痰，伴痰中带鲜红色血，量少，无发热、畏寒、寒战，无胸痛、胸闷、呼吸困难，无头昏、头痛，无端坐呼吸及夜间阵发性呼吸困难，无双下肢水肿，于当地诊所自行购买感冒药（具体药物不详）后无好转，入院2天前，患者咳嗽、咳痰仍明显，为求进一步治疗，遂至我院，门诊行胸部ct提示右肺下叶支气管气管周围肿块，考虑中央型肺癌，门诊以“左肺块待查”收入我科住院治疗。", "event": [ { "core_name": "咳嗽", "tendency": "", "character": [ "受凉后" ], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "受凉后", "白色", "泡沫痰" ], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "鲜红色血", "量少" ], "anatomy_list": [] }, { "core_name": "发热", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "畏寒", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "寒战", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "胸" ] }, { "core_name": "胸闷", "tendency": "否定", "character": [], "anatomy_list": [ "胸" ] }, { "core_name": "呼吸困难", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "头昏", "tendency": "否定", "character": [], "anatomy_list": [ "头" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "头" ] }, { "core_name": "端坐呼吸", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "呼吸困难", "tendency": "否定", "character": [ "夜间", "阵发性" ], "anatomy_list": [] }, { "core_name": "水肿", "tendency": "否定", "character": [], "anatomy_list": [ "双下肢" ] }, { "core_name": "咳嗽", "tendency": "", "character": [ "明显" ], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "明显" ], "anatomy_list": [] }, { "core_name": "肿块", "tendency": "", "character": [], "anatomy_list": [ "右肺下叶", "支气管气管周围" ] }, { "core_name": "癌", "tendency": "不确定", "character": [ "中央型" ], "anatomy_list": [ "肺" ] }, { "core_name": "肿块", "tendency": "", "character": [], "anatomy_list": [ "左肺" ] } ] }, { "id": 1227, "text": "1天前，患者无明显诱因再次出现阴道流血，量不详，伴腹痛，患者为进一步治疗入我院，门诊以“宫颈癌”收入我科住院治疗。", "event": [ { "core_name": "出血", "tendency": "", "character": [ "量不详" ], "anatomy_list": [ "阴道" ] }, { "core_name": "疼痛", "tendency": "", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "癌", "tendency": "", "character": [], "anatomy_list": [ "宫颈" ] } ] } ]