[ { "id": 268, "text": "患者本次发病以来，食欲正常，神志清醒，精神尚可，睡眠欠佳，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": [ "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": "体重变化", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [] } ] }, { "id": 1425, "text": "请外科会诊后建议至上级医院手术或者放化疗，但患者拒绝并办理出院；此后患者仍诉张口困难，偶有左侧面颈部轻微疼痛，无发热，无咳嗽咯痰，无腹痛腹泻，22天前患者在家属陪同下再次到我科住院治疗，入院后完善检查无化疗禁忌，征得患者及家属同意后于5-25日行紫杉醇240mg d1+奈达铂120mg d1化疗，并于5月29日给予帕米磷酸二钠抗溶骨治疗，治疗过程顺利，化疗后患者面部包块缩小，今日患者为行下一疗程化疗入院，门诊以“口腔粘膜恶性肿瘤 口腔鳞状细胞癌 t4n2M0”收治入院。", "event": [ { "core_name": "张口困难", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "", "character": [ "轻微" ], "anatomy_list": [ "左侧面", "左侧颈部" ] }, { "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": [ "腹" ] }, { "core_name": "腹泻", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "包块", "tendency": "", "character": [ "化疗后", "缩小" ], "anatomy_list": [ "面部" ] }, { "core_name": "肿瘤", "tendency": "", "character": [ "恶性" ], "anatomy_list": [ "口腔粘膜" ] }, { "core_name": "鳞癌", "tendency": "", "character": [], "anatomy_list": [ "口腔" ] } ] }, { "id": 149, "text": "肝功仍轻度异常，乙肝标志物示hbsag、hbeab、hbcab阳性。", "event": [ { "core_name": "肝功能异常", "tendency": "", "character": [ "轻度" ], "anatomy_list": [ "肝" ] }, { "core_name": "hbsag", "tendency": "", "character": [ "阳性" ], "anatomy_list": [] }, { "core_name": "hbeab", "tendency": "", "character": [ "阳性" ], "anatomy_list": [] }, { "core_name": "hbcab", "tendency": "", "character": [ "阳性" ], "anatomy_list": [] } ] }, { "id": 1636, "text": "胸部ct平扫+增强，全腹部ct平扫：1.结肠ca术后改变，肝右叶后段段结节，转移瘤可能；2.右肺下叶胸膜下浅淡结节，性质待定，建议短期随访除外转移。", "event": [ { "core_name": "癌", "tendency": "", "character": [ "术后改变" ], "anatomy_list": [ "结肠" ] }, { "core_name": "结节", "tendency": "", "character": [], "anatomy_list": [ "肝右叶后段" ] }, { "core_name": "瘤", "tendency": "不确定", "character": [ "转移" ], "anatomy_list": [ "肝右叶后段" ] }, { "core_name": "结节", "tendency": "", "character": [ "浅淡" ], "anatomy_list": [ "右肺下叶胸膜下" ] } ] }, { "id": 1539, "text": "4.双肾囊肿； 5.脾脏增大； 6.直肠下段改变，考虑肿瘤性病变，累及浆膜层，腹膜后及直肠周围多发淋巴结显示；考虑诊断直肠腺癌明确，经新辅助化疗3次后，经多学科讨论会诊后有手术指征，患者及家属同意手术，积极术前准备后，于2016-03-16全麻下行腹腔镜下直肠癌根治术（dixon术），手术顺利，术后病检回示：直肠中分化腺癌，侵及全层，近远端未见癌累及，肠周脂肪组织中淋巴结见癌转移（6/17）。", "event": [ { "core_name": "囊肿", "tendency": "", "character": [], "anatomy_list": [ "双肾" ] }, { "core_name": "脾增大", "tendency": "", "character": [], "anatomy_list": [ "脾" ] }, { "core_name": "改变", "tendency": "", "character": [], "anatomy_list": [ "直肠下段" ] }, { "core_name": "病变", "tendency": "不确定", "character": [ "肿瘤性", "累及浆膜层" ], "anatomy_list": [ "腹膜后淋巴结", "直肠周围淋巴结" ] }, { "core_name": "腺癌", "tendency": "不确定", "character": [], "anatomy_list": [ "直肠" ] }, { "core_name": "腺癌", "tendency": "", "character": [ "中分化", "侵及全层", "近远端未见癌累及" ], "anatomy_list": [ "直肠" ] }, { "core_name": "癌", "tendency": "", "character": [ "转移" ], "anatomy_list": [ "肠周脂肪组织", "淋巴结" ] } ] }, { "id": 561, "text": "无尿频、尿急、尿痛。", "event": [ { "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": [] } ] }, { "id": 1876, "text": "7天前，患者自觉腹痛较前加重，为中上腹蹿气样痛伴后背部放射痛，持续时间较前延长（具体不详），伴纳差，进食量减少1/3，伴解成形黑大便1次，量不多，伴头昏，无厌油、乏力，无黑曚、晕厥，无腹胀、腹泻、便秘，无血便、粘液便，无里急后重、排便不尽，患者院外购买胃药（具体不详）服用后症状无缓解。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [ "较前加重" ], "anatomy_list": [ "腹" ] }, { "core_name": "疼痛", "tendency": "", "character": [ "蹿气样" ], "anatomy_list": [ "中上腹" ] }, { "core_name": "疼痛", "tendency": "", "character": [ "放射性" ], "anatomy_list": [ "后背部" ] }, { "core_name": "纳差", "tendency": "", "character": [ "进食量减少1/3" ], "anatomy_list": [] }, { "core_name": "黑便", "tendency": "", "character": [ "量不多" ], "anatomy_list": [] }, { "core_name": "头昏", "tendency": "", "character": [], "anatomy_list": [ "头" ] }, { "core_name": "厌油", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "乏力", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "黒朦", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "晕厥", "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": "血便", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "粘液便", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "里急后重", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "排便不尽", "tendency": "否定", "character": [], "anatomy_list": [] } ] }, { "id": 245, "text": "门诊以“腰椎椎管内占位椎管内占位性病”变收入我科。", "event": [ { "core_name": "病变", "tendency": "", "character": [ "占位性" ], "anatomy_list": [ "腰椎椎管内" ] } ] }, { "id": 1089, "text": "患者2+年前无明显诱因出现大便次数增多，约5-6次/天，量少呈糊状，无黑便、脓血便，偶有粘液便，伴肛门坠胀、里急后重感，遂到我院就诊，直肠指诊及腹部ct提示直肠癌，于2013.6.14日下午在全麻下行冰冻活检+剖腹探查+直肠癌根治术(miles)+放射性粒子植入术,手术顺利，术后病检示：1.（直肠）送检肠壁组织显示炎症改变，未见癌。", "event": [ { "core_name": "大便", "tendency": "", "character": [ "次数增多", "约5-6次/天", "量少", "呈糊状" ], "anatomy_list": [] }, { "core_name": "黑便", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "大便", "tendency": "否定", "character": [ "脓血" ], "anatomy_list": [] }, { "core_name": "大便", "tendency": "", "character": [ "偶有", "粘液" ], "anatomy_list": [] }, { "core_name": "坠胀", "tendency": "", "character": [], "anatomy_list": [ "肛门" ] }, { "core_name": "里急后重感", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "癌", "tendency": "", "character": [], "anatomy_list": [ "直肠" ] }, { "core_name": "炎症", "tendency": "", "character": [ "改变" ], "anatomy_list": [ "直肠" ] }, { "core_name": "癌", "tendency": "否定", "character": [], "anatomy_list": [ "直肠" ] } ] }, { "id": 2068, "text": "鼻窦ct提示左侧上颌窦占位。", "event": [ { "core_name": "占位", "tendency": "", "character": [], "anatomy_list": [ "左侧上颌窦" ] } ] }, { "id": 1571, "text": "于2019-09-04到我院消化科就诊，行电子结肠镜检查及病检提示：直乙交界腺癌、结肠多发息肉；于2019-09-17到某医院在腹腔镜下直肠癌根治术，术后病检：（直肠）中分化腺癌，浸润肠壁深肌层，双侧切缘及吻合环无癌，肠周淋巴结无癌（0/19）。", "event": [ { "core_name": "腺癌", "tendency": "", "character": [], "anatomy_list": [ "直乙交界" ] }, { "core_name": "息肉", "tendency": "", "character": [ "多发" ], "anatomy_list": [ "结肠" ] }, { "core_name": "腺癌", "tendency": "", "character": [ "中分化" ], "anatomy_list": [ "直肠" ] }, { "core_name": "癌", "tendency": "", "character": [ "浸润" ], "anatomy_list": [ "肠壁深肌层" ] }, { "core_name": "癌", "tendency": "否定", "character": [], "anatomy_list": [ "双侧切缘", "吻合环" ] }, { "core_name": "癌", "tendency": "否定", "character": [], "anatomy_list": [ "肠周淋巴结" ] } ] }, { "id": 673, "text": "化疗期间及化疗后无恶心等不良反应，无寒战高热，无心慌胸闷，无呼吸困难，无四肢乏力。", "event": [ { "core_name": "恶心", "tendency": "否定", "character": [], "anatomy_list": [] }, { "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": 2014, "text": "3天前开始，患者出现发热（体温波动在38.5摄氏度左右），下午明显，无畏寒，无胸闷胸痛等不适，自行口服药物（具体不详），体温下降，随后又反复出现发热。", "event": [ { "core_name": "发热", "tendency": "", "character": [ "下午明显" ], "anatomy_list": [] }, { "core_name": "体温", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "畏寒", "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": "体温下降", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "发热", "tendency": "", "character": [ "反复" ], "anatomy_list": [] } ] }, { "id": 1659, "text": "于2017-01-04日行第二次化疗，方案：表柔比星 80mg ivgtt qd+维a酸 10mg po tid，并辅以碱化尿液、水化、止吐等治疗，化疗后患者出现恶心、呕吐，血常规提示白细胞及血小板减少，予以升血、止吐等治疗，患者好转后出院。", "event": [ { "core_name": "恶心", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "呕吐", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "白细胞", "tendency": "", "character": [ "减少" ], "anatomy_list": [] }, { "core_name": "血小板", "tendency": "", "character": [ "减少" ], "anatomy_list": [] } ] }, { "id": 1440, "text": "06-19常规病理检查报告（123456）：<右肺>低分化癌，结合免疫组化结果符合低分化腺癌。", "event": [ { "core_name": "癌", "tendency": "", "character": [ "低分化" ], "anatomy_list": [ "右肺" ] }, { "core_name": "腺癌", "tendency": "", "character": [ "低分化" ], "anatomy_list": [ "右肺" ] } ] }, { "id": 894, "text": "给予抗感染、解痉、抗纤维化等对症支持治疗，症状缓解，但仍感阵时喘累，于我院住院治疗，住院期间出现喘累加重，考虑并发院内感染，于1月4日给予哌拉西林舒巴坦抗感染治疗，于今日结账再次入院。", "event": [ { "core_name": "喘累", "tendency": "", "character": [ "阵时" ], "anatomy_list": [] }, { "core_name": "喘累", "tendency": "", "character": [ "加重" ], "anatomy_list": [] }, { "core_name": "院内感染", "tendency": "不确定", "character": [], "anatomy_list": [] } ] }, { "id": 233, "text": "入院前3年，患者因“腹胀”于我院消化科住院治疗，查冠脉cta：1.右优势型冠状动脉2.左侧冠状动脉钱简直远端壁冠状动脉显示，上腹部增强ct：1.右肾囊肿2.双侧髂总动脉管壁钙化，诊断为“1.慢性胃炎2.功能性腹胀；3.2型糖尿病；4.冠心病，5.高血压病3级 很高危，予以相应治疗后，好转出院，院外长期口服“格列美脲4mg、 瑞格列奈4mg qd ”控制血糖。", "event": [ { "core_name": "腹胀", "tendency": "", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "囊肿", "tendency": "", "character": [], "anatomy_list": [ "右肾" ] }, { "core_name": "钙化", "tendency": "", "character": [], "anatomy_list": [ "双侧髂总动脉管壁" ] }, { "core_name": "胃炎", "tendency": "", "character": [ "慢性" ], "anatomy_list": [ "胃" ] }, { "core_name": "腹胀", "tendency": "", "character": [ "功能性" ], "anatomy_list": [ "腹" ] }, { "core_name": "糖尿病", "tendency": "", "character": [ "2型" ], "anatomy_list": [] }, { "core_name": "冠心病", "tendency": "", "character": [], "anatomy_list": [ "心" ] }, { "core_name": "高血压", "tendency": "", "character": [ "3级", "很高危" ], "anatomy_list": [] } ] }, { "id": 647, "text": "患者于入院前十二小时前无明显诱因突发晕厥，伴意识不清，站立不稳，伴言语不能，无大汗，无头晕、目眩，无恶心、呕吐，无四肢发麻等，患者自测血糖约为“3.5mm/h”，于夜间灌服少量牛奶及葡萄糖水外未做任何处理。", "event": [ { "core_name": "晕厥", "tendency": "", "character": [ "突发" ], "anatomy_list": [] }, { "core_name": "意识", "tendency": "", "character": [ "不清" ], "anatomy_list": [] }, { "core_name": "站立", "tendency": "", "character": [ "不稳" ], "anatomy_list": [] }, { "core_name": "语言表达", "tendency": "", "character": [ "不能" ], "anatomy_list": [] }, { "core_name": "大汗", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "头晕", "tendency": "否定", "character": [], "anatomy_list": [ "头" ] }, { "core_name": "目眩", "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": "发麻", "tendency": "否定", "character": [], "anatomy_list": [ "四肢" ] } ] }, { "id": 607, "text": "术后恢复良好，患者意识清晰，肢体活动良好于2012-9-7出院，此次再入院行cik/dc细胞治疗，未感特殊不适。", "event": [ { "core_name": "意识", "tendency": "", "character": [ "清晰" ], "anatomy_list": [] }, { "core_name": "活动", "tendency": "", "character": [ "良好" ], "anatomy_list": [ "肢体" ] } ] }, { "id": 1117, "text": "患者无明显夜间阵发性呼吸困难，无泡沫尿，无黄疸，无性格改变，无食欲改变等情况。", "event": [ { "core_name": "呼吸困难", "tendency": "否定", "character": [ "夜间", "阵发性", "明显" ], "anatomy_list": [] }, { "core_name": "泡沫尿", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "黄疸", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "性格", "tendency": "否定", "character": [ "改变" ], "anatomy_list": [] }, { "core_name": "食欲", "tendency": "否定", "character": [ "改变" ], "anatomy_list": [] } ] }, { "id": 1771, "text": "23天前，患者入我科例行复查，胸部ct示：双肺多发结节、纵隔淋巴结肿大，考虑转移。", "event": [ { "core_name": "结节", "tendency": "", "character": [ "多发" ], "anatomy_list": [ "双肺" ] }, { "core_name": "肿大", "tendency": "", "character": [], "anatomy_list": [ "纵隔淋巴结" ] }, { "core_name": "转移", "tendency": "", "character": [], "anatomy_list": [] } ] }, { "id": 1310, "text": "近两年来患者头晕症状发作较既往频繁。", "event": [ { "core_name": "头晕", "tendency": "", "character": [ "发作较既往频繁" ], "anatomy_list": [ "头" ] } ] }, { "id": 1506, "text": "现患儿无发热及咳嗽，无恶心、呕吐，无皮肤瘀斑瘀点、牙龈出血、鼻衄等出血倾向，无进行性面色苍白，无黄疸，无骨关节关节疼痛。", "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": "瘀斑", "tendency": "否定", "character": [], "anatomy_list": [ "皮肤" ] }, { "core_name": "瘀点", "tendency": "否定", "character": [], "anatomy_list": [ "皮肤" ] }, { "core_name": "出血", "tendency": "否定", "character": [], "anatomy_list": [ "牙龈" ] }, { "core_name": "鼻衄", "tendency": "否定", "character": [], "anatomy_list": [ "鼻" ] }, { "core_name": "出血倾向", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "黄疸", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "骨关节" ] }, { "core_name": "面色苍白", "tendency": "否定", "character": [ "进行性" ], "anatomy_list": [ "面" ] } ] }, { "id": 1598, "text": "入院前8+月，患者再次因“活动后心累、气促，伴胸闷、心悸，伴夜间阵发性呼吸困难及双下肢水肿”于我院住院治疗，完善心脏彩超：左房（43mm），左室（64mm），右房（42mm）增大，左室下壁节段性运动幅度减低，二尖瓣轻度反流、主动脉瓣轻度反流，左室功能减低（EF38%）。", "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": "胸闷", "tendency": "", "character": [], "anatomy_list": [ "胸" ] }, { "core_name": "心悸", "tendency": "", "character": [], "anatomy_list": [ "心" ] }, { "core_name": "呼吸困难", "tendency": "", "character": [ "夜间", "阵发性" ], "anatomy_list": [] }, { "core_name": "水肿", "tendency": "", "character": [], "anatomy_list": [ "双下肢" ] }, { "core_name": "增大", "tendency": "", "character": [], "anatomy_list": [ "右房" ] }, { "core_name": "运动幅度", "tendency": "", "character": [ "节段性", "减低" ], "anatomy_list": [ "左室下壁" ] }, { "core_name": "反流", "tendency": "", "character": [ "轻度" ], "anatomy_list": [ "二尖瓣" ] }, { "core_name": "反流", "tendency": "", "character": [ "轻度" ], "anatomy_list": [ "主动脉瓣" ] }, { "core_name": "左室功能减低", "tendency": "", "character": [ "EF38%" ], "anatomy_list": [ "左室" ] } ] }, { "id": 389, "text": "术后患者恢复可，伤口无感染渗液，愈合情况良好。", "event": [ { "core_name": "感染", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "渗液", "tendency": "否定", "character": [], "anatomy_list": [] } ] }, { "id": 642, "text": "今日遵医嘱行第6次化疗，遂入我科门诊，门诊以“升结肠癌（pT4n0M0）术后，第6次化疗。", "event": [ { "core_name": "癌", "tendency": "", "character": [ "术后", "pT4n0M0", "第6次化疗" ], "anatomy_list": [ "升结肠" ] } ] }, { "id": 1047, "text": "2天前出现咳嗽，为阵发性干咳，无咳痰，无咯血及胸痛，无气促等不适，遂到我院门诊就诊，行“上下腹部平扫+增强ct示：1.肝硬化，2.肝囊肿、右肾囊肿，3.腹腔、盆腔积液，4.腹膜后腹主动脉左侧结节：淋巴结肿大？肿瘤？5.扫描范围双侧胸膜增厚。", "event": [ { "core_name": "咳嗽", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "咳嗽", "tendency": "", "character": [ "阵发性", "干性" ], "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": [ "胸" ] }, { "core_name": "气促", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "硬化", "tendency": "", "character": [], "anatomy_list": [ "肝" ] }, { "core_name": "囊肿", "tendency": "", "character": [], "anatomy_list": [ "肝" ] }, { "core_name": "囊肿", "tendency": "", "character": [], "anatomy_list": [ "右肾" ] }, { "core_name": "积液", "tendency": "", "character": [], "anatomy_list": [ "腹腔", "盆腔" ] }, { "core_name": "结节", "tendency": "", "character": [], "anatomy_list": [ "腹膜后腹主动脉左侧" ] }, { "core_name": "肿大", "tendency": "不确定", "character": [], "anatomy_list": [ "淋巴结" ] }, { "core_name": "增厚", "tendency": "", "character": [], "anatomy_list": [ "双侧胸膜" ] } ] }, { "id": 1216, "text": "2016.12，患者无明显诱因出现阴道分泌物增多，呈咖啡色，偶有异味，同房后症状加重，伴阴道有少量鲜红色血液流出，无发热、寒战、腹痛、腹胀。", "event": [ { "core_name": "分泌物", "tendency": "", "character": [ "呈咖啡色", "偶有异味", "同房后症状加重", "增多" ], "anatomy_list": [ "阴道" ] }, { "core_name": "出血", "tendency": "", "character": [ "少量", "鲜红色" ], "anatomy_list": [ "阴道" ] }, { "core_name": "发热", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "寒颤", "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" ] } ] }, { "id": 2057, "text": "手术顺利，术后病理提示：(右半结肠及回盲部肿瘤)隆起型管状腺癌ii级伴坏死,部分呈粘液腺癌(约30%)癌组织侵出浆膜达脂肪组织,其中回盲部肿瘤累及腹壁肌肉,未见确切癌栓及神经侵犯,回肠切缘,结肠切缘干净,环周切缘见粘液腺癌累及,阑尾区未见癌累及,盆侧壁见癌累及,结肠息肉绒毛状腺瘤,区域淋巴结见癌转移(1/19)肠周脂肪淋巴结(1/18)，肠系膜上淋巴结(0/1),诊断:ct4bn1bm0iiic期,术后给于8次洛铂联合氟尿嘧啶(具体方案不详)化疗,未行规律复查。", "event": [ { "core_name": "肿瘤", "tendency": "", "character": [], "anatomy_list": [ "右半结肠", "回盲部" ] }, { "core_name": "管状腺癌", "tendency": "", "character": [ "管状", "隆起型", "ii级" ], "anatomy_list": [ "右半结肠", "回盲部" ] }, { "core_name": "坏死", "tendency": "", "character": [], "anatomy_list": [ "右半结肠", "回盲部" ] }, { "core_name": "腺癌", "tendency": "", "character": [ "部分", "粘液" ], "anatomy_list": [ "右半结肠", "回盲部" ] }, { "core_name": "癌组织", "tendency": "", "character": [ "侵出浆膜达脂肪组织" ], "anatomy_list": [] }, { "core_name": "肿瘤", "tendency": "", "character": [], "anatomy_list": [ "回盲部" ] }, { "core_name": "肿瘤", "tendency": "", "character": [ "累及" ], "anatomy_list": [ "腹壁肌肉" ] }, { "core_name": "癌栓", "tendency": "", "character": [ "未见确切" ], "anatomy_list": [] }, { "core_name": "肿瘤", "tendency": "", "character": [ "侵犯" ], "anatomy_list": [ "神经" ] }, { "core_name": "腺癌", "tendency": "", "character": [ "累及", "粘液" ], "anatomy_list": [ "结肠环周切缘" ] }, { "core_name": "癌", "tendency": "否定", "character": [ "累及" ], "anatomy_list": [ "阑尾区" ] }, { "core_name": "癌", "tendency": "", "character": [ "累及" ], "anatomy_list": [ "盆侧壁" ] }, { "core_name": "息肉", "tendency": "", "character": [], "anatomy_list": [ "结肠" ] }, { "core_name": "腺瘤", "tendency": "", "character": [ "绒毛状" ], "anatomy_list": [ "结肠" ] }, { "core_name": "癌", "tendency": "", "character": [ "转移" ], "anatomy_list": [ "区域淋巴结", "肠周脂肪淋巴结", "肠系膜上淋巴结" ] } ] }, { "id": 1455, "text": "入院前2天，患者无明显诱因出现左肩部隐痛不适，呈持续性，左肩部活动时疼痛加重，呈刺痛，停止活动疼痛可缓解，今为进一步治疗入我科。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [ "隐痛", "持续性" ], "anatomy_list": [ "左肩部" ] }, { "core_name": "疼痛", "tendency": "", "character": [ "活动时疼痛加重", "呈刺痛", "停止活动可缓解" ], "anatomy_list": [ "左肩部" ] } ] }, { "id": 1643, "text": "腋窝淋巴结未见癌转移（0/11），免疫组化：er（-），pr（-），ccrbb-2（3+），ki676730%（+）。", "event": [ { "core_name": "癌", "tendency": "否定", "character": [ "转移" ], "anatomy_list": [ "腋窝淋巴结" ] } ] }, { "id": 337, "text": "患者于1+月前在我科诊断右侧浸润性乳腺癌明确，充分术前准备后于2018-05-18在全麻下行了右侧乳腺癌改良根治术，术后患者病情恢复可，术后病理提示：右侧浸润性乳腺癌，er（—），pr（—），her-2（—），p53（+），腋窝淋巴结20/21枚转移。", "event": [ { "core_name": "癌", "tendency": "", "character": [ "浸润性" ], "anatomy_list": [ "右侧乳腺" ] }, { "core_name": "癌", "tendency": "", "character": [ "浸润性" ], "anatomy_list": [ "右侧乳腺" ] }, { "core_name": "转移", "tendency": "", "character": [], "anatomy_list": [ "腋窝淋巴结" ] } ] }, { "id": 814, "text": "3天前患者无明显诱因下出现咳嗽、咳痰，为白色粘痰，易咳出，1天前出现呼吸困难，端坐呼吸，伴双下肢水肿、乏力，病程中无潮热、盗汗、咯血，无头昏、头痛，无心悸、胸闷、胸痛，无反酸、嗳气，无恶心、呕吐，无肩背部放射痛等不适。", "event": [ { "core_name": "咳嗽", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "白色", "粘性", "易咳出" ], "anatomy_list": [] }, { "core_name": "呼吸困难", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "端坐呼吸", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "水肿", "tendency": "", "character": [], "anatomy_list": [ "双下肢" ] }, { "core_name": "乏力", "tendency": "", "character": [], "anatomy_list": [ "双下肢" ] }, { "core_name": "潮热", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "盗汗", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "咯血", "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": "心悸", "tendency": "否定", "character": [], "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": "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": [ "放射性" ], "anatomy_list": [ "肩背部" ] } ] }, { "id": 378, "text": "4、脾大，脾内增强回声结节。", "event": [ { "core_name": "脾大", "tendency": "", "character": [ "大" ], "anatomy_list": [ "脾" ] }, { "core_name": "结节", "tendency": "", "character": [ "增强回声" ], "anatomy_list": [ "脾内" ] } ] }, { "id": 317, "text": "昨日患者于我院复查，门诊遂以“宫腔内异常回声待查：子宫内膜癌？子宫内膜炎？宫内节育器嵌顿？”收入我科。", "event": [ { "core_name": "异常回声", "tendency": "不确定", "character": [], "anatomy_list": [ "宫腔内" ] }, { "core_name": "癌", "tendency": "不确定", "character": [], "anatomy_list": [ "子宫内膜" ] }, { "core_name": "子宫内膜炎", "tendency": "不确定", "character": [], "anatomy_list": [ "子宫内膜" ] }, { "core_name": "节育器嵌顿", "tendency": "不确定", "character": [], "anatomy_list": [ "宫内" ] } ] }, { "id": 1758, "text": "入院前5+月，患者因“发现左乳包块1+年”入院，入院后完善相关辅助检查：ct(256)检查(123456):1.左乳内上象限肿块，性质待定，建议结合mri检查。", "event": [ { "core_name": "包块", "tendency": "", "character": [], "anatomy_list": [ "左乳" ] }, { "core_name": "肿块", "tendency": "", "character": [ "性质待定" ], "anatomy_list": [ "左乳内上象限" ] } ] }, { "id": 1458, "text": "患者咯血症状无缓解，为进一步治疗，于我院门诊就诊，门诊以“咯血”收入我科。", "event": [ { "core_name": "咯血", "tendency": "否定", "character": [ "缓解" ], "anatomy_list": [] }, { "core_name": "咯血", "tendency": "", "character": [], "anatomy_list": [] } ] }, { "id": 1755, "text": "患者遂至某医院就诊，上腹部ct平扫示：1.肝左内叶缺失，邻近肝实质见多发高密度高密度影，胆囊未见确切显示；2.肝硬化，脾大，腹水；3.肝内胆管扩张；4.右侧胸腔中量积液，右肺下叶实变不张。", "event": [ { "core_name": "缺失", "tendency": "", "character": [ "缺失" ], "anatomy_list": [ "肝左内叶" ] }, { "core_name": "密度影", "tendency": "", "character": [ "多发" ], "anatomy_list": [ "邻近肝实质" ] }, { "core_name": "硬化", "tendency": "", "character": [], "anatomy_list": [ "肝" ] }, { "core_name": "脾大", "tendency": "", "character": [], "anatomy_list": [ "脾" ] }, { "core_name": "腹水", "tendency": "", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "扩张", "tendency": "", "character": [ "扩张" ], "anatomy_list": [ "肝内胆管" ] }, { "core_name": "积液", "tendency": "", "character": [ "中量" ], "anatomy_list": [ "右侧胸腔" ] }, { "core_name": "肺不张", "tendency": "", "character": [], "anatomy_list": [ "右肺下叶" ] }, { "core_name": "实变", "tendency": "", "character": [], "anatomy_list": [ "右肺下叶" ] } ] }, { "id": 995, "text": "患者2016年8月因喘累、呼吸困难于新桥医院行ct检查发现气管新生物致支气管狭窄，遂于某医院行气管镜活检，病理诊断：气管腺样囊性癌。", "event": [ { "core_name": "喘累", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "呼吸困难", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "气管新生物", "tendency": "", "character": [], "anatomy_list": [ "气管" ] }, { "core_name": "狭窄", "tendency": "", "character": [ "新生物致" ], "anatomy_list": [ "支气管" ] }, { "core_name": "癌", "tendency": "", "character": [ "腺样囊性" ], "anatomy_list": [ "气管" ] } ] }, { "id": 501, "text": "于2016-10-11再入院行第1次化疗（奈达铂120mg+多西他赛100mg）后无明显不适后出院，出院后患者出现进食后胃液反流，偶有呕吐，不伴进食梗阻感，不伴腹痛，左侧手术伤口处有疼痛。", "event": [ { "core_name": "反流", "tendency": "", "character": [ "进食后", "胃液" ], "anatomy_list": [] }, { "core_name": "呕吐", "tendency": "", "character": [ "偶有" ], "anatomy_list": [] }, { "core_name": "梗阻感", "tendency": "否定", "character": [ "进食" ], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "疼痛", "tendency": "", "character": [], "anatomy_list": [ "左侧手术伤口处" ] } ] }, { "id": 77, "text": "患儿患病以来精神好，食欲好，大小便正常。", "event": [ { "core_name": "精神", "tendency": "", "character": [ "好" ], "anatomy_list": [] }, { "core_name": "食欲", "tendency": "", "character": [ "好" ], "anatomy_list": [] }, { "core_name": "大小便", "tendency": "", "character": [ "正常" ], "anatomy_list": [] } ] }, { "id": 1031, "text": "（2018-1-15 我院）病检结果（123456）提示直肠腺癌。", "event": [ { "core_name": "腺癌", "tendency": "", "character": [], "anatomy_list": [ "直肠" ] } ] }, { "id": 184, "text": "于2020-4-27至6-1行腹腔姑息性放疗（ptv70G/35f5次/周），后因胃潴留共完成24次。", "event": [ { "core_name": "胃潴留", "tendency": "", "character": [], "anatomy_list": [ "胃" ] } ] }, { "id": 455, "text": "肝中静脉显示欠佳，请结合临床随诊。", "event": [ { "core_name": "显示", "tendency": "", "character": [ "欠佳" ], "anatomy_list": [ "肝中静脉" ] } ] }, { "id": 34, "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,小便量少,体重无明显变化。", "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": [ "量少" ], "anatomy_list": [] }, { "core_name": "体重变化", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [] } ] }, { "id": 1714, "text": "患者自患病以来，精神、食欲较前下降，大小便正常，体重下降约15kg。", "event": [ { "core_name": "精神", "tendency": "", "character": [ "较前下降" ], "anatomy_list": [] }, { "core_name": "食欲", "tendency": "", "character": [ "较前下降" ], "anatomy_list": [] }, { "core_name": "大小便", "tendency": "", "character": [ "正常" ], "anatomy_list": [] }, { "core_name": "体重下降", "tendency": "", "character": [], "anatomy_list": [] } ] }, { "id": 288, "text": "患者未重视未就诊，期间胸痛程度逐渐加重。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [ "程度逐渐加重" ], "anatomy_list": [ "胸" ] } ] }, { "id": 949, "text": "入院前1月患者饮酒后出现上腹隐痛不适，持续数秒后可自行好转，伴有上腹饱胀感、嗳气、反酸、烧心不适，不伴有恶心、呕吐、便血、粘液脓血便等不适，无厌油、乏力、皮肤及巩膜黄染、尿黄等不适，患者未予重视，未正规治疗。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [ "饮酒后", "隐痛", "持续数秒后可自行好转" ], "anatomy_list": [ "上腹" ] }, { "core_name": "饱胀感", "tendency": "", "character": [], "anatomy_list": [ "上腹" ] }, { "core_name": "嗳气", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "反酸", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "烧心", "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": "便血", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "大便", "tendency": "否定", "character": [ "粘液", "脓血" ], "anatomy_list": [] }, { "core_name": "厌油", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "乏力", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "黄染", "tendency": "否定", "character": [], "anatomy_list": [ "皮肤" ] }, { "core_name": "黄染", "tendency": "否定", "character": [], "anatomy_list": [ "巩膜" ] }, { "core_name": "尿黄", "tendency": "否定", "character": [], "anatomy_list": [] } ] }, { "id": 1099, "text": "伴尿频、尿急、尿痛，严重影响日常生活及睡眠，无肉眼血尿，无畏寒发热，至我院门诊就诊，门诊予以导尿术，但未成功，后患者自行回家。", "event": [ { "core_name": "尿频", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "尿急", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "睡眠", "tendency": "", "character": [ "严重影响" ], "anatomy_list": [] }, { "core_name": "尿痛", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "血尿", "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": 297, "text": "病程中患者自诉症状未见明显缓解，6小时前于我院门诊行膀胱镜检查示：膀胱右前壁可见一大小约3*3*2cm菜花样新生物，有蒂。", "event": [ { "core_name": "新生物", "tendency": "", "character": [ "菜花样", "有蒂" ], "anatomy_list": [ "膀胱右前壁" ] } ] }, { "id": 973, "text": "患者遂至我院住院治疗，自诉完善检查后诊断：胸腔积液待查，住院期间反复抽胸水，胸水量减少后出院。", "event": [ { "core_name": "积液", "tendency": "", "character": [], "anatomy_list": [ "胸腔" ] }, { "core_name": "减少", "tendency": "", "character": [ "胸水量" ], "anatomy_list": [] } ] }, { "id": 377, "text": "2、门静脉增宽，门静脉内低回声（栓子？）3、胆囊结石。", "event": [ { "core_name": "增宽", "tendency": "", "character": [], "anatomy_list": [ "门静脉" ] }, { "core_name": "回声", "tendency": "", "character": [ "低" ], "anatomy_list": [ "门静脉内" ] }, { "core_name": "栓子", "tendency": "不确定", "character": [], "anatomy_list": [ "门静脉内" ] }, { "core_name": "结石", "tendency": "", "character": [], "anatomy_list": [ "胆囊" ] } ] }, { "id": 1993, "text": "入院前5月，患者因在我院诊断为结肠腺癌，遂于2018-09-23日在全麻下行腹腔镜下右半结肠癌根治术+腹腔镜下肠粘连松解+腹腔镜下双侧附件切除+腹腔镜下子宫肌瘤切除术，标本送常规病检(123456):（升结肠）中分化腺癌，侵及全层，部分为粘液性腺癌，双侧切缘及系膜切缘未见癌累及，肠周脂肪组织中淋巴结未见癌转移（0/5）。网膜组织。阑尾组织。", "event": [ { "core_name": "腺癌", "tendency": "", "character": [], "anatomy_list": [ "结肠" ] }, { "core_name": "腺癌", "tendency": "", "character": [ "中分化", "侵及全层" ], "anatomy_list": [ "升结肠" ] }, { "core_name": "腺癌", "tendency": "", "character": [ "粘液性", "部分" ], "anatomy_list": [ "升结肠" ] }, { "core_name": "癌", "tendency": "否定", "character": [ "累及" ], "anatomy_list": [ "双侧切缘及系膜切缘" ] }, { "core_name": "癌", "tendency": "否定", "character": [ "转移", "淋巴结" ], "anatomy_list": [ "肠周脂肪组织" ] } ] }, { "id": 472, "text": "主动脉瓣狭窄（中度）伴关闭不全（轻度）。", "event": [ { "core_name": "狭窄", "tendency": "", "character": [ "中度" ], "anatomy_list": [ "主动脉瓣" ] }, { "core_name": "关闭不全", "tendency": "", "character": [ "轻度" ], "anatomy_list": [ "主动脉瓣" ] } ] }, { "id": 1558, "text": "3+月前，患者无明显诱因出现进食梗阻，进食粗糙食物明显，无恶心、呕吐，无胸骨后灼烧感，无腹胀痛，无反酸、嗳气，无声嘶及饮水呛咳，无畏寒、发热等不适。", "event": [ { "core_name": "梗阻", "tendency": "", "character": [ "进食", "进食粗糙食物明显" ], "anatomy_list": [] }, { "core_name": "恶心", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "呕吐", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "灼烧感", "tendency": "否定", "character": [], "anatomy_list": [ "胸骨后" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [ "胀痛" ], "anatomy_list": [ "腹部" ] }, { "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": "声嘶", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "呛咳", "tendency": "否定", "character": [ "饮水" ], "anatomy_list": [] }, { "core_name": "发热", "tendency": "否定", "character": [], "anatomy_list": [] } ] }, { "id": 736, "text": "入院10+年前患者打麻将时突发意识丧失，自述1分钟左右意识逐渐恢复（家属未看到），发病形式、过程不能准确描述，未予重视及治疗。", "event": [ { "core_name": "意识丧失", "tendency": "", "character": [ "突发" ], "anatomy_list": [] }, { "core_name": "意识恢复", "tendency": "", "character": [ "1分钟左右", "逐渐", "家属未看到", "发病形式不能准确描述", "发病过程不能准确描述" ], "anatomy_list": [] } ] }, { "id": 1314, "text": "神志清醒，精神欠佳，睡眠尚可，大便正常，小便正常，体重无明显变化。", "event": [ { "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": [ "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": 942, "text": "2、上腹部平扫未见明显异常。", "event": [ { "core_name": "异常", "tendency": "否定", "character": [], "anatomy_list": [ "上腹部" ] } ] }, { "id": 1604, "text": "2020-7-20患者因“下腹坠胀伴阴道出血二十余天”于某医院某医院行宫颈液基超薄细胞检测（123456）提示：高度鳞状上皮病变；hpv16型阳性。", "event": [ { "core_name": "坠胀", "tendency": "", "character": [], "anatomy_list": [ "下腹" ] }, { "core_name": "出血", "tendency": "", "character": [], "anatomy_list": [ "阴道" ] }, { "core_name": "病变", "tendency": "", "character": [ "高度" ], "anatomy_list": [ "鳞状上皮" ] }, { "core_name": "hpv16型", "tendency": "", "character": [ "阳性" ], "anatomy_list": [] } ] }, { "id": 502, "text": "不伴肛门排气排便等特殊不适，今为进一步治疗，门诊以“食管癌术后”收入我科。", "event": [ { "core_name": "排气", "tendency": "否定", "character": [], "anatomy_list": [ "肛门" ] }, { "core_name": "排便", "tendency": "否定", "character": [], "anatomy_list": [ "肛门" ] }, { "core_name": "癌", "tendency": "", "character": [ "术后" ], "anatomy_list": [ "食管" ] } ] }, { "id": 1351, "text": "后患者自觉左侧乳房乳房包块逐渐增大，遂2017-9-22于某医院行针吸细胞学检查示：乳腺癌，遂行手术治疗（具体不详），术后病检：左侧乳腺浸润性癌，术后恢复可,。", "event": [ { "core_name": "包块", "tendency": "", "character": [ "逐渐增大" ], "anatomy_list": [ "左侧乳房" ] }, { "core_name": "癌", "tendency": "", "character": [], "anatomy_list": [ "乳腺" ] }, { "core_name": "癌", "tendency": "", "character": [ "浸润性", "术后恢复可" ], "anatomy_list": [ "左侧乳腺" ] } ] }, { "id": 597, "text": "4、胆囊壁增厚，与邻近肝脏病灶分界欠清，肿瘤累及？慢性炎症？请随诊。", "event": [ { "core_name": "增厚", "tendency": "", "character": [ "与邻近肝脏病灶分界欠清" ], "anatomy_list": [ "胆囊壁" ] }, { "core_name": "炎症", "tendency": "不确定", "character": [ "慢性" ], "anatomy_list": [] }, { "core_name": "肿瘤", "tendency": "不确定", "character": [ "累及" ], "anatomy_list": [] } ] }, { "id": 100, "text": "转入我科后于2015-06-01在全麻下行“腹腔镜下胃癌根治术（残胃切除术）”，术后病检（123456）：残胃吻合口低分化腺癌。", "event": [ { "core_name": "腺癌", "tendency": "", "character": [ "低分化" ], "anatomy_list": [ "残胃吻合口" ] }, { "core_name": "残胃", "tendency": "", "character": [], "anatomy_list": [ "胃" ] } ] }, { "id": 1166, "text": "1周前，患者无明显诱因再次出现胸闷、心悸，体位改变时有头昏，自觉阵阵咳嗽，以干咳为主，仍无畏寒、发热、头痛，无恶心、呕吐，无腹痛、腹泻，无咯血。", "event": [ { "core_name": "胸闷", "tendency": "", "character": [], "anatomy_list": [ "胸" ] }, { "core_name": "心悸", "tendency": "", "character": [], "anatomy_list": [ "心" ] }, { "core_name": "头昏", "tendency": "", "character": [ "体位改变时" ], "anatomy_list": [ "头" ] }, { "core_name": "咳嗽", "tendency": "", "character": [ "阵阵", "干咳为主" ], "anatomy_list": [] }, { "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" ] }, { "core_name": "咯血", "tendency": "否定", "character": [], "anatomy_list": [] } ] }, { "id": 390, "text": "今患者为进一步治疗入我院，门诊以“左乳腺癌根治术后”收入我科。", "event": [ { "core_name": "腺癌", "tendency": "", "character": [ "根治术后" ], "anatomy_list": [ "左乳腺" ] } ] }, { "id": 1703, "text": "患者本次发病以来，神志清楚，精神尚可，饮食一般，睡眠可，大小便无明显异常，体重无明显减轻。", "event": [ { "core_name": "神志", "tendency": "", "character": [ "清楚" ], "anatomy_list": [] }, { "core_name": "精神", "tendency": "", "character": [ "尚可" ], "anatomy_list": [] }, { "core_name": "饮食", "tendency": "", "character": [ "一般" ], "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": "体重减轻", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [] } ] }, { "id": 541, "text": "8月前患者出现活动后心悸、气促，走平路即感气促，伴双下肢凹陷性水肿，遂于我院就诊，完善上腹部ct明确诊断为“肝癌”，患者出院后遂于“某中医院”行肝癌介入术。", "event": [ { "core_name": "心悸", "tendency": "", "character": [ "活动后" ], "anatomy_list": [ "心" ] }, { "core_name": "气促", "tendency": "", "character": [ "活动后" ], "anatomy_list": [] }, { "core_name": "气促", "tendency": "", "character": [ "走平路即感" ], "anatomy_list": [] }, { "core_name": "水肿", "tendency": "", "character": [ "凹陷性" ], "anatomy_list": [ "双下肢" ] }, { "core_name": "癌", "tendency": "", "character": [], "anatomy_list": [ "肝" ] } ] }, { "id": 172, "text": "左侧输尿管上段受累狭窄，致左侧输尿管上段及肾孟扩张、积水。", "event": [ { "core_name": "狭窄", "tendency": "", "character": [ "受累" ], "anatomy_list": [ "左侧输尿管上段" ] }, { "core_name": "扩张", "tendency": "", "character": [], "anatomy_list": [ "左侧输尿管上段", "肾盂" ] }, { "core_name": "积水", "tendency": "", "character": [], "anatomy_list": [ "左侧输尿管上段", "肾盂" ] } ] }, { "id": 1985, "text": "患者 23天 前于我院行左半结肠癌根治术+部分小肠切除术，术后给予患者抗感染、输血、纠正低蛋白血症、纠正电解质紊乱、祛痰等对症治疗，恢复良好，于3天前出院，出院后患者感切口疼痛不适，伴腹部疼痛，无恶心、呕吐，无呕血，无眩晕、黑蒙，无心悸、胸闷，无咳嗽、咳痰，无腹胀、腹泻，为求进一步治疗，门诊以“结肠癌术后”收治入院。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [], "anatomy_list": [ "切口" ] }, { "core_name": "切口不适", "tendency": "", "character": [], "anatomy_list": [ "切口" ] }, { "core_name": "疼痛", "tendency": "", "character": [], "anatomy_list": [ "腹部" ] }, { "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": "眩晕", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "黑朦", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "心悸", "tendency": "否定", "character": [], "anatomy_list": [ "心" ] }, { "core_name": "胸闷", "tendency": "否定", "character": [], "anatomy_list": [ "胸" ] }, { "core_name": "咳嗽", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "咳痰", "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": [ "结肠" ] } ] }, { "id": 232, "text": "入院前10+年，患者无明显诱因出现多饮、多尿，每日饮水量2000ml，饮水量与尿量相当，伴全身乏力乏力不适，无双下肢麻木，无易饥多食，无视物模糊，无腹痛、腹泻，无心前区疼痛、活动后心累、气促，无四肢肢端麻木，遂至我院治疗，完善相关检查诊断为“2型糖尿病”，给予口服降糖药（具体不详）等控制血糖，服药期间未有规律监测血糖，偶有测空腹血糖8-10mm10mmol/L左右（具体不详）。", "event": [ { "core_name": "多饮", "tendency": "", "character": [ "每日饮水量2000ml" ], "anatomy_list": [] }, { "core_name": "多尿", "tendency": "", "character": [ "饮水量与尿量相当" ], "anatomy_list": [] }, { "core_name": "乏力", "tendency": "", "character": [], "anatomy_list": [ "全身" ] }, { "core_name": "麻木", "tendency": "否定", "character": [], "anatomy_list": [ "双下肢" ] }, { "core_name": "易饥多食", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "视物模糊", "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": [ "心前区" ] }, { "core_name": "心累", "tendency": "否定", "character": [ "活动后" ], "anatomy_list": [ "心" ] }, { "core_name": "气促", "tendency": "否定", "character": [ "活动后" ], "anatomy_list": [] }, { "core_name": "麻木", "tendency": "否定", "character": [], "anatomy_list": [ "四肢肢端" ] }, { "core_name": "糖尿病", "tendency": "", "character": [ "2型" ], "anatomy_list": [] } ] }, { "id": 1713, "text": "入院前20+天，患者无明显诱因突然出现食欲下降，进食量较前减少约1/2，以流质饮食为主，无乏力、头昏，无咳嗽、咳痰，无腹痛、腹泻等表现，患者及家属未予以重视；2+天前，患者开始出现全身乏力，不能行走，之后出现嗜睡，呼之能应，对答切题，无头痛、呕吐、抽搐、大小便失禁等表现，今为求进一步治疗，故来我院，急诊科完善相关检查后，以“肺部感染”收入我科。", "event": [ { "core_name": "食欲下降", "tendency": "", "character": [ "突然出现" ], "anatomy_list": [] }, { "core_name": "进食", "tendency": "", "character": [ "量较前减少约1/2", "以流质饮食为主" ], "anatomy_list": [] }, { "core_name": "乏力", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "头昏", "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": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "腹泻", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "乏力", "tendency": "", "character": [], "anatomy_list": [ "全身" ] }, { "core_name": "不能行走", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "嗜睡", "tendency": "", "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": "抽搐", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "大小便失禁", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "感染", "tendency": "", "character": [], "anatomy_list": [ "肺部" ] } ] }, { "id": 1082, "text": "今日患者拟更换膀胱造瘘管遂到我院就诊，门诊以“前列腺增生，膀胱造造瘘术后”收入我科。", "event": [ { "core_name": "增生", "tendency": "", "character": [], "anatomy_list": [ "前列腺" ] }, { "core_name": "造瘘", "tendency": "", "character": [ "术后" ], "anatomy_list": [ "膀胱" ] } ] }, { "id": 347, "text": "院外期间患者小便仍时有滴沥感，反复多次导尿及对症治疗后好转。", "event": [ { "core_name": "小便", "tendency": "", "character": [ "滴沥感" ], "anatomy_list": [] } ] }, { "id": 556, "text": "腹胀伴肛门停止排气、排便。", "event": [ { "core_name": "腹胀", "tendency": "", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "排气", "tendency": "", "character": [ "停止" ], "anatomy_list": [ "肛门" ] }, { "core_name": "排便", "tendency": "", "character": [ "停止" ], "anatomy_list": [ "肛门" ] } ] }, { "id": 8, "text": "癌胚抗原异常增高”,建议患者进一步完善相关检查排除有无肿瘤性病变,但患者家属拒绝,临床考虑为食管癌。", "event": [ { "core_name": "癌胚抗原", "tendency": "", "character": [ "异常增高" ], "anatomy_list": [] }, { "core_name": "病变", "tendency": "不确定", "character": [ "肿瘤性" ], "anatomy_list": [] }, { "core_name": "癌", "tendency": "不确定", "character": [], "anatomy_list": [ "食管" ] } ] }, { "id": 839, "text": "（左前哨前哨淋巴结）见癌转移（1/3），术后行6次化疗(方案为多西他赛120mg+环磷酰胺800mg)及2次赫赛汀靶向治疗，今为行靶向治疗收入院。", "event": [ { "core_name": "癌", "tendency": "", "character": [ "转移" ], "anatomy_list": [ "左前哨淋巴结" ] } ] }, { "id": 278, "text": "进一步送检外周血至乐土精准医疗行基因检测（2018.8.16），未检验出相关基因突变。", "event": [ { "core_name": "基因突变", "tendency": "否定", "character": [], "anatomy_list": [] } ] }, { "id": 1596, "text": "但患者活动后心累气促仍旧反复发作，活动耐量逐渐下降，入院前3+年，患者活动后（平路行走）心累、气促加重，伴夜间阵发性呼吸困难，双下肢水肿，偶有心前区紧闷等症状，遂于我院就诊，完善冠状动脉造影：“右冠优势型，左主干未见异常，前降支近中段斑块形成，最严重处狭窄约50%，回旋支管腔细小，中段局限性斑块浸润，最严重处狭窄约80%，右冠近段向心性斑块形成，最严重处狭窄约40%”，予以抗血小板、稳定斑块、降压、利尿对症等治疗，好转出院。", "event": [ { "core_name": "心累", "tendency": "", "character": [ "活动后反复发作" ], "anatomy_list": [ "心" ] }, { "core_name": "气促", "tendency": "", "character": [ "活动后反复发作" ], "anatomy_list": [] }, { "core_name": "活动耐量", "tendency": "", "character": [ "逐渐下降" ], "anatomy_list": [] }, { "core_name": "心累", "tendency": "", "character": [ "平路行走后加重", "活动后加重" ], "anatomy_list": [ "心" ] }, { "core_name": "气促", "tendency": "", "character": [ "平路行走后加重", "活动后加重" ], "anatomy_list": [] }, { "core_name": "呼吸困难", "tendency": "", "character": [ "夜间", "阵发性" ], "anatomy_list": [] }, { "core_name": "水肿", "tendency": "", "character": [], "anatomy_list": [ "双下肢" ] }, { "core_name": "紧闷", "tendency": "", "character": [ "偶有" ], "anatomy_list": [ "心前区" ] }, { "core_name": "右冠优势型", "tendency": "", "character": [], "anatomy_list": [ "右冠" ] }, { "core_name": "异常", "tendency": "否定", "character": [], "anatomy_list": [ "左主干" ] }, { "core_name": "斑块", "tendency": "", "character": [], "anatomy_list": [ "前降支近中段" ] }, { "core_name": "细小", "tendency": "", "character": [ "管腔" ], "anatomy_list": [ "回旋支" ] }, { "core_name": "斑块", "tendency": "", "character": [ "局限性", "浸润" ], "anatomy_list": [ "回旋支中段" ] }, { "core_name": "斑块", "tendency": "", "character": [ "向心性" ], "anatomy_list": [ "右冠近段" ] }, { "core_name": "狭窄", "tendency": "", "character": [ "最严重处狭窄约80%" ], "anatomy_list": [ "回旋支中段" ] }, { "core_name": "狭窄", "tendency": "", "character": [ "最严重处狭窄约40%" ], "anatomy_list": [ "右冠状动脉近段" ] }, { "core_name": "狭窄", "tendency": "", "character": [ "最严重处狭窄约50%" ], "anatomy_list": [ "左主干" ] } ] }, { "id": 1852, "text": "4月前，患者因头昏头痛伴呕吐入我院，查头颅mri检查未见脑转移征象，行对症处理及骨治疗，好转出院。", "event": [ { "core_name": "头昏", "tendency": "", "character": [], "anatomy_list": [ "头" ] }, { "core_name": "疼痛", "tendency": "", "character": [], "anatomy_list": [ "头" ] }, { "core_name": "呕吐", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "转移", "tendency": "否定", "character": [], "anatomy_list": [ "脑" ] } ] }, { "id": 613, "text": "患者自行购药后咳嗽、咳痰稍有好转，未再痰中带血，但之后病情反复，为进一步诊治，患者到某医院就诊，胸部ct提示左上肺包块，最大直径约1.8*2.3cm，行纤维支气管镜检及病理结果为左上肺肺鳞癌，骨扫描未见骨转移，诊断为：左上肺肺鳞癌t2n0M0期。", "event": [ { "core_name": "咳嗽", "tendency": "", "character": [ "稍好转" ], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "稍好转" ], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "否定", "character": [ "带血" ], "anatomy_list": [] }, { "core_name": "包块", "tendency": "", "character": [], "anatomy_list": [ "左上肺" ] }, { "core_name": "鳞癌", "tendency": "", "character": [ "纤维支气管镜检及病理" ], "anatomy_list": [ "左上肺" ] }, { "core_name": "转移", "tendency": "否定", "character": [], "anatomy_list": [ "骨组织" ] }, { "core_name": "鳞癌", "tendency": "", "character": [ "t2n0M0期" ], "anatomy_list": [ "左上肺" ] } ] }, { "id": 1206, "text": "3.主动脉壁钙化。", "event": [ { "core_name": "钙化", "tendency": "", "character": [], "anatomy_list": [ "主动脉壁" ] } ] }, { "id": 1003, "text": "乙肝三对示“大三阳”。", "event": [ { "core_name": "肝炎", "tendency": "", "character": [], "anatomy_list": [ "肝" ] }, { "core_name": "大三阳", "tendency": "", "character": [], "anatomy_list": [] } ] }, { "id": 1471, "text": "今为行再诱导i化疗，门诊以“急性白血病”收住院。", "event": [ { "core_name": "白血病", "tendency": "", "character": [ "急性" ], "anatomy_list": [] } ] }, { "id": 646, "text": "患者出院后无阴道阴道流血、流液，无葡萄胎样组织排出，无肛门坠胀感，无咳嗽、咯血、心慌、恶心、发热等不适，今日患者要求进一步治疗入院，门诊以“滋养细胞肿瘤”收入我科。", "event": [ { "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": "排出", "tendency": "否定", "character": [ "葡萄胎样组织" ], "anatomy_list": [ "阴道" ] }, { "core_name": "坠胀", "tendency": "否定", "character": [], "anatomy_list": [ "肛门" ] }, { "core_name": "咳嗽", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "咯血", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "心慌", "tendency": "否定", "character": [], "anatomy_list": [ "心" ] }, { "core_name": "恶心", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "发热", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "肿瘤", "tendency": "", "character": [], "anatomy_list": [ "滋养细胞" ] } ] }, { "id": 1416, "text": "术后分别予以tp方案行了五周期化疗，化疗过程顺利，复查肝肾功、血常规、电解质无异常，出院后无发热、腹胀痛、阴道异常流血流液等双下肢疼痛等，有恶心、呕吐等反应，现患者要求入院择期行第六周期化疗，门诊以“1.左侧卵巢卵巢腺癌iv期术后；2.tp第六次化疗”收入院。", "event": [ { "core_name": "发热", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "否定", "character": [ "胀痛" ], "anatomy_list": [ "腹" ] }, { "core_name": "出血", "tendency": "否定", "character": [ "异常" ], "anatomy_list": [ "阴道" ] }, { "core_name": "流液", "tendency": "否定", "character": [ "异常" ], "anatomy_list": [ "阴道" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "双下肢" ] }, { "core_name": "恶心", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "呕吐", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "腺癌", "tendency": "", "character": [ "iv期", "术后" ], "anatomy_list": [ "左侧卵巢" ] } ] }, { "id": 855, "text": "患者上次出院至今，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": 1789, "text": "无右下肢行走困难，无右踝关节关节活动受限，无下肢感觉异常，患者当时自觉行走时疼痛加重，但可耐受，故未行特殊处理。", "event": [ { "core_name": "行走困难", "tendency": "否定", "character": [], "anatomy_list": [ "右下肢" ] }, { "core_name": "活动受限", "tendency": "否定", "character": [], "anatomy_list": [ "右踝关节" ] }, { "core_name": "感觉异常", "tendency": "否定", "character": [], "anatomy_list": [ "下肢" ] }, { "core_name": "疼痛", "tendency": "", "character": [ "可耐受", "行走时加重" ], "anatomy_list": [] } ] }, { "id": 285, "text": "门诊遂以“后循环缺血”收治入院。", "event": [ { "core_name": "缺血", "tendency": "", "character": [], "anatomy_list": [ "后循环" ] } ] }, { "id": 2069, "text": "为进一步明确诊治转至我院，即以“左侧上颌骨上颌骨肿瘤”收入院。", "event": [ { "core_name": "肿瘤", "tendency": "", "character": [], "anatomy_list": [ "左侧上颌骨" ] } ] }, { "id": 1255, "text": "超声胃镜提示：胃窦粘膜下肿瘤（来源第四层，平滑肌可能性大）。", "event": [ { "core_name": "肿瘤", "tendency": "", "character": [], "anatomy_list": [ "胃窦粘膜下" ] }, { "core_name": "肿瘤", "tendency": "不确定", "character": [], "anatomy_list": [ "胃窦平滑肌" ] } ] }, { "id": 385, "text": "患者自发病以来， 精神可 ， 食欲较差 ， 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": [ "可" ], "anatomy_list": [] }, { "core_name": "食欲", "tendency": "", "character": [ "较差" ], "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": "体重变化", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [] } ] }, { "id": 1664, "text": "患者本次发病以来，食欲下降， 神志清醒，精神欠佳，睡眠尚可，大便正常，小便量多（具体不详），近一月体重下降（具体不详）。", "event": [ { "core_name": "食欲", "tendency": "", "character": [ "下降" ], "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": [ "尚可" ], "anatomy_list": [] }, { "core_name": "大便", "tendency": "", "character": [ "正常" ], "anatomy_list": [] }, { "core_name": "小便", "tendency": "", "character": [ "量多" ], "anatomy_list": [] }, { "core_name": "体重", "tendency": "", "character": [ "下降" ], "anatomy_list": [] } ] }, { "id": 1592, "text": "患者左乳无红肿，无破损，无乳头溢液，无乳头凹陷，无发热、寒战等其他症状。", "event": [ { "core_name": "红肿", "tendency": "否定", "character": [], "anatomy_list": [ "左乳" ] }, { "core_name": "破损", "tendency": "否定", "character": [], "anatomy_list": [ "左乳" ] }, { "core_name": "溢液", "tendency": "否定", "character": [], "anatomy_list": [ "左乳" ] }, { "core_name": "凹陷", "tendency": "否定", "character": [], "anatomy_list": [ "乳头" ] }, { "core_name": "发热", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "寒战", "tendency": "否定", "character": [], "anatomy_list": [] } ] }, { "id": 1556, "text": "诊断为\"左颈淋巴结转移性鳞癌\"，于2014-08-22、2014-09-12、2014-10-13、2014-11-11按tp方案化疗4周期；于2014-12-8、2015-1-13行第5、6周期tp+恩度原方案化疗。", "event": [ { "core_name": "鳞癌", "tendency": "", "character": [ "转移性" ], "anatomy_list": [ "左颈淋巴结" ] } ] }, { "id": 691, "text": "1天前，患者出现少量阴道流血，于今日就诊我院，妇科彩超提示：1.宫内孕囊68mm×32mm×52mm，卵黄囊未见显示，胎芽可见，大小约18mm×6mm（相当于8w2d），原始心管搏动可见。", "event": [ { "core_name": "出血", "tendency": "", "character": [ "少量" ], "anatomy_list": [ "阴道" ] }, { "core_name": "孕囊", "tendency": "", "character": [], "anatomy_list": [ "宫内" ] }, { "core_name": "卵黄囊", "tendency": "", "character": [ "未见" ], "anatomy_list": [ "宫内" ] }, { "core_name": "胎芽", "tendency": "", "character": [ "可见" ], "anatomy_list": [ "宫内" ] }, { "core_name": "搏动", "tendency": "", "character": [ "原始", "可见" ], "anatomy_list": [ "心管" ] } ] }, { "id": 376, "text": "入院 2月 前，患者出现上述症状加重，伴有剑突下隐痛不适，无呕血、黑便，无发热、畏寒，无皮肤、巩膜黄染，无意识改变，患者未引起重视未给予特殊检查与治疗，患者症状持续不缓解，遂来我院门诊就诊，上腹部彩超：1、肝回声增粗不均质，肝内异常回声(肝ca？)，建议进一步检查。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [ "隐痛" ], "anatomy_list": [ "剑突下" ] }, { "core_name": "呕血", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "黑便", "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": "黄染", "tendency": "否定", "character": [], "anatomy_list": [ "皮肤", "巩膜" ] }, { "core_name": "意识改变", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "回声", "tendency": "", "character": [ "增粗", "不均质" ], "anatomy_list": [ "肝" ] }, { "core_name": "异常回声", "tendency": "", "character": [], "anatomy_list": [ "肝内" ] }, { "core_name": "癌", "tendency": "不确定", "character": [], "anatomy_list": [ "肝" ] } ] }, { "id": 62, "text": "2.肝左叶叶异常信号及强化结节，上述征象提示肝ca可能，故于2013.9.22行肝动脉造影及肿瘤滋养动脉超选择性ＴＡＣＥ治疗，手术顺利，给予对症支持治疗后出院，患者定期门诊随访。", "event": [ { "core_name": "异常信号", "tendency": "", "character": [], "anatomy_list": [ "肝左叶" ] }, { "core_name": "结节", "tendency": "", "character": [ "强化" ], "anatomy_list": [ "肝左叶" ] }, { "core_name": "癌", "tendency": "不确定", "character": [], "anatomy_list": [ "肝" ] } ] }, { "id": 130, "text": "今患者为行第4次化疗入我科住院治疗，门诊以“左乳癌术后第3次化疗后”收入我科。", "event": [ { "core_name": "癌", "tendency": "", "character": [ "术后", "第3次化疗后" ], "anatomy_list": [ "左乳" ] } ] }, { "id": 1889, "text": "某医院完善头颅mri考虑“鼻咽癌”，未予以特殊处理，建议患者于某肿瘤医院进一步诊治，完善相关检查确诊为“鼻咽癌伴肺转移”，给予6周期化疗（具体方案及时间不详，患者化疗规范），于2013.12月开始行放疗（因患者无任何资料，故具体放疗方式及放疗剂量均不详），放射期间患者无鼻衄，无呼吸困难，无胃肠道反应，无骨髓抑制及脱发等副反应。", "event": [ { "core_name": "癌", "tendency": "不确定", "character": [], "anatomy_list": [ "鼻咽" ] }, { "core_name": "癌", "tendency": "", "character": [], "anatomy_list": [ "鼻咽" ] }, { "core_name": "癌", "tendency": "", "character": [ "转移" ], "anatomy_list": [ "肺" ] }, { "core_name": "鼻衄", "tendency": "否定", "character": [], "anatomy_list": [ "鼻" ] }, { "core_name": "呼吸困难", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "胃肠道反应", "tendency": "否定", "character": [], "anatomy_list": [ "胃肠道" ] }, { "core_name": "骨髓抑制", "tendency": "否定", "character": [], "anatomy_list": [ "骨髓" ] }, { "core_name": "脱发", "tendency": "否定", "character": [], "anatomy_list": [] } ] }, { "id": 1016, "text": "患者为行进一步治疗，门诊以“脾血管肉瘤术后”收入我科。", "event": [ { "core_name": "肉瘤", "tendency": "", "character": [ "术后", "血管" ], "anatomy_list": [ "脾" ] } ] }, { "id": 98, "text": "门诊以“宫颈包块，粘膜下肌瘤”收入我科住院治疗。", "event": [ { "core_name": "包块", "tendency": "", "character": [], "anatomy_list": [ "宫颈" ] }, { "core_name": "肌瘤", "tendency": "", "character": [], "anatomy_list": [ "粘膜下" ] } ] }, { "id": 323, "text": "患者2年前常规体检行乳腺彩超提示左乳一纤维腺瘤（未见报告），患者未予处理。", "event": [ { "core_name": "纤维腺瘤", "tendency": "", "character": [], "anatomy_list": [ "左乳" ] } ] }, { "id": 1303, "text": "分别于10月11日、11月11日、12月05日给予dp方案化疗3周期（药物总量：多西他赛290mg，顺铂240mg）化疗过程顺利，化疗期间患者无明显消化道反应及神经毒性反应，患者未规范监测血常规。", "event": [ { "core_name": "消化道反应", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [ "消化道" ] }, { "core_name": "毒性反应", "tendency": "否定", "character": [], "anatomy_list": [ "神经" ] } ] }, { "id": 1589, "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，体重增加。", "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", "tendency": "", "character": [ "增加" ], "anatomy_list": [] } ] }, { "id": 1501, "text": "病程中患者多次因贫血、感染入院，予以输血、抗感染等治疗后好转出院，院外长期予以沙利度按治疗。", "event": [ { "core_name": "贫血", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "感染", "tendency": "", "character": [], "anatomy_list": [] } ] }, { "id": 1103, "text": "完善纤支镜提示黏膜上皮细胞，无手术禁忌症，于2016年12月06日在全麻下行右肺下叶肿物切除术，术后病检示：中分化鳞状细胞癌，（叶间裂）淋巴结2/2枚有低分化鳞状转移。", "event": [ { "core_name": "鳞癌", "tendency": "", "character": [ "中分化" ], "anatomy_list": [] }, { "core_name": "转移", "tendency": "", "character": [ "低分化", "鳞状" ], "anatomy_list": [ "（叶间裂）淋巴结" ] } ] }, { "id": 496, "text": "患者于 1周 前无意中发现 左侧乳腺外上象限 肿块， 大小约2*3cm，质韧，无压痛 ，无局部红肿热痛，无发热寒战，无乳头溢液，无橘皮症，无酒窝征。", "event": [ { "core_name": "肿块", "tendency": "", "character": [ "质韧" ], "anatomy_list": [ "左侧乳腺外上象限" ] }, { "core_name": "压痛", "tendency": "否定", "character": [], "anatomy_list": [ "左侧乳腺外上象限" ] }, { "core_name": "红肿", "tendency": "否定", "character": [ "局部" ], "anatomy_list": [ "左侧乳腺外上象限" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [ "热痛", "局部" ], "anatomy_list": [ "左侧乳腺外上象限" ] }, { "core_name": "发热", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "寒颤", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "溢液", "tendency": "否定", "character": [], "anatomy_list": [ "乳头" ] }, { "core_name": "橘皮症", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "酒窝征", "tendency": "否定", "character": [], "anatomy_list": [] } ] }, { "id": 1073, "text": "入院前1月，患者 无明显诱因 出现咳嗽，干咳为主，偶有少许白色泡沫痰，无 呼吸困难、气促 ，无 胸痛 ，无 咯血 ，无畏寒、发热，无盗汗， 不伴腹痛、腹泻 ； 不伴双下肢肿 。", "event": [ { "core_name": "咳嗽", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "咳嗽", "tendency": "", "character": [ "干性" ], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "白色", "泡沫", "偶有", "少许" ], "anatomy_list": [] }, { "core_name": "呼吸困难", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "气促", "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": "畏寒", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "发热", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "盗汗", "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": "肿", "tendency": "否定", "character": [], "anatomy_list": [ "双下肢" ] } ] }, { "id": 47, "text": "1+月前,患者因“腹胀、乏力、恶心、纳差10天”入院,查肝功:丙氨酸氨基转移酶:456U/L、门冬氨酸氨基转移酶:241U/L、γ谷氨酰基转移酶:86U/L、球蛋白:18.0g/L；血常规:淋巴细胞#:10.45*10^9/L、淋巴细胞百分比:72.7%、提示淋巴细胞升高,可见异常淋巴细胞；骨髓涂片：成熟淋巴细胞占74.5%；外周疑血疑难细胞学分析：1.有核细胞稍增多；2.粒细胞占26%,形态无明显异常；3.成熟红细胞无明显形态异常,计数一百个有核红细胞未见有核红细胞；4.淋巴细胞占72%,均为成熟淋巴细胞,单核细胞占2%,均为成熟单核细胞；5.血小板散在、少见。", "event": [ { "core_name": "腹胀", "tendency": "", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "乏力", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "恶心", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "纳差", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "淋巴细胞异常", "tendency": "", "character": [], "anatomy_list": [ "淋巴细胞" ] } ] }, { "id": 1029, "text": "患者2015-10-22于我院在全麻下腹腔腹腔镜下行卵巢恶性肿瘤细胞减灭术（全子宫、双侧附件、大网膜、阑尾、盆腹膜腹膜转移灶切除术+盆腔淋巴结清扫术），术后病检（123456）示：（左、右卵巢）浆液性乳头状腺癌，中-低分化；（幽门下方大网膜，有髂外，左盆腔，右盆腔）淋巴结见癌转移（2/5、1/1、3/11、16/23），（直肠系膜，左侧盆腔盆腔腹膜腹膜后）见癌累及；（大网膜）未见癌累及；左输卵管系膜囊肿；慢性宫颈炎；增生期子宫内膜；双侧输卵管；（腹水）涂片见癌细胞；阑尾组织。", "event": [ { "core_name": "腺癌", "tendency": "", "character": [ "浆液性", "乳头状", "中-低分化" ], "anatomy_list": [ "左右卵巢" ] }, { "core_name": "癌", "tendency": "", "character": [ "转移" ], "anatomy_list": [ "右盆腔淋巴结" ] }, { "core_name": "癌", "tendency": "", "character": [ "转移" ], "anatomy_list": [ "幽门下方大网膜淋巴结" ] }, { "core_name": "癌", "tendency": "", "character": [ "转移" ], "anatomy_list": [ "左盆腔淋巴结" ] }, { "core_name": "癌", "tendency": "", "character": [ "转移" ], "anatomy_list": [ "髂外淋巴结" ] }, { "core_name": "癌", "tendency": "", "character": [ "转移" ], "anatomy_list": [ "右盆腔淋巴结" ] }, { "core_name": "癌", "tendency": "", "character": [ "累及" ], "anatomy_list": [ "直肠系膜" ] }, { "core_name": "癌", "tendency": "", "character": [ "累及" ], "anatomy_list": [ "左侧盆腔腹膜后" ] }, { "core_name": "癌", "tendency": "否定", "character": [ "累及" ], "anatomy_list": [ "大网膜" ] }, { "core_name": "囊肿", "tendency": "", "character": [], "anatomy_list": [ "左输卵管系膜" ] }, { "core_name": "宫颈炎", "tendency": "", "character": [ "慢性" ], "anatomy_list": [ "宫颈" ] }, { "core_name": "增生", "tendency": "", "character": [], "anatomy_list": [ "子宫内膜" ] }, { "core_name": "癌", "tendency": "", "character": [ "腹水见" ], "anatomy_list": [ "细胞" ] } ] }, { "id": 1373, "text": "半年前患者再次双下肢凹陷性水肿，伴气促，无咳嗽、咳痰，无胸闷、胸痛，无心悸，入我院肾内科诊治，血红蛋白 93g/L ↓，肌酐 476.6umol/L，内生肌酐清除率 11.1ml/min，b型尿钠肽前体 10944.00pg/ml，予以降血压、控制血糖、改善循环、营养神经、延缓肾衰、纠正贫血及补钙、利尿等对症支持治疗，患者好转出院。", "event": [ { "core_name": "水肿", "tendency": "", "character": [ "凹陷性" ], "anatomy_list": [ "双下肢" ] }, { "core_name": "气促", "tendency": "", "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": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "胸" ] }, { "core_name": "心悸", "tendency": "否定", "character": [], "anatomy_list": [ "心" ] } ] }, { "id": 2048, "text": "2011-09-01患者门诊胃镜示：浅表性胃窦炎；十二指肠球部隆起（息肉？）；胃体息肉；食管胃吻合口炎。", "event": [ { "core_name": "胃窦炎", "tendency": "", "character": [ "浅表性" ], "anatomy_list": [ "胃窦" ] }, { "core_name": "十二指肠球隆起", "tendency": "", "character": [], "anatomy_list": [ "十二指肠球" ] }, { "core_name": "息肉", "tendency": "不确定", "character": [], "anatomy_list": [ "十二指肠球" ] }, { "core_name": "息肉", "tendency": "", "character": [], "anatomy_list": [ "胃体" ] }, { "core_name": "食管胃吻合口炎", "tendency": "", "character": [], "anatomy_list": [ "食管胃吻合口" ] } ] }, { "id": 1954, "text": "入院前5+月，患者无明显诱因出现咳嗽，偶伴咯痰，不伴胸痛，不伴咯血，不伴活动后心累、气促，不咯黄脓痰及铁锈色痰，不伴畏寒、寒战、高热，不伴潮热、盗汗及午后低热。", "event": [ { "core_name": "咳嗽", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "咯痰", "tendency": "", "character": [ "偶" ], "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": "气促", "tendency": "否定", "character": [ "活动后" ], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "否定", "character": [ "铁锈色", "黄脓" ], "anatomy_list": [] }, { "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": [ "高" ], "anatomy_list": [] }, { "core_name": "潮热", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "盗汗", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "发热", "tendency": "否定", "character": [ "午后", "低" ], "anatomy_list": [] } ] }, { "id": 406, "text": "疑诊直肠癌。", "event": [ { "core_name": "癌", "tendency": "", "character": [], "anatomy_list": [ "直肠" ] } ] }, { "id": 1717, "text": "未到医院诊治，未服药，咽喉疼痛及痰中带血症状逐渐消失。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [ "逐渐消失" ], "anatomy_list": [ "咽", "喉" ] }, { "core_name": "咳痰", "tendency": "", "character": [ "带血", "逐渐消失" ], "anatomy_list": [] } ] }, { "id": 822, "text": "入院前1月，患者感上腹胀感，进食后加重，肛门排气及解便后可缓解，伴有烧心、纳差等症状，无恶心、呕吐、畏寒、发热、腹泻、黑便等不适，遂来我院门诊就诊，遂收住入院。", "event": [ { "core_name": "腹胀", "tendency": "", "character": [ "进食后加重", "肛门排气后缓解", "解便后可缓解" ], "anatomy_list": [ "上腹" ] }, { "core_name": "烧心", "tendency": "", "character": [], "anatomy_list": [ "胃" ] }, { "core_name": "纳差", "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": "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": 1156, "text": "患病以来，精神、食欲尚可，大便正常，小便如上述，体重无明显变化。", "event": [ { "core_name": "精神", "tendency": "", "character": [ "尚可" ], "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": "体重改变", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [] } ] }, { "id": 1254, "text": "2.慢性非萎缩性胃炎。", "event": [ { "core_name": "胃炎", "tendency": "", "character": [ "慢性", "非萎缩性" ], "anatomy_list": [ "胃" ] } ] }, { "id": 1237, "text": "入院前2月，患者无明显诱因出现厌油、纳差，饭量为既往的1/2，无反酸、嗳气，无腹痛、腹胀，无头昏、头痛，无发热、寒战，无心悸、气促，无身黄、尿黄等不适，患者未予以重视及治疗。", "event": [ { "core_name": "厌油", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "纳差", "tendency": "", "character": [ "饭量为既往的1/2" ], "anatomy_list": [] }, { "core_name": "反酸", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "嗳气", "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": "头昏", "tendency": "否定", "character": [], "anatomy_list": [ "头" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "头" ] }, { "core_name": "发热", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "寒颤", "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": "黄染", "tendency": "否定", "character": [], "anatomy_list": [ "身" ] }, { "core_name": "尿黄", "tendency": "否定", "character": [], "anatomy_list": [] } ] }, { "id": 1358, "text": "门诊以“1.宫颈鳞状细胞癌；2.肝细胞癌切除术后；”收入我科。", "event": [ { "core_name": "鳞癌", "tendency": "", "character": [], "anatomy_list": [ "宫颈" ] }, { "core_name": "癌", "tendency": "", "character": [ "切除", "术后" ], "anatomy_list": [ "肝细胞" ] } ] }, { "id": 2015, "text": "今为求进一步诊治来我院，门诊以“慢性阻塞性肺病伴急性加重”收入我科。", "event": [ { "core_name": "肺病", "tendency": "", "character": [ "慢性", "阻塞性", "急性加重" ], "anatomy_list": [ "肺" ] } ] }, { "id": 1655, "text": "行骨髓细胞形态学检查：骨髓增生极度活跃，早幼粒细胞85%；进一步流式细胞检测；cd117+细胞占83.1%，其免疫表型为cd34-，cd117+，cd33+，cd13+，hladr-，cd64+部分，cd14-，cd56-，cd19-，cd7-，cd5-，cd20-。", "event": [ { "core_name": "增生", "tendency": "", "character": [ "极度活跃" ], "anatomy_list": [ "骨髓" ] } ] }, { "id": 967, "text": "院外患者继续予以中成药抗肿瘤，患者仍述右侧胸痛明显，呈刀割样，伴有右侧后背部牵扯痛，咳嗽及深呼吸加重，持续10秒左右自行缓，予以曲马多缓释片 0.1g q12h 口服可缓解，无咳嗽咳痰，无咯血，无畏寒、发热，无心慌、胸闷，无腹胀、腹泻、腹痛等不适。现拟行维持性化疗入院。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [ "明显", "呈刀割样" ], "anatomy_list": [ "右侧胸" ] }, { "core_name": "疼痛", "tendency": "", "character": [ "牵扯", "咳嗽及深呼吸加重", "持续10秒左右自行缓解" ], "anatomy_list": [ "右侧后背部" ] }, { "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": "畏寒", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "发热", "tendency": "否定", "character": [], "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": "腹胀", "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": [ "腹" ] } ] }, { "id": 145, "text": "入院前3天，患者因呕吐就诊于某医院，行胸部x线检查提示：双肺中上野见小片、结节状影，感染？其他？建议行ct检查。", "event": [ { "core_name": "呕吐", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "结节状影", "tendency": "", "character": [ "小片", "结节状" ], "anatomy_list": [ "双肺中上野" ] }, { "core_name": "感染", "tendency": "不确定", "character": [], "anatomy_list": [ "双肺中上野" ] } ] }, { "id": 1513, "text": "现患者疼痛较前减轻，但右肩活动、深呼吸时仍疼痛明显，右上肢活动、呼吸运动受限，为进一步康复治疗就诊于我科。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [ "较前减轻" ], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "", "character": [ "活动、深呼吸时", "明显" ], "anatomy_list": [ "右肩" ] }, { "core_name": "活动受限", "tendency": "", "character": [], "anatomy_list": [ "右上肢" ] }, { "core_name": "呼吸运动受限", "tendency": "", "character": [], "anatomy_list": [] } ] }, { "id": 1687, "text": "入院前2月患者疼痛加重，并出现右腰骶部胀痛，口服药物后疼痛缓解，停药后再次加重，患者为明确病情，遂就诊于某医院门诊，行腰椎mri（2019.10.15）检查示“腰5-骶1椎间盘突出；腰5椎体血管瘤”。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [ "加重" ], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "", "character": [ "胀痛" ], "anatomy_list": [ "右腰骶部" ] }, { "core_name": "疼痛", "tendency": "", "character": [ "口服药物后缓解" ], "anatomy_list": [ "右腰骶部" ] }, { "core_name": "疼痛", "tendency": "", "character": [ "停药后再次加重" ], "anatomy_list": [ "右腰骶部" ] }, { "core_name": "突出", "tendency": "", "character": [], "anatomy_list": [ "腰5-骶1椎间盘" ] }, { "core_name": "瘤", "tendency": "", "character": [ "血管" ], "anatomy_list": [ "腰5椎体" ] } ] }, { "id": 426, "text": "无明显食欲下降及体重减轻。", "event": [ { "core_name": "食欲", "tendency": "否定", "character": [ "明显", "下降" ], "anatomy_list": [] }, { "core_name": "体重减轻", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [] } ] }, { "id": 682, "text": "4.纵隔及双肺门多发淋巴结肿大伴钙化。", "event": [ { "core_name": "肿大", "tendency": "", "character": [ "多发" ], "anatomy_list": [ "纵隔淋巴结", "双肺门淋巴结" ] }, { "core_name": "钙化", "tendency": "", "character": [ "多发" ], "anatomy_list": [ "纵隔淋巴结", "双肺门淋巴结" ] } ] }, { "id": 1178, "text": "bcr/abl基因检测：p210阳性；骨髓流式：异常髓系表达，异常细胞r4占88.60%，表达cd33,cd15,cd38,cd11b部分细胞表达cd16,cd64但cd19,cd7,cd10,cd117,cd34,cd123,hladr,cd13均为阴性。", "event": [ { "core_name": "p210", "tendency": "", "character": [ "阳性" ], "anatomy_list": [] }, { "core_name": "异常", "tendency": "", "character": [ "髓系表达" ], "anatomy_list": [] } ] }, { "id": 1279, "text": "4+月前患者无明显诱因出现阴道不规则点滴流血，无畏寒、发热，无腹痛、腹胀及阴道流液，无咳嗽、咳痰等不适，当时未引起重视，为求进一步治疗，遂到某医院就诊，行宫腔镜及诊断性刮宫提示子宫内膜癌，经金域检验中心会诊后，病检结果（123456）提示：子宫腔腺癌，结合免疫表型及he形态符合低分化子宫内膜样腺癌，免疫组化结果：ck(2+)、vim(2+)、er(小灶+)、pr（-)、p16(2+)、p53(2+)、a-inhibin（-)、ki-67(2+,约80%)。", "event": [ { "core_name": "出血", "tendency": "", "character": [ "不规则", "点滴" ], "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": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "腹胀", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "流液", "tendency": "否定", "character": [], "anatomy_list": [ "阴道" ] }, { "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": [], "anatomy_list": [ "子宫内膜" ] }, { "core_name": "腺癌", "tendency": "", "character": [], "anatomy_list": [ "子宫腔" ] }, { "core_name": "腺癌", "tendency": "", "character": [ "低分化", "子宫内膜样" ], "anatomy_list": [ "子宫腔" ] } ] }, { "id": 186, "text": "现患者一般情况可，为求进一步诊疗而来，门诊以“卵巢癌术后腹膜后转移”收入院。", "event": [ { "core_name": "一般情况", "tendency": "", "character": [ "可" ], "anatomy_list": [] }, { "core_name": "癌", "tendency": "", "character": [], "anatomy_list": [ "卵巢" ] }, { "core_name": "转移", "tendency": "", "character": [ "术后" ], "anatomy_list": [ "腹膜后" ] } ] }, { "id": 1652, "text": "入院前5+月，患者受凉后出现发热，体温不详，伴畏寒，无寒战，稍咳嗽、咳痰，咳少量白色粘痰，伴乏力、活动后心累、气促不适，自行予以口服药物退热治疗后体温降至正常（具体不详），无恶心、呕吐，无腹痛、腹胀，无牙龈出血、鼻出血、呕血，无晕厥、黑曚。", "event": [ { "core_name": "发热", "tendency": "", "character": [ "受凉后", "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": [ "稍" ], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "稍" ], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "少量", "白色", "粘" ], "anatomy_list": [] }, { "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": [], "anatomy_list": [] }, { "core_name": "体温", "tendency": "", "character": [ "口服药物退热治疗后降至正常" ], "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": "出血", "tendency": "否定", "character": [], "anatomy_list": [ "牙龈" ] }, { "core_name": "出血", "tendency": "否定", "character": [], "anatomy_list": [ "鼻" ] }, { "core_name": "呕血", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "晕厥", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "黒朦", "tendency": "否定", "character": [], "anatomy_list": [] } ] }, { "id": 490, "text": "（乳头）未见癌累及。", "event": [ { "core_name": "癌", "tendency": "否定", "character": [ "累及" ], "anatomy_list": [ "乳头" ] } ] }, { "id": 1780, "text": "患者1月前因乙状结肠癌，于我院行腹腔镜下乙状结肠癌根治术，术中见盆腔内少许淡黄色腹水。", "event": [ { "core_name": "癌", "tendency": "", "character": [], "anatomy_list": [ "乙状结肠" ] }, { "core_name": "腹水", "tendency": "", "character": [ "少许", "淡黄色" ], "anatomy_list": [ "盆腔内" ] } ] }, { "id": 878, "text": "1年前，患者出现活动后气促，行走不到100米便可诱发，无胸闷、胸痛、心悸、黑朦、晕厥，无咳嗽、咳痰、畏寒、发热，夜间半卧位休息，偶有双下肢水肿，伴有夜间阵发性呼吸困难，先后于A医院、B医院、C医院及我院治疗，考虑“心衰、冠心病？”，建议完善冠脉造影进一步明确，患者及家属拒绝完善冠脉造影，药物治疗后症状好转，未规律服药。上述症状反复发作。", "event": [ { "core_name": "气促", "tendency": "", "character": [ "活动后", "行走不到100米便可诱发" ], "anatomy_list": [] }, { "core_name": "胸闷", "tendency": "否定", "character": [], "anatomy_list": [ "胸" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "胸部" ] }, { "core_name": "心悸", "tendency": "否定", "character": [], "anatomy_list": [ "心" ] }, { "core_name": "黑朦", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "晕厥", "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": "畏寒", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "发热", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "水肿", "tendency": "", "character": [ "偶有" ], "anatomy_list": [ "双下肢" ] }, { "core_name": "呼吸困难", "tendency": "", "character": [ "夜间", "阵发性" ], "anatomy_list": [] }, { "core_name": "心力衰竭", "tendency": "不确定", "character": [], "anatomy_list": [ "心" ] }, { "core_name": "冠心病", "tendency": "不确定", "character": [], "anatomy_list": [ "心" ] } ] }, { "id": 1675, "text": "患者自发病以来，精神、食欲可，睡眠可，大便通畅，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": [ "通畅" ], "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": 1120, "text": "我院门诊b超提示：盆腔内混合性包块。", "event": [ { "core_name": "包块", "tendency": "", "character": [ "混合性" ], "anatomy_list": [ "盆腔内" ] } ] }, { "id": 163, "text": "后为求进一步治疗于某医院就诊，完善全腹部ct示：左肾门下方腹主动脉旁占位主动脉旁占位性病变，并侵及相邻上段输尿管伴上方输尿管及左肾积水，腰44椎体结节状状高密度高密度影。", "event": [ { "core_name": "病变", "tendency": "", "character": [ "占位性" ], "anatomy_list": [ "左肾门下方腹主动脉旁" ] }, { "core_name": "病变", "tendency": "", "character": [], "anatomy_list": [ "上段输尿管" ] }, { "core_name": "积水", "tendency": "", "character": [], "anatomy_list": [ "上方输尿管", "左肾" ] }, { "core_name": "密度影", "tendency": "", "character": [ "高", "高密度", "结节状" ], "anatomy_list": [ "腰L4椎体" ] } ] }, { "id": 242, "text": "无畏寒、发热，无午后潮热、盗汗，无腹痛、腹胀，双下肢无明显麻木、乏力等不适。", "event": [ { "core_name": "畏寒", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "发热", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "潮热", "tendency": "否定", "character": [ "午后" ], "anatomy_list": [] }, { "core_name": "盗汗", "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": "麻木", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [ "双下肢" ] }, { "core_name": "乏力", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [ "双下肢" ] } ] }, { "id": 833, "text": "2019年7月4日拟行第二次后装治疗，但镜下发现患者气道内情况相对稳定，故未行第二次后装治疗。", "event": [ { "core_name": "情况稳定", "tendency": "", "character": [ "相对" ], "anatomy_list": [ "气道内" ] } ] }, { "id": 634, "text": "现患者无发热、腹痛、腹胀、腹泻等不适，为进一步治疗，患者今来我院，要求住院治疗。", "event": [ { "core_name": "发热", "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" ] } ] }, { "id": 1537, "text": "入院前1+年（2016年1月），患者于无明显诱因出现大便带血，为进一步治疗就诊于我院胃肠外科，行ct检查提示(2016-01-18 某医院):肺气肿征，左肺上叶尖后段肺大泡；右肺下叶外侧基底段小结节，性质待定；肝脏内多发小圆形低密度影，转移性肿瘤？双肾囊肿；直肠肠壁明显增厚，考虑肿瘤性病变，直肠癌可能性大；盆腔内内淋巴结淋巴结肿大；电子肠镜示：直肠距肛7~12cm见一个环状新生物，表面溃疡，肠腔狭窄；病理活检：（直肠）腺上皮中-重度异型增生，局部癌变。", "event": [ { "core_name": "大便", "tendency": "", "character": [ "带血" ], "anatomy_list": [] }, { "core_name": "肺气肿", "tendency": "", "character": [], "anatomy_list": [ "肺" ] }, { "core_name": "肺大疱", "tendency": "", "character": [], "anatomy_list": [ "左肺上叶尖后段" ] }, { "core_name": "结节", "tendency": "", "character": [ "小" ], "anatomy_list": [ "右肺下叶外侧基底段" ] }, { "core_name": "密度影", "tendency": "", "character": [ "多发", "小", "圆形", "低" ], "anatomy_list": [ "肝脏内" ] }, { "core_name": "肿瘤", "tendency": "不确定", "character": [ "转移性" ], "anatomy_list": [] }, { "core_name": "囊肿", "tendency": "", "character": [], "anatomy_list": [ "双肾" ] }, { "core_name": "增厚", "tendency": "", "character": [ "明显" ], "anatomy_list": [ "直肠肠壁" ] }, { "core_name": "病变", "tendency": "不确定", "character": [ "肿瘤性" ], "anatomy_list": [ "直肠" ] }, { "core_name": "癌", "tendency": "不确定", "character": [], "anatomy_list": [ "直肠" ] }, { "core_name": "肿大", "tendency": "", "character": [], "anatomy_list": [ "盆腔内淋巴结" ] }, { "core_name": "新生物", "tendency": "", "character": [ "环状", "表面溃疡" ], "anatomy_list": [ "直肠距肛7~12CM" ] }, { "core_name": "狭窄", "tendency": "", "character": [ "肠腔" ], "anatomy_list": [ "直" ] }, { "core_name": "增生", "tendency": "", "character": [ "异型", "中-重度", "腺上皮" ], "anatomy_list": [ "直肠上皮" ] }, { "core_name": "癌变", "tendency": "", "character": [ "局部" ], "anatomy_list": [ "直肠上皮" ] } ] }, { "id": 1236, "text": "入院前8年，患者健康体检时发现乙肝标志物：hbsag阳性，肝功正常，病毒载量不详，当时无任何不适症状，患者未予以重视，未进一步随诊。", "event": [ { "core_name": "hbsag", "tendency": "", "character": [ "阳性" ], "anatomy_list": [] } ] }, { "id": 1708, "text": "骨髓病理检查（123456）提示多发性骨髓瘤。", "event": [ { "core_name": "瘤", "tendency": "", "character": [ "多发性" ], "anatomy_list": [ "骨髓" ] } ] }, { "id": 1263, "text": "5.胆囊结石。", "event": [ { "core_name": "结石", "tendency": "", "character": [], "anatomy_list": [ "胆囊" ] } ] }, { "id": 1239, "text": "患者遂来我院消化科门诊就诊，行胃镜检查提示慢性胃炎，予以抑酸护胃治疗（具体药物不详），效果欠佳。", "event": [ { "core_name": "胃炎", "tendency": "", "character": [ "慢性" ], "anatomy_list": [ "胃" ] } ] }, { "id": 1470, "text": "现患儿精神食欲较好，无发热、咳嗽、吐泻，无进行性面色苍白，无皮肤瘀斑瘀点及鼻衄、牙龈出血等；3+天前患儿诉双侧踝关节疼痛，不剧，可忍受，阵发性发作，无活动受限。", "event": [ { "core_name": "精神", "tendency": "", "character": [ "较好" ], "anatomy_list": [] }, { "core_name": "食欲", "tendency": "", "character": [ "较好" ], "anatomy_list": [] }, { "core_name": "发热", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "咳嗽", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "呕吐", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "腹泻", "tendency": "", "character": [], "anatomy_list": [ "腹" ] }, { "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": "疼痛", "tendency": "", "character": [ "不剧", "可忍受", "阵发性发作", "无活动受限" ], "anatomy_list": [ "双侧踝关节" ] } ] }, { "id": 1584, "text": "3、慢性宫颈炎伴潴留囊肿形成。", "event": [ { "core_name": "宫颈炎", "tendency": "", "character": [ "慢性" ], "anatomy_list": [ "宫颈" ] }, { "core_name": "囊肿", "tendency": "", "character": [ "潴留" ], "anatomy_list": [] } ] }, { "id": 239, "text": "3月前排便困难加重，偶有尿踌躇，因排便困难反复就诊于我院肛肠门诊和胃肠外科，行盆腔ct（我院2016-04-09）提示：盆腔少量积液。", "event": [ { "core_name": "排便困难", "tendency": "", "character": [ "加重" ], "anatomy_list": [] }, { "core_name": "排便困难", "tendency": "", "character": [ "反复" ], "anatomy_list": [] }, { "core_name": "尿踌躇", "tendency": "", "character": [ "偶有" ], "anatomy_list": [] }, { "core_name": "积液", "tendency": "", "character": [ "少量" ], "anatomy_list": [ "盆腔" ] } ] }, { "id": 174, "text": "左侧腹膜后肿物病理示：（左侧）腹膜后低分化腺癌。结合免疫组化，以卵巢源性可能性大。", "event": [ { "core_name": "肿物", "tendency": "", "character": [], "anatomy_list": [ "左侧腹膜后" ] }, { "core_name": "腺癌", "tendency": "", "character": [ "低分化" ], "anatomy_list": [ "左侧腹膜后" ] }, { "core_name": "癌", "tendency": "不确定", "character": [ "卵巢源性" ], "anatomy_list": [] } ] }, { "id": 545, "text": "4+月前，患者受凉后出现咳嗽、咳痰，为白色泡沫痰，伴发热，自测体温38.5℃，伴气促、乏力，无畏寒、盗汗，无恶心、呕吐，无胸痛、咯血，患者遂至某医院输液治疗（具体不详）后未见明显好转，仍咳嗽、咳痰，伴发热、乏力，体温仍波动于38℃左右，患者活动耐力下降，走平路即感气喘。", "event": [ { "core_name": "咳嗽", "tendency": "", "character": [ "受凉后" ], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "白色", "泡沫痰", "受凉后" ], "anatomy_list": [] }, { "core_name": "体温", "tendency": "", "character": [ "升高", "受凉后" ], "anatomy_list": [] }, { "core_name": "发热", "tendency": "", "character": [ "受凉后" ], "anatomy_list": [] }, { "core_name": "气促", "tendency": "", "character": [ "受凉后" ], "anatomy_list": [] }, { "core_name": "乏力", "tendency": "", "character": [ "受凉后" ], "anatomy_list": [] }, { "core_name": "畏寒", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "盗汗", "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": [ "胸" ] }, { "core_name": "咯血", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "咳嗽", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "发热", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "乏力", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "体温", "tendency": "", "character": [ "波动", "升高" ], "anatomy_list": [] }, { "core_name": "活动耐量", "tendency": "", "character": [ "下降" ], "anatomy_list": [] }, { "core_name": "气喘", "tendency": "", "character": [ "走平路" ], "anatomy_list": [] } ] }, { "id": 631, "text": "2018-4-19于我院复查宫颈hpv仍提示16型阳性，宫颈tct未见上皮内病变及恶性病变。", "event": [ { "core_name": "宫颈hpv16型", "tendency": "", "character": [ "阳性" ], "anatomy_list": [] }, { "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": 1490, "text": "入院前1+年，患者因\"反复腹痛2余年，加重2余月\"于我科住院治疗,诊断为原发性肝癌,完善相关辅助检查后入介入科行了肝动脉化疗栓塞（tace）手术治疗,术后给予保肝、制酸及对症支持治疗,病情好转后出院,院外遵医嘱按时服用保肝类药物(具体药物不详)。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [ "反复", "加重" ], "anatomy_list": [ "腹" ] }, { "core_name": "癌", "tendency": "", "character": [ "原发性" ], "anatomy_list": [ "肝" ] } ] }, { "id": 1971, "text": "门诊以“消化道出血”收入住院。", "event": [ { "core_name": "出血", "tendency": "", "character": [], "anatomy_list": [ "消化道" ] } ] }, { "id": 920, "text": "入院前1年，患者于某卫生院常规体检发现双侧尿路结石，为进一步检查，未诊治。", "event": [ { "core_name": "结石", "tendency": "", "character": [], "anatomy_list": [ "双侧尿路" ] } ] }, { "id": 1276, "text": "1月余前，患者使用“诺和锐3030R 早晚各18u，阿卡波糖50mg tid”情况下，患者无明显诱因出现血糖控制不佳，空腹血糖波动于4-8mm/ l,餐后2小时血糖波动于11-16mm/ l，遂改为“诺和锐3030R 早晚各18u，伏格列波糖0.2mg tid”控制血糖，患者血糖波动情况仍同前。", "event": [ { "core_name": "血糖", "tendency": "", "character": [ "控制不佳" ], "anatomy_list": [] }, { "core_name": "血糖", "tendency": "", "character": [ "空腹", "波动于4-8mm/ l" ], "anatomy_list": [] }, { "core_name": "血糖", "tendency": "", "character": [ "餐后2小时", "波动于11-16mm/ l" ], "anatomy_list": [] }, { "core_name": "血糖", "tendency": "", "character": [ "波动" ], "anatomy_list": [] } ] }, { "id": 1984, "text": "患病以来患者食欲差，大、小便正常。", "event": [ { "core_name": "食欲", "tendency": "", "character": [ "差" ], "anatomy_list": [] }, { "core_name": "大小便", "tendency": "", "character": [ "正常" ], "anatomy_list": [] } ] }, { "id": 937, "text": "起病以来，患者精神尚可，睡眠欠佳，大小便正常，体重无明显变化。", "event": [ { "core_name": "精神", "tendency": "", "character": [ "尚可" ], "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": "体重改变", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [] } ] }, { "id": 1669, "text": "无恶心呕吐，无畏寒发热、无胸闷气促、无尿频尿急尿痛等不适。", "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": "胸闷", "tendency": "否定", "character": [], "anatomy_list": [ "胸" ] }, { "core_name": "气促", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "尿急", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "尿频", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "尿痛", "tendency": "否定", "character": [], "anatomy_list": [] } ] }, { "id": 1352, "text": "后就诊我科，完善相关检查明确无明显放化疗禁忌症后，分别于10-10、11.2、11.22、12-23行tac方案化疗，过程中患者出现四肢麻木，予以“甲钴胺”对症后好转，并于10-16行同步放疗50G/25f/5w，患者无特殊不适，现为行下一周期治疗，就诊我院，门诊以“乳腺癌”收住我科。", "event": [ { "core_name": "麻木", "tendency": "", "character": [], "anatomy_list": [ "四肢" ] }, { "core_name": "癌", "tendency": "", "character": [], "anatomy_list": [ "乳腺" ] } ] }, { "id": 1848, "text": "右侧肾肾周间隙改变，考虑感染。", "event": [ { "core_name": "感染", "tendency": "不确定", "character": [], "anatomy_list": [] }, { "core_name": "间隙改变", "tendency": "", "character": [], "anatomy_list": [ "右侧肾周" ] } ] }, { "id": 1308, "text": "患者诉20+年前开始发作头晕，伴视物旋转，明显恶心呕吐，大汗淋漓，体位改变时症状明显加重，发生过2-3次耳鸣，每次均不能自行缓解，需到医院用药治疗（具体诊断及用药不详）。", "event": [ { "core_name": "头晕", "tendency": "", "character": [ "体位改变时明显加重" ], "anatomy_list": [ "头" ] }, { "core_name": "视物旋转", "tendency": "", "character": [ "体位改变时明显加重" ], "anatomy_list": [] }, { "core_name": "恶心", "tendency": "", "character": [ "明显" ], "anatomy_list": [] }, { "core_name": "呕吐", "tendency": "", "character": [ "明显" ], "anatomy_list": [] }, { "core_name": "出汗", "tendency": "", "character": [ "大汗", "体位改变时明显加重" ], "anatomy_list": [] }, { "core_name": "耳鸣", "tendency": "", "character": [ "2-3次", "不能自行缓解" ], "anatomy_list": [ "耳" ] } ] }, { "id": 1588, "text": "现患者拟行第四次化疗来我院，门诊以“子宫内膜癌术后，第3次化疗后”收入我科。", "event": [ { "core_name": "癌", "tendency": "", "character": [ "术后", "第3次化疗后" ], "anatomy_list": [ "子宫内膜" ] } ] }, { "id": 1027, "text": "提示肿瘤复发；2019-05-14故给予dp方案化疗3周期:多西他赛100mg ivd1，顺铂 40mg ivd1-3 ；化疗过程顺利，无骨髓抑制及胃肠反应；今日为行下一周期化疗，门诊以\"宫颈癌\"收入院。", "event": [ { "core_name": "肿瘤", "tendency": "", "character": [ "复发" ], "anatomy_list": [] }, { "core_name": "骨髓抑制", "tendency": "否定", "character": [], "anatomy_list": [ "骨髓" ] }, { "core_name": "胃肠反应", "tendency": "否定", "character": [], "anatomy_list": [ "胃", "肠" ] }, { "core_name": "癌", "tendency": "", "character": [], "anatomy_list": [ "宫颈" ] } ] }, { "id": 2024, "text": "入院前4月，患者无明显诱因开始出现咳嗽、咳痰，为阵发性咳嗽，咯白色痰液，痰中带少量血丝，伴潮热、多汗，活动后偶有气促，偶有胸部发紧，与活动无明显关系，无恶心、呕吐、头晕、头痛，无乏力、浮肿、体重减轻。", "event": [ { "core_name": "咳嗽", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "咳嗽", "tendency": "", "character": [ "阵发性" ], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "白色" ], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "少量血丝" ], "anatomy_list": [] }, { "core_name": "潮热", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "多汗", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "气促", "tendency": "", "character": [ "活动后", "偶有" ], "anatomy_list": [] }, { "core_name": "发紧", "tendency": "", "character": [ "与活动无明显关系" ], "anatomy_list": [ "胸部" ] }, { "core_name": "恶心", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "呕吐", "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": "乏力", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "浮肿", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "体重减轻", "tendency": "否定", "character": [], "anatomy_list": [] } ] }, { "id": 2026, "text": "病程中咳嗽偶有发生，偶有少量血丝，咳嗽无明显诱发与缓解因素。", "event": [ { "core_name": "咳嗽", "tendency": "", "character": [ "偶有" ], "anatomy_list": [] }, { "core_name": "血丝", "tendency": "", "character": [ "少量", "偶有" ], "anatomy_list": [] }, { "core_name": "咳嗽", "tendency": "", "character": [ "无明显诱发与缓解因素" ], "anatomy_list": [] } ] }, { "id": 1913, "text": "胃镜提示：慢性食管炎；慢性非萎缩性胃炎伴胆汁反流。", "event": [ { "core_name": "食管炎", "tendency": "", "character": [ "慢性" ], "anatomy_list": [ "食管" ] }, { "core_name": "胃炎", "tendency": "", "character": [ "慢性", "非萎缩性" ], "anatomy_list": [ "胃" ] }, { "core_name": "反流", "tendency": "", "character": [], "anatomy_list": [ "胆汁" ] } ] }, { "id": 1639, "text": "入院前7小时，患者无明显诱因出现中上腹疼痛，为串气样隐痛，无放射痛，与进食无明显相关，伴嗳气，无反酸、烧心、恶心、呕吐、腹泻，无畏寒、发热、黄疸、潮热、盗汗，无尿频、尿急、尿痛，无肛门停止排便、排气。未引起患者重视，未行诊治。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [], "anatomy_list": [ "中上腹" ] }, { "core_name": "疼痛", "tendency": "", "character": [ "串气样隐痛" ], "anatomy_list": [ "中上腹" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [ "放射性" ], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "", "character": [ "进食无明显相关" ], "anatomy_list": [] }, { "core_name": "嗳气", "tendency": "", "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": "恶心", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "呕吐", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "腹泻", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "畏寒", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "发热", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "黄疸", "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": "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": "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" ] } ] }, { "id": 533, "text": "13年前因患者偶测血糖控制不佳至某医院调整为胰岛素降糖至今，使用三短一长方案降糖，监测血糖波动8-20mm20mmol/L，最高38mmol/L，每月至某医院复诊调整血糖方案，多次在某医院住院调整治疗方案。", "event": [ { "core_name": "血糖", "tendency": "", "character": [ "控制不佳" ], "anatomy_list": [] }, { "core_name": "血糖", "tendency": "", "character": [ "波动" ], "anatomy_list": [] } ] }, { "id": 882, "text": "患者于2020-01无明显诱因开始出现右上腹不适，活动时疼痛，伴有食欲下降，乏力、纳差，无恶心、呕吐、反酸、嗳气，无腹胀、腹泻，无发热、畏寒、寒颤，予以保胃等治疗，无明显好转。", "event": [ { "core_name": "不适", "tendency": "", "character": [], "anatomy_list": [ "右上腹" ] }, { "core_name": "疼痛", "tendency": "", "character": [ "活动时" ], "anatomy_list": [ "右上腹" ] }, { "core_name": "食欲", "tendency": "", "character": [ "下降" ], "anatomy_list": [] }, { "core_name": "乏力", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "纳差", "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": "反酸", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "嗳气", "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": "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": 1886, "text": "消化内科考虑慢性胃炎，给予予以六味能消胶囊1.8g tid、马来酸曲美布汀分散片 0.2g tid口服，但患者腹胀症状未见明显缓解；今日遂至我院门诊就诊，门诊查得血糖偏高（具体不详），门诊以“2型糖尿病”收入我科住院治疗。", "event": [ { "core_name": "胃炎", "tendency": "", "character": [ "慢性" ], "anatomy_list": [ "胃" ] }, { "core_name": "腹胀", "tendency": "", "character": [ "未见明显缓解" ], "anatomy_list": [ "腹" ] }, { "core_name": "血糖", "tendency": "", "character": [ "偏高" ], "anatomy_list": [] }, { "core_name": "糖尿病", "tendency": "", "character": [ "2型" ], "anatomy_list": [] } ] }, { "id": 1066, "text": "入院前2+年，患者无明显诱因出现一左侧腹股沟腹股沟包块，大小约1cm*1cm，质韧，与周围分界清楚，伴疼痛，表面光滑，无红肿及溃烂，无渗血、渗液。", "event": [ { "core_name": "包块", "tendency": "", "character": [ "质韧", "与周围分界清楚", "疼痛", "表面光滑", "无红肿及溃烂", "无渗血、渗液" ], "anatomy_list": [ "左侧腹股沟" ] } ] }, { "id": 1301, "text": "患者于2018-5-30复查胸部ct提示左肺占位，后在某医院行肺穿活检提示鳞状细胞癌，考虑肿瘤转移，于6月5日按tp方案化疗1周期（药物总量：紫杉醇210mg，奈达铂100mg），化疗后出现ii°白细胞下降，予以粒细胞刺激因子升白细胞治疗后好转出院。", "event": [ { "core_name": "占位", "tendency": "", "character": [], "anatomy_list": [ "左肺" ] }, { "core_name": "鳞癌", "tendency": "", "character": [], "anatomy_list": [ "肺" ] }, { "core_name": "肿瘤", "tendency": "不确定", "character": [ "转移" ], "anatomy_list": [] } ] }, { "id": 430, "text": "入院前 3天，患者胸痛加重，家人为进一步治疗送入我科，遂以“胸痛待诊”收入住院 患者自发病以来， 精神较差 ， 食欲较差 ， 睡眠可 ， 大便如常 ， 小便如常 ， 体重减轻约5kg 。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [ "加重" ], "anatomy_list": [ "胸" ] }, { "core_name": "疼痛", "tendency": "", "character": [], "anatomy_list": [ "胸" ] }, { "core_name": "精神", "tendency": "", "character": [ "较差" ], "anatomy_list": [] }, { "core_name": "食欲", "tendency": "", "character": [ "较差" ], "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": "体重减轻", "tendency": "", "character": [], "anatomy_list": [] } ] }, { "id": 60, "text": "3年前，患者无明显诱因出现尿色加深，如茶水样，偶有痰中带血，为鲜红色，量不等，无全身皮肤瘙痒，无陶土样大便、无腹痛腹胀等不适，患者仍未引起重视。", "event": [ { "core_name": "尿色", "tendency": "", "character": [ "加深", "如茶水样" ], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "偶有", "鲜红色", "量不等" ], "anatomy_list": [] }, { "core_name": "瘙痒", "tendency": "否定", "character": [], "anatomy_list": [ "全身皮肤" ] }, { "core_name": "大便", "tendency": "否定", "character": [ "陶土样" ], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "腹胀", "tendency": "否定", "character": [], "anatomy_list": [] } ] }, { "id": 1573, "text": "1+月前，患者无诱因出现恶心伴上腹部胀痛不适，为阵发性隐痛，疼痛可忍受，不影响睡眠，无反酸、嗳气，无呃逆，无腹泻等不适，无畏寒、发热，完善胃镜：慢性浅表性全胃炎 糜烂性胃窦炎 十二指肠炎 活检：胃窦粘膜中度慢性炎症伴活动（+）、糜烂，hp（+）。", "event": [ { "core_name": "恶心", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "", "character": [ "胀痛" ], "anatomy_list": [ "上腹部" ] }, { "core_name": "疼痛", "tendency": "", "character": [ "阵发性隐痛" ], "anatomy_list": [ "上腹部" ] }, { "core_name": "疼痛", "tendency": "", "character": [ "可忍受", "不影响睡眠" ], "anatomy_list": [] }, { "core_name": "反酸", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "嗳气", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "呃逆", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "腹泻", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "畏寒", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "发热", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "全胃炎", "tendency": "", "character": [ "慢性", "浅表性" ], "anatomy_list": [ "全胃" ] }, { "core_name": "胃窦炎", "tendency": "", "character": [ "糜烂性" ], "anatomy_list": [ "胃窦" ] }, { "core_name": "十二指肠炎", "tendency": "", "character": [], "anatomy_list": [ "十二指肠" ] }, { "core_name": "炎症", "tendency": "", "character": [ "中度", "慢性" ], "anatomy_list": [ "胃窦粘膜" ] }, { "core_name": "糜烂", "tendency": "", "character": [], "anatomy_list": [ "胃窦粘膜" ] } ] }, { "id": 895, "text": "患者自发病以来，精神较差，食欲较差，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": [ "较差" ], "anatomy_list": [] }, { "core_name": "食欲", "tendency": "", "character": [ "较差" ], "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": [ "正常" ], "anatomy_list": [] }, { "core_name": "体重改变", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [] } ] }, { "id": 1421, "text": "患者自起病以来，精神可，胃纳可，大便如常，小便如常 。", "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": [] } ] }, { "id": 1054, "text": "完善颈部淋巴结彩超示：右侧颌下淋巴结肿大，皮髓质分界不清，约1.3cm*0.4cm大小。", "event": [ { "core_name": "肿大", "tendency": "", "character": [ "分界不清" ], "anatomy_list": [ "右侧颌下淋巴结", "皮髓质" ] } ] }, { "id": 1403, "text": "自患病以来，患者精神、食欲、睡眠可，二便正常，体征未见明显变化。", "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": [ "正常" ], "anatomy_list": [] }, { "core_name": "小便", "tendency": "", "character": [ "正常" ], "anatomy_list": [] } ] }, { "id": 1309, "text": "近20多年来上述症状约1-2年发作一次，听力无明显下降，每次治疗后可缓解。", "event": [ { "core_name": "听力下降", "tendency": "否定", "character": [ "明显下降" ], "anatomy_list": [] } ] }, { "id": 1183, "text": "入院前1月余(2015.2.27)，患者因“发现右乳房无痛性肿块4月”入院。", "event": [ { "core_name": "肿块", "tendency": "", "character": [ "无痛性" ], "anatomy_list": [ "右乳房" ] } ] }, { "id": 1557, "text": "6周期化疗结束后完善颈部及胸部增强ct后诊断为：左下肺鳞癌伴肺门、纵膈、锁骨上淋巴结转移、胸膜转移（ct3n3Mm1a iva期）。", "event": [ { "core_name": "鳞癌", "tendency": "", "character": [ "转移", "ct3n3Mm1a iva期" ], "anatomy_list": [ "左下肺" ] }, { "core_name": "癌", "tendency": "", "character": [ "转移", "ct3n3Mm1a iva期" ], "anatomy_list": [ "肺门淋巴结 " ] }, { "core_name": "癌", "tendency": "", "character": [ "转移", "ct3n3Mm1a iva期" ], "anatomy_list": [ "纵隔淋巴结" ] }, { "core_name": "癌", "tendency": "", "character": [ "转移", "ct3n3Mm1a iva期" ], "anatomy_list": [ "锁骨上淋巴结" ] }, { "core_name": "癌", "tendency": "", "character": [ "转移", "ct3n3Mm1a iva期" ], "anatomy_list": [ "胸膜" ] } ] }, { "id": 1861, "text": "患者约1月前（2020-6-22）于我院普外科行腹腔镜探查术+大网膜结节活检术+盆腔肿物切除术+腹腔热灌注套管置管术，术后病检：大网膜网膜结节及右侧盆腔盆腔病变组织恶性肿瘤伴大片出血、坏死，免疫组化支持低分化腺癌，考虑为卵巢高级别浆液性癌转移。", "event": [ { "core_name": "结节", "tendency": "", "character": [], "anatomy_list": [ "大网膜" ] }, { "core_name": "肿瘤", "tendency": "", "character": [ "恶性" ], "anatomy_list": [ "右侧盆腔病变组织" ] }, { "core_name": "出血", "tendency": "", "character": [ "大片" ], "anatomy_list": [] }, { "core_name": "坏死", "tendency": "", "character": [ "大片" ], "anatomy_list": [] }, { "core_name": "腺癌", "tendency": "", "character": [ "低分化" ], "anatomy_list": [] }, { "core_name": "癌", "tendency": "", "character": [ "高级别", "浆液性", "转移" ], "anatomy_list": [ "卵巢" ] } ] }, { "id": 1246, "text": "1+年来间断性出现咳嗽不适。", "event": [ { "core_name": "咳嗽", "tendency": "", "character": [ "间断性" ], "anatomy_list": [] } ] }, { "id": 140, "text": "既往有“冠状动脉粥样硬化性心脏病”病史6+年，正规口服冠心病二级预防药物治疗。", "event": [ { "core_name": "冠状动脉粥样硬化性心脏病", "tendency": "", "character": [ "粥样", "硬化性", "病史6+年" ], "anatomy_list": [ "冠状动脉", "心脏" ] } ] }, { "id": 1378, "text": "遂急诊入我院，患者呼吸困难进行性加重，氧饱和度下降至40%，于急诊科行气管插管后急转我科。", "event": [ { "core_name": "呼吸困难", "tendency": "", "character": [ "进行性加重" ], "anatomy_list": [] } ] }, { "id": 1250, "text": "1月前开始，患者每次餐后开始出现中上腹疼痛，为绞痛，无放射痛，程度剧烈，难以忍受，每次约持续5秒后自行缓解。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [ "绞痛", "餐后开始出现", "无放射痛", "程度剧烈", "难以忍受", "每次约持续5秒后自行缓解" ], "anatomy_list": [ "中上腹" ] } ] }, { "id": 1975, "text": "某医院考虑诊断：前列腺癌？给予积极止血、抗感染等治疗，患者血尿缓解出院。", "event": [ { "core_name": "癌", "tendency": "不确定", "character": [], "anatomy_list": [ "前列腺" ] }, { "core_name": "血尿", "tendency": "", "character": [ "缓解" ], "anatomy_list": [] } ] }, { "id": 747, "text": "6月余前患者因“间断便血5年余”入我院就诊，入院肠镜提示直肠肿瘤，无明显手术禁忌，于2016-1-27在全麻下行腹腔镜下直肠癌根治术（dixon)+放射性粒子置入术，手术顺利，术后安返病房，组织病理：（直肠）中-低分化管状腺癌，浸及肠壁深肌层，脉管内见癌栓。", "event": [ { "core_name": "便血", "tendency": "", "character": [ "间断" ], "anatomy_list": [] }, { "core_name": "肿瘤", "tendency": "", "character": [], "anatomy_list": [ "直肠" ] }, { "core_name": "腺癌", "tendency": "", "character": [ "中-低分化", "管状", "浸及肠壁深肌层" ], "anatomy_list": [ "直肠" ] }, { "core_name": "癌栓", "tendency": "", "character": [], "anatomy_list": [ "脉管内" ] } ] }, { "id": 885, "text": "双肺多发结节，考虑转移可能大。", "event": [ { "core_name": "结节", "tendency": "", "character": [ "多发" ], "anatomy_list": [ "双肺" ] }, { "core_name": "转移", "tendency": "不确定", "character": [], "anatomy_list": [ "双肺" ] } ] }, { "id": 1389, "text": "自行口服药物治疗后无明显好转；今日4+天前于我科门诊就诊，诊断为：慢性咽炎/左侧声带新生物。", "event": [ { "core_name": "咽炎", "tendency": "", "character": [ "慢性" ], "anatomy_list": [ "咽" ] }, { "core_name": "新生物", "tendency": "", "character": [], "anatomy_list": [ "左侧声带" ] } ] }, { "id": 1811, "text": "<左上肺前段+舌段>浸润性腺癌，以贴壁样生长方式为主；支气管切缘及肺切缘未见癌累及。", "event": [ { "core_name": "腺癌", "tendency": "", "character": [ "浸润性", "贴壁样生长方式为主" ], "anatomy_list": [ "左上肺前段舌段" ] }, { "core_name": "癌", "tendency": "否定", "character": [ "累及" ], "anatomy_list": [ "支气管切缘", "肺切缘" ] } ] }, { "id": 1067, "text": "无畏寒、发热，无潮热、盗汗；伴体重下降；无头昏、眼花，无乏力、面色苍白，无心悸，无气促、心前区压榨感，无恶心、呕吐，无腹胀、腹痛、腹泻，无咳嗽、咳痰，无咯血，无进食梗阻感，无声嘶，无胸闷、气促，无耳鸣及听力下降，无回吸性涕血，无尿频、尿急、尿痛，无排尿困难及血尿，无头昏、头疼。", "event": [ { "core_name": "畏寒", "tendency": "否定", "character": [], "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": "体重下降", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "头昏", "tendency": "否定", "character": [], "anatomy_list": [ "头" ] }, { "core_name": "眼花", "tendency": "否定", "character": [], "anatomy_list": [ "眼" ] }, { "core_name": "乏力", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "面色苍白", "tendency": "否定", "character": [], "anatomy_list": [ "面" ] }, { "core_name": "心悸", "tendency": "否定", "character": [], "anatomy_list": [ "心" ] }, { "core_name": "气促", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "压榨感", "tendency": "否定", "character": [], "anatomy_list": [ "心前区" ] }, { "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": "腹泻", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "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": "梗阻感", "tendency": "否定", "character": [ "进食" ], "anatomy_list": [] }, { "core_name": "声嘶", "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": "耳鸣", "tendency": "否定", "character": [], "anatomy_list": [ "耳" ] }, { "core_name": "听力下降", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "鼻涕", "tendency": "否定", "character": [ "带血", "回吸性" ], "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": "排尿困难", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "血尿", "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" ] } ] }, { "id": 348, "text": "1月前，患者自觉腹胀、腹痛，到我科就诊，诊断为造瘘口梗阻，经积极对症治疗后好转，此后反复发作，予以安置引流管后能排除粪便，本次患者为求巩固治疗及要求化疗再次到我科就诊，门诊以“直肠癌术后”收入住院。", "event": [ { "core_name": "腹胀", "tendency": "", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "疼痛", "tendency": "", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "梗阻", "tendency": "", "character": [], "anatomy_list": [ "造瘘口" ] }, { "core_name": "癌", "tendency": "", "character": [ "术后" ], "anatomy_list": [ "直肠" ] } ] }, { "id": 1893, "text": "1天前，患者食欲明显降低，不思饮食，恶心，呕吐胃内容物一次，非喷射状，不含血液及胆汁，全身乏力。", "event": [ { "core_name": "食欲", "tendency": "", "character": [ "明显", "降低" ], "anatomy_list": [] }, { "core_name": "不思饮食", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "恶心", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "呕吐", "tendency": "", "character": [ "胃内容物", "非喷射状", "不含血液及胆汁" ], "anatomy_list": [] }, { "core_name": "乏力", "tendency": "", "character": [], "anatomy_list": [ "全身" ] } ] }, { "id": 957, "text": "9天前（2016.09.04 22:00），患者睡前休息时突发胸骨中下段压榨性疼痛，伴大汗淋漓、双肩胀痛，双上肢乏力，持续约20分20分钟，无黑蒙、晕厥，无恶心、呕吐，无呼吸困难，疼痛持续无缓解，患者遂于某医院就诊，查心电图示：窦性心律，iii、avf 导联qs型，患者未予药物治疗后胸痛自行缓解，此次发病至今，患者反复出现胸骨中下段疼痛，伴呼吸困难，每次持续约2-3m，自行缓解，与活动及呼吸无明显关系，无夜间高枕卧位，无头昏、视物模糊，无四肢乏力，无咳嗽咳痰，无恶心呕吐症状，疼痛与呼吸活动无关，为进一步诊治，患者今日于我院心内科门诊就诊，门诊行心电图（2016-10-13 08:04）提示：窦性心律，ii 呈qr型，iii、avf 呈qs型，v2-v5 st段抬高0.1-0.2m，以“冠心病”收治入院。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [ "睡前休息时", "突发", "压榨性" ], "anatomy_list": [ "胸骨中段下段" ] }, { "core_name": "大汗淋漓", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "", "character": [ "胀痛" ], "anatomy_list": [ "双肩" ] }, { "core_name": "乏力", "tendency": "", "character": [], "anatomy_list": [ "双上肢" ] }, { "core_name": "黑朦", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "晕厥", "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": "呼吸困难", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "否定", "character": [ "持续", "缓解" ], "anatomy_list": [] }, { "core_name": "窦性心律", "tendency": "", "character": [], "anatomy_list": [ "心" ] }, { "core_name": "疼痛", "tendency": "", "character": [ "缓解" ], "anatomy_list": [ "胸部" ] }, { "core_name": "疼痛", "tendency": "", "character": [], "anatomy_list": [ "胸骨中段下段" ] }, { "core_name": "呼吸困难", "tendency": "", "character": [ "自行缓解", "与活动及呼吸无明显关系" ], "anatomy_list": [] }, { "core_name": "卧位", "tendency": "否定", "character": [ "夜间", "高枕" ], "anatomy_list": [] }, { "core_name": "头昏", "tendency": "否定", "character": [], "anatomy_list": [ "头" ] }, { "core_name": "视物模糊", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "乏力", "tendency": "否定", "character": [], "anatomy_list": [ "四肢" ] }, { "core_name": "咳嗽", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "咳痰", "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": "", "character": [ "与呼吸活动无关" ], "anatomy_list": [] }, { "core_name": "窦性心律", "tendency": "", "character": [], "anatomy_list": [ "心" ] }, { "core_name": "冠心病", "tendency": "", "character": [], "anatomy_list": [ "心" ] } ] }, { "id": 1366, "text": "入院前 1周 ，患者再次因受凉后咳嗽，喘息加重，不能平卧，咯少许 黄色粘痰 （每日约 10 毫升）。", "event": [ { "core_name": "咳嗽", "tendency": "", "character": [ "受凉后" ], "anatomy_list": [] }, { "core_name": "喘息", "tendency": "", "character": [ "加重", "不能平卧" ], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "黄色", "粘", "少许", "每日约 10 毫升" ], "anatomy_list": [] } ] }, { "id": 398, "text": "于 我院门诊 查 腹部ct示肠梗阻 ，为进一步诊疗，门诊以“肠梗阻”收入我科。", "event": [ { "core_name": "梗阻", "tendency": "", "character": [], "anatomy_list": [ "肠" ] }, { "core_name": "梗阻", "tendency": "", "character": [], "anatomy_list": [ "肠" ] } ] }, { "id": 412, "text": "诊疗期间患者仍反复出现便血，仍为少量鲜红色血液，伴少许粘液，大便渐行变细，排便困难渐行加重，仍无明显腹痛、腹泻，无发热、寒战等不适。", "event": [ { "core_name": "便血", "tendency": "", "character": [ "反复", "仍为少量鲜红色血液", "少许粘液" ], "anatomy_list": [] }, { "core_name": "大便", "tendency": "", "character": [ "逐渐变细" ], "anatomy_list": [] }, { "core_name": "排便困难", "tendency": "", "character": [ "渐行加重" ], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [ "腹" ] }, { "core_name": "腹泻", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [ "腹" ] }, { "core_name": "发热", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "寒颤", "tendency": "否定", "character": [], "anatomy_list": [] } ] }, { "id": 1581, "text": "遂入住我院行“经腹广泛性全子宫切除术+双侧附件切除术+盆腔淋巴结清扫术”，手术顺利，术后病理诊断：1、宫内膜中分化宫内膜样腺癌，浸及肌层2/3，脉管中见癌栓，神经未见癌侵犯，阴道壁残端，宫颈、颈管未见癌累及，双侧附件未见癌转移。", "event": [ { "core_name": "癌", "tendency": "", "character": [ "浸及" ], "anatomy_list": [ "肌层2/3" ] }, { "core_name": "癌栓", "tendency": "", "character": [], "anatomy_list": [ "脉管" ] }, { "core_name": "癌", "tendency": "否定", "character": [ "侵犯" ], "anatomy_list": [ "神经" ] }, { "core_name": "腺癌", "tendency": "", "character": [ "中分化", "内膜样", "浸及肌层2/3" ], "anatomy_list": [ "宫内膜" ] }, { "core_name": "癌", "tendency": "否定", "character": [ "累及" ], "anatomy_list": [ "阴道壁残端", "宫颈", "宫颈管" ] }, { "core_name": "癌", "tendency": "否定", "character": [ "转移" ], "anatomy_list": [ "双侧附件" ] } ] }, { "id": 1908, "text": "7.其他：双侧上颌窦炎症;肝小囊肿；脊柱退行性变。", "event": [ { "core_name": "炎症", "tendency": "", "character": [], "anatomy_list": [ "双侧上颌窦" ] }, { "core_name": "囊肿", "tendency": "", "character": [ "小" ], "anatomy_list": [ "肝" ] }, { "core_name": "病变", "tendency": "", "character": [ "退行性" ], "anatomy_list": [ "脊柱" ] } ] }, { "id": 1564, "text": "今患者为求进一步治疗再来我院就诊，行乳腺彩超（2020-04-07）示：左侧乳腺实质性肿块，超声bi-rads 3类。", "event": [ { "core_name": "肿块", "tendency": "", "character": [ "实质性", "超声bi-rads 3类" ], "anatomy_list": [ "左侧乳腺" ] } ] }, { "id": 1830, "text": "患者遂至我院就诊，查彩超（123456）示：膀胱实性占位（考虑膀胱ca），建议进一步检查。门诊医生建议住院治疗，患者拒绝。", "event": [ { "core_name": "占位", "tendency": "", "character": [ "实性" ], "anatomy_list": [ "膀胱" ] }, { "core_name": "癌", "tendency": "不确定", "character": [], "anatomy_list": [ "膀胱" ] } ] }, { "id": 366, "text": "今为行ir间期治疗第2次静脉化疗入院，门诊血常规（2017.01.09）提示wbc 1.98(*10^9/L)，plt 217(*10^9/L)，rbc 2.54(*10^12/L)，hb 80(g/l)，anc 0.83(*10^9/L)；门诊以“急性普通b淋巴细胞淋巴细胞白血病l11型（中危，缓解期）”收入院。", "event": [ { "core_name": "白血病", "tendency": "", "character": [ "急性", "普通", "l11型", "中危", "缓解期" ], "anatomy_list": [ "b淋巴细胞" ] } ] }, { "id": 1651, "text": "患者自发病以来，精神可，食欲可，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": [ "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": [ "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": 1051, "text": "患者7年前因感冒发现左颌下颌下包块，如黄豆大小，有触痛，未重视未就医。", "event": [ { "core_name": "感冒", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "包块", "tendency": "", "character": [ "黄豆大小", "有触痛" ], "anatomy_list": [ "左颌下" ] } ] }, { "id": 969, "text": "3月前，患者入我院完善相关辅助检查，未见明显手术禁忌，遂于2017-7-4在局麻+静脉麻醉下行右乳溢血导管及其所属腺体切除术+术中冰冻，病理示：（右乳）导管内癌伴微灶浸润，免疫组化：er局灶（+） pr（－） cerbb-2（++） ki-67（+）5%。", "event": [ { "core_name": "癌", "tendency": "", "character": [ "导管内" ], "anatomy_list": [ "右乳" ] }, { "core_name": "浸润", "tendency": "", "character": [ "微灶" ], "anatomy_list": [ "右乳" ] } ] }, { "id": 1808, "text": "后就诊于我院胸外科，2019/10/28ct检查报告：左肺上叶、下叶背段及右肺中叶散在实性/混合密度影，符合部分肿瘤性病变征象，部分病灶感染性病变待排。", "event": [ { "core_name": "密度影", "tendency": "", "character": [ "散在", "实性" ], "anatomy_list": [ "左肺上叶、下叶背段及右肺中叶" ] }, { "core_name": "密度影", "tendency": "", "character": [ "散在", "混合" ], "anatomy_list": [ "左肺上叶、下叶背段及右肺中叶" ] }, { "core_name": "病变", "tendency": "", "character": [ "肿瘤性", "部分" ], "anatomy_list": [] }, { "core_name": "病变", "tendency": "不确定", "character": [ "感染性", "部分病灶" ], "anatomy_list": [] } ] }, { "id": 1004, "text": "患者无腹痛、腹胀，无肝区疼痛等不适。", "event": [ { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "腹胀", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "肝区" ] } ] }, { "id": 14, "text": "出院后患儿无呕吐,无抽搐,一般情况可。", "event": [ { "core_name": "呕吐", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "抽搐", "tendency": "否定", "character": [], "anatomy_list": [] } ] }, { "id": 1745, "text": "患者本次发病以来，饮食较差，睡眠尚可，小便正常，2-3天解一次大便，近1年来体重减轻约5kg 。", "event": [ { "core_name": "饮食", "tendency": "", "character": [ "较差" ], "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", "tendency": "", "character": [ "减轻" ], "anatomy_list": [] } ] }, { "id": 2007, "text": "并于2016-11-28日行术后第一次tac化疗，2016-12-18行术后第二次tac化疗，化疗过程中有恶心等不适，予以对症处理，缓解后出院。", "event": [ { "core_name": "恶心", "tendency": "", "character": [], "anatomy_list": [] } ] }, { "id": 180, "text": "2020-4于我院就诊，2020/4/27ct：腹膜后偏左侧占位，结合病史考虑转移可能，病灶包饶腹主动脉、左肾动静脉，伴左侧输尿管、左侧肾上腺、左侧腰大肌受侵可能，邻近腰2、3椎体受侵，左肾受压移位，功能降低，左侧肾盂肾盏扩张积水，左侧输尿管显示不清。", "event": [ { "core_name": "占位", "tendency": "", "character": [], "anatomy_list": [ "腹膜后左侧" ] }, { "core_name": "转移", "tendency": "不确定", "character": [], "anatomy_list": [] }, { "core_name": "病灶", "tendency": "", "character": [], "anatomy_list": [ "腹主动脉动脉", "左肾动脉", "左肾静脉" ] }, { "core_name": "病灶", "tendency": "不确定", "character": [ "受侵" ], "anatomy_list": [ "左侧输尿管", "左侧肾上腺", "左侧腰大肌" ] }, { "core_name": "病灶", "tendency": "", "character": [ "受侵" ], "anatomy_list": [ "腰椎L2、3椎体" ] }, { "core_name": "移位", "tendency": "", "character": [ "受压" ], "anatomy_list": [ "左肾" ] }, { "core_name": "功能降低", "tendency": "", "character": [], "anatomy_list": [ "左肾" ] }, { "core_name": "扩张积水", "tendency": "", "character": [], "anatomy_list": [ "左侧肾盂", "左侧肾盏" ] }, { "core_name": "显示不清", "tendency": "", "character": [], "anatomy_list": [ "左侧输尿管" ] } ] }, { "id": 410, "text": "患者后于该院会诊病检（未见原报告）提示恶性黑色素瘤。", "event": [ { "core_name": "黑色素瘤", "tendency": "", "character": [ "恶性" ], "anatomy_list": [] } ] }, { "id": 1794, "text": "于2013年09月23日在腰硬联合麻醉下行经尿道前列腺汽化电切术+双侧睾丸切除术+尿道狭窄扩张术+膀胱结石钬激光碎石术，术后予以心电监护，抗炎止血处理，病检提示（123456）：前列腺腺癌（3+3=6分）术后患者仍有尿频及尿不净感，诉腰背部疼痛，于2013年10月18日来我院治疗，游离前列腺特异抗原：1.14ng/ml，总前列腺特异抗原：10.90ng/ml，予以氟他胺口服行内分泌治疗，每月一次唑来磷酸静脉滴入抗溶骨治疗。", "event": [ { "core_name": "腺癌", "tendency": "", "character": [ "3+3=6分" ], "anatomy_list": [ "前列腺" ] }, { "core_name": "尿频", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "尿不净", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "", "character": [], "anatomy_list": [ "腰背部" ] } ] }, { "id": 1686, "text": "入院前10+年，患者无明显诱因出现左侧腰腿腿部胀痛，疼痛能忍受，久站、久坐及久行后加重，卧床休息可缓解，不伴双下肢麻木、乏力，无潮热、盗汗，无咳嗽、咳痰，无胸闷、气促，无大小便失禁等；予以腰椎牵引等对症治疗后症状缓解；此后患者左侧腰腿疼痛反反复复，尤以劳累后明显，且逐渐加重，患者自行服用止痛药物（具体不详）后可缓解，仍未重视及进一步检查。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [ "胀痛", "久站久坐久行后加重", "卧床休息可缓解" ], "anatomy_list": [ "左侧腰腿部" ] }, { "core_name": "疼痛", "tendency": "", "character": [ "能忍受" ], "anatomy_list": [] }, { "core_name": "麻木", "tendency": "否定", "character": [], "anatomy_list": [ "双下肢" ] }, { "core_name": "乏力", "tendency": "否定", "character": [], "anatomy_list": [ "双下肢" ] }, { "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": "大小便失禁", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "", "character": [ "反反复复", "劳累后明显", "逐渐加重" ], "anatomy_list": [ "左侧腰", "左侧腿" ] } ] }, { "id": 1382, "text": "4.双侧胸膜增厚。", "event": [ { "core_name": "增厚", "tendency": "", "character": [], "anatomy_list": [ "双侧胸膜" ] } ] }, { "id": 1787, "text": "病程中患者无胸闷气紧，无头晕头痛，无咳嗽咳痰等症状，今日患者为求术后第二周期化疗入我科。", "event": [ { "core_name": "胸闷", "tendency": "否定", "character": [], "anatomy_list": [ "胸" ] }, { "core_name": "气紧", "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": "咳嗽", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "否定", "character": [], "anatomy_list": [] } ] }, { "id": 665, "text": "门诊以“胸腔积液待查”收入我科住院治疗。", "event": [ { "core_name": "积液", "tendency": "", "character": [], "anatomy_list": [ "胸腔" ] } ] }, { "id": 757, "text": "评估为sd，故建议行维持治疗，后自行服用吉非替尼250mg qd，2016年10月复查ct提示病灶稍增大，建议其考虑化疗或行基因检测指导分子靶向治疗，患者及其家属拒绝，继续服用吉非替尼250mg qd治疗。", "event": [ { "core_name": "SD", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "病灶", "tendency": "", "character": [ "稍增大" ], "anatomy_list": [] } ] }, { "id": 1631, "text": "今为进一步治疗，门诊以“颈椎病”进一步治疗收入院。", "event": [ { "core_name": "颈椎病", "tendency": "", "character": [], "anatomy_list": [ "颈椎" ] } ] }, { "id": 328, "text": "无畏寒、发热，无咳嗽、咳痰，无心慌、乏力，患者就诊于当地医院，疑为尿路结石，行右侧尿路双j管置入术，术后疼痛未见明显好转。", "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": "否定", "character": [], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "心慌", "tendency": "否定", "character": [], "anatomy_list": [ "心" ] }, { "core_name": "乏力", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "结石", "tendency": "不确定", "character": [], "anatomy_list": [ "尿路" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [ "术后", "明显好转" ], "anatomy_list": [] } ] }, { "id": 674, "text": "入院前20+年患者无明显诱因出现咳嗽、咳痰，为阵发性咳嗽，冷空气刺激后、活动后咳嗽加重，休息后缓解，咳白色泡沫痰,痰量少，较易咳出，无发热,无胸闷、胸痛，无心悸、呼吸困难，无潮热、盗汗、咯血或痰中带血丝,冬春季节、季节变化时症状加重，患者自服\"奥亭、抗生素\"（具体不详）后，上述症状稍缓解。", "event": [ { "core_name": "咳嗽", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "咳嗽", "tendency": "", "character": [ "阵发性" ], "anatomy_list": [] }, { "core_name": "咳嗽", "tendency": "", "character": [ "冷空气刺激后加重", "活动后加重", "休息后缓解" ], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "白色", "泡沫痰", "量少", "较易咳出" ], "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": "心悸", "tendency": "否定", "character": [], "anatomy_list": [ "心" ] }, { "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": "咯血", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "否定", "character": [ "带血丝" ], "anatomy_list": [] } ] }, { "id": 998, "text": "5+月前，患者因“右侧乳房包块1+年、腋窝及锁骨上淋巴结肿大2+月”就诊于我院普外科，当时查体包块位于全象限，质硬，偶有胀痛，乳头无流脓，溢液，周围皮肤无红肿、热痛；腋窝及锁骨上窝淋巴结约“黄豆”大小；完善彩超示：右侧乳腺实质性肿块伴右侧腋窝淋巴结肿大，超声bi-rads4c类，高度可疑恶性，遂于该科行右乳包块穿刺活检术，术后病理示浸润性癌非特殊类型；于2016.02.28予以tac方案化疗（吡柔比星60mg d1+紫杉醇240mg d2+环磷酰胺800mg d3）；辅以止吐、保肝等治疗，患者未诉明显恶心、呕吐等不适；后患者未遵医嘱定期行化疗；3+月前，患者因“右乳及上肢红肿胀10+天”于普外科1住院治疗，当时右上肢皮温升高，右侧乳腺皮肤呈橘皮样改变，乳头向内凹陷，无皮肤破损及异常流液;予以活血化瘀、消肿、抗感染等治疗，治疗4天后患者因治疗效果较差要求出院，出院后患者于某医院及其他医院就诊，具体诊治情况不详，但未予以放化疗等治疗；患者右上肢肿胀无明显好转，1月前肿胀逐渐加重，肿胀至手背，患者遂于2+天前就诊于某医院，行彩超示右锁骨下静脉起始部部分血栓形成；右乳ca伴双侧腋窝、颈部淋巴结肿大；予以曲马多100mg q12h镇痛治疗，建议回当地医院继续治疗；今患者为求诊治，遂于我院就诊，门诊以“乳腺癌 锁骨下静脉血栓”收入我科住院治疗。", "event": [ { "core_name": "包块", "tendency": "", "character": [], "anatomy_list": [ "右侧乳房" ] }, { "core_name": "肿大", "tendency": "", "character": [], "anatomy_list": [ "腋窝淋巴结" ] }, { "core_name": "肿大", "tendency": "", "character": [], "anatomy_list": [ "锁骨上淋巴结" ] }, { "core_name": "包块", "tendency": "", "character": [ "质硬" ], "anatomy_list": [ "全象限" ] }, { "core_name": "疼痛", "tendency": "", "character": [ "胀痛", "偶有" ], "anatomy_list": [ "右侧乳房" ] }, { "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", "tendency": "否定", "character": [ "周围皮肤" ], "anatomy_list": [ "右侧乳房" ] }, { "core_name": "肿", "tendency": "否定", "character": [ "周围皮肤" ], "anatomy_list": [ "右侧乳房" ] }, { "core_name": "发热", "tendency": "否定", "character": [ "周围皮肤" ], "anatomy_list": [ "右侧乳房" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [ "周围皮肤" ], "anatomy_list": [ "右侧乳房" ] }, { "core_name": "增大", "tendency": "", "character": [ "黄豆大小" ], "anatomy_list": [ "腋窝淋巴结" ] }, { "core_name": "增大", "tendency": "", "character": [ "黄豆大小" ], "anatomy_list": [ "锁骨上淋巴结" ] }, { "core_name": "肿块", "tendency": "", "character": [ "实质性", "超声bi-rads4c类", "高度可疑恶性" ], "anatomy_list": [ "右侧乳腺" ] }, { "core_name": "肿大", "tendency": "", "character": [ "实质性", "超声bi-rads4c类", "高度可疑恶性" ], "anatomy_list": [ "右侧腋窝淋巴结" ] }, { "core_name": "癌", "tendency": "", "character": [ "浸润性", "非特殊类型" ], "anatomy_list": [ "右乳" ] }, { "core_name": "恶心", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [] }, { "core_name": "呕吐", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "红肿", "tendency": "", "character": [], "anatomy_list": [ "右乳", "上肢" ] }, { "core_name": "胀", "tendency": "", "character": [], "anatomy_list": [ "右乳", "上肢" ] }, { "core_name": "皮温", "tendency": "", "character": [ "升高" ], "anatomy_list": [ "右上肢" ] }, { "core_name": "改变", "tendency": "", "character": [ "橘皮样" ], "anatomy_list": [ "右侧乳腺" ] }, { "core_name": "凹陷", "tendency": "", "character": [ "向内" ], "anatomy_list": [ "乳头" ] }, { "core_name": "破损", "tendency": "否定", "character": [], "anatomy_list": [ "乳房" ] }, { "core_name": "流液", "tendency": "否定", "character": [ "异常" ], "anatomy_list": [ "乳头" ] }, { "core_name": "肿胀", "tendency": "否定", "character": [ "明显好转" ], "anatomy_list": [ "右上肢" ] }, { "core_name": "肿胀", "tendency": "", "character": [ "逐渐加重" ], "anatomy_list": [ "右上肢" ] }, { "core_name": "肿胀", "tendency": "", "character": [], "anatomy_list": [ "手背" ] }, { "core_name": "血栓形成", "tendency": "", "character": [ "部分" ], "anatomy_list": [ "右锁骨下静脉" ] }, { "core_name": "癌", "tendency": "", "character": [], "anatomy_list": [ "右乳" ] }, { "core_name": "肿大", "tendency": "", "character": [], "anatomy_list": [ "双侧腋窝淋巴结" ] }, { "core_name": "肿大", "tendency": "", "character": [], "anatomy_list": [ "颈部淋巴结" ] }, { "core_name": "癌", "tendency": "", "character": [], "anatomy_list": [ "乳腺" ] }, { "core_name": "血栓", "tendency": "", "character": [], "anatomy_list": [ "锁骨下静脉" ] } ] }, { "id": 1442, "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，体重减少约3kg。", "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": 132, "text": "1+月前，患者自行发现右乳房乳房包块，为8点钟方向，约黄豆大小，质硬，活动度欠佳，无发热，无皮肤红肿、无皮肤橘皮样改变，无乳头溢液，无压痛。", "event": [ { "core_name": "包块", "tendency": "", "character": [ "8点钟方向", "约黄豆大小", "质硬", "活动度欠佳" ], "anatomy_list": [ "右乳" ] }, { "core_name": "发热", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "红肿", "tendency": "否定", "character": [], "anatomy_list": [ "皮肤" ] }, { "core_name": "改变", "tendency": "否定", "character": [ "橘皮样" ], "anatomy_list": [ "皮肤" ] }, { "core_name": "溢液", "tendency": "否定", "character": [], "anatomy_list": [ "乳头" ] }, { "core_name": "压痛", "tendency": "否定", "character": [], "anatomy_list": [] } ] }, { "id": 1221, "text": "诊断为“宫颈癌”，遂收入住院治疗，入院后查ct:宫颈改变，考虑宫颈癌，病变与直肠及膀胱分界不清，膀胱壁稍均匀增厚。", "event": [ { "core_name": "癌", "tendency": "", "character": [], "anatomy_list": [ "宫颈" ] }, { "core_name": "改变", "tendency": "", "character": [], "anatomy_list": [ "宫颈" ] }, { "core_name": "癌", "tendency": "不确定", "character": [], "anatomy_list": [ "宫颈" ] }, { "core_name": "病变", "tendency": "", "character": [ "与直肠及膀胱分界不清" ], "anatomy_list": [] }, { "core_name": "增厚", "tendency": "", "character": [ "稍", "均匀" ], "anatomy_list": [ "膀胱壁" ] } ] }, { "id": 1937, "text": "入院前2+年，患者无明显诱因出现剑突下疼痛，伴嗳气、反酸，有咳嗽、咳痰伴胸背部疼痛，呈胀痛，评分：7分，无加重缓解因素，无胸闷、咯血、呼吸困难，无潮热、盗汗、疲乏、消瘦，无畏寒、发热，于我院消化内科就诊，完善胸部ct：左肺下叶软组织块块影，考虑肺ca；遂转入我科。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [], "anatomy_list": [ "剑突下" ] }, { "core_name": "嗳气", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "反酸", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "咳嗽", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "", "character": [], "anatomy_list": [ "胸背部" ] }, { "core_name": "疼痛", "tendency": "", "character": [ "胀痛", "评分：7分" ], "anatomy_list": [ "胸背部" ] }, { "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": [] }, { "core_name": "块影", "tendency": "", "character": [], "anatomy_list": [ "左肺下叶软组织" ] }, { "core_name": "癌", "tendency": "不确定", "character": [], "anatomy_list": [ "肺" ] } ] }, { "id": 128, "text": "于2016-07-21行“麦默通微创旋切术”手术治疗，术后病检提示：（左乳）粘液癌，免疫组化：e-ca(+),gatf-3(+),gcdpf(+),mammaglobi(+)，34βe12(+)，c-erbb-2(1+)，er(-),pr(-),p63(-)。", "event": [ { "core_name": "粘液癌", "tendency": "", "character": [], "anatomy_list": [ "左乳" ] } ] }, { "id": 1242, "text": "入院前2月，患者因右侧乳腺肿块，于某医院就诊，行乳腺彩超示：右乳1点腺体边缘异常回声，性质待定？右侧腋下组淋巴结淋巴结肿大，性质待定？进一步行胸部ct：右乳结节，穿刺活检示浸润性癌，诊断为右乳癌ct2n0M0，明确有手术指针，无明显手术禁忌症后，于2018-7-16行前哨淋巴结探查及活检术+保留胸肌式右乳癌扩大根治术，术后病检：右乳浸润性癌，非特殊性，脉管内未见明确癌栓。", "event": [ { "core_name": "肿块", "tendency": "", "character": [], "anatomy_list": [ "右侧乳腺" ] }, { "core_name": "回声", "tendency": "不确定", "character": [ "异常" ], "anatomy_list": [ "右乳1点腺体边缘" ] }, { "core_name": "肿大", "tendency": "不确定", "character": [], "anatomy_list": [ "右侧腋下组淋巴结" ] }, { "core_name": "结节", "tendency": "", "character": [], "anatomy_list": [ "右乳" ] }, { "core_name": "癌", "tendency": "", "character": [ "浸润性" ], "anatomy_list": [ "右乳" ] }, { "core_name": "癌", "tendency": "", "character": [ "ct2n0M0" ], "anatomy_list": [ "右乳" ] }, { "core_name": "癌栓", "tendency": "否定", "character": [], "anatomy_list": [ "脉管内" ] }, { "core_name": "癌", "tendency": "", "character": [ "浸润性" ], "anatomy_list": [ "右乳" ] } ] }, { "id": 1632, "text": "患者自起病以来，精神可，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": [ "可" ], "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": 1040, "text": "入院前1-年，患者无明显诱因出现大便次数增多，约5-6次/天，大便稀塘，量少，不成形，吃油腻食物后加重，清淡饮食时稍缓解，时有肛门坠胀，伴腹胀，排气后腹胀可缓解，无腹痛、呕血、黑便，无头昏、头痛、发热，无恶心、呕吐、食欲下降等症状，于2014-04-16某医院就诊，行电子乙状结肠结肠镜示：直肠癌？取病理活检示直肠腺癌，建议转上级医院就诊。", "event": [ { "core_name": "大便", "tendency": "", "character": [ "次数增多", "约5-6次/天" ], "anatomy_list": [] }, { "core_name": "大便", "tendency": "", "character": [ "稀塘", "量少", "不成形", "吃油腻食物后加重", "清淡饮食时稍缓解" ], "anatomy_list": [] }, { "core_name": "坠胀", "tendency": "", "character": [ "时有" ], "anatomy_list": [ "肛门" ] }, { "core_name": "腹胀", "tendency": "", "character": [ "排气后缓解" ], "anatomy_list": [ "腹" ] }, { "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": "头昏", "tendency": "否定", "character": [], "anatomy_list": [ "头" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "头" ] }, { "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": "食欲", "tendency": "否定", "character": [ "下降" ], "anatomy_list": [] }, { "core_name": "癌", "tendency": "不确定", "character": [], "anatomy_list": [ "直肠" ] }, { "core_name": "腺癌", "tendency": "", "character": [], "anatomy_list": [ "直肠" ] } ] }, { "id": 1129, "text": "1月前，患者出现右上腹胀，未到医院检查治疗。", "event": [ { "core_name": "腹胀", "tendency": "", "character": [], "anatomy_list": [ "右上腹" ] } ] }, { "id": 1607, "text": "2020-7-29患者进一步于我院就诊，行妇科彩超示：宫颈体积增大(4.7×4.3cm)，回声及血流改变，考虑：ca。", "event": [ { "core_name": "增大", "tendency": "", "character": [ "体积" ], "anatomy_list": [ "宫颈" ] }, { "core_name": "回声", "tendency": "", "character": [ "改变" ], "anatomy_list": [ "宫颈" ] }, { "core_name": "血流", "tendency": "", "character": [ "改变" ], "anatomy_list": [ "宫颈" ] }, { "core_name": "癌", "tendency": "", "character": [], "anatomy_list": [ "宫颈" ] } ] }, { "id": 2040, "text": "入院前2+月，患者因右乳包块入我院就诊，于2018-04-28行“右乳包块切除+术中冰冻”，术中冰冻回报示恶性，遂于全麻下行右乳改良根治术；术后病检提示:(右乳)浸润性癌，非特殊类型，ii级7分。乳头未见累及。", "event": [ { "core_name": "包块", "tendency": "", "character": [], "anatomy_list": [ "右乳" ] }, { "core_name": "包块", "tendency": "", "character": [ "恶性" ], "anatomy_list": [] }, { "core_name": "癌", "tendency": "", "character": [ "浸润性", "非特殊类型", "ii级7分" ], "anatomy_list": [ "右乳" ] }, { "core_name": "癌", "tendency": "", "character": [ "累及" ], "anatomy_list": [ "乳头" ] } ] }, { "id": 1809, "text": "术后病理提示：<左下肺>浸润性腺癌，以腺泡状生长方式为主，另见乳头状生长方式约占5%。", "event": [ { "core_name": "腺癌", "tendency": "", "character": [ "浸润性", "腺泡状生长方式为主", "乳头状生长方式约占5%" ], "anatomy_list": [ "左下肺" ] } ] }, { "id": 298, "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，小便如上诉，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": [ "如上诉" ], "anatomy_list": [] }, { "core_name": "体重变化", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [] } ] }, { "id": 1968, "text": "无黑朦，无抽搐，无意识障碍，无恶心呕吐，无厌油，大便正常，呈黄色，成型，近1周，精神欠佳，伴全身乏力。", "event": [ { "core_name": "黑朦", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "抽搐", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "意识障碍", "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": "厌油", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "大便", "tendency": "否定", "character": [ "正常", "黄色", "成型" ], "anatomy_list": [] }, { "core_name": "精神", "tendency": "", "character": [ "欠佳" ], "anatomy_list": [] }, { "core_name": "乏力", "tendency": "", "character": [], "anatomy_list": [ "全身" ] } ] }, { "id": 1662, "text": "门诊以“急性早幼粒细胞性白血病”收入我科住院治疗。", "event": [ { "core_name": "白血病", "tendency": "", "character": [ "急性", "早幼粒细胞" ], "anatomy_list": [] } ] }, { "id": 1503, "text": "化疗间歇期患者仍觉头昏、乏力等不适，考虑疾病未缓解，排除化疗禁忌，于2019.12.20开始行阿扎胞苷联合半量tag方案化疗，具体为：阿扎胞苷 140mg qd d1-7，阿糖胞苷 20mg ih bid d1-10,吡柔比星 10mg 隔天一次 ivgtt，化疗第88天复查血常规示三系明显减少，且患者自觉头昏、乏力等不适较前加重，故予暂停使用阿糖胞苷化疗，后多次复查血常规示三系极低，且伴肺部感染、肛周脓肿，予反复输注悬浮红细胞、血小板、抗感染等治疗后未再发热，但复查血常规示三系仍低，患者要求出院，遂办理自动出院。", "event": [ { "core_name": "头昏", "tendency": "", "character": [], "anatomy_list": [ "头" ] }, { "core_name": "乏力", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "头昏", "tendency": "", "character": [ "较前加重" ], "anatomy_list": [ "头" ] }, { "core_name": "乏力", "tendency": "", "character": [ "较前加重" ], "anatomy_list": [] }, { "core_name": "感染", "tendency": "", "character": [], "anatomy_list": [ "肺部" ] }, { "core_name": "脓肿", "tendency": "", "character": [], "anatomy_list": [ "肛周" ] }, { "core_name": "发热", "tendency": "否定", "character": [], "anatomy_list": [] } ] }, { "id": 742, "text": "入院前5月余于我院诊断“（左扁桃体）结合he及组化非霍奇金氏淋巴瘤（弥漫大“b”）”，现已行5次行chop方案化疗（泼尼松片，长春瑞滨（盖诺）注射液，环磷酰胺粉针、多柔比星粉针（山西））化疗，化疗期间无明显头昏、头痛、恶心、呕吐等不适。", "event": [ { "core_name": "瘤", "tendency": "", "character": [ "弥漫大“b”" ], "anatomy_list": [ "左扁桃体" ] }, { "core_name": "瘤", "tendency": "", "character": [ "非霍奇金氏" ], "anatomy_list": [ "左扁桃体", "淋巴" ] }, { "core_name": "头昏", "tendency": "否定", "character": [ "化疗期间", "明显" ], "anatomy_list": [ "头" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [ "化疗期间", "明显" ], "anatomy_list": [ "头" ] }, { "core_name": "恶心", "tendency": "否定", "character": [ "化疗期间", "明显" ], "anatomy_list": [] }, { "core_name": "呕吐", "tendency": "否定", "character": [ "化疗期间", "明显" ], "anatomy_list": [] } ] }, { "id": 1078, "text": "5年前，患者于外院体检时发现血尿酸偏高（具体不详），以后每次查血尿酸均高于正常值，院外口服“小苏打”治疗，血尿酸水平控制可，近2天前，患者进食大量高蛋白饮食后，出现左足第一足趾关节红肿伴疼痛，压痛明显，有明显痛风结节，伴右手第3、4、5指关节及左手第2、3、4、5指关节关节红肿，轻压痛，病程中患者未诉右足趾关节疼痛，未诉腰痛等不适。", "event": [ { "core_name": "血尿酸", "tendency": "", "character": [ "偏高", "高于正常值" ], "anatomy_list": [] }, { "core_name": "进食", "tendency": "", "character": [ "大量" ], "anatomy_list": [] }, { "core_name": "血尿酸水平", "tendency": "", "character": [ "控制可" ], "anatomy_list": [] }, { "core_name": "红肿", "tendency": "", "character": [], "anatomy_list": [ "左足第一足趾关节" ] }, { "core_name": "疼痛", "tendency": "", "character": [], "anatomy_list": [ "左足第一足趾关节" ] }, { "core_name": "压痛", "tendency": "", "character": [ "明显" ], "anatomy_list": [ "左足第一足趾关节" ] }, { "core_name": "痛风结节", "tendency": "", "character": [ "明显" ], "anatomy_list": [ "左足第一足趾关节" ] }, { "core_name": "红肿", "tendency": "", "character": [], "anatomy_list": [ "右手第3、4、5指关节", "左手2、3、4、5指关节" ] }, { "core_name": "压痛", "tendency": "", "character": [ "轻" ], "anatomy_list": [ "右手第3、4、5指关节", "左手2、3、4、5指关节" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "右足趾关节" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "腰" ] } ] }, { "id": 1621, "text": "3.右肺中叶内侧段及左肺上叶下舌段纤维灶。", "event": [ { "core_name": "纤维灶", "tendency": "", "character": [], "anatomy_list": [ "右肺中叶内侧段" ] }, { "core_name": "纤维灶", "tendency": "", "character": [], "anatomy_list": [ "左肺上叶下舌段" ] } ] }, { "id": 1746, "text": "患者于1月前发现右侧睾丸睾丸增大，无尿痛及肉眼血尿及脓尿；无发热、畏寒、恶心、呕吐、头昏、头痛、胸痛、胸闷、心慌、心悸、腹痛、腹泻等不适；于某医院门诊就诊，行阴囊彩超提示右侧睾丸内不均质回声，未予以进一步治疗。", "event": [ { "core_name": "增大", "tendency": "", "character": [], "anatomy_list": [ "右侧睾丸" ] }, { "core_name": "尿痛", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "血尿", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "脓尿", "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": "头昏", "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": "胸闷", "tendency": "否定", "character": [], "anatomy_list": [ "胸" ] }, { "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": "腹泻", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "回声", "tendency": "", "character": [ "不均质" ], "anatomy_list": [ "右侧睾丸内" ] } ] }, { "id": 1599, "text": "心电图：窦性心律；完全性右束支传导阻滞。", "event": [ { "core_name": "窦性心律", "tendency": "", "character": [], "anatomy_list": [ "心" ] }, { "core_name": "传导阻滞", "tendency": "", "character": [ "完全性" ], "anatomy_list": [ "右束支" ] } ] }, { "id": 1049, "text": "患者于3+月前在我院诊断左侧乳腺癌，充分术前准备，于2019-02-11病人于全麻下行了左侧乳腺癌改良根治术，术后病人恢复较好，患者无恶心、呕吐，无心慌气短。", "event": [ { "core_name": "癌", "tendency": "", "character": [], "anatomy_list": [ "左侧乳腺" ] }, { "core_name": "恶心", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "呕吐", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "心慌", "tendency": "否定", "character": [], "anatomy_list": [ "心" ] }, { "core_name": "气短", "tendency": "否定", "character": [], "anatomy_list": [] } ] }, { "id": 1151, "text": "入院前半年，患者受凉后出现阵发性咳嗽，非高调金属声样咳嗽及鸡鸣样咳嗽，昼夜均较频繁，咳少许白色粘痰，未见咯血，无明显呼吸困难，无畏寒、发热，无潮热、盗汗，无胸痛、声嘶，无皮疹及关节红肿，无恶心、呕吐、腹痛、腹泻、便血，无颜面及下肢水肿，间断在当地医院治疗（具体不详）后病情未有缓解，随来我院就医，门诊以\"咳嗽原因待查\"收入住院治疗。", "event": [ { "core_name": "咳嗽", "tendency": "", "character": [ "受凉后", "阵发性", "非高调金属声样", "鸡鸣样", "昼夜均较频繁" ], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "白色", "粘性", "少许" ], "anatomy_list": [] }, { "core_name": "咯血", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "呼吸困难", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [] }, { "core_name": "畏寒", "tendency": "否定", "character": [], "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": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "胸" ] }, { "core_name": "声嘶", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "皮疹", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "红肿", "tendency": "否定", "character": [], "anatomy_list": [ "关节" ] }, { "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" ] }, { "core_name": "便血", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "水肿", "tendency": "否定", "character": [], "anatomy_list": [ "颜面", "下肢" ] }, { "core_name": "咳嗽", "tendency": "", "character": [], "anatomy_list": [] } ] }, { "id": 2034, "text": "骨髓活检符合急性早幼粒细胞白血病。", "event": [ { "core_name": "白血病", "tendency": "", "character": [ "急性" ], "anatomy_list": [ "早幼粒细胞" ] } ] }, { "id": 590, "text": "无胸闷、心悸及心前区压榨感。", "event": [ { "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" ] } ] }, { "id": 1590, "text": "7天前，患者于我院门诊体检时行钼靶发现左乳乳头后方一小结节，大小约为0.6*0.8cm。", "event": [ { "core_name": "结节", "tendency": "", "character": [ "小", "一" ], "anatomy_list": [ "左乳乳头后方" ] } ] }, { "id": 436, "text": "12天前患者单位体检行超声发现左肾积水，就诊于我院门诊，行泌尿系超声检查提示：1、膀胱右后壁输尿管开口区域低回声结节，建议进一步检查。", "event": [ { "core_name": "积水", "tendency": "", "character": [], "anatomy_list": [ "左肾" ] }, { "core_name": "结节", "tendency": "", "character": [ "低回声" ], "anatomy_list": [ "膀胱右后壁输尿管开口区域" ] } ] }, { "id": 1478, "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，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": "体重改变", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [] } ] }, { "id": 1862, "text": "结合术中情况及术后病检诊断：卵巢高级别浆液性癌iiic期，术后转入我科，于2020-7-3行紫杉醇（白蛋白结合型）210mg+卡铂600mg静脉化疗，化疗反应轻，化疗后有脱发、无明显恶心、呕吐，食欲可，全身无淤血淤斑、皮疹，有轻微口腔溃疡等症状。", "event": [ { "core_name": "癌", "tendency": "", "character": [ "高级别", "浆液性", "iiic期" ], "anatomy_list": [ "卵巢" ] }, { "core_name": "脱发", "tendency": "", "character": [ "化疗后" ], "anatomy_list": [] }, { "core_name": "恶心", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [] }, { "core_name": "呕吐", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "食欲", "tendency": "否定", "character": [ "可" ], "anatomy_list": [] }, { "core_name": "瘀血", "tendency": "否定", "character": [], "anatomy_list": [ "全身" ] }, { "core_name": "瘀斑", "tendency": "否定", "character": [], "anatomy_list": [ "全身" ] }, { "core_name": "皮疹", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "溃疡", "tendency": "", "character": [ "轻微" ], "anatomy_list": [ "口腔" ] } ] }, { "id": 200, "text": "3、（胃食管食管残端）未见癌累及。", "event": [ { "core_name": "癌", "tendency": "否定", "character": [ "累及" ], "anatomy_list": [ "胃", "食管", "食管残端" ] } ] }, { "id": 952, "text": "入院前12小时患者无明显诱因再次出现解不成形黑便，量约250g，无心悸、一过性黑蒙、乏力、四肢发冷不适。", "event": [ { "core_name": "大便", "tendency": "", "character": [ "不成形", "黑" ], "anatomy_list": [] }, { "core_name": "心悸", "tendency": "否定", "character": [], "anatomy_list": [ "心" ] }, { "core_name": "黑朦", "tendency": "否定", "character": [ "一过性" ], "anatomy_list": [] }, { "core_name": "乏力", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "发冷", "tendency": "", "character": [], "anatomy_list": [ "四肢" ] } ] }, { "id": 1274, "text": "10年前，患者口服药物欠佳，故改为口服药物联合皮下注射胰岛素，自述血糖控制良好。", "event": [ { "core_name": "血糖", "tendency": "", "character": [ "控制良好" ], "anatomy_list": [] } ] }, { "id": 1656, "text": "诊断为急性髓系白血病（m3），于2016-11-17日行化疗，方案：维a酸+亚砷酸+米托蒽醌方案，并辅以水化、碱化尿液、止吐等治疗。", "event": [ { "core_name": "白血病", "tendency": "", "character": [ "急性", "髓系", "M3" ], "anatomy_list": [] } ] }, { "id": 1818, "text": "现患者一般情况可，诉轻微咳嗽，少量白痰，为求进一步诊疗而来，门诊以“肺癌术后”收治入科。", "event": [ { "core_name": "咳嗽", "tendency": "", "character": [ "轻微" ], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "少量", "白痰" ], "anatomy_list": [] }, { "core_name": "癌", "tendency": "", "character": [ "术后" ], "anatomy_list": [ "肺" ] } ] }, { "id": 592, "text": "院外，患者仍感上腹部隐痛不适，2017-9-8于我院行胸腹部ct提示肝实质内数个稍低密度肿块影及结节影，考虑转移性肿瘤可能；胃贲门贲门区胃壁增厚，软组织影增多，考虑胃癌可能，伴小弯侧多发肿大淋巴结肿大淋巴结影，为治疗入住我科，评估无明显化疗禁忌症后，于2017.10.25、2017.11.15、2017.12.15、2018.1.9、2018.2.7、2018.3.14行tp方案（紫杉醇240mg+奥沙利铂200mg）行6周期化疗，过程顺利，无特殊不适，期间患者复查胸腹部ct提示病灶缩小，疗效评价pr，但患者未再继续治疗。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [ "隐痛" ], "anatomy_list": [ "上腹部" ] }, { "core_name": "肿块影", "tendency": "", "character": [ "数个", "稍低密度" ], "anatomy_list": [ "肝实质内" ] }, { "core_name": "结节影", "tendency": "", "character": [ "数个", "稍低密度" ], "anatomy_list": [ "肝实质内" ] }, { "core_name": "肿瘤", "tendency": "不确定", "character": [ "转移性" ], "anatomy_list": [ "肝" ] }, { "core_name": "增厚", "tendency": "", "character": [], "anatomy_list": [ "胃贲门区胃壁" ] }, { "core_name": "软组织影", "tendency": "", "character": [ "增多" ], "anatomy_list": [] }, { "core_name": "癌", "tendency": "不确定", "character": [], "anatomy_list": [ "胃" ] }, { "core_name": "淋巴结影", "tendency": "", "character": [ "多发", "肿大" ], "anatomy_list": [ "胃小弯" ] }, { "core_name": "病灶", "tendency": "", "character": [ "缩小" ], "anatomy_list": [] } ] }, { "id": 974, "text": "11年前，患者再次出现咳嗽、咳痰，伴胸闷、气促，伴低热、盗汗，无咯血、胸痛，无乏力、纳差、消瘦等。", "event": [ { "core_name": "咳嗽", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "胸闷", "tendency": "", "character": [], "anatomy_list": [ "胸" ] }, { "core_name": "气促", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "发热", "tendency": "", "character": [ "低" ], "anatomy_list": [] }, { "core_name": "盗汗", "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": "乏力", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "纳差", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "消瘦", "tendency": "否定", "character": [], "anatomy_list": [] } ] }, { "id": 610, "text": "为进一步诊治入我院，门诊以“膀胱结石、前列腺增生”收入我科。", "event": [ { "core_name": "结石", "tendency": "", "character": [], "anatomy_list": [ "膀胱" ] }, { "core_name": "增生", "tendency": "", "character": [], "anatomy_list": [ "前列腺" ] } ] }, { "id": 678, "text": "后患者出院继续左氧氟沙星抗感染治疗，患者自觉症状缓解不明显，遂来我院就诊，门诊以“肺炎”收治入院。", "event": [ { "core_name": "肺炎", "tendency": "", "character": [], "anatomy_list": [ "肺" ] } ] }, { "id": 1526, "text": "本次入院前3月余，患者因“咳嗽、痰中带血2周”于我院住院治疗，患者一般情况良好，无畏寒、发热，无咯血、胸痛、呼吸困难，无胸闷、气促、心悸，无头晕、头痛，无恶心、呕吐，无腹痛、腹泻等不适。", "event": [ { "core_name": "咳嗽", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "带血" ], "anatomy_list": [] }, { "core_name": "畏寒", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "发热", "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": "呼吸困难", "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": "心悸", "tendency": "否定", "character": [], "anatomy_list": [ "心" ] }, { "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": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "腹泻", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] } ] }, { "id": 1665, "text": "患者5月前因“间歇性中上腹疼痛6月，再发10天”入我院治疗，完善相关检查后考虑诊断“胰腺恶性肿瘤”。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [ "间歇性", "再发" ], "anatomy_list": [ "中上腹" ] }, { "core_name": "肿瘤", "tendency": "不确定", "character": [ "恶性" ], "anatomy_list": [ "胰腺" ] } ] }, { "id": 365, "text": "入院前1天有腹泻，2次/天，呈黄色稀水便，无粘液及血丝，无里急后重感，无发热，无呕吐；无咳嗽，无进行性面色苍白，无出血倾向，无结膜充血、眼痒等表现。", "event": [ { "core_name": "腹泻", "tendency": "", "character": [ "呈黄色稀水便", "无粘液及血丝" ], "anatomy_list": [ "腹" ] }, { "core_name": "里急后重感", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "发热", "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": "面色苍白", "tendency": "否定", "character": [ "进行性" ], "anatomy_list": [ "面" ] }, { "core_name": "出血", "tendency": "否定", "character": [ "倾向" ], "anatomy_list": [] }, { "core_name": "充血", "tendency": "否定", "character": [], "anatomy_list": [ "结膜" ] }, { "core_name": "痒", "tendency": "否定", "character": [], "anatomy_list": [ "眼" ] } ] }, { "id": 1593, "text": "为求进一步治疗，遂于今日与我院门诊，门诊以“左乳包块待查”收治入院。", "event": [ { "core_name": "包块", "tendency": "不确定", "character": [], "anatomy_list": [ "左乳" ] } ] }, { "id": 1452, "text": "11周前（2016年12月）患者再次于某医院复查，ct见双肺多发结节，考虑转移，仍未进一步治疗，院外休息。", "event": [ { "core_name": "结节", "tendency": "", "character": [ "多发" ], "anatomy_list": [ "双肺" ] }, { "core_name": "转移", "tendency": "不确定", "character": [], "anatomy_list": [] } ] }, { "id": 148, "text": "入院前9年患者体检时发现乙肝表面抗原阳性，自诉肝功轻度异常（具体不详），无明显乏力、纳差等不适，患者自行长期口服中药治疗（具体治疗方案不详），并长期随访肝功等检查。", "event": [ { "core_name": "乙肝表面抗原", "tendency": "", "character": [ "阳性" ], "anatomy_list": [] }, { "core_name": "肝功能异常", "tendency": "", "character": [ "轻度" ], "anatomy_list": [ "肝" ] }, { "core_name": "乏力", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [] }, { "core_name": "纳差", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [] } ] }, { "id": 178, "text": "5+月前（2020-1-22）开始出现双下肢活动障碍。", "event": [ { "core_name": "活动障碍", "tendency": "", "character": [], "anatomy_list": [ "双下肢" ] } ] }, { "id": 1681, "text": "遂于我院门诊就诊，行血图分析示：白细胞数目：17.53×109/l 中性粒细胞百分比：88.9％，后以“aecopd”收住入院，给予抗感染、解痉平喘、止咳祛痰等对症治疗后，上述症状缓解出院，出院后1天即感咳嗽咳痰、喘累，故再次以“慢性阻塞性肺疾病 急性加重期”收治入院。", "event": [ { "core_name": "肺疾病", "tendency": "", "character": [ "慢性", "阻塞性", "急性加重期" ], "anatomy_list": [ "肺" ] }, { "core_name": "咳嗽", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "喘累", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "肺疾病", "tendency": "", "character": [ "慢性", "阻塞性", "急性加重期" ], "anatomy_list": [ "肺" ] } ] }, { "id": 1743, "text": "患者入院20余天欠无明显原因出现咳嗽、咳痰，呈阵发性发作，痰粘稠不易咳出，咳出痰为白色黏痰，伴食欲不振，全身乏力，活动后明显，无发热、畏寒，无喘累，无肩背部放射痛，无反酸、恶心、呕吐，无腹痛、腹泻，双下肢不肿，自行购买药物（具体不详）处理上述症状缓解不明显。", "event": [ { "core_name": "咳嗽", "tendency": "", "character": [ "阵发性发作" ], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "阵发性发作" ], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "不易咳出", "粘稠" ], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "白色", "黏痰" ], "anatomy_list": [] }, { "core_name": "乏力", "tendency": "", "character": [ "活动后明显" ], "anatomy_list": [ "全身" ] }, { "core_name": "食欲", "tendency": "", "character": [ "不振" ], "anatomy_list": [] }, { "core_name": "发热", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "畏寒", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "喘累", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "否定", "character": [ "放射性" ], "anatomy_list": [ "肩", "背部" ] }, { "core_name": "反酸", "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" ] }, { "core_name": "肿", "tendency": "否定", "character": [], "anatomy_list": [ "双下肢" ] } ] }, { "id": 808, "text": "上述症状逐渐加重，伴食欲下降，进食少，今家属带患者进一步诊治，遂到我科门诊就诊，门诊以“慢性酒精性神经病”收入我科住院治疗。", "event": [ { "core_name": "食欲下降", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "进食少", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "神经病", "tendency": "", "character": [ "慢性", "酒精性" ], "anatomy_list": [] } ] }, { "id": 1044, "text": "现患者仍有腹胀，遂于今日到我院就诊，门诊以“直肠癌”收入我科住院治疗。", "event": [ { "core_name": "腹胀", "tendency": "", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "癌", "tendency": "", "character": [], "anatomy_list": [ "直肠" ] } ] }, { "id": 508, "text": "随后到某肿瘤医院就诊，经完善相关检查，胸部ct提示双肺结节，考虑良性可能性大，但不能除外恶性，患者及家属手术意愿强烈，无绝对手术禁忌症，于2017年10月26日行胸腹腔镜联合食管癌根治术+胸膜烙断术+肠粘连松解术。", "event": [ { "core_name": "结节", "tendency": "不确定", "character": [ "良性", "恶性" ], "anatomy_list": [ "双肺" ] } ] }, { "id": 17, "text": "4月余前,患者因“发现右乳包块伴乳房胀痛1+年”就诊于我院普外科1,行彩超、钼钯等检查,提示右乳占位性病变,考虑乳腺癌,完善胸片、骨ect、腹部彩超等辅查后,于2016年11月11日行右乳包块切除+术中冰冻+右乳癌改良根治术,术中见：右乳包块直径约3.5cm大小,位于右乳外侧腺体内,质硬,无明显包膜,边界不清。", "event": [ { "core_name": "包块", "tendency": "", "character": [], "anatomy_list": [ "右乳" ] }, { "core_name": "疼痛", "tendency": "", "character": [ "胀痛" ], "anatomy_list": [ "乳房" ] }, { "core_name": "病变", "tendency": "", "character": [ "占位性" ], "anatomy_list": [ "右乳" ] }, { "core_name": "癌", "tendency": "不确定", "character": [], "anatomy_list": [ "乳腺" ] }, { "core_name": "包块", "tendency": "", "character": [], "anatomy_list": [ "右乳" ] }, { "core_name": "包块", "tendency": "", "character": [ "质硬", "无明显包膜", "边界不清" ], "anatomy_list": [ "右乳外侧腺体内" ] } ] }, { "id": 1601, "text": "入院前1+月，患者自觉心悸、心前区紧闷不适，活动后心累、气促不适，偶感心前区刺痛，无肩部放射痛，口服速效救心丸后好转，无黑曚、晕厥，无腹胀、纳差、恶心、呕吐等不适，遂就诊于我科，完善相关辅助检查后诊断为“1.冠心病 缺血性心肌病 心脏扩大 心功能iii级 2.原发性高血压病3级 很高危 3.高血压性心脏病 心脏扩大 心功能iii级 4.2型糖尿病 5.左肺下叶实性病灶 6.转移性肝ca？7.肝囊肿 8.前列腺增生症”；予以对症处置后好转出院。", "event": [ { "core_name": "心悸", "tendency": "", "character": [], "anatomy_list": [ "心" ] }, { "core_name": "紧闷", "tendency": "", "character": [], "anatomy_list": [ "心前区" ] }, { "core_name": "心累", "tendency": "", "character": [ "活动后", "不适" ], "anatomy_list": [ "心" ] }, { "core_name": "气促", "tendency": "", "character": [ "活动后", "不适" ], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "", "character": [ "偶有", "刺痛" ], "anatomy_list": [ "心前区" ] }, { "core_name": "疼痛", "tendency": "", "character": [ "放射性" ], "anatomy_list": [ "肩部" ] }, { "core_name": "黑朦", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "晕厥", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "腹胀", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "纳差", "tendency": "否定", "character": [ "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": "心脏病", "tendency": "", "character": [ "粥样", "硬化性" ], "anatomy_list": [ "冠状动脉", "心脏" ] }, { "core_name": "心肌病", "tendency": "", "character": [ "缺血性" ], "anatomy_list": [ "心肌" ] }, { "core_name": "扩大", "tendency": "", "character": [ "扩大" ], "anatomy_list": [ "心脏" ] }, { "core_name": "心功能", "tendency": "", "character": [ "iii级" ], "anatomy_list": [ "心" ] }, { "core_name": "高血压", "tendency": "", "character": [ "很高危", "原发性", "3级" ], "anatomy_list": [] }, { "core_name": "心脏病", "tendency": "", "character": [ "高血压性" ], "anatomy_list": [ "心脏" ] }, { "core_name": "扩大", "tendency": "", "character": [ "扩大" ], "anatomy_list": [ "心脏" ] }, { "core_name": "心功能", "tendency": "", "character": [ "iii级" ], "anatomy_list": [ "心" ] }, { "core_name": "糖尿病", "tendency": "", "character": [ "2型" ], "anatomy_list": [] }, { "core_name": "病灶", "tendency": "", "character": [ "实性" ], "anatomy_list": [ "左肺下叶" ] }, { "core_name": "癌", "tendency": "不确定", "character": [ "转移性" ], "anatomy_list": [ "肝" ] }, { "core_name": "囊肿", "tendency": "", "character": [], "anatomy_list": [ "肝" ] }, { "core_name": "增生", "tendency": "", "character": [], "anatomy_list": [ "前列腺" ] } ] }, { "id": 1213, "text": "院外患者诉右下肢肿胀不适,今为求下一周期化疗,以\"宫颈癌\"收入我科住院治疗。", "event": [ { "core_name": "肿胀", "tendency": "", "character": [], "anatomy_list": [ "右下肢" ] }, { "core_name": "癌", "tendency": "", "character": [], "anatomy_list": [ "宫颈" ] } ] }, { "id": 809, "text": "入院6+月前患者因“腹部疼痛1月”入院，入院后完善相关辅助检查后考虑横结肠癌，未见绝对手术禁忌症，向患者家属交代病情后家属要求手术，于2020.4.4全麻下行横结肠癌根治性切除术，手术顺利，术后继续给予抗感染，补液，营养支持，雾化祛痰等对症治疗后，术后活检为：横结肠结肠黏膜中分化管状腺癌，部分为黏液腺癌，肿瘤侵犯肠壁全层（t3），血管内未见癌栓，横结肠近端及远端切缘未见癌组织，肠系膜淋巴结未见癌转移（0/15）。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [], "anatomy_list": [ "腹部" ] }, { "core_name": "癌", "tendency": "不确定", "character": [], "anatomy_list": [ "横结肠" ] }, { "core_name": "腺癌", "tendency": "", "character": [ "中分化", "管状", "结肠黏膜" ], "anatomy_list": [ "横结肠" ] }, { "core_name": "腺癌", "tendency": "", "character": [ "黏液" ], "anatomy_list": [] }, { "core_name": "肿瘤", "tendency": "", "character": [ "侵犯肠壁全层（t3）" ], "anatomy_list": [] }, { "core_name": "癌栓", "tendency": "否定", "character": [], "anatomy_list": [ "血管内" ] }, { "core_name": "癌组织", "tendency": "否定", "character": [], "anatomy_list": [ "横结肠近端切缘", "横结肠远端切缘" ] }, { "core_name": "癌", "tendency": "否定", "character": [ "转移" ], "anatomy_list": [ "肠系膜淋巴结" ] } ] }, { "id": 1474, "text": "后包块逐渐增大，久站及剧烈咳嗽时突出较明显，仍伴有间歇性胀痛，可回纳，不伴畏寒、发热，不伴下肢静脉静脉扩张、迂曲，不伴潮热、盗汗等不适。", "event": [ { "core_name": "包块", "tendency": "", "character": [ "逐渐增大", "久站及剧烈咳嗽时突出较明显", "间歇性胀痛", "可回纳" ], "anatomy_list": [] }, { "core_name": "畏寒", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "发热", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "扩张", "tendency": "否定", "character": [], "anatomy_list": [ "下肢静脉" ] }, { "core_name": "迂曲", "tendency": "否定", "character": [], "anatomy_list": [ "下肢静脉" ] }, { "core_name": "潮热", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "盗汗", "tendency": "否定", "character": [], "anatomy_list": [] } ] }, { "id": 1253, "text": "2017-01-09就诊于我院行胃镜检查提示：1.胃窦病变待查。", "event": [ { "core_name": "病变", "tendency": "不确定", "character": [], "anatomy_list": [ "胃窦" ] } ] }, { "id": 1559, "text": "遂到我院门诊就诊，完善胃镜及病理活检：“食管新生物”鳞状细胞癌（123456）。", "event": [ { "core_name": "新生物", "tendency": "", "character": [], "anatomy_list": [ "食管" ] }, { "core_name": "癌", "tendency": "", "character": [], "anatomy_list": [ "食管", "鳞状细胞" ] } ] }, { "id": 439, "text": "患者于2年前常因气候变化，受凉后出现咳嗽、咳痰，咳白色泡沫痰，经抗感染、支气管解痉、化痰对症治疗后缓解。", "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" ], "anatomy_list": [] } ] }, { "id": 33, "text": "为进一步诊治门诊以“尿毒症”收入我科。", "event": [ { "core_name": "尿毒症", "tendency": "", "character": [], "anatomy_list": [] } ] }, { "id": 364, "text": "入院前5+月，患儿因“间断发热半月,发现面色苍白1周”于我院就诊，经骨髓micm分型诊断为“急性普通b淋巴细胞淋巴细胞白血病l11型（中危）”，确诊至今按cccg-all-2015化疗方案已经完成dex+vdlp、cat、mm巩固化疗第1-4次hd-mtx、ir间期第1次静脉化疗。", "event": [ { "core_name": "发热", "tendency": "", "character": [ "间断" ], "anatomy_list": [] }, { "core_name": "面色苍白", "tendency": "", "character": [], "anatomy_list": [ "面" ] }, { "core_name": "白血病", "tendency": "", "character": [ "急性", "普通", "中危", "l11型" ], "anatomy_list": [ "b淋巴细胞" ] } ] }, { "id": 1280, "text": "遂到我院妇产科就诊，我院病理科会诊，病检（123456）：腺癌。", "event": [ { "core_name": "腺癌", "tendency": "", "character": [], "anatomy_list": [] } ] }, { "id": 1165, "text": "曾于我院住院治疗，诊断为“冠心病（心绞痛型）、腔隙性脑梗死”，给予活血、扩冠、营养心肌等处理后好转出院，出院后未正规服用冠心病二级预防药物，但平素症状不明显。", "event": [ { "core_name": "心脏病", "tendency": "", "character": [ "硬化性", "粥样", "心绞痛型" ], "anatomy_list": [ "冠状动脉", "心脏" ] }, { "core_name": "梗塞", "tendency": "", "character": [ "腔隙性" ], "anatomy_list": [ "脑" ] } ] }, { "id": 1585, "text": "术后诊断：1.子宫内膜癌（Ⅰc期）；2.子宫腺肌症。", "event": [ { "core_name": "癌", "tendency": "", "character": [ "Ⅰc期" ], "anatomy_list": [ "子宫内膜" ] }, { "core_name": "腺肌症", "tendency": "", "character": [], "anatomy_list": [ "子宫" ] } ] }, { "id": 1961, "text": "入院2天前患者无明显诱发出现腰部疼痛，呈间歇性胀痛，不伴双下肢放射痛及麻木症状，症状在弯腰活动及起卧翻身时明显，平卧休息时可稍缓解，院外行局部按摩后症状暂时缓解，自行在家中休息2天后腰痛无缓解，进行性加重，严重影响日常生活，为进一步治疗，遂来我科就诊，门诊以“腰痛待查？”收治入院。", "event": [ { "core_name": "疼痛", "tendency": "否定", "character": [ "间歇性", "胀痛" ], "anatomy_list": [ "腰部" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [ "放射性" ], "anatomy_list": [ "双下肢" ] }, { "core_name": "麻木", "tendency": "否定", "character": [], "anatomy_list": [ "双下肢" ] }, { "core_name": "疼痛", "tendency": "", "character": [ "腰活动及起卧翻身时明显", "平卧休息时可稍缓解" ], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "", "character": [ "休息后无缓解", "进行性加重", "严重影响日常生活" ], "anatomy_list": [ "腰部" ] }, { "core_name": "疼痛", "tendency": "不确定", "character": [], "anatomy_list": [ "腰" ] } ] }, { "id": 452, "text": "9月余前，患者规律随访，行mri检查提示肿瘤复发，遂于2016-11-28在全麻下行“1.原发性肝癌hifu术；2.人工胸水注射术；3.b超引导下肝癌放射性粒子植入术+pei术”，术后患者恢复可。", "event": [ { "core_name": "肿瘤", "tendency": "", "character": [ "复发" ], "anatomy_list": [] } ] }, { "id": 1705, "text": "患者遂转诊某中医院，行“小针刀”治疗后右腿疼痛较前无明显好转。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [ "较前无明显好转" ], "anatomy_list": [ "右腿" ] } ] }, { "id": 564, "text": "行左侧颈部淋巴结淋巴结活检提示：非霍奇金氏淋巴瘤（弥漫大b细胞淋巴瘤）可能性大。", "event": [ { "core_name": "瘤", "tendency": "不确定", "character": [ "非霍奇金氏" ], "anatomy_list": [ "淋巴" ] }, { "core_name": "瘤", "tendency": "不确定", "character": [], "anatomy_list": [ "弥漫大b细胞", "淋巴" ] } ] }, { "id": 612, "text": "入院前1-年（2016年10月），患者无诱因出现咳嗽、咳痰，为白色粘痰伴偶痰中带血，呈暗红色，偶为刺激性咳嗽，痰量少，不易咳出，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": [], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "白色", "粘性" ], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "带血", "暗红色", "偶尔" ], "anatomy_list": [] }, { "core_name": "咳嗽", "tendency": "", "character": [ "刺激性", "偶尔" ], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "量少", "不易咳出" ], "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": "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": 1048, "text": "今患者再次到我院门诊就诊，门诊以“肝硬化”收入我科住院治疗。", "event": [ { "core_name": "硬化", "tendency": "", "character": [], "anatomy_list": [ "肝" ] } ] }, { "id": 1955, "text": "无明显食欲下降。", "event": [ { "core_name": "食欲下降", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [] } ] }, { "id": 1203, "text": "入院前10月（2018-06），患者因“感右大腿伴右侧外阴肿胀不适”就诊于我院门诊，完善相关辅助检查，妇科彩超（2018-06-27 我院）提示：宫颈占位，考虑宫颈癌；彩超检查（2018-06-27 我院）：右侧腹股沟区皮下水肿，右侧腹股沟区可见肿大淋巴结，考虑淋巴结反应性增生；患者遂就诊我院妇科，行内窥镜检查（2018-06-28）提示：宫颈癌，厚的醋酸白色上皮，取活检结果回示（病理号：123456）：（宫颈）鳞状细胞癌；免疫组化：p16(+)，ki676790%（+）；建议患者立即入院，完善相关辅助检查，明确具体分期，行下一步治疗，患者及家属商量后表示拒绝；院外自行予以中药（具体不详）治疗，未予以手术、放化疗等积极抗肿瘤治疗，未定期复查；院外患者右侧下肢及右侧外阴肿胀不适进行性加重，偶有出血，量少，现患者下腹部胀痛不适，难以忍受，影响睡眠，为求进一步治疗，遂到我科就诊，行ct检查(2019-02-15):1.右肺下叶后基底段纤维灶。", "event": [ { "core_name": "肿胀", "tendency": "", "character": [], "anatomy_list": [ "右侧外阴", "右大腿" ] }, { "core_name": "占位", "tendency": "", "character": [], "anatomy_list": [ "宫颈" ] }, { "core_name": "癌", "tendency": "不确定", "character": [], "anatomy_list": [ "宫颈" ] }, { "core_name": "水肿", "tendency": "", "character": [], "anatomy_list": [ "右侧腹股沟区皮下" ] }, { "core_name": "肿大", "tendency": "", "character": [], "anatomy_list": [ "右侧腹股沟区", "淋巴结" ] }, { "core_name": "增生", "tendency": "不确定", "character": [ "反应性" ], "anatomy_list": [ "淋巴结" ] }, { "core_name": "癌", "tendency": "", "character": [], "anatomy_list": [ "宫颈" ] }, { "core_name": "鳞癌", "tendency": "", "character": [], "anatomy_list": [ "宫颈" ] }, { "core_name": "肿胀", "tendency": "", "character": [ "进行性加重" ], "anatomy_list": [ "右侧下肢", "右侧外阴" ] }, { "core_name": "出血", "tendency": "", "character": [ "偶有", "量少" ], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "", "character": [ "胀痛", "难以忍受", "影响睡眠" ], "anatomy_list": [ "下腹部" ] }, { "core_name": "纤维灶", "tendency": "", "character": [], "anatomy_list": [ "右肺下叶后基底段" ] } ] }, { "id": 1059, "text": "2015年6月因上述症状来我院行胃镜检查示“慢性非萎缩性胃炎”肠镜示：“结肠多发性息肉”，行“结肠息肉电凝术”，症状有所缓解。", "event": [ { "core_name": "胃炎", "tendency": "", "character": [ "慢性", "非萎缩性" ], "anatomy_list": [ "胃" ] }, { "core_name": "息肉", "tendency": "", "character": [ "多发性" ], "anatomy_list": [ "结肠" ] } ] }, { "id": 1797, "text": "3天前患者感右侧肩关节疼痛，活动受限 今为求进一步治疗来我院门诊就诊，门诊以“前列腺癌骨转移”收入我科8+年患者无明显诱因出现咳嗽、咳痰，咳白色粘液痰，伴活动后心累、气促，心前区不适，持续约2分2分钟，休息后可缓解，平路快走及爬楼梯后尤甚，无发热、寒战，无咯血、胸痛，无咯粉红色泡沫痰，无夜间阵发性呼吸困难及端坐呼吸，无双下肢水肿。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [], "anatomy_list": [ "右侧肩关节" ] }, { "core_name": "活动受限", "tendency": "", "character": [], "anatomy_list": [ "右侧肩关节" ] }, { "core_name": "癌", "tendency": "", "character": [ "骨转移" ], "anatomy_list": [ "前列腺" ] }, { "core_name": "咳嗽", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "白色", "粘液痰" ], "anatomy_list": [] }, { "core_name": "心累", "tendency": "", "character": [ "活动后" ], "anatomy_list": [] }, { "core_name": "气促", "tendency": "", "character": [ "活动后" ], "anatomy_list": [] }, { "core_name": "心前区不适", "tendency": "", "character": [ "持续约2分钟", "休息后可缓解", "平路快走及爬楼梯后尤甚" ], "anatomy_list": [ "心前区" ] }, { "core_name": "发热", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "寒颤", "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": "咳痰", "tendency": "否定", "character": [ "粉红色", "泡沫痰" ], "anatomy_list": [] }, { "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": "水肿", "tendency": "否定", "character": [], "anatomy_list": [ "下肢" ] } ] }, { "id": 598, "text": "心脏彩超：右心及左房增大。", "event": [ { "core_name": "增大", "tendency": "", "character": [], "anatomy_list": [ "右心", "左房" ] } ] }, { "id": 173, "text": "卵巢癌术后改变；腹膜后异常信号影，考虑转移性肿瘤伴左侧输尿管上段侵犯可能性大。", "event": [ { "core_name": "癌", "tendency": "", "character": [ "术后改变" ], "anatomy_list": [ "卵巢" ] }, { "core_name": "异常信号影", "tendency": "", "character": [], "anatomy_list": [ "腹膜后" ] }, { "core_name": "肿瘤", "tendency": "不确定", "character": [ "转移性" ], "anatomy_list": [] }, { "core_name": "肿瘤", "tendency": "不确定", "character": [ "侵犯" ], "anatomy_list": [ "左侧输尿管上段" ] } ] }, { "id": 450, "text": "患者入院26月余前，因在家做清洁后出现右上腹疼痛，呈间断性隐痛，稍作休息后有所缓解，无肩背部放射性痛，无恶心、呕吐，无咳嗽、咳痰，无咯血、胸痛，无腹胀、腹泻，无畏寒、发热等不适，遂于某医院行超声（2015-9-18）检查示左右肝低回声病灶，超声造影支持肝ca诊断，遂于我院肝胆外科住院治疗，2015-9-25我院行上腹部mr提示肝左外叶左外叶上段结节影、肝右后叶右后叶下段段肿块肿块影考虑肝ca可能，予以保肝、抑酸、静脉营养等对症处理，由于患者自身原因，拒绝进一步治疗出院。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [ "呈间断性隐痛", "稍作休息后有所缓解" ], "anatomy_list": [ "右上腹" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [ "放射性" ], "anatomy_list": [ "肩", "背部" ] }, { "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": [] }, { "core_name": "咯血", "tendency": "否定", "character": [], "anatomy_list": [] }, { "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": "畏寒", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "发热", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "病灶", "tendency": "", "character": [ "低回声" ], "anatomy_list": [ "左右肝" ] }, { "core_name": "癌", "tendency": "", "character": [], "anatomy_list": [ "肝" ] }, { "core_name": "结节影", "tendency": "", "character": [], "anatomy_list": [ "肝左外叶上段" ] }, { "core_name": "肿块影", "tendency": "", "character": [], "anatomy_list": [ "肝右后叶下段" ] }, { "core_name": "癌", "tendency": "不确定", "character": [], "anatomy_list": [ "肝" ] } ] }, { "id": 1587, "text": "1+月前（09-02）行第二次tp方案化疗，24天前（09-27）行第三次tp方案化疗，患者诉后两次化疗期间，有四肢末端麻木，伴轻度恶心，无呕吐，无腹痛、腹泻等不适。", "event": [ { "core_name": "麻木", "tendency": "", "character": [], "anatomy_list": [ "四肢末端" ] }, { "core_name": "恶心", "tendency": "", "character": [ "轻度" ], "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": 1997, "text": "于2018-10-16、2018-11-07、2018-12-03、2018-12-26在我院行4次化疗，遵医嘱于今日拟于我院行结肠癌术后第5次化疗，门诊遂以\"结肠癌术后5月，拟行第5次化疗\"收入我科住院治疗。", "event": [ { "core_name": "癌", "tendency": "", "character": [ "术后" ], "anatomy_list": [ "结肠" ] }, { "core_name": "癌", "tendency": "", "character": [ "术后" ], "anatomy_list": [ "结肠" ] } ] }, { "id": 1034, "text": "直肠活检（123456）：<直肠>腺癌；补做免疫组化：cdx-2（-）、ca125（+）、wt-1(+)、ck7小灶（+）、ck20（-）、villin（-）、cea（-）、p16弥漫(+)、p53弥漫（强+）、er（+）、pr（-）、pax-2（-）、ki676750%（+）；（直肠）腺癌，结合临床病史和免疫组化符合卵巢癌转移。", "event": [ { "core_name": "腺癌", "tendency": "", "character": [], "anatomy_list": [ "直肠" ] }, { "core_name": "腺癌", "tendency": "", "character": [], "anatomy_list": [ "直肠" ] }, { "core_name": "癌", "tendency": "", "character": [ "转移" ], "anatomy_list": [ "卵巢" ] } ] }, { "id": 619, "text": "患者平素月经规则，周期27-30天，经期5-7天，量中，偶有血凝块，无痛经，既往白带正常，无异味。", "event": [ { "core_name": "月经", "tendency": "", "character": [ "规则" ], "anatomy_list": [] }, { "core_name": "月经", "tendency": "", "character": [ "量中", "偶有血凝块" ], "anatomy_list": [] }, { "core_name": "痛经", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "白带", "tendency": "", "character": [ "正常", "无异味" ], "anatomy_list": [] } ] }, { "id": 1100, "text": "现为求进一步检查治疗，遂到我院门诊就诊，门诊以“尿潴留，前列腺占位？”收入住院。", "event": [ { "core_name": "尿潴留", "tendency": "不确定", "character": [], "anatomy_list": [] }, { "core_name": "占位", "tendency": "不确定", "character": [], "anatomy_list": [ "前列腺" ] } ] }, { "id": 198, "text": "1、（食管）高分化鳞状细胞癌，侵及食管壁全层，食管壁壁淋巴结未见癌转移（0/5），胃周淋巴结未见癌转移（0/22）。", "event": [ { "core_name": "鳞癌", "tendency": "", "character": [ "高分化" ], "anatomy_list": [ "食管" ] }, { "core_name": "侵及", "tendency": "", "character": [], "anatomy_list": [ "食管壁全层" ] }, { "core_name": "癌", "tendency": "否定", "character": [ "转移" ], "anatomy_list": [ "食管壁淋巴结" ] }, { "core_name": "癌", "tendency": "否定", "character": [ "转移" ], "anatomy_list": [ "胃周淋巴结" ] } ] }, { "id": 486, "text": "患者于5月前因右乳癌，于2017-06-02在我院于全麻下行右侧乳腺皮下腺体切除+右侧前哨淋巴结活检，手术顺利，患者术后恢复好，术后病理示：（右乳浸润性癌，非特殊类型（原切片号：123456）活检术后，目前行乳腺切除）送检组织见少量癌组织；（右腋窝蓝染）淋巴结见癌转移（1/1）；（右腋窝、右腋窝深组无蓝染）淋巴结未见癌转移（分别为0/1，0/4）；（右乳晕深部、穿刺孔皮肤、肿瘤表面皮肤）未见癌累及；（左乳）纤维腺瘤；免疫组化示：er80%（+），pr20%（+），cerbb-2（-），p63（-），ki67（由于癌组织太少、掉片，无法显示），p120（+），e-ca（+），mhc（-），caponin（-），p53（-），ck5/6（-）。", "event": [ { "core_name": "癌", "tendency": "", "character": [], "anatomy_list": [ "右乳" ] }, { "core_name": "癌", "tendency": "", "character": [ "浸润性", "非特殊类型" ], "anatomy_list": [ "右乳" ] }, { "core_name": "癌组织", "tendency": "", "character": [ "送检组织见", "少量" ], "anatomy_list": [] }, { "core_name": "癌", "tendency": "", "character": [ "转移" ], "anatomy_list": [ "右腋窝淋巴结" ] }, { "core_name": "癌", "tendency": "否定", "character": [ "转移" ], "anatomy_list": [ "右腋窝淋巴结", "右腋窝深组淋巴结" ] }, { "core_name": "癌", "tendency": "否定", "character": [ "累及" ], "anatomy_list": [ "右乳晕深部", "穿刺孔皮肤", "肿瘤表面皮肤" ] }, { "core_name": "纤维腺瘤", "tendency": "", "character": [], "anatomy_list": [ "左乳" ] } ] }, { "id": 1390, "text": "建议住院治疗，患者因自身原因未住院，今日患者再次就诊我科要求住院，门诊即以“声带新生物”收入院治疗。", "event": [ { "core_name": "新生物", "tendency": "", "character": [], "anatomy_list": [ "声带" ] } ] }, { "id": 1420, "text": "现因锁骨上包块来我院门诊就诊，为进一步诊治，收入院。", "event": [ { "core_name": "包块", "tendency": "", "character": [], "anatomy_list": [ "锁骨上" ] } ] }, { "id": 4, "text": "近1+年来症状逐渐加重,稍活动后即感喘累、气促,多为卧床休息或床旁活动。", "event": [ { "core_name": "喘累", "tendency": "", "character": [ "稍活动后即感" ], "anatomy_list": [] }, { "core_name": "气促", "tendency": "", "character": [ "稍活动后即感" ], "anatomy_list": [] } ] }, { "id": 667, "text": "2天前，患者咳嗽、咳痰较前加重，伴气促，轻度日常活动即感劳累，伴胸痛、盗汗，咳嗽时加重，与活动、饮食无关，无畏寒、发热，无心前区压榨感，无心悸、黑曚、晕厥，伴头昏不适，无头痛、恶心、呕吐，无视物旋转，偶伴耳鸣，无肢体活动障碍、意识障碍等，患者为求进一步诊治，遂来我院，门诊拟“肺炎”收入我科。", "event": [ { "core_name": "咳嗽", "tendency": "", "character": [ "加重" ], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "加重" ], "anatomy_list": [] }, { "core_name": "气促", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "劳累", "tendency": "", "character": [ "轻度日常活动" ], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "", "character": [ "咳嗽时加重", "与活动饮食无关" ], "anatomy_list": [ "胸" ] }, { "core_name": "盗汗", "tendency": "", "character": [ "咳嗽时加重", "与活动饮食无关" ], "anatomy_list": [] }, { "core_name": "畏寒", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "发热", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "压榨感", "tendency": "否定", "character": [], "anatomy_list": [ "心前区" ] }, { "core_name": "心悸", "tendency": "否定", "character": [], "anatomy_list": [ "心" ] }, { "core_name": "黒朦", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "晕厥", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "头昏", "tendency": "", "character": [], "anatomy_list": [ "头" ] }, { "core_name": "疼痛", "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": "视物旋转", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "耳鸣", "tendency": "", "character": [], "anatomy_list": [ "耳" ] }, { "core_name": "活动障碍", "tendency": "否定", "character": [], "anatomy_list": [ "肢体" ] }, { "core_name": "意识障碍", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "肺炎", "tendency": "", "character": [], "anatomy_list": [ "肺" ] } ] }, { "id": 1283, "text": "双侧慢性输卵管炎。", "event": [ { "core_name": "输卵管炎", "tendency": "", "character": [ "慢性" ], "anatomy_list": [ "双侧输卵管" ] } ] }, { "id": 70, "text": "患者于入院前50年无明显诱因出现咳嗽、咳脓痰，伴咯血，约50ml/日，于当地医院就诊，行相关检查提示：支气管扩张，予以药物治疗后上述症状有所好转，但此后咯血症状反复发作约5年左右，均予以抗感染、止血等治疗后好转（具体治疗不详）。", "event": [ { "core_name": "咳嗽", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "脓痰" ], "anatomy_list": [] }, { "core_name": "咯血", "tendency": "", "character": [ "约50ml/日" ], "anatomy_list": [] }, { "core_name": "扩张", "tendency": "", "character": [], "anatomy_list": [ "支气管" ] }, { "core_name": "咯血", "tendency": "", "character": [ "反复发作" ], "anatomy_list": [] } ] }, { "id": 1414, "text": "阑尾未见癌转移。", "event": [ { "core_name": "癌", "tendency": "否定", "character": [ "转移" ], "anatomy_list": [ "阑尾" ] } ] }, { "id": 137, "text": "入院前3+月，患者因“双肺结节”于某医院就诊，考虑诊断“左肺腺癌伴全身多处转移”，行左肺上叶肿瘤射频消融术，其余肺内结节考虑原发性肿瘤可能性大，予口服“吉非替尼”治疗。", "event": [ { "core_name": "结节", "tendency": "", "character": [], "anatomy_list": [ "双肺" ] }, { "core_name": "腺癌", "tendency": "不确定", "character": [ "全身多处转移" ], "anatomy_list": [ "左肺" ] }, { "core_name": "肿瘤", "tendency": "不确定", "character": [ "原发性" ], "anatomy_list": [] }, { "core_name": "结节", "tendency": "", "character": [], "anatomy_list": [ "肺" ] } ] }, { "id": 146, "text": "ct检查：右肺上叶、双肺下叶背段示多个结节影，炎性结节可能，随访；双肾积水、双侧输尿管全程扩张，左侧输尿管管壁全程增厚，膀胱壁增厚，提示炎变所致可能，结核待排除，请结合临床；右侧附近区示囊性结节，随访。", "event": [ { "core_name": "结节影", "tendency": "", "character": [ "多个" ], "anatomy_list": [ "右肺上叶", "双肺下叶背段" ] }, { "core_name": "结节", "tendency": "不确定", "character": [ "炎性" ], "anatomy_list": [ "右肺上叶", "双肺下叶背段" ] }, { "core_name": "积水", "tendency": "", "character": [], "anatomy_list": [ "双肾" ] }, { "core_name": "扩张", "tendency": "", "character": [ "全程" ], "anatomy_list": [ "双侧输尿管" ] }, { "core_name": "增厚", "tendency": "", "character": [ "全程" ], "anatomy_list": [ "左侧输尿管管壁" ] }, { "core_name": "增厚", "tendency": "", "character": [], "anatomy_list": [ "膀胱壁" ] }, { "core_name": "炎变", "tendency": "不确定", "character": [], "anatomy_list": [ "膀胱" ] }, { "core_name": "结核", "tendency": "不确定", "character": [], "anatomy_list": [] }, { "core_name": "结节", "tendency": "", "character": [ "囊性" ], "anatomy_list": [ "右侧附近区" ] } ] }, { "id": 1555, "text": "行头颅mri、纤支镜、骨扫描未见异常。", "event": [ { "core_name": "异常", "tendency": "否定", "character": [], "anatomy_list": [] } ] }, { "id": 1202, "text": "患者于4天前前头痛症状加重，伴双眼胀痛，为求进一步诊治，遂入我院，以“高血压病”收入我科。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [ "加重" ], "anatomy_list": [ "头" ] }, { "core_name": "疼痛", "tendency": "", "character": [ "胀痛" ], "anatomy_list": [ "双眼" ] }, { "core_name": "高血压", "tendency": "", "character": [], "anatomy_list": [] } ] }, { "id": 252, "text": "入院前2月，患者无意中发现颈前有鸡蛋大小包块，质稍韧，无压痛，活动度可，随吞咽上下移动，无声嘶、饮水呛咳，无食欲亢进，无恶心、呕吐，无吞咽困难、呼吸困难，无发热、畏寒，今患者为求进一步治疗，遂至我院就诊，查彩超提示：双侧甲状腺偏低回声包块，结节性甲状腺肿？甲状腺腺瘤？；查ect提示：1.甲状腺右叶“凉结节”，有供血，结合图像融合考虑：甲状腺腺瘤伴钙化（1）甲状腺腺瘤？2）甲状腺恶性病变不能排除？）。", "event": [ { "core_name": "包块", "tendency": "", "character": [ "鸡蛋大小", "质稍韧", "活动度可", "无压痛", "随吞咽上下移动" ], "anatomy_list": [ "颈前" ] }, { "core_name": "饮水呛咳", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "声嘶", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "食欲亢进", "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": "呼吸困难", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "吞咽困难", "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": "包块", "tendency": "", "character": [ "偏低回声" ], "anatomy_list": [ "双侧甲状腺" ] }, { "core_name": "肿", "tendency": "不确定", "character": [ "结节性" ], "anatomy_list": [ "甲状腺" ] }, { "core_name": "腺瘤", "tendency": "不确定", "character": [], "anatomy_list": [ "甲状腺" ] }, { "core_name": "凉结节", "tendency": "不确定", "character": [ "有供血" ], "anatomy_list": [ "甲状腺右叶" ] }, { "core_name": "腺瘤", "tendency": "", "character": [], "anatomy_list": [ "甲状腺" ] }, { "core_name": "钙化", "tendency": "", "character": [], "anatomy_list": [ "甲状腺" ] }, { "core_name": "腺瘤", "tendency": "不确定", "character": [], "anatomy_list": [ "甲状腺" ] }, { "core_name": "病变", "tendency": "不确定", "character": [ "恶性" ], "anatomy_list": [ "甲状腺" ] } ] }, { "id": 1229, "text": "患者 2小时 前无明显诱因下开始出现腹部疼痛，肚脐周围疼痛为主，为阵发性绞痛，喜屈曲卧位，伴呕吐，呕吐为胃内容物，为非喷射状，呕吐物无血丝、血凝块。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [ "阵发性", "绞痛" ], "anatomy_list": [ "腹部", "肚脐周围" ] }, { "core_name": "呕吐", "tendency": "", "character": [ "呕吐为胃内容物", "为非喷射状", "呕吐物无血丝、血凝块" ], "anatomy_list": [] } ] }, { "id": 683, "text": "5.肝右叶后上段病灶，考虑血管瘤可能。", "event": [ { "core_name": "病灶", "tendency": "", "character": [], "anatomy_list": [ "肝右叶后上段" ] }, { "core_name": "瘤", "tendency": "不确定", "character": [ "血管" ], "anatomy_list": [] } ] }, { "id": 1551, "text": "入院前1+年，患者无意发现左锁骨上1包包块，约黄豆大小，伴轻压痛，无红肿，无局部皮肤颜色改变，无畏寒、发热，无咳嗽、咳痰，无鼻塞、流涕，无胸闷、胸痛等不适。患者未重视，未就诊。", "event": [ { "core_name": "包块", "tendency": "", "character": [ "轻微压痛", "约黄豆大小" ], "anatomy_list": [ "左锁骨上" ] }, { "core_name": "红肿", "tendency": "否定", "character": [], "anatomy_list": [ "左锁骨上" ] }, { "core_name": "颜色改变", "tendency": "否定", "character": [], "anatomy_list": [ "局部皮肤" ] }, { "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": "鼻塞", "tendency": "否定", "character": [], "anatomy_list": [ "鼻" ] }, { "core_name": "流涕", "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" ] } ] }, { "id": 1294, "text": "患者患病以来，神清，精神、食欲、睡眠欠佳，未解大便，小便正常，体重无明显改变。", "event": [ { "core_name": "神志", "tendency": "", "character": [ "清" ], "anatomy_list": [] }, { "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": "大便", "tendency": "", "character": [ "未解" ], "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": 1060, "text": "患者因便秘，反复于我科住院，治疗上予以保护消化道黏膜等治疗、予以乳果糖口服液，聚乙二醇导泻对症改善便秘症状、予以莫沙必利片促消化等治疗后好转出院。", "event": [ { "core_name": "便秘", "tendency": "", "character": [ "好转" ], "anatomy_list": [] } ] }, { "id": 1580, "text": "3月前为进一步诊治于我院门诊行诊刮术，术后病检提示：血块和破碎宫内膜显示复杂性增生过长，局灶腺体中到重度不典型增生（血块中夹杂少许增生粘液上皮）。", "event": [ { "core_name": "增生", "tendency": "", "character": [ "复杂性", "过长" ], "anatomy_list": [] }, { "core_name": "增生", "tendency": "", "character": [ "不典型性", "中到重度" ], "anatomy_list": [ "局灶腺体" ] }, { "core_name": "增生粘液上皮", "tendency": "", "character": [ "少许", "血块中夹杂" ], "anatomy_list": [] } ] }, { "id": 175, "text": "结合患者病史，考虑患者为卵巢癌术后复发伴左侧腹膜后淋巴结转移，2018-5-15、6-12、7-15、8-11予以1-4周期治疗，具体方案：贝伐单抗400mg1+紫杉醇210mg2+洛铂50mg3，21天。", "event": [ { "core_name": "癌", "tendency": "不确定", "character": [ "术后复发" ], "anatomy_list": [ "卵巢" ] }, { "core_name": "转移", "tendency": "不确定", "character": [], "anatomy_list": [ "左侧腹膜后淋巴结" ] } ] }, { "id": 53, "text": "肠壁上淋巴结见癌转移（5/10）。", "event": [ { "core_name": "癌", "tendency": "", "character": [ "转移" ], "anatomy_list": [ "肠壁上淋巴结" ] } ] }, { "id": 2050, "text": "2、（胃体）息肉。", "event": [ { "core_name": "息肉", "tendency": "", "character": [], "anatomy_list": [ "胃体" ] } ] }, { "id": 943, "text": "1+年前，患者无明显诱因出现右下肢疼痛，为持续性隐痛，可忍受，不影响休息及活动，后自觉右下肢疼痛较前有所加重，影响行走及睡眠，并出现颈部疼痛，转颈等活动受限，就诊我科行头颅mri：脑实质内多发结节状异常信号影，增强后明显环形强化，考虑肺癌脑转移。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [ "持续性", "隐痛", "可忍受", "不影响休息及活动" ], "anatomy_list": [ "右下肢" ] }, { "core_name": "疼痛", "tendency": "", "character": [ "加重", "影响行走及睡眠" ], "anatomy_list": [ "右下肢" ] }, { "core_name": "疼痛", "tendency": "", "character": [], "anatomy_list": [ "颈部" ] }, { "core_name": "活动受限", "tendency": "", "character": [ "转颈" ], "anatomy_list": [] }, { "core_name": "信号影", "tendency": "", "character": [ "多发", "结节", "异常", "增强后明显环形强化" ], "anatomy_list": [ "脑实质" ] }, { "core_name": "癌", "tendency": "不确定", "character": [ "脑转移" ], "anatomy_list": [ "肺" ] } ] }, { "id": 856, "text": "患者于2年前开始出现乏力，食欲下降，精神不振，伴恶心，无呕吐。", "event": [ { "core_name": "乏力", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "食欲下降", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "精神", "tendency": "", "character": [ "不振" ], "anatomy_list": [] }, { "core_name": "恶心", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "呕吐", "tendency": "否定", "character": [], "anatomy_list": [] } ] }, { "id": 1105, "text": "1+年前，患者无诱因出现上腹胀不适，完善胸腹部ct提示纵膈淋巴结较前增大，于2019年02月18日开始给予肺部病灶及相关淋巴引流区适形调强放射治疗。", "event": [ { "core_name": "腹胀", "tendency": "", "character": [], "anatomy_list": [ "上腹" ] }, { "core_name": "增大", "tendency": "", "character": [ "较前" ], "anatomy_list": [ "纵膈淋巴结" ] } ] }, { "id": 1224, "text": "腹部mri:1.子宫宫颈占位性病变，考虑恶性肿瘤，累及阴道前壁上1/3及宫颈旁组织，伴双侧附件转移。", "event": [ { "core_name": "病变", "tendency": "", "character": [ "占位性" ], "anatomy_list": [ "子宫宫颈" ] }, { "core_name": "肿瘤", "tendency": "不确定", "character": [ "恶性", "累及阴道前壁上1/3及宫颈旁组织" ], "anatomy_list": [ "子宫宫颈" ] }, { "core_name": "转移", "tendency": "", "character": [], "anatomy_list": [ "双侧附件" ] } ] }, { "id": 1225, "text": "<宫颈>神经内分泌癌。", "event": [ { "core_name": "癌", "tendency": "", "character": [ "神经内分泌" ], "anatomy_list": [ "宫颈" ] } ] }, { "id": 404, "text": "行乙状结肠结肠镜见直肠包块伴管腔狭窄（未见原报告）。", "event": [ { "core_name": "包块", "tendency": "", "character": [], "anatomy_list": [ "直肠" ] }, { "core_name": "狭窄", "tendency": "", "character": [], "anatomy_list": [ "直肠管腔" ] } ] }, { "id": 1927, "text": "”胸部ct提示“吻合口下方肿块影，考虑肿瘤复发或转移可能”。", "event": [ { "core_name": "肿块影", "tendency": "", "character": [], "anatomy_list": [ "吻合口下方" ] }, { "core_name": "肿瘤", "tendency": "不确定", "character": [ "复发" ], "anatomy_list": [] }, { "core_name": "肿瘤", "tendency": "不确定", "character": [ "转移" ], "anatomy_list": [] } ] }, { "id": 59, "text": "患者13年前体检时查肝功异常（具体不详），乙肝标志物阳性（hbsag阳性，余不详），患者未感乏力、纳差等不适，患者未引起重视，自行间断服用“护肝片”治疗。", "event": [ { "core_name": "肝功能异常", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "乙肝标志物", "tendency": "", "character": [ "阳性" ], "anatomy_list": [] }, { "core_name": "hbsag", "tendency": "", "character": [ "阳性" ], "anatomy_list": [] }, { "core_name": "乏力", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "纳差", "tendency": "否定", "character": [], "anatomy_list": [] } ] }, { "id": 504, "text": "患儿因“诊断急性早幼粒细胞白血病（m3b型 pml/rarαxxxbcr3（+））2年6月，需继续治疗”。", "event": [ { "core_name": "白血病", "tendency": "", "character": [ "急性", "m3b型", "pml/rarαxxxbcr3（+）" ], "anatomy_list": [ "早幼粒细胞" ] } ] }, { "id": 1109, "text": "无禁忌症，行了颈部包块穿刺，2020-10-15手术活检病检（颈部包块）转移性小细胞癌；免疫组化结果：ttf-1（+），ck7（-），napsina（-），ck5/6（-），p63（-），cd56（+），syn（+），cga（+），lca（-），ki676780%（+）。", "event": [ { "core_name": "包块", "tendency": "", "character": [], "anatomy_list": [ "颈部" ] }, { "core_name": "癌", "tendency": "", "character": [ "转移性", "小细胞" ], "anatomy_list": [ "颈部" ] } ] }, { "id": 1324, "text": "考虑患者目前为乳腺癌伴肝肺转移，既往行内分泌治疗及蒽环类化疗后疾病进展，排除化疗禁忌后于2018年11月17日、2018年12月8日给予紫杉醇脂质体180mg单药治疗2周期。", "event": [ { "core_name": "癌", "tendency": "不确定", "character": [], "anatomy_list": [ "乳腺" ] }, { "core_name": "癌", "tendency": "不确定", "character": [ "转移" ], "anatomy_list": [ "肝", "肺" ] } ] }, { "id": 1467, "text": "2+年患者在某医院诊断为“原发性高血压3级很高危”，现使用“氯沙坦氢氯噻嗪1片qd，硝苯地平控释片30mg”控制血压，平时血压控制不详。", "event": [ { "core_name": "高血压", "tendency": "", "character": [ "原发性", "3级", "很高危" ], "anatomy_list": [] } ] }, { "id": 1486, "text": "患者于入院前1月，患者无诱因出现食欲减退，伴咳嗽、咳痰，痰液性质不清，无恶心、呕吐，无反酸、嗳气，无腹痛、腹胀、腹泻、黄疸等不适，自行于附近诊所就诊，予以药物对症治疗后咳嗽、咳痰好转，随后出现腹泻，解稀水样便，约3次，无黑便、鲜血便，再次于当地诊所予以“诺氟沙星”对症治疗后腹泻好转，但仍觉食欲差、腹部不适，遂于某医院就诊，予以“黄连素、多酶片、安达”对症治疗后腹部不适好转，但仍觉食欲差。", "event": [ { "core_name": "食欲", "tendency": "", "character": [ "减退" ], "anatomy_list": [] }, { "core_name": "咳嗽", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "痰液性质不清" ], "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": "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": "黄疸", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "好转" ], "anatomy_list": [] }, { "core_name": "咳嗽", "tendency": "", "character": [ "好转" ], "anatomy_list": [] }, { "core_name": "腹泻", "tendency": "", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "大便", "tendency": "", "character": [ "稀水样", "约3次" ], "anatomy_list": [] }, { "core_name": "黑便", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "血便", "tendency": "否定", "character": [ "鲜" ], "anatomy_list": [] }, { "core_name": "腹泻", "tendency": "", "character": [ "好转" ], "anatomy_list": [ "腹" ] }, { "core_name": "食欲", "tendency": "", "character": [ "差" ], "anatomy_list": [] }, { "core_name": "腹部不适", "tendency": "", "character": [], "anatomy_list": [ "腹部" ] }, { "core_name": "腹部不适", "tendency": "", "character": [ "好转" ], "anatomy_list": [ "腹部" ] }, { "core_name": "食欲", "tendency": "", "character": [ "差" ], "anatomy_list": [] } ] }, { "id": 1976, "text": "今患者为行进一步诊治转诊于我院，门诊故以“前列腺癌？、前列腺增生、双侧睾丸鞘膜积液”收入我科。", "event": [ { "core_name": "癌", "tendency": "不确定", "character": [], "anatomy_list": [ "前列腺" ] }, { "core_name": "增生", "tendency": "", "character": [], "anatomy_list": [ "前列腺" ] }, { "core_name": "积液", "tendency": "", "character": [], "anatomy_list": [ "双侧睾丸鞘膜" ] } ] }, { "id": 343, "text": "于 我院门诊 行肛门指检查提示 直肠包块待查 ，门诊以“直肠包块”收入我科。", "event": [ { "core_name": "包块", "tendency": "不确定", "character": [], "anatomy_list": [ "直肠" ] }, { "core_name": "包块", "tendency": "", "character": [], "anatomy_list": [ "直肠" ] } ] }, { "id": 139, "text": "既往有“慢性胃炎”病史20+年，间断服用抑酸护胃药物治疗。", "event": [ { "core_name": "胃炎", "tendency": "", "character": [ "慢性", "病史20+年" ], "anatomy_list": [ "胃" ] } ] }, { "id": 372, "text": "1月来，患者仍诉心累、气促，无咳嗽、咳痰，无心前区压榨感、端坐呼吸等不适。", "event": [ { "core_name": "心累", "tendency": "", "character": [], "anatomy_list": [ "心" ] }, { "core_name": "气促", "tendency": "", "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": "压榨感", "tendency": "否定", "character": [], "anatomy_list": [ "心前区" ] }, { "core_name": "端坐呼吸", "tendency": "否定", "character": [], "anatomy_list": [] } ] }, { "id": 886, "text": "患者考虑升结肠肿瘤伴肝肺转移，进一步完善肠镜检查，2020-03-18病检结果回示（病理号：123456）：<升结肠>腺癌。", "event": [ { "core_name": "肿瘤", "tendency": "不确定", "character": [], "anatomy_list": [ "升结肠" ] }, { "core_name": "转移", "tendency": "不确定", "character": [], "anatomy_list": [ "肝", "肺" ] }, { "core_name": "腺癌", "tendency": "", "character": [], "anatomy_list": [ "升结肠" ] } ] }, { "id": 357, "text": "后膝关节疼痛反反复复、逐渐加重，出现双膝关节疼痛。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [ "反反复复", "逐渐加重" ], "anatomy_list": [ "后膝关节" ] }, { "core_name": "疼痛", "tendency": "", "character": [], "anatomy_list": [ "双膝关节" ] } ] }, { "id": 1491, "text": "入院前2天，患者无明显诱因出现右下腹疼痛，呈持续性，伴恶心、呕吐、腹胀，诉咽部不适，无腹泻、黑便，无发热、畏寒，无尿频、尿急，无心前区疼痛不适，于当地卫生院治疗，疗效欠佳。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [ "持续性" ], "anatomy_list": [ "右下腹" ] }, { "core_name": "恶心", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "呕吐", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "腹胀", "tendency": "", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "咽部不适", "tendency": "", "character": [], "anatomy_list": [ "咽部" ] }, { "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": "畏寒", "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": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "心前区" ] } ] }, { "id": 912, "text": "患病以来，患者精神食纳可，睡眠可。", "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": [] } ] }, { "id": 1608, "text": "宫腔积液。", "event": [ { "core_name": "积液", "tendency": "", "character": [], "anatomy_list": [ "宫腔" ] } ] }, { "id": 692, "text": "门诊以“稽留流产”收入我科。", "event": [ { "core_name": "流产", "tendency": "", "character": [ "稽留" ], "anatomy_list": [] } ] }, { "id": 97, "text": "今为求进一步治疗，就诊于我院门诊，行彩超检查提示：宫颈见偏低回声，子宫实性占位（符合子宫肌瘤声像图改变）。", "event": [ { "core_name": "回声", "tendency": "", "character": [ "偏低" ], "anatomy_list": [ "宫颈" ] }, { "core_name": "占位", "tendency": "", "character": [ "实性" ], "anatomy_list": [ "子宫" ] }, { "core_name": "肌瘤", "tendency": "", "character": [], "anatomy_list": [ "子宫" ] } ] }, { "id": 250, "text": "现患者为求进一步治疗，就诊于我院，门诊以“肝癌？”收入我科。", "event": [ { "core_name": "癌", "tendency": "不确定", "character": [], "anatomy_list": [ "肝" ] } ] }, { "id": 922, "text": "2天前于我院复查腹部彩超：右肾结石；双肾积液，双侧输尿管中上段扩张，中下段扩张不明显，建议进一步检查，肝回声不均，盆腔积液，胆、胰、脾未见明显异常。", "event": [ { "core_name": "结石", "tendency": "", "character": [], "anatomy_list": [ "右肾" ] }, { "core_name": "积液", "tendency": "", "character": [], "anatomy_list": [ "双肾" ] }, { "core_name": "扩张", "tendency": "", "character": [], "anatomy_list": [ "双侧输尿管中上段" ] }, { "core_name": "扩张", "tendency": "", "character": [ "不明显" ], "anatomy_list": [ "双侧输尿管中下段" ] }, { "core_name": "回声", "tendency": "", "character": [ "不均" ], "anatomy_list": [ "肝" ] }, { "core_name": "积液", "tendency": "", "character": [], "anatomy_list": [ "盆腔" ] }, { "core_name": "异常", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [ "胆", "胰", "脾" ] } ] }, { "id": 2041, "text": "腋窝淋巴结未见癌转移（0/30）；免疫组化：er 90%(+),pr 90%(+),cerbb-2(1+),p535310%(+),ki676720%(+),p120膜（+），e-cad膜（+），e-cad(+),p63(-),calponin(-),sma(-);术后患者恢复可,于05-15予以tc方案(紫杉醇+环磷酰胺)术后第一次化疗,2018年6月6日行第2次化疗，化疗后诉轻微恶心、呕吐、吞咽困难等不适，予以对症处理后患者好转，今患者为求术后第3次化疗，来我科住院，门诊以“右乳癌术后，第2次化疗后”收入我科住院治疗。", "event": [ { "core_name": "癌", "tendency": "否定", "character": [ "转移" ], "anatomy_list": [ "腋窝淋巴结" ] }, { "core_name": "恶心", "tendency": "", "character": [ "轻微", "化疗后" ], "anatomy_list": [] }, { "core_name": "呕吐", "tendency": "", "character": [ "轻微", "化疗后" ], "anatomy_list": [] }, { "core_name": "吞咽困难", "tendency": "", "character": [ "轻微", "化疗后" ], "anatomy_list": [] }, { "core_name": "癌", "tendency": "", "character": [ "术后", "第2次化疗后" ], "anatomy_list": [ "右乳" ] } ] }, { "id": 609, "text": "上述症状逐渐加重，半年前开始出现尿不尽、尿分叉，伴有全程无痛淡红色血尿3-4次，无血凝块排出，自服“前列康、金钱草等”，症状有所缓解，但症状反复，遂于某医院就诊，尿常规提示：红细胞+++；泌尿系彩超提示：膀胱结石、前列腺饱满。", "event": [ { "core_name": "尿不尽", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "尿分叉", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "血尿", "tendency": "", "character": [ "淡红色", "3-4次", "无血凝块排出" ], "anatomy_list": [] }, { "core_name": "尿痛", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "结石", "tendency": "", "character": [], "anatomy_list": [ "膀胱" ] }, { "core_name": "前列腺饱满", "tendency": "", "character": [], "anatomy_list": [ "前列腺" ] } ] }, { "id": 322, "text": "门诊以“前列腺癌”收治入院。", "event": [ { "core_name": "癌", "tendency": "", "character": [], "anatomy_list": [ "前列腺" ] } ] }, { "id": 718, "text": "入院前3年，患者因肝癌于我院行肝癌射频消融术，术中见肝脏萎缩，大小约２３×１２×７ｃｍ，以肝左叶萎缩明显，肝脏色暗红，表面布满大小不等结节，边缘锐利，肝右叶第Ⅷ段位置可扪及一质硬包块，大小约２×３ｃｍ，边界较清晰。", "event": [ { "core_name": "癌", "tendency": "", "character": [], "anatomy_list": [ "肝" ] }, { "core_name": "萎缩", "tendency": "", "character": [], "anatomy_list": [ "肝脏" ] }, { "core_name": "萎缩", "tendency": "", "character": [ "明显" ], "anatomy_list": [ "肝左叶" ] }, { "core_name": "肝脏色暗红", "tendency": "", "character": [], "anatomy_list": [ "肝脏" ] }, { "core_name": "结节", "tendency": "", "character": [ "大小不等" ], "anatomy_list": [ "肝脏表面" ] }, { "core_name": "边缘锐利", "tendency": "", "character": [], "anatomy_list": [ "肝脏" ] }, { "core_name": "包块", "tendency": "", "character": [ "质硬", "边界较清晰" ], "anatomy_list": [ "肝右叶第Ⅷ段" ] } ] }, { "id": 108, "text": "患者于30余年前体检发现乙肝表面抗原阳性，e抗原不详，肝功能正常，无乏力、纳差、身黄等不适，此后未正规检查及治疗，未抗病毒等治疗，亦无乏力、纳差、身黄等不适。", "event": [ { "core_name": "乙肝表面抗原", "tendency": "", "character": [ "阳性" ], "anatomy_list": [] }, { "core_name": "乏力", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "纳差", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "黄染", "tendency": "否定", "character": [], "anatomy_list": [ "身" ] }, { "core_name": "乏力", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "纳差", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "黄染", "tendency": "否定", "character": [], "anatomy_list": [ "身" ] } ] }, { "id": 207, "text": "诊断“右肺小细胞肺癌广泛期”；于2019-05-22行依托伯苷110mg(d1-d5)+奈达铂140mg(d1)化疗，辅以增强免疫力、护胃、止吐等治疗后好转出院。", "event": [ { "core_name": "癌", "tendency": "", "character": [ "广泛期" ], "anatomy_list": [ "右肺", "小细胞" ] } ] }, { "id": 1488, "text": "遂于肾内科住院治疗，查免疫球蛋白轻链(κ ）/免疫球蛋白轻链(γ）=0.81，骨髓涂片示多发性骨髓瘤可能，免疫固定电泳：lam型m蛋白血症，当时肾功能：cr：539.7umol/L，血红蛋白：81g/l，考虑iii期。", "event": [ { "core_name": "瘤", "tendency": "不确定", "character": [ "多发性", "iii期" ], "anatomy_list": [ "骨髓" ] } ] }, { "id": 578, "text": "2、左乳囊性无回声区：囊肿可能（bi-rads分类：2类）。", "event": [ { "core_name": "囊肿", "tendency": "不确定", "character": [ "囊性无回声区", "bi-rads分类：2类" ], "anatomy_list": [ "左乳" ] } ] }, { "id": 816, "text": "前哨淋巴结活检阴性，术后诊断病理诊断为：（左乳）浸润性导管癌，淋巴结未见癌转移（0/9），免疫组化：er（+++）＞75%pr（+++）＞75%cerbb-2（+） ki-67（++）。", "event": [ { "core_name": "导管癌", "tendency": "", "character": [ "浸润性" ], "anatomy_list": [ "左乳" ] }, { "core_name": "癌", "tendency": "否定", "character": [ "转移" ], "anatomy_list": [ "淋巴结" ] } ] }, { "id": 433, "text": "化疗期间有轻度胃肠道反应及骨髓抑制，给予对症治疗后好转。", "event": [ { "core_name": "胃肠道反应", "tendency": "", "character": [ "化疗期间", "轻度" ], "anatomy_list": [ "胃肠道" ] }, { "core_name": "骨髓抑制", "tendency": "", "character": [ "化疗期间", "轻度" ], "anatomy_list": [ "骨髓" ] } ] }, { "id": 1033, "text": "ct检查提示:1.右肺下叶小结节；2.纵隔及心膈角淋巴结显示；3.主动脉及冠状动脉壁钙化；4.肝内胆管及胆总管轻度扩张；5.乙状结肠远段及直肠上段改变，考虑肿瘤性病变，周围脂肪间隙模糊，邻近肠系膜淋巴结显示，右侧盆壁及肠系膜根部淋巴结淋巴结肿大；6.右上腹上腹部腹膜结节状增厚，考虑转移可能；7.“卵巢癌术后”：子宫及双侧附件术后缺如；8.腰5双侧椎弓峡部裂。", "event": [ { "core_name": "结节", "tendency": "", "character": [ "小" ], "anatomy_list": [ "右肺下叶" ] }, { "core_name": "钙化", "tendency": "", "character": [], "anatomy_list": [ "主动脉", "冠状动脉壁" ] }, { "core_name": "扩张", "tendency": "", "character": [ "轻度" ], "anatomy_list": [ "胆总管", "肝内胆管" ] }, { "core_name": "改变", "tendency": "", "character": [], "anatomy_list": [ "乙状结肠远段", "直肠上段" ] }, { "core_name": "病变", "tendency": "不确定", "character": [ "肿瘤性" ], "anatomy_list": [ "乙状结肠远段", "直肠上段" ] }, { "core_name": "间隙模糊", "tendency": "", "character": [], "anatomy_list": [ "周围脂肪" ] }, { "core_name": "肿大", "tendency": "", "character": [], "anatomy_list": [ "右侧盆壁淋巴结", "肠系膜根淋巴结" ] }, { "core_name": "增厚", "tendency": "", "character": [ "结节状" ], "anatomy_list": [ "右上腹腹膜" ] }, { "core_name": "转移", "tendency": "不确定", "character": [], "anatomy_list": [] }, { "core_name": "癌", "tendency": "", "character": [ "术后" ], "anatomy_list": [ "卵巢" ] }, { "core_name": "缺如", "tendency": "", "character": [ "术后" ], "anatomy_list": [ "双侧附件", "子宫" ] }, { "core_name": "椎弓峡部裂", "tendency": "", "character": [], "anatomy_list": [ "腰椎L5双侧" ] } ] }, { "id": 1307, "text": "1月前，患者无明显诱因出现咳嗽、咳痰，咳白色粘液痰，量少，痰可咳出，伴吞咽呛咳，心累、气促明显，活动后明显加重，走平路时即可出现心累气促症状，无咯血及咯粉红色泡沫痰，无胸痛及心前区压榨感，无夜间阵发性呼吸困难及端坐呼吸，无畏寒、发热，无潮热、盗汗，无恶心、呕吐，无腹痛、腹泻，患者遂至当地卫生院治疗，予以口服药物及抗生素输液治疗（具体情况不详），患者症状无缓解，今日患者症状加重，喘累明显，为求进一步治疗，遂今日来我院就诊，以“慢性阻塞性肺疾病急性加重期”收入我科住院治疗。", "event": [ { "core_name": "咳嗽", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "白色", "粘液", "量少", "可咳出" ], "anatomy_list": [] }, { "core_name": "呛咳", "tendency": "", "character": [ "吞咽" ], "anatomy_list": [] }, { "core_name": "心累", "tendency": "", "character": [ "明显", "活动后加重", "走平路时即可出现" ], "anatomy_list": [ "心" ] }, { "core_name": "气促", "tendency": "", "character": [ "明显", "活动后加重", "走平路时即可出现" ], "anatomy_list": [] }, { "core_name": "咯血", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "否定", "character": [ "粉红色", "泡沫痰" ], "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": "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": "畏寒", "tendency": "否定", "character": [], "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": "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" ] }, { "core_name": "喘累", "tendency": "", "character": [ "明显" ], "anatomy_list": [] }, { "core_name": "肺疾病", "tendency": "", "character": [ "慢性", "阻塞性", "急性加重期" ], "anatomy_list": [ "肺" ] } ] }, { "id": 1354, "text": "治疗过程中，患者出现呼吸急促、血氧饱和度显著下降等危急症征，转入我院中心icu，后病情好转后转回我科继续治疗，待患者病情好转后，再次予以维甲酸，治疗过程中患者出现左侧胸痛、呼吸困难，经全科病例讨论后，考虑有维甲酸综合征可能，故停用维甲酸，给予无创呼吸机、地塞米松、人免疫球蛋白、亚胺培南、血小板等对症支持治疗，经治疗后患者呼吸困难缓解，即撤除呼吸机，逐渐将激素减量，调整抗生素，病情稳定后，予以亚砷酸化疗。", "event": [ { "core_name": "呼吸", "tendency": "", "character": [ "急促" ], "anatomy_list": [] }, { "core_name": "血氧饱和度", "tendency": "", "character": [ "显著下降" ], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "", "character": [], "anatomy_list": [ "左侧胸" ] }, { "core_name": "呼吸困难", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "维甲酸综合征", "tendency": "不确定", "character": [], "anatomy_list": [] }, { "core_name": "呼吸困难", "tendency": "", "character": [ "缓解" ], "anatomy_list": [] } ] }, { "id": 338, "text": "患者病情恢复可，患者今遵医嘱返院行第1次化疗，患者自发病以来， 精神可 ， 食欲可 ， 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": [ "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": [ "如常" ], "anatomy_list": [] }, { "core_name": "小便", "tendency": "", "character": [ "如常" ], "anatomy_list": [] }, { "core_name": "体重变化", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [] } ] }, { "id": 807, "text": "入院前5天，患者无明显诱因感四肢乏力，伴行走不能，伴双上肢不自主抖动，咳嗽、咳痰，伴吞咽困难，不伴头痛、恶心、呕吐、耳鸣，无意识障碍、肢体活动障碍及言语障碍，无饮水呛咳，无大小便失禁，无发热、鼻涕、畏寒，无心慌、胸闷、大汗、面色苍白，无明显缓解加重因素，上述症状持续存在，患者及家属未予重视，未诊治。", "event": [ { "core_name": "乏力", "tendency": "", "character": [], "anatomy_list": [ "四肢" ] }, { "core_name": "行走", "tendency": "", "character": [ "不能" ], "anatomy_list": [] }, { "core_name": "抖动", "tendency": "", "character": [ "不自主" ], "anatomy_list": [ "双上肢" ] }, { "core_name": "咳嗽", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "吞咽困难", "tendency": "", "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": "耳鸣", "tendency": "否定", "character": [], "anatomy_list": [ "耳" ] }, { "core_name": "意识障碍", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "活动障碍", "tendency": "否定", "character": [], "anatomy_list": [ "肢体" ] }, { "core_name": "言语障碍", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "呛咳", "tendency": "否定", "character": [ "饮水" ], "anatomy_list": [] }, { "core_name": "大小便", "tendency": "否定", "character": [ "失禁" ], "anatomy_list": [] }, { "core_name": "发热", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "鼻涕", "tendency": "", "character": [ "无" ], "anatomy_list": [] }, { "core_name": "畏寒", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "心慌", "tendency": "否定", "character": [], "anatomy_list": [ "心" ] }, { "core_name": "憋闷", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "大汗", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "苍白", "tendency": "否定", "character": [ "面色" ], "anatomy_list": [] } ] }, { "id": 624, "text": "20年前患者因受凉后出现咳嗽，咳白色泡沫痰，无咯血，无活动后喘累，无胸痛、胸闷，无潮热、盗汗，无发热、寒颤，无夜间阵发性呼吸困难，无双下肢水肿。", "event": [ { "core_name": "咳嗽", "tendency": "", "character": [ "受凉后" ], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "白色", "泡沫痰" ], "anatomy_list": [] }, { "core_name": "咯血", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "喘累", "tendency": "否定", "character": [ "活动后" ], "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": "潮热", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "盗汗", "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": "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" ] } ] }, { "id": 42, "text": "患者平素月经尚规律,初潮12岁,经期7天,周期30天,lmp2019-06-23,经量中等,无明显痛经。", "event": [ { "core_name": "月经", "tendency": "", "character": [ "规律", "初潮12岁" ], "anatomy_list": [] }, { "core_name": "经量", "tendency": "", "character": [ "中等" ], "anatomy_list": [] }, { "core_name": "痛经", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [] } ] }, { "id": 191, "text": "无发热、盗汗、咯血、胸闷、胸痛、心悸、双下肢水肿等，来我院就诊，门诊以“慢性阻塞性肺疾病伴有急性加重”收入院。", "event": [ { "core_name": "发热", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "盗汗", "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": "心悸", "tendency": "否定", "character": [], "anatomy_list": [ "心" ] }, { "core_name": "水肿", "tendency": "否定", "character": [], "anatomy_list": [ "双下肢" ] }, { "core_name": "肺疾病", "tendency": "", "character": [ "慢性", "阻塞性", "急性加重" ], "anatomy_list": [ "肺" ] } ] }, { "id": 1195, "text": "患者自起病以来，精神可，胃纳可，大便次数增多，小便如常，体重下降5kg。", "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": "小便", "tendency": "", "character": [ "如常" ], "anatomy_list": [] }, { "core_name": "体重下降", "tendency": "", "character": [], "anatomy_list": [] } ] }, { "id": 777, "text": "于2017-4-12至某肿瘤医院行纤支镜检查提示：（右肺上叶刷片）查见腺癌细胞。", "event": [ { "core_name": "腺癌细胞", "tendency": "", "character": [], "anatomy_list": [ "右肺上叶" ] } ] }, { "id": 266, "text": "2、双肺散在感染；右肺中叶支气管扩张，以“冠心病？”收入我科进一步治疗。", "event": [ { "core_name": "感染", "tendency": "", "character": [ "散在" ], "anatomy_list": [ "双肺" ] }, { "core_name": "扩张", "tendency": "", "character": [], "anatomy_list": [ "右肺中叶", "支气管" ] }, { "core_name": "冠心病", "tendency": "不确定", "character": [], "anatomy_list": [ "心" ] } ] }, { "id": 386, "text": "3月余前患者无明显诱因发现左乳下方约1cm*1cm大小包块，活动度稍差，质地较硬，无红肿、压痛，表面皮肤无破溃，无乳头渗血渗液、无发热乏力，无咳嗽咳痰，无胸闷胸痛，无四肢疼痛，未予以重视。", "event": [ { "core_name": "包块", "tendency": "", "character": [ "活动度稍差", "质地较硬" ], "anatomy_list": [ "左乳下方" ] }, { "core_name": "红肿", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "压痛", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "破溃", "tendency": "否定", "character": [], "anatomy_list": [ "表面皮肤" ] }, { "core_name": "渗血", "tendency": "否定", "character": [], "anatomy_list": [ "乳头" ] }, { "core_name": "渗液", "tendency": "否定", "character": [], "anatomy_list": [ "乳头" ] }, { "core_name": "发热", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "乏力", "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": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "胸" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "四肢" ] } ] }, { "id": 1729, "text": "患者自身无特殊不适，无畏寒、发热，无皮肤黏膜出血,无咳嗽、咳痰及咽痛，无胸闷、气促，无晕厥及意识障碍。", "event": [ { "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": [ "皮肤黏膜" ] }, { "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": [ "咽" ] }, { "core_name": "胸闷", "tendency": "否定", "character": [], "anatomy_list": [ "胸" ] }, { "core_name": "气促", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "晕厥", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "意识障碍", "tendency": "否定", "character": [], "anatomy_list": [] } ] }, { "id": 1, "text": "入院前 1年,患者于“某医院”发现“肺癌”,后至我院行“化疗”,4小时前,患者突发呼之不应,呼吸急促,伴口吐白沫、四肢抽搐,双眼向上凝视,无大小便失禁 ,未经治疗,家属呼120急诊入院,急诊以“意识障碍待诊”收入我科。", "event": [ { "core_name": "癌", "tendency": "", "character": [], "anatomy_list": [ "肺" ] }, { "core_name": "呼之不应", "tendency": "", "character": [ "突发" ], "anatomy_list": [] }, { "core_name": "呼吸急促", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "口吐白沫", "tendency": "", "character": [], "anatomy_list": [ "口" ] }, { "core_name": "抽搐", "tendency": "", "character": [], "anatomy_list": [ "四肢" ] }, { "core_name": "凝视", "tendency": "", "character": [ "向上" ], "anatomy_list": [ "双眼" ] }, { "core_name": "大小便", "tendency": "否定", "character": [ "失禁" ], "anatomy_list": [] }, { "core_name": "意识障碍", "tendency": "不确定", "character": [], "anatomy_list": [] } ] }, { "id": 329, "text": "半月后疑为胆囊结石，遂在腹腔镜下行胆囊切除术。", "event": [ { "core_name": "结石", "tendency": "不确定", "character": [], "anatomy_list": [ "胆囊" ] } ] }, { "id": 193, "text": "1+月前患者受凉后咳嗽、咳白痰，自行予以“止咳”治疗症状无缓解，就诊于某医院输液治疗（具体不详），症状稍缓解，诉活动后气促、喘累。", "event": [ { "core_name": "咳嗽", "tendency": "", "character": [ "受凉后" ], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "白痰", "受凉后" ], "anatomy_list": [] }, { "core_name": "气促", "tendency": "", "character": [ "活动后" ], "anatomy_list": [] }, { "core_name": "喘累", "tendency": "", "character": [ "活动后" ], "anatomy_list": [] } ] }, { "id": 773, "text": "1周前患者上述症状加重，伴气促，无呕血及黑便，为进一步诊治，今日来我院就诊，门诊以“贫血待诊”收入我科。", "event": [ { "core_name": "气促", "tendency": "", "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": "贫血", "tendency": "", "character": [], "anatomy_list": [] } ] }, { "id": 87, "text": "此后反复于我科予以输血治疗，未再行化疗；之后多处因贫血于我科输血改善贫血治疗。", "event": [ { "core_name": "贫血", "tendency": "", "character": [], "anatomy_list": [] } ] }, { "id": 1612, "text": "头颅mr：1.双侧额叶、侧脑室周围少许缺血灶。", "event": [ { "core_name": "缺血灶", "tendency": "", "character": [ "少许" ], "anatomy_list": [ "双侧额叶", "侧脑室周围" ] } ] }, { "id": 1075, "text": "2、肝内散在小结节影，囊肿？遂以“肺部病灶待诊”收治入院。", "event": [ { "core_name": "结节影", "tendency": "", "character": [ "散在", "小" ], "anatomy_list": [ "肝内" ] }, { "core_name": "囊肿", "tendency": "不确定", "character": [], "anatomy_list": [ "肝内" ] }, { "core_name": "病灶", "tendency": "不确定", "character": [], "anatomy_list": [ "肺部" ] } ] }, { "id": 306, "text": "结合患者病史考虑淋巴结转移，病情进展，遂于2014-09-25、2014-10-28、2014-11-25、2014-12-22、2015-01-21行“吉西他滨1000mg d1，d8”方案化疗，化疗后患者左锁骨上锁骨上包块稍有缩小，化疗副反应较小，于2015.5.12在超声引导下行左颈部颈部转移转移性肿瘤放射性粒子植入术，术后患者一般情况可。", "event": [ { "core_name": "转移", "tendency": "不确定", "character": [], "anatomy_list": [ "淋巴结" ] }, { "core_name": "包块缩小", "tendency": "", "character": [ "化疗后", "稍" ], "anatomy_list": [ "左锁骨上" ] }, { "core_name": "化疗副反应", "tendency": "", "character": [ "较小" ], "anatomy_list": [] }, { "core_name": "一般情况", "tendency": "", "character": [ "可" ], "anatomy_list": [] } ] }, { "id": 1788, "text": "入院2天前患者右侧小腿湿疹处挠破皮后右小腿突发红肿、胀痛，疼痛为阵发性，可耐受。", "event": [ { "core_name": "湿疹", "tendency": "", "character": [], "anatomy_list": [ "右侧小腿" ] }, { "core_name": "破皮", "tendency": "", "character": [ "挠" ], "anatomy_list": [ "右侧小腿" ] }, { "core_name": "红肿", "tendency": "", "character": [ "突发" ], "anatomy_list": [ "右小腿" ] }, { "core_name": "疼痛", "tendency": "", "character": [ "可耐受", "阵发性" ], "anatomy_list": [ "右小腿" ] }, { "core_name": "疼痛", "tendency": "", "character": [ "胀痛" ], "anatomy_list": [ "右小腿" ] } ] }, { "id": 958, "text": "1年前患者无明显诱因出现右侧胸痛，呈阵发性隐痛，持续性加重，咳嗽加重，故于某医院就诊呼吸科，行肺部穿刺活检涂片结果示：找到癌细胞（腺癌），后转胸外科行胸腔镜手术，术中见右肺上、中、下叶及胸壁、膈肌广泛播散粟粒样结节，右肺中叶前段一结节，质硬，大小约2*2cm,与心包脂肪脂肪垫粘连密切，右肺下叶后基底段一结节，质硬，大小约1*2cm。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [ "阵发性隐痛", "持续性加重" ], "anatomy_list": [ "右侧胸" ] }, { "core_name": "咳嗽", "tendency": "", "character": [ "加重" ], "anatomy_list": [] }, { "core_name": "癌", "tendency": "", "character": [ "腺癌" ], "anatomy_list": [ "细胞" ] }, { "core_name": "结节", "tendency": "", "character": [ "广泛", "播散", "粟粒样" ], "anatomy_list": [ "右肺上中下叶" ] }, { "core_name": "结节", "tendency": "", "character": [ "广泛", "播散", "粟粒样" ], "anatomy_list": [ "胸壁" ] }, { "core_name": "结节", "tendency": "", "character": [ "广泛", "播散", "粟粒样" ], "anatomy_list": [ "膈肌" ] }, { "core_name": "结节", "tendency": "", "character": [ "质硬", "与心包脂肪脂肪垫粘连密切" ], "anatomy_list": [] }, { "core_name": "结节", "tendency": "", "character": [ "质硬" ], "anatomy_list": [ "右肺下叶后基底段" ] } ] }, { "id": 471, "text": "左室壁运动弥漫性减弱，左室收缩功能减退。", "event": [ { "core_name": "运动减弱", "tendency": "", "character": [ "弥漫性" ], "anatomy_list": [ "左室壁" ] }, { "core_name": "收缩功能减退", "tendency": "", "character": [ "减退" ], "anatomy_list": [ "左室" ] } ] }, { "id": 835, "text": "患者气道狭窄诊断明确，于2019年12月6日镇静镇痛+喉罩下行支气管镜检查+气道介入治疗，镜下诊断声门下至气管中下段可见多发新生物，活检钳清理、冷冻，针形电刀电切、激光消融、apc治疗，于2019年12月10日镇痛镇定下行坏死清理术，术后患者喘累症状明显好转，于2019-12-12在我院行tp方案化疗一周期（多西他赛120mg+奈达铂120mg），于2020-1-3日镇静镇痛+喉罩下行支气管镜检查+气道介入治疗，镜下诊断：声门下至气管中下段可见多发新生物、apc治疗，于2020-1-6镇痛镇定下行坏死清理术，建议患者到当地某医院行全身治疗，目前患者无明显呼吸困难，无痰中带血，今为求化疗来我院门诊就诊，门诊以“肺癌 气道鳞癌”收入我科。", "event": [ { "core_name": "狭窄", "tendency": "", "character": [], "anatomy_list": [ "气道" ] }, { "core_name": "新生物", "tendency": "", "character": [ "多发" ], "anatomy_list": [ "声门下至气管中下段" ] }, { "core_name": "喘累", "tendency": "", "character": [ "明显好转" ], "anatomy_list": [] }, { "core_name": "新生物", "tendency": "", "character": [ "多发" ], "anatomy_list": [ "声门下至气管中下段" ] }, { "core_name": "呼吸困难", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "否定", "character": [ "带血" ], "anatomy_list": [] }, { "core_name": "癌", "tendency": "", "character": [], "anatomy_list": [ "肺" ] }, { "core_name": "鳞癌", "tendency": "", "character": [], "anatomy_list": [ "气道" ] } ] }, { "id": 325, "text": "半天前于我院常规体检，行乳腺彩超示：1.左乳极低回声结节，考虑纤维腺瘤可能；2.双乳乳管样回声，考虑扩张乳管可能；3.双侧乳腺增生。bi-radsⅢ级。", "event": [ { "core_name": "结节", "tendency": "", "character": [ "极低回声" ], "anatomy_list": [ "左乳" ] }, { "core_name": "腺瘤", "tendency": "不确定", "character": [ "纤维" ], "anatomy_list": [ "左乳" ] }, { "core_name": "回声", "tendency": "", "character": [ "乳管样" ], "anatomy_list": [ "双乳" ] }, { "core_name": "扩张", "tendency": "不确定", "character": [], "anatomy_list": [ "乳管" ] }, { "core_name": "增生", "tendency": "", "character": [], "anatomy_list": [ "双侧乳腺" ] } ] }, { "id": 627, "text": "15天前患者再次因受凉后出现咳嗽、咳白色黏痰，无痰中带血，伴活动后喘累、反酸、嗳气、腹胀不适，无发热、畏寒、寒战，无潮热、盗汗、胸痛、咯血，无端坐呼吸、夜间阵发性呼吸困难，无双下肢水肿。", "event": [ { "core_name": "咳嗽", "tendency": "", "character": [ "受凉后" ], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "白色", "粘" ], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "否定", "character": [ "带血" ], "anatomy_list": [] }, { "core_name": "喘累", "tendency": "", "character": [ "活动后" ], "anatomy_list": [] }, { "core_name": "返酸", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "嗳气", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "腹胀", "tendency": "", "character": [], "anatomy_list": [ "腹" ] }, { "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": "潮热", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "盗汗", "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": "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" ] } ] }, { "id": 660, "text": "于2015-01-05到某医院，完善相关检查“胸部ct(256层)(2016-01-05):1.双肺下叶基底段炎性病变，请随访复查 2.右肺中叶纤维灶，右侧斜裂胸膜增厚 3.右肺门结节影，淋巴结肿大？建议结合增强ct检查 4.纵隔多发淋巴结淋巴结增大 5.右侧少量胸腔胸腔积液，双侧胸膜增厚；胸部增强ct(256层)(2016-01-09):1、右肺下叶炎性病变，建议治疗后复查 2、左肺上叶纤维灶 3、气管前间隙、主肺动脉窗、后心膈角及双侧肺门见多发肿大淋巴结，右肺门软组织软组织影，肿瘤性病变不能除外，建议进一步检查 4、右侧胸腔少量积液 5、心包积液 6、扫描范围胰腺后方淋巴结淋巴结肿大；纤支镜检查见右肺开口处可见粘膜下有隆起，表面光滑，右肺中叶支气管中叶支气管管腔呈外压性狭窄，表面光滑，表面凹凸不平，未见充血水肿及新生物，肺灌洗液找抗酸杆菌：阴性，肺灌洗液培养：正常菌群生长，纤支镜刷检：送检刷片见大量纤毛柱状上皮和少量炎症细胞，送检灌洗液涂片见大量柱状上皮，少量组织细胞和炎症细胞，部分细胞轻度异型；经皮肺穿刺活检：肉芽肿炎，活检组织抗酸杆菌染色阴性”，诊断“1、右肺门病灶待查？2、双侧肺炎”，给予抗炎治疗（具体不详），症状缓解，为求进一步治疗，遂到某医院胸外科住院治疗，诊断为“1、右肺、右侧胸壁、右纵膈慢性肉芽肿性炎2、双肺肺炎”，于2016-02-01在全麻下胸腔镜下行右肺病损切除术，右侧胸壁结节切除术，右纵膈淋巴结纵膈淋巴结切除术，好转后出院，出院时ct（某医院 2016-02-11）示：右下肺术后，右肺部分缺如，残余右肺感染，右侧胸腔积液并包裹，右侧胸腔局部少许积气，左侧胸腔少量积液。", "event": [ { "core_name": "病变", "tendency": "", "character": [ "炎性" ], "anatomy_list": [ "双肺下叶基底段" ] }, { "core_name": "纤维灶", "tendency": "", "character": [], "anatomy_list": [ "右肺中叶" ] }, { "core_name": "增厚", "tendency": "", "character": [], "anatomy_list": [ "右侧斜裂胸膜" ] }, { "core_name": "结节影", "tendency": "", "character": [], "anatomy_list": [ "右肺门" ] }, { "core_name": "肿大", "tendency": "不确定", "character": [], "anatomy_list": [ "肺门淋巴结" ] }, { "core_name": "增大", "tendency": "", "character": [ "多发" ], "anatomy_list": [ "纵隔淋巴结" ] }, { "core_name": "积液", "tendency": "", "character": [ "少量" ], "anatomy_list": [ "右胸腔" ] }, { "core_name": "增厚", "tendency": "", "character": [], "anatomy_list": [ "双侧胸膜" ] }, { "core_name": "病变", "tendency": "", "character": [ "炎性" ], "anatomy_list": [ "右肺下叶" ] }, { "core_name": "纤维灶", "tendency": "", "character": [], "anatomy_list": [ "左肺上叶" ] }, { "core_name": "肿大", "tendency": "", "character": [ "多发" ], "anatomy_list": [ "气管前间隙淋巴结" ] }, { "core_name": "肿大", "tendency": "", "character": [ "多发" ], "anatomy_list": [ "主肺动脉窗淋巴结" ] }, { "core_name": "肿大", "tendency": "", "character": [ "多发" ], "anatomy_list": [ "后心膈角淋巴结" ] }, { "core_name": "肿大", "tendency": "", "character": [ "多发" ], "anatomy_list": [ "双侧肺门角淋巴结" ] }, { "core_name": "软组织影", "tendency": "", "character": [], "anatomy_list": [ "右肺门" ] }, { "core_name": "菌群生长", "tendency": "", "character": [ "正常" ], "anatomy_list": [] }, { "core_name": "病变", "tendency": "不确定", "character": [ "肿瘤性" ], "anatomy_list": [ "右肺门" ] }, { "core_name": "积液", "tendency": "不确定", "character": [ "少量" ], "anatomy_list": [ "右侧胸腔" ] }, { "core_name": "积液", "tendency": "", "character": [], "anatomy_list": [ "心包" ] }, { "core_name": "肿大", "tendency": "", "character": [], "anatomy_list": [ "胰腺后方淋巴结" ] }, { "core_name": "隆起", "tendency": "", "character": [ "表面光滑" ], "anatomy_list": [ "右肺开口处" ] }, { "core_name": "狭窄", "tendency": "", "character": [ "外压性", "光滑", "凹凸不平", "未见充血水肿", "未见新生物" ], "anatomy_list": [ "右肺中叶支气管" ] }, { "core_name": "炎症细胞", "tendency": "", "character": [ "少量", "大量" ], "anatomy_list": [ "纤毛柱状上皮", "细胞" ] }, { "core_name": "部分细胞轻度异型", "tendency": "", "character": [ "少量", "大量", "轻度异型" ], "anatomy_list": [ "柱状上皮", "组织细胞", "部分细胞" ] }, { "core_name": "肉芽肿炎", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "病灶", "tendency": "", "character": [], "anatomy_list": [ "右肺门" ] }, { "core_name": "肺炎", "tendency": "", "character": [], "anatomy_list": [ "双侧肺" ] }, { "core_name": "症状", "tendency": "", "character": [ "缓解" ], "anatomy_list": [] }, { "core_name": "右肺炎", "tendency": "", "character": [ "慢性", "肉芽肿性" ], "anatomy_list": [ "右肺" ] }, { "core_name": "右侧胸壁炎", "tendency": "", "character": [ "慢性", "肉芽肿性" ], "anatomy_list": [ "右侧胸壁" ] }, { "core_name": "右纵隔炎", "tendency": "", "character": [ "慢性", "肉芽肿性" ], "anatomy_list": [ "右纵膈" ] }, { "core_name": "肺炎", "tendency": "", "character": [], "anatomy_list": [ "双肺" ] }, { "core_name": "术后", "tendency": "", "character": [ "术后" ], "anatomy_list": [ "右下肺" ] }, { "core_name": "缺如", "tendency": "", "character": [ "部分" ], "anatomy_list": [ "右肺" ] }, { "core_name": "感染", "tendency": "", "character": [ "残余" ], "anatomy_list": [ "右肺" ] }, { "core_name": "积液", "tendency": "", "character": [ "包裹" ], "anatomy_list": [ "右侧胸腔" ] }, { "core_name": "积气", "tendency": "", "character": [ "局部", "少许" ], "anatomy_list": [ "右侧胸腔" ] }, { "core_name": "积液", "tendency": "", "character": [ "少量" ], "anatomy_list": [ "左侧胸腔" ] } ] }, { "id": 1070, "text": "诊断为“弥漫大b细胞淋巴瘤iv期 b组”，于某医院血液科给予r-chop方案行全身化疗8周期（具体时间及药物剂量不详），化疗期间及化疗后无明显胃肠道反应、神经毒性、骨髓抑制等毒副症状。", "event": [ { "core_name": "瘤", "tendency": "", "character": [ "弥漫性", "大B细胞" ], "anatomy_list": [ "淋巴" ] }, { "core_name": "胃肠道反应", "tendency": "否定", "character": [ "明显", "化疗期间", "化疗后" ], "anatomy_list": [ "胃肠道" ] }, { "core_name": "神经毒性", "tendency": "否定", "character": [ "明显", "化疗期间", "化疗后" ], "anatomy_list": [] }, { "core_name": "骨髓抑制", "tendency": "否定", "character": [ "明显", "化疗期间", "化疗后" ], "anatomy_list": [ "骨髓" ] } ] }, { "id": 1940, "text": "06月27日、07月25日及8月15日行dp方案化疗3周期（多西他赛220mg+卡铂1200mg），09.16复查胸部ct提示纵膈淋巴结稍增大，故于2017.09.17、2017.10.10、2017.11.09、2017.12.13、2018.01.16更换化疗方案为dp（多西他赛590mg，顺铂600mg），化疗期间及化疗后无明显胃肠道反、骨髓抑制等毒副症状。", "event": [ { "core_name": "增大", "tendency": "", "character": [ "稍" ], "anatomy_list": [ "纵膈淋巴结" ] }, { "core_name": "胃肠道反应", "tendency": "否定", "character": [ "明显", "化疗后", "化疗期间" ], "anatomy_list": [ "胃", "肠" ] }, { "core_name": "骨髓抑制", "tendency": "否定", "character": [ "明显", "化疗后", "化疗期间" ], "anatomy_list": [ "骨髓" ] } ] }, { "id": 396, "text": "患者 1天 前无明显诱因下开始出现 腹部 疼痛 ， 疼痛呈胀痛伴阵发性加重 ， 无放射痛 。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [ "疼痛呈胀痛", "伴阵发性加重" ], "anatomy_list": [ "腹部" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [ "放射痛" ], "anatomy_list": [ "腹部" ] } ] }, { "id": 1740, "text": "于6月24日给予第3疗程“阿扎胞苷”方案化疗，多次复查血常规未见血象恢复，后长期于我科输血维持治疗。", "event": [ { "core_name": "血象", "tendency": "否定", "character": [ "恢复" ], "anatomy_list": [] } ] }, { "id": 1106, "text": "放疗后于04月16日起给予dp方案化疗3周期（药物总量：多西他赛360mg，奈达铂360mg），2019-07-03给予gp方案化疗1周期（药物总量：吉西他滨1.4g d1、d8，洛铂60mg），过程顺利，患者无恶心、呕吐等特殊不适。", "event": [ { "core_name": "恶心", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "呕吐", "tendency": "否定", "character": [], "anatomy_list": [] } ] }, { "id": 420, "text": "病检回示：左侧前颅底颅眶沟通腺样囊性癌（实体型）。", "event": [ { "core_name": "癌", "tendency": "", "character": [ "颅眶沟通", "腺样囊性", "实体型" ], "anatomy_list": [ "左侧前颅底" ] } ] }, { "id": 61, "text": "4于月前患者无明显诱因出现肝区隐痛，为间断性疼痛，活动后可稍缓解，无乏力纳差，无恶心呕吐，无咳嗽咳痰，患者自诉食用水果等食物之后出现腹泻，每天4-6次，为黄色稀便，患者遂到当地医院就诊，查肝功异常：alt/ast10.23/15.4715.47U/L，tb/db 22.14/2.102.10umol/L，腹部彩超提示：肝硬化、脾大、门脉高压，胆囊壁粗糙前光滑，上腹部ct提示：肝硬化，肝右叶低密度结节：1.血管瘤？小肝癌？其他？2.脾脏明显增大，3.胆囊见高密度影，胆囊结石可能大，遂到我科就诊，完善腹部mr（2013-9-17）：腹部mr增强 1.肝硬化，少量腹水，脾大，门脉高压，侧枝循环开放。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [ "隐痛", "间断性", "活动后可稍缓解" ], "anatomy_list": [ "肝区" ] }, { "core_name": "乏力", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "纳差", "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": "咳嗽", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "腹泻", "tendency": "", "character": [ "食用水果等食物之后", "黄色", "稀便" ], "anatomy_list": [] }, { "core_name": "肝功能异常", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "硬化", "tendency": "", "character": [], "anatomy_list": [ "肝" ] }, { "core_name": "脾大", "tendency": "", "character": [], "anatomy_list": [ "脾" ] }, { "core_name": "门脉高压", "tendency": "", "character": [], "anatomy_list": [ "门脉" ] }, { "core_name": "欠光滑", "tendency": "", "character": [], "anatomy_list": [ "胆囊壁" ] }, { "core_name": "粗糙", "tendency": "", "character": [], "anatomy_list": [ "胆囊壁" ] }, { "core_name": "硬化", "tendency": "", "character": [], "anatomy_list": [ "肝" ] }, { "core_name": "结节", "tendency": "", "character": [ "低密度" ], "anatomy_list": [ "肝右叶" ] }, { "core_name": "血管瘤", "tendency": "不确定", "character": [], "anatomy_list": [] }, { "core_name": "癌", "tendency": "不确定", "character": [ "小" ], "anatomy_list": [ "肝" ] }, { "core_name": "增大", "tendency": "", "character": [ "明显" ], "anatomy_list": [ "脾脏" ] }, { "core_name": "密度影", "tendency": "", "character": [ "高" ], "anatomy_list": [ "胆囊" ] }, { "core_name": "结石", "tendency": "不确定", "character": [], "anatomy_list": [ "胆囊" ] }, { "core_name": "硬化", "tendency": "", "character": [], "anatomy_list": [ "肝" ] }, { "core_name": "腹水", "tendency": "", "character": [ "少量" ], "anatomy_list": [] }, { "core_name": "脾大", "tendency": "", "character": [], "anatomy_list": [ "脾" ] }, { "core_name": "门脉高压", "tendency": "", "character": [], "anatomy_list": [ "门脉" ] }, { "core_name": "侧支循环开放", "tendency": "", "character": [], "anatomy_list": [ "侧支循环" ] } ] }, { "id": 121, "text": "化疗期间无骨髓抑制，；无胃肠道反应，。", "event": [ { "core_name": "骨髓抑制", "tendency": "否定", "character": [], "anatomy_list": [ "骨髓" ] }, { "core_name": "胃肠道反应", "tendency": "否定", "character": [], "anatomy_list": [ "胃肠道" ] } ] }, { "id": 1015, "text": "脾脏血管瘤为软组织肿瘤，免疫组化支持血管肉瘤。", "event": [ { "core_name": "瘤", "tendency": "", "character": [ "血管" ], "anatomy_list": [ "脾脏" ] }, { "core_name": "肿瘤", "tendency": "", "character": [ "软组织" ], "anatomy_list": [ "脾脏" ] }, { "core_name": "肉瘤", "tendency": "", "character": [], "anatomy_list": [ "血管" ] } ] }, { "id": 209, "text": "患者入院前2月无明显诱因出现巩膜黄染，尿液颜色加深，如浓茶色，伴全身皮肤瘙痒，无发热，无腰部疼痛及酱油色小便，大便稀糊状，不成形，暗褐色，无陶土样大便，稍感乏力，但不影响生活及工作，无厌油，无纳差，无腹胀，无腹围增大，无鼻腔及牙龈出血，无肝区疼痛，无肩部疼痛，到某医院就诊，行上腹部mr提示：肝门部占位并胆管梗阻。", "event": [ { "core_name": "黄染", "tendency": "", "character": [], "anatomy_list": [ "巩膜" ] }, { "core_name": "尿液", "tendency": "", "character": [ "颜色加深", "浓茶色" ], "anatomy_list": [] }, { "core_name": "瘙痒", "tendency": "", "character": [], "anatomy_list": [ "全身皮肤" ] }, { "core_name": "发热", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "腰部" ] }, { "core_name": "小便", "tendency": "否定", "character": [ "酱油色" ], "anatomy_list": [] }, { "core_name": "大便", "tendency": "", "character": [ "稀糊状", "不成形", "暗褐色" ], "anatomy_list": [] }, { "core_name": "大便", "tendency": "否定", "character": [ "陶土样" ], "anatomy_list": [] }, { "core_name": "乏力", "tendency": "", "character": [ "稍感" ], "anatomy_list": [] }, { "core_name": "厌油", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "纳差", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "腹胀", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "腹围", "tendency": "否定", "character": [ "增大" ], "anatomy_list": [ "腹" ] }, { "core_name": "出血", "tendency": "否定", "character": [], "anatomy_list": [ "鼻腔" ] }, { "core_name": "出血", "tendency": "否定", "character": [], "anatomy_list": [ "牙龈" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "肝区" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "肩部" ] }, { "core_name": "占位", "tendency": "", "character": [], "anatomy_list": [ "肝门" ] }, { "core_name": "梗阻", "tendency": "", "character": [], "anatomy_list": [ "胆管" ] } ] }, { "id": 780, "text": "口服吉非替尼2周左右自行停止服用及停止止痛药物，服用中草药治疗，1周前，患者全身多处疼痛，较前加重，主要为胸背部及双侧髂骨，再次口服羟考酮缓释片 30mg q12h止痛处理，伴多汗，间断喘累不适，偶有咳嗽、咳痰，自诉数天前痰中带血，无发热，无头晕、头痛，为求进一步治疗，遂至我院就诊，门诊以“肺癌”收入我科。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [ "较前加重" ], "anatomy_list": [ "全身多处", "胸背部及双侧髂骨" ] }, { "core_name": "多汗", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "喘累", "tendency": "", "character": [ "间断" ], "anatomy_list": [] }, { "core_name": "咳嗽", "tendency": "", "character": [ "偶有" ], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "偶有" ], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "带血" ], "anatomy_list": [] }, { "core_name": "发热", "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": "癌", "tendency": "", "character": [], "anatomy_list": [ "肺" ] } ] }, { "id": 1835, "text": "患者此次患病以来精神食欲欠佳，大便正常，感尿频尿急，睡眠每日约2-3小时，长期口服中药帮助睡眠，有感活动后喘累、气促，体力逐渐下降，长期发现下午下肢水肿，近来感双侧腰腰部酸痛体力，体重无明显改变。", "event": [ { "core_name": "精神", "tendency": "", "character": [ "欠佳" ], "anatomy_list": [] }, { "core_name": "食欲", "tendency": "", "character": [ "欠佳" ], "anatomy_list": [] }, { "core_name": "大便", "tendency": "", "character": [ "正常" ], "anatomy_list": [] }, { "core_name": "尿急", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "尿频", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "喘累", "tendency": "", "character": [ "活动后" ], "anatomy_list": [] }, { "core_name": "气促", "tendency": "", "character": [ "活动后" ], "anatomy_list": [] }, { "core_name": "体力下降", "tendency": "", "character": [ "逐渐" ], "anatomy_list": [] }, { "core_name": "水肿", "tendency": "", "character": [ "下午" ], "anatomy_list": [ "下肢" ] }, { "core_name": "疼痛", "tendency": "", "character": [ "酸痛" ], "anatomy_list": [ "双侧腰部" ] }, { "core_name": "体力活动", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "体重改变", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [] } ] }, { "id": 2042, "text": "入院前1+年，患者无明显诱因出现发热，伴咳嗽咳痰，咳白色粘痰，量少，无畏寒寒战，伴头昏、乏力，活动后心累气促，伴牙龈和口腔黏膜溃疡，无皮下瘀斑、瘀点，无肉眼血尿，无呕血、黑便、便血，无视力障碍，无耳鸣，无头疼、恶心、呕吐，意识障碍，无畏寒、发热，无鼻塞、流涕，无咽痛，无腹痛、腹泻，无肛周疼痛，无尿频、尿急、尿痛，无骨关节关节疼痛，患者到某医院就诊，查血常规提示白细胞增高，血红蛋白及血小板降低，进一步完善相关检查诊断“急性白血病m5”，未见相关报告，给予5周期全身化疗（具体方案不详），半年前行自体移植（具体不详），移植术后具体情况不详；2月前，患者家属诉复查血常规提示白细胞增高、贫血、血小板减少（未见报告），给予输血对症治疗，近2月反复出现间断发热，体温情况不详，伴轻微咳嗽咳痰，痰少，患者于当地医院输液对症处理（具体情况不详），2月前患者出现头昏、乏力，无视物旋转，黑朦，伴活动后喘累不适，进行性加重，平素日常活动受限，无端坐呼吸，无夜间阵发性呼吸困难，无呕血黑便，无肉眼血尿，无牙龈出血，无鼻出血，铜梁区大庙镇中心卫生院：血常规：白细胞数5.4*10^9/L;血红蛋白43g/L;血小板数8*10^9/L，我院骨髓涂片：考虑急性髓细胞白血病m5复发。", "event": [ { "core_name": "发热", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "咳嗽", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "白色", "粘性", "量少" ], "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": "", "character": [], "anatomy_list": [ "头" ] }, { "core_name": "乏力", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "心累", "tendency": "", "character": [ "活动后" ], "anatomy_list": [] }, { "core_name": "气促", "tendency": "", "character": [ "活动后" ], "anatomy_list": [] }, { "core_name": "溃疡", "tendency": "", "character": [ "黏膜" ], "anatomy_list": [ "牙龈", "口腔" ] }, { "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": "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": "便血", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "视力障碍", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "耳鸣", "tendency": "否定", "character": [], "anatomy_list": [ "耳" ] }, { "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": "意识障碍", "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": "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": [ "咽" ] }, { "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": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "骨关节" ] }, { "core_name": "白血病", "tendency": "", "character": [ "急性", "m5" ], "anatomy_list": [] }, { "core_name": "白细胞增高", "tendency": "", "character": [], "anatomy_list": [ "白细胞" ] }, { "core_name": "血红蛋白降低", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "血小板降低", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "白细胞增高", "tendency": "", "character": [], "anatomy_list": [ "白细胞" ] }, { "core_name": "血小板", "tendency": "", "character": [ "减少" ], "anatomy_list": [] }, { "core_name": "贫血", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "发热", "tendency": "", "character": [ "反复间断" ], "anatomy_list": [] }, { "core_name": "体温", "tendency": "", "character": [ "情况不详" ], "anatomy_list": [] }, { "core_name": "咳嗽", "tendency": "", "character": [ "轻微" ], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "量少" ], "anatomy_list": [] }, { "core_name": "头昏", "tendency": "", "character": [], "anatomy_list": [ "头" ] }, { "core_name": "乏力", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "黑朦", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "视物旋转", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "喘累", "tendency": "", "character": [ "活动后", "进行性加重" ], "anatomy_list": [] }, { "core_name": "活动受限", "tendency": "", "character": [ "平素日常" ], "anatomy_list": [] }, { "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": "呕血", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "黑便", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "血尿", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "出血", "tendency": "否定", "character": [], "anatomy_list": [ "牙龈" ] }, { "core_name": "出血", "tendency": "否定", "character": [], "anatomy_list": [ "鼻" ] }, { "core_name": "白血病", "tendency": "", "character": [ "急性", "复发", "m5" ], "anatomy_list": [ "髓细胞" ] } ] }, { "id": 1972, "text": "患者6年前诊断高血压病后长期服用阿司匹林肠溶片，每日100mg治疗。", "event": [ { "core_name": "高血压", "tendency": "", "character": [], "anatomy_list": [] } ] }, { "id": 2029, "text": "患者于 5+年 前无意中发现右肩背部肿物，初发时包块大小 约为 2*2cm，边界清，活动可，无压痛。", "event": [ { "core_name": "肿物", "tendency": "", "character": [], "anatomy_list": [ "右肩背部" ] }, { "core_name": "包块", "tendency": "", "character": [ "边界清", "活动可", "无压痛" ], "anatomy_list": [ "右肩背部" ] } ] }, { "id": 136, "text": "入院前1天，患者受凉后出现阵发性咳嗽，非高调金属声样咳嗽及鸡鸣样咳嗽，无明显咳痰，活动后稍气促，以爬坡或上楼时明显，活动耐力无明显下降，无发热，无畏寒、寒战，不伴潮热、盗汗，无头痛、咯血，无心悸、胸痛，无恶心、呕吐，无腹痛、腹泻、便血，无颜面及下肢水肿，为进一步治疗遂入我院，我科遂以“咳嗽待诊”收入住院治疗。", "event": [ { "core_name": "咳嗽", "tendency": "", "character": [ "受凉后", "阵发性" ], "anatomy_list": [] }, { "core_name": "咳嗽", "tendency": "否定", "character": [ "高调金属声样" ], "anatomy_list": [] }, { "core_name": "咳嗽", "tendency": "否定", "character": [ "鸡鸣样" ], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [] }, { "core_name": "气促", "tendency": "", "character": [ "活动后", "稍", "爬坡或上楼时明显" ], "anatomy_list": [] }, { "core_name": "活动耐力下降", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [] }, { "core_name": "发热", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "畏寒", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "寒颤", "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": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "头" ] }, { "core_name": "咯血", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "心悸", "tendency": "否定", "character": [], "anatomy_list": [ "心" ] }, { "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": "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": "水肿", "tendency": "否定", "character": [], "anatomy_list": [ "颜面" ] }, { "core_name": "水肿", "tendency": "否定", "character": [], "anatomy_list": [ "下肢" ] }, { "core_name": "咳嗽", "tendency": "", "character": [], "anatomy_list": [] } ] }, { "id": 294, "text": "1年前于当地医院检查示：隐血++，6天前患者于当地医院门诊查尿常规示：尿隐血+++，未进行任何治疗，今为进一步诊治，遂至我院门诊就诊，门诊检查提示：隐血+，红细胞形态为非均一型（100%异常红细胞），细菌476.4/ul，尿微量白蛋白 35.6mg/L，尿肌酐 27.3mmol/L，尿α1微球蛋白24.89mg/L，泌尿系彩超未见明显异常，门诊以“血尿原因待查：尿路感染？”收治入科。", "event": [ { "core_name": "感染", "tendency": "不确定", "character": [], "anatomy_list": [ "尿道" ] } ] }, { "id": 143, "text": "患病以来，精神、食欲、睡眠欠佳，大便正常，小便如上述，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": 166, "text": "左侧腹膜后团块影，fdg代谢增高，倾向于转移。", "event": [ { "core_name": "团块影", "tendency": "", "character": [ "团块" ], "anatomy_list": [ "左侧腹膜后" ] }, { "core_name": "fdg", "tendency": "", "character": [ "代谢增高" ], "anatomy_list": [] }, { "core_name": "转移", "tendency": "不确定", "character": [], "anatomy_list": [] } ] }, { "id": 984, "text": "１４小时前，患者出现排尿困难，不能排出小便，伴下腹部胀痛，无双下肢水肿，随就诊于我院，门诊以“肺结核”收治入院。", "event": [ { "core_name": "排尿困难", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "排出小便", "tendency": "", "character": [ "不能" ], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "", "character": [ "胀痛" ], "anatomy_list": [ "下腹部" ] }, { "core_name": "水肿", "tendency": "否定", "character": [], "anatomy_list": [ "双下肢" ] }, { "core_name": "结核", "tendency": "", "character": [], "anatomy_list": [ "肺" ] } ] }, { "id": 12, "text": "第1次入院经过入院5+月前患儿因\"发热,头痛伴反复呕吐10天,加重1天\"于2016年08月01日入院,诊断为1.右侧小脑占位性病变海绵状血管瘤,2.梗阻性脑积水,3.支气管肺炎入院,于2015-08-01行左侧脑室外引流术（储液囊）,术予以予以止血、补液等治疗,2015年08月04日行后颅窝肿瘤切除术,术后营养神经、止血、预防感染、营养支持支持治疗,于2015年08月13日行腰大池引流术。", "event": [ { "core_name": "发热", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "", "character": [], "anatomy_list": [ "头" ] }, { "core_name": "呕吐", "tendency": "", "character": [ "反复" ], "anatomy_list": [] }, { "core_name": "病变", "tendency": "", "character": [ "占位性" ], "anatomy_list": [ "右侧小脑" ] }, { "core_name": "瘤", "tendency": "", "character": [ "海绵状" ], "anatomy_list": [ "右侧小脑血管" ] }, { "core_name": "积水", "tendency": "", "character": [ "梗阻性" ], "anatomy_list": [ "脑" ] }, { "core_name": "支气管肺炎", "tendency": "", "character": [], "anatomy_list": [ "支气管", "肺" ] } ] }, { "id": 238, "text": "无畏寒、发热，无午后潮热、盗汗，双下肢无明显疼痛、麻木、乏力等不适。", "event": [ { "core_name": "畏寒", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "发热", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "潮热", "tendency": "否定", "character": [ "午后" ], "anatomy_list": [] }, { "core_name": "盗汗", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [ "双下肢" ] }, { "core_name": "麻木", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [ "双下肢" ] }, { "core_name": "乏力", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [ "双下肢" ] } ] }, { "id": 1699, "text": "患者本次发病以来，食欲正常， 神志清醒，精神尚可，睡眠欠佳，大便2次每日，小便如上述，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": [ "欠佳" ], "anatomy_list": [] }, { "core_name": "大便", "tendency": "", "character": [ "2次每日" ], "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": 2009, "text": "10+年患者反复在受凉后出现咳嗽、咳痰、气促，咳白色粘痰，多在受凉及冬春季节加重，每次持续1-2月，到当地诊所予以“抗感染、化痰”等对症治疗（具体不详）后可好转，当时无发热、畏寒。", "event": [ { "core_name": "咳嗽", "tendency": "", "character": [ "反复", "在受凉后出现" ], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "反复", "在受凉后出现" ], "anatomy_list": [] }, { "core_name": "气促", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "白色", "粘痰", "多在受凉及冬春季节加重", "每次持续1-2月" ], "anatomy_list": [] }, { "core_name": "发热", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "畏寒", "tendency": "否定", "character": [], "anatomy_list": [] } ] }, { "id": 1936, "text": "患者于2017-5-2就诊某医院，建议予以二线化疗，今日患者再次返院化疗，门诊以“升结肠癌术后复发化疗”收入我科。", "event": [ { "core_name": "癌", "tendency": "", "character": [ "术后", "复发", "化疗" ], "anatomy_list": [ "升结肠" ] } ] }, { "id": 109, "text": "入院前1月，患者出现右上腹隐痛，阵发性，可忍受，伴肩部放射痛；有乏力，不影响正常工作及生活；无厌油，无恶心、呕吐，食欲无影响。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [ "阵发性", "隐痛", "可忍受" ], "anatomy_list": [ "右上腹" ] }, { "core_name": "疼痛", "tendency": "", "character": [ "放射痛" ], "anatomy_list": [ "肩部" ] }, { "core_name": "乏力", "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": "食欲", "tendency": "", "character": [ "无影响" ], "anatomy_list": [] } ] }, { "id": 858, "text": "病程中反复出现呕血、黑便，在我科对症治疗后可好转。", "event": [ { "core_name": "呕血", "tendency": "", "character": [ "反复出现" ], "anatomy_list": [] }, { "core_name": "黑便", "tendency": "", "character": [ "反复出现" ], "anatomy_list": [] } ] }, { "id": 552, "text": "诊断为“类风湿性关节炎”，予以“来氟米特片20mg po. qd、甲氨蝶呤片 7.5mg po. qd、叶酸片 5MG po qd、洛索洛芬钠片 60mg po tid”。建议患者治疗后随访。", "event": [ { "core_name": "关节炎", "tendency": "", "character": [ "类风湿性" ], "anatomy_list": [ "关节" ] } ] }, { "id": 1369, "text": "院外感纳差、消瘦，饱食后有恶心呕吐不适，无发热、腹痛腹胀、腹泻不适，无皮肤巩膜黄染，当地医院查血示肝功能异常、甲胎蛋白增高。", "event": [ { "core_name": "纳差", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "消瘦", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "恶心", "tendency": "", "character": [ "饱食后" ], "anatomy_list": [] }, { "core_name": "呕吐", "tendency": "", "character": [ "饱食后" ], "anatomy_list": [] }, { "core_name": "发热", "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": "黄染", "tendency": "否定", "character": [], "anatomy_list": [ "皮肤" ] }, { "core_name": "黄染", "tendency": "否定", "character": [], "anatomy_list": [ "巩膜" ] }, { "core_name": "肝功异常", "tendency": "", "character": [], "anatomy_list": [ "肝" ] }, { "core_name": "甲胎蛋白增高", "tendency": "", "character": [], "anatomy_list": [] } ] }, { "id": 1542, "text": "3.双肺下叶多个结节，结合胸部检查。", "event": [ { "core_name": "结节", "tendency": "", "character": [ "多个" ], "anatomy_list": [ "双肺下叶" ] } ] }, { "id": 810, "text": "患者术后先后给予化疗4次，现患者术后恢复可，返院行术后第5次化疗，门诊以“横结肠癌术后化疗”收入我科。", "event": [ { "core_name": "癌", "tendency": "", "character": [ "术后化疗" ], "anatomy_list": [ "横结肠" ] } ] }, { "id": 1847, "text": "直肠后方肿块影，考虑转移可能性大，侵犯直肠壁。", "event": [ { "core_name": "肿块影", "tendency": "", "character": [], "anatomy_list": [ "直肠后方" ] }, { "core_name": "转移", "tendency": "不确定", "character": [], "anatomy_list": [ "直肠后方" ] }, { "core_name": "侵犯", "tendency": "", "character": [], "anatomy_list": [ "直肠壁" ] } ] }, { "id": 509, "text": "手术顺利，术后病检：（食管）腺鳞癌鳞癌（低分化低分化腺癌成分约占60%，低分化鳞癌约占40%），肿瘤侵犯至食管壁外膜，未见明确癌栓及肿瘤侵犯神经，胃组织无癌，上下切缘切缘净。", "event": [ { "core_name": "腺鳞癌", "tendency": "", "character": [], "anatomy_list": [ "食管" ] }, { "core_name": "腺癌", "tendency": "", "character": [ "低分化" ], "anatomy_list": [ "食管" ] }, { "core_name": "鳞癌", "tendency": "", "character": [ "低分化" ], "anatomy_list": [ "食管" ] }, { "core_name": "肿瘤", "tendency": "", "character": [ "侵犯" ], "anatomy_list": [ "食管壁外膜" ] }, { "core_name": "癌栓", "tendency": "否定", "character": [ "明确" ], "anatomy_list": [] }, { "core_name": "肿瘤", "tendency": "否定", "character": [ "侵犯" ], "anatomy_list": [ "神经" ] }, { "core_name": "癌", "tendency": "否定", "character": [], "anatomy_list": [ "胃组织" ] } ] }, { "id": 1009, "text": "术后恢复可，于5月前返院行第一次化疗，后顺利出院，院外无恶心、呕吐、腹痛等不适，现患者入院拟行6次化疗，门诊以“右半结肠非霍奇金氏淋巴瘤（弥漫大b细胞型）根治术后”收入我科。", "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": "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": 302, "text": "3年余前，患者无明显诱因出现左侧胸部疼痛，为阵发性刺痛，吸气及咳嗽时明显，行胸部ct示：左肺癌切除术后改变，及同侧胸腔包裹性积液改变，纵膈小淋巴结显示，于某医院行pet/ct（2011-10-22）提示:1.左肺癌术后；2.近左下肺肺门处结节状状高密度高密度影，fdg代谢增高，考虑炎性增生；3.左侧胸膜增厚并胸腔积液。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [ "阵发性刺痛", "吸气及咳嗽时明显" ], "anatomy_list": [ "左侧胸部" ] }, { "core_name": "术后改变", "tendency": "", "character": [ "左肺癌切除" ], "anatomy_list": [ "左肺" ] }, { "core_name": "积液", "tendency": "", "character": [ "包裹性" ], "anatomy_list": [ "同侧胸腔" ] }, { "core_name": "显示", "tendency": "", "character": [], "anatomy_list": [ "纵膈小淋巴结" ] }, { "core_name": "癌", "tendency": "", "character": [ "术后" ], "anatomy_list": [ "左肺" ] }, { "core_name": "密度影", "tendency": "", "character": [ "结节状", "高" ], "anatomy_list": [ "近左下肺门" ] }, { "core_name": "fdg", "tendency": "", "character": [ "代谢增高" ], "anatomy_list": [] }, { "core_name": "增生", "tendency": "不确定", "character": [ "炎性" ], "anatomy_list": [] }, { "core_name": "增厚", "tendency": "", "character": [], "anatomy_list": [ "左侧胸膜" ] }, { "core_name": "积液", "tendency": "", "character": [], "anatomy_list": [ "胸腔" ] } ] }, { "id": 1894, "text": "为进一步治疗，今日到我科就诊，查“肝功：谷丙转氨酶560U/L，谷草转氨酶710U/L，谷酰转肽酶183U/L，碱性磷酸酶173U/L；肾功示尿酸687umol/L；血常规：白细胞计数：12.4*10^9/L，中性粒细胞百分比：57.8%，c反应蛋白：75.9mg/L”，门诊以“肺结核，药物性肝炎”收入我科住院治疗。", "event": [ { "core_name": "结核", "tendency": "", "character": [], "anatomy_list": [ "肺" ] }, { "core_name": "肝炎", "tendency": "", "character": [ "药物性" ], "anatomy_list": [ "肝" ] } ] }, { "id": 38, "text": "曾多次在我院呼吸科住院,诊断“慢性支气管炎伴肺气肿”,给予对症治疗后病情缓解。", "event": [ { "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" ] } ] }, { "id": 720, "text": "患者自起病以来，精神可，食欲欠佳，睡眠可，大小便可，体重未见明显下降。", "event": [ { "core_name": "精神", "tendency": "", "character": [ "可" ], "anatomy_list": [] }, { "core_name": "食欲", "tendency": "", "character": [ "欠佳" ], "anatomy_list": [] }, { "core_name": "睡眠", "tendency": "", "character": [ "可" ], "anatomy_list": [] }, { "core_name": "大小便", "tendency": "", "character": [ "可" ], "anatomy_list": [] }, { "core_name": "体重下降", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [] } ] }, { "id": 1152, "text": "患病以来，精神、食欲、睡眠尚可，大小便正常，体重无明显变化。", "event": [ { "core_name": "精神", "tendency": "", "character": [ "尚可" ], "anatomy_list": [] }, { "core_name": "食欲", "tendency": "", "character": [ "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": 498, "text": "1周来自觉左侧乳腺肿块逐渐增大，今日为求进一步诊疗而来我院，门诊以“乳房肿物”收入我科。", "event": [ { "core_name": "肿块增大", "tendency": "", "character": [ "逐渐", "增大" ], "anatomy_list": [ "左侧乳腺" ] }, { "core_name": "肿物", "tendency": "", "character": [], "anatomy_list": [ "乳房" ] } ] }, { "id": 1618, "text": "2.子宫肌瘤可能，请随诊或mr检查。", "event": [ { "core_name": "肌瘤", "tendency": "不确定", "character": [], "anatomy_list": [ "子宫" ] } ] }, { "id": 715, "text": "患者男，因“大便性状改变5月，伴腹痛1月，便血2周”入院，于2015-09-14全麻腹腔镜下行直肠癌根治术，手术顺利，术后安返病房，术后病理结果：2015-9-21 组织病理学检查报告：（直肠）溃疡型中分化管状腺癌（含粘液腺癌成份），侵及肠壁全层，两切缘未见癌累及，肠壁淋巴结未见癌转移（0/11）。", "event": [ { "core_name": "大便", "tendency": "", "character": [ "性状改变" ], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "", "character": [], "anatomy_list": [ "腹部" ] }, { "core_name": "便血", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "腺癌", "tendency": "", "character": [ "溃疡型", "中分化", "管状", "含粘液腺癌成份", "侵及肠壁全层" ], "anatomy_list": [ "直肠" ] }, { "core_name": "癌", "tendency": "否定", "character": [ "累及" ], "anatomy_list": [ "肠壁切缘" ] }, { "core_name": "癌", "tendency": "否定", "character": [ "转移" ], "anatomy_list": [ "肠壁淋巴结" ] } ] }, { "id": 129, "text": "于2016-08-11行（左）乳癌保乳术，术后恢复看可，术后予tc方案化疗3次，化疗过程顺利，未出现明显化疗副反应。", "event": [ { "core_name": "化疗副反应", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [] } ] }, { "id": 2013, "text": "5天前，患者因受凉后出现上述症状加重，咳嗽次数频繁，咳痰色白呈泡沫状，不易咳出，稍微活动则气促，伴下腹部胀痛，疼痛剧烈时汗出，疼痛无转移，自行在药店购买药物口服治疗（具体不详），下腹部胀痛缓解。", "event": [ { "core_name": "咳嗽", "tendency": "", "character": [ "次数频繁" ], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "白色", "泡沫状", "不易咳出" ], "anatomy_list": [] }, { "core_name": "气促", "tendency": "", "character": [ "稍微活动" ], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "", "character": [ "剧烈时出汗", "胀痛", "无转移" ], "anatomy_list": [ "下腹部" ] }, { "core_name": "疼痛", "tendency": "", "character": [ "缓解", "胀痛" ], "anatomy_list": [ "下腹部" ] } ] }, { "id": 1364, "text": "患者自发病以来， 精神可 ， 食欲一般 ， 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": [ "可" ], "anatomy_list": [] }, { "core_name": "食欲", "tendency": "", "character": [ "一般" ], "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": 1863, "text": "化疗后于外院随访血常规提示ii度骨髓抑制，未行特殊治疗，肝肾功能未见明显异常，现第1次化疗后19天，轻微口腔溃疡，偶有腹部串气样疼痛，轻微腹胀，走路时有下腹坠胀坠胀感，无手足麻木，无畏寒、发热、恶心、呕吐、咳嗽、关节疼痛、心慌气短等不适，全身无淤血淤斑、皮疹，无阴道阴道流血等症状，今来院要求行第二次化疗，门诊以“卵巢高级别浆液性癌iiic期第1次化疗后”收入院。", "event": [ { "core_name": "骨髓抑制", "tendency": "", "character": [ "ii度" ], "anatomy_list": [ "骨髓" ] }, { "core_name": "肝功能异常", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [ "肝" ] }, { "core_name": "肾功能异常", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [ "肾" ] }, { "core_name": "溃疡", "tendency": "", "character": [ "轻微" ], "anatomy_list": [ "口腔" ] }, { "core_name": "疼痛", "tendency": "", "character": [ "串气样", "偶有" ], "anatomy_list": [ "腹部" ] }, { "core_name": "腹胀", "tendency": "", "character": [ "轻微" ], "anatomy_list": [ "腹" ] }, { "core_name": "坠胀感", "tendency": "", "character": [ "走路时" ], "anatomy_list": [ "下腹" ] }, { "core_name": "麻木", "tendency": "否定", "character": [], "anatomy_list": [ "手", "足" ] }, { "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": "咳嗽", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "关节" ] }, { "core_name": "心慌", "tendency": "否定", "character": [], "anatomy_list": [ "心" ] }, { "core_name": "气短", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "瘀血", "tendency": "否定", "character": [], "anatomy_list": [ "全身" ] }, { "core_name": "瘀斑", "tendency": "否定", "character": [], "anatomy_list": [ "全身" ] }, { "core_name": "皮疹", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "出血", "tendency": "否定", "character": [], "anatomy_list": [ "阴道" ] }, { "core_name": "癌", "tendency": "", "character": [ "高级别", "浆液性", "第1次化疗后", "iiic期" ], "anatomy_list": [ "卵巢" ] } ] }, { "id": 818, "text": "入院前4+小时，患者晨起时无明显诱因出现恶心、呕吐，呕吐物约300ml咖啡色胃内容物，同时出现大便失禁，解少许黑色稀大便，伴头晕，自觉发热（未测体温），伴腹痛、腹胀、纳差，无胸闷、心悸、胸痛，无意识障碍，无咳嗽、咳痰等。", "event": [ { "core_name": "恶心", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "呕吐", "tendency": "", "character": [ "呕吐物约300ml咖啡色胃内容物" ], "anatomy_list": [] }, { "core_name": "大便", "tendency": "", "character": [ "失禁" ], "anatomy_list": [] }, { "core_name": "大便", "tendency": "", "character": [ "少许", "黑色", "稀便" ], "anatomy_list": [] }, { "core_name": "大便", "tendency": "", "character": [ "失禁" ], "anatomy_list": [] }, { "core_name": "小便", "tendency": "", "character": [ "失禁" ], "anatomy_list": [] }, { "core_name": "头晕", "tendency": "", "character": [], "anatomy_list": [ "头" ] }, { "core_name": "发热", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "腹胀", "tendency": "", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "纳差", "tendency": "", "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": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "胸" ] }, { "core_name": "意识障碍", "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": 1159, "text": "今患者为行进一步诊治就诊于我院，门诊故以“左肾绞痛”收入我科。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [ "绞痛" ], "anatomy_list": [ "左肾" ] } ] }, { "id": 1816, "text": "分别于2019-12-11、2020-1-4、2020-1-31、2020-2-22行静脉化疗，具体化疗方案为：培美曲塞0.8g+洛铂50mg，化疗过程中，患者稍有恶心、反酸，予以对症处理后好转。", "event": [ { "core_name": "恶心", "tendency": "", "character": [ "稍有" ], "anatomy_list": [] }, { "core_name": "返酸", "tendency": "", "character": [ "稍有" ], "anatomy_list": [] } ] }, { "id": 369, "text": "起初咳痰困难，后逐渐咳白色粘痰，伴声音嘶哑、咽喉疼痛，吞咽时更为明显，同时伴有鼻塞。", "event": [ { "core_name": "咳痰", "tendency": "", "character": [ "困难" ], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "白色", "粘性" ], "anatomy_list": [] }, { "core_name": "声音嘶哑", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "", "character": [ "吞咽时更为明显" ], "anatomy_list": [ "咽", "喉" ] }, { "core_name": "鼻塞", "tendency": "", "character": [], "anatomy_list": [] } ] }, { "id": 1785, "text": "<吻合口切缘，另一侧切缘，环周切缘，盆腔左侧壁与肿瘤粘连组织袋>未见癌累及。", "event": [ { "core_name": "癌", "tendency": "否定", "character": [ "累及" ], "anatomy_list": [ "盆腔左侧壁" ] }, { "core_name": "癌", "tendency": "否定", "character": [ "累及" ], "anatomy_list": [ "吻合口切缘" ] }, { "core_name": "癌", "tendency": "否定", "character": [ "累及" ], "anatomy_list": [ "环周切缘" ] }, { "core_name": "癌", "tendency": "否定", "character": [ "累及" ], "anatomy_list": [ "组织袋" ] }, { "core_name": "粘连", "tendency": "", "character": [ "肿瘤" ], "anatomy_list": [ "盆腔左侧壁" ] } ] }, { "id": 659, "text": "无发热、寒战，无潮热、盗汗，无胸痛、咯血，无心累、气促，无恶心、呕吐，无腹胀、腹痛。", "event": [ { "core_name": "发热", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "寒颤", "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": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "胸" ] }, { "core_name": "咯血", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "心累", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "气促", "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": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] } ] }, { "id": 399, "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": [ "如常" ], "anatomy_list": [] }, { "core_name": "小便", "tendency": "", "character": [ "如常" ], "anatomy_list": [] }, { "core_name": "体重变化", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [] } ] }, { "id": 318, "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，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": "体重变化", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [] } ] }, { "id": 1905, "text": "4.右肺中叶及左肺下小结节影，fdg代谢未见异常增高，建议随访观察。", "event": [ { "core_name": "结节影", "tendency": "", "character": [ "小" ], "anatomy_list": [ "右肺中叶及左肺下叶" ] }, { "core_name": "fdg代谢", "tendency": "否定", "character": [ "异常增高" ], "anatomy_list": [] } ] }, { "id": 107, "text": "患者自发病以来， 精神可 ， 食欲可 ， 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": [ "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": [ "如常" ], "anatomy_list": [] }, { "core_name": "小便", "tendency": "", "character": [ "如常" ], "anatomy_list": [] }, { "core_name": "体重变化", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [] } ] }, { "id": 265, "text": "入院前1周，患者不明诱因出现活动后气短，爬坡上楼明显，休息缓解，间断有咳嗽，咯少许白色粘痰，无胸痛及放射痛，无胸闷、心悸，无夜间阵发性呼吸困难及端坐呼吸，无发热，无咯血及咯黄痰等，于外院体检心电图提示：窦性心律，t波改变，遂进一步在我院门诊就诊，查冠脉cta：左回旋支近段管壁可见非钙化斑块，管腔轻度狭窄。", "event": [ { "core_name": "气短", "tendency": "", "character": [ "活动后", "爬坡上楼明显", "休息缓解" ], "anatomy_list": [] }, { "core_name": "咳嗽", "tendency": "", "character": [ "间断" ], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "少许", "白色", "粘性" ], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "", "character": [], "anatomy_list": [ "胸" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [ "放射性" ], "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": "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": "发热", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "咯血", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "否定", "character": [ "黄色" ], "anatomy_list": [] }, { "core_name": "t波改变", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "斑块", "tendency": "", "character": [ "非钙化" ], "anatomy_list": [ "左回旋支近段管壁" ] }, { "core_name": "狭窄", "tendency": "", "character": [ "轻度" ], "anatomy_list": [ "左回旋支近段管腔" ] } ] }, { "id": 1871, "text": "1周前患者无明显诱因出现大便困难，肛门坠胀，无便血、黑便、腹泻等，无恶心、呕吐、腹胀、畏寒、发热，遂在当地诊所予以药物治疗（具体用药不详）无明显好转。", "event": [ { "core_name": "大便困难", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "坠胀", "tendency": "", "character": [], "anatomy_list": [ "肛门" ] }, { "core_name": "便血", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "黑便", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "腹泻", "tendency": "否定", "character": [], "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": "腹胀", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "畏寒", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "发热", "tendency": "否定", "character": [], "anatomy_list": [] } ] }, { "id": 1429, "text": "今日患者为进一步诊治就诊于我院门诊，查血压：174/101mmhg，后患者为求进一步诊治，门诊拟“高血压”收入我科。", "event": [ { "core_name": "高血压", "tendency": "", "character": [], "anatomy_list": [] } ] }, { "id": 1534, "text": "5+月前，患者因受凉后出现咳嗽、咳痰，咳白色粘液痰，伴胸痛，以左侧为甚，为持续胀痛，夜间未影响睡眠，无咯血；稍活动即感心累、气促，无恶心、呕吐、发热、寒战，无低热、盗汗等不适，遂再次来我院，完善胸部ct提示肺部包块较前有所增大，故再次予以按tp方案化疗（药物总量为：多西他赛 110mg+奈达铂 120mg）；化疗期间及化疗结束后患者无恶心、呕吐、肢端麻木及骨髓抑制等不适，于2015年11月10日来我院，复查胸部ct提示为肺部包块较前有所增大，故更换化疗方案为gp方案（药物总量为 吉西他滨 3.2g、顺铂 120mg），建议其化疗结束后可到上级医院放疗，但患者本人及家属均拒绝。", "event": [ { "core_name": "咳嗽", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "白色", "粘液" ], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "", "character": [ "持续胀痛", "以左侧为甚", "夜间未影响睡眠" ], "anatomy_list": [ "胸" ] }, { "core_name": "咯血", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "心累", "tendency": "", "character": [ "稍微活动后" ], "anatomy_list": [ "心" ] }, { "core_name": "气促", "tendency": "", "character": [ "稍微活动后" ], "anatomy_list": [] }, { "core_name": "恶心", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "呕吐", "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": "发热", "tendency": "否定", "character": [ "低" ], "anatomy_list": [] }, { "core_name": "盗汗", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "包块", "tendency": "", "character": [ "较前增大" ], "anatomy_list": [ "肺部" ] }, { "core_name": "恶心", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "呕吐", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "麻木", "tendency": "否定", "character": [], "anatomy_list": [ "肢端" ] }, { "core_name": "骨髓抑制", "tendency": "否定", "character": [], "anatomy_list": [ "骨髓" ] }, { "core_name": "包块", "tendency": "", "character": [ "较前增大" ], "anatomy_list": [ "肺部" ] } ] }, { "id": 1783, "text": "肿瘤位于乙状结肠下段，肿瘤侵出浆膜，大小约5*6cm，并可疑侵犯盆腔左侧壁，剖视肿瘤累及管腔全周，表面溃疡形成，致不全性肠梗阻，系膜内未扪及确切肿大淋巴结。", "event": [ { "core_name": "肿瘤", "tendency": "", "character": [], "anatomy_list": [ "乙状结肠下段" ] }, { "core_name": "肿瘤", "tendency": "", "character": [ "侵出" ], "anatomy_list": [ "浆膜" ] }, { "core_name": "肿瘤", "tendency": "不确定", "character": [ "侵犯" ], "anatomy_list": [ "盆腔左侧壁" ] }, { "core_name": "肿瘤", "tendency": "", "character": [ "累及" ], "anatomy_list": [ "管腔全周" ] }, { "core_name": "溃疡", "tendency": "", "character": [ "表面" ], "anatomy_list": [ "管腔全周" ] }, { "core_name": "梗阻", "tendency": "", "character": [ "不完全性" ], "anatomy_list": [ "肠" ] }, { "core_name": "肿大", "tendency": "否定", "character": [], "anatomy_list": [ "系膜内淋巴结" ] } ] }, { "id": 1396, "text": "宫颈活检：宫颈3点鳞状上皮乳头瘤样增生，建议免疫组化3项协助诊断。", "event": [ { "core_name": "增生", "tendency": "", "character": [ "乳头瘤样" ], "anatomy_list": [ "宫颈3点鳞状上皮" ] } ] }, { "id": 1757, "text": "患者自起病以来，精神可，胃纳略差，大便如常，小便如常，体重未见明显下降。", "event": [ { "core_name": "精神", "tendency": "", "character": [ "可" ], "anatomy_list": [] }, { "core_name": "胃纳", "tendency": "", "character": [ "略差" ], "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": 1096, "text": "无腰痛，无尿急、尿痛等，无肉眼血尿，无畏寒发热，未引起患者重视。", "event": [ { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "腰" ] }, { "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": "畏寒", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "发热", "tendency": "否定", "character": [], "anatomy_list": [] } ] }, { "id": 205, "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，体重无明显变化。", "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": "体重变化", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [] } ] }, { "id": 727, "text": "无腹痛、黑便，便后无肛门出血。", "event": [ { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "黑便", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "出血", "tendency": "", "character": [ "便后" ], "anatomy_list": [ "肛门" ] } ] }, { "id": 237, "text": "入院前6+月患者无明显诱因出现排便、排尿困难，排便无力，大便干结成块状，便后感肛周抽痛。", "event": [ { "core_name": "排便困难", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "排尿困难", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "排便无力", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "大便", "tendency": "", "character": [ "干结", "成块状" ], "anatomy_list": [] }, { "core_name": "抽痛", "tendency": "", "character": [ "便后" ], "anatomy_list": [ "肛周" ] } ] }, { "id": 2052, "text": "院外多次随访上腹部ct+增强、电子胃镜，未见明显异常。", "event": [ { "core_name": "异常", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [ "上腹部" ] } ] }, { "id": 474, "text": "2+月前患者无明显诱因出现间断头晕不适，自测血压110-120/60-70mmHg，不伴耳鸣、眩晕、头痛、面红、恶心、呕吐，不伴咳嗽、咳痰、鼻塞、流涕、畏寒、寒战、发热，无胸闷、胸痛、咽部紧缩感、压榨感、肩背部放射痛，无腹痛、腹泻、呕血、黑便、尿频、尿急、尿痛不适。", "event": [ { "core_name": "头晕", "tendency": "", "character": [ "间断" ], "anatomy_list": [ "头" ] }, { "core_name": "耳鸣", "tendency": "否定", "character": [], "anatomy_list": [ "耳" ] }, { "core_name": "眩晕", "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": "面红", "tendency": "否定", "character": [], "anatomy_list": [ "面" ] }, { "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": [] }, { "core_name": "鼻塞", "tendency": "否定", "character": [], "anatomy_list": [ "鼻" ] }, { "core_name": "流涕", "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": "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": "紧缩感", "tendency": "否定", "character": [], "anatomy_list": [ "咽部" ] }, { "core_name": "压榨感", "tendency": "否定", "character": [], "anatomy_list": [ "咽部" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [ "放射性" ], "anatomy_list": [ "肩背部" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "腹泻", "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": "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": [] } ] }, { "id": 1981, "text": "患者于入院前10天无明显诱因出现头晕，呈昏沉感，伴右耳发堵、闷胀感，自觉站立不稳、行走漂浮，伴右侧脑鸣，无视物旋转、恶心、呕吐，无头痛，无复视，无言语不清、饮水呛咳及复视，无肢体麻木、无力及抽搐，无心悸、胸闷、黑蒙，无意识丧失及大小便失禁，症状持续存在，与体位改变无明显相关，于我院门诊行头部ct检查提示双侧基底节区多发腔隙性脑梗塞，予以输液治疗（具体不详），症状缓解不明显，今为求进一步诊治，遂来我院，门诊以“腔隙性脑梗塞”收入我科。", "event": [ { "core_name": "头晕", "tendency": "", "character": [], "anatomy_list": [ "头" ] }, { "core_name": "昏沉感", "tendency": "", "character": [], "anatomy_list": [ "头" ] }, { "core_name": "发堵", "tendency": "", "character": [], "anatomy_list": [ "右耳" ] }, { "core_name": "闷胀感", "tendency": "", "character": [], "anatomy_list": [ "右耳" ] }, { "core_name": "站立", "tendency": "", "character": [ "不稳" ], "anatomy_list": [] }, { "core_name": "行走", "tendency": "", "character": [ "漂浮" ], "anatomy_list": [] }, { "core_name": "脑鸣", "tendency": "", "character": [], "anatomy_list": [ "右侧脑" ] }, { "core_name": "视物旋转", "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": "复视", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "言语不清", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "呛咳", "tendency": "否定", "character": [ "饮水" ], "anatomy_list": [] }, { "core_name": "复视", "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": "抽搐", "tendency": "否定", "character": [], "anatomy_list": [ "肢体" ] }, { "core_name": "心悸", "tendency": "否定", "character": [], "anatomy_list": [ "心" ] }, { "core_name": "胸闷", "tendency": "否定", "character": [], "anatomy_list": [ "胸" ] }, { "core_name": "黑朦", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "意识丧失", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "大小便失禁", "tendency": "否定", "character": [ "失禁" ], "anatomy_list": [] }, { "core_name": "脑梗塞", "tendency": "", "character": [ "多发性", "腔隙性" ], "anatomy_list": [ "双侧基底节区" ] }, { "core_name": "梗塞", "tendency": "", "character": [ "腔隙性" ], "anatomy_list": [ "脑" ] } ] }, { "id": 82, "text": "原始包块：左乳11点钟距乳头约3cm处腺体层内可见一低回声区，范围约2.0*1.5cm，见3个低回声结节，其中一个大小约2.3*1.4cm。", "event": [ { "core_name": "包块", "tendency": "", "character": [ "原始" ], "anatomy_list": [] }, { "core_name": "回声区", "tendency": "", "character": [ "低" ], "anatomy_list": [ "左乳11点钟距乳头约3cm处腺体层内" ] }, { "core_name": "结节", "tendency": "", "character": [ "低回声", "3个" ], "anatomy_list": [] } ] }, { "id": 118, "text": "腋窝淋巴结见癌转移（7/17）。", "event": [ { "core_name": "癌", "tendency": "", "character": [ "转移" ], "anatomy_list": [ "腋窝淋巴结" ] } ] }, { "id": 1376, "text": "此后患者一周行3次规律透析，未再诉心累气促。", "event": [ { "core_name": "心累", "tendency": "否定", "character": [], "anatomy_list": [ "心" ] }, { "core_name": "气促", "tendency": "否定", "character": [], "anatomy_list": [] } ] }, { "id": 316, "text": "病程中患者无发热，无头晕、头痛，无心慌、乏力、心悸、胸闷、呼吸困难，无黑朦、四肢阙冷、出冷汗等不适。", "event": [ { "core_name": "发热", "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": "心慌", "tendency": "否定", "character": [], "anatomy_list": [ "心" ] }, { "core_name": "乏力", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "心悸", "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": "黑朦", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "阙冷", "tendency": "否定", "character": [], "anatomy_list": [ "四肢" ] }, { "core_name": "出汗", "tendency": "否定", "character": [ "冷" ], "anatomy_list": [] } ] }, { "id": 24, "text": "全身骨显像、腹部彩超暂未见明确异常。", "event": [ { "core_name": "异常", "tendency": "否定", "character": [ "明确" ], "anatomy_list": [ "全身骨", "腹部" ] } ] }, { "id": 566, "text": "全腹部ct增强：1.脾脏明显增大伴多发低密度低密度结节影，2.腹膜后及双侧腹股沟淋巴结增大。", "event": [ { "core_name": "增大", "tendency": "", "character": [ "增大" ], "anatomy_list": [ "脾脏" ] }, { "core_name": "结节影", "tendency": "", "character": [ "多发", "低密度" ], "anatomy_list": [ "脾脏" ] }, { "core_name": "增大", "tendency": "", "character": [], "anatomy_list": [ "腹膜后淋巴结", "双侧腹股沟淋巴结" ] } ] }, { "id": 1138, "text": "患儿无发热、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": 605, "text": "骨扫描未见明显异常，提示肿瘤进展，于10.26、11.17行dpf方案化疗2周期（多西他赛100mg+奈达铂100mg+氟尿嘧啶3.75g)，过程顺利，无特殊不适，现为继续化疗，门诊以胃癌收住我科。", "event": [ { "core_name": "异常", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [ "骨" ] }, { "core_name": "肿瘤", "tendency": "", "character": [ "进展" ], "anatomy_list": [] }, { "core_name": "癌", "tendency": "", "character": [], "anatomy_list": [ "胃" ] } ] }, { "id": 1650, "text": "今日再次入院拟给予术后第三周期化疗，此次以“手术后恶性肿瘤化学化学治疗”入住我科。", "event": [ { "core_name": "肿瘤", "tendency": "", "character": [ "手术后", "恶性", "化学治疗" ], "anatomy_list": [] } ] }, { "id": 1030, "text": "（2018-1-11 我院）电子肠镜：直肠新生物。", "event": [ { "core_name": "新生物", "tendency": "", "character": [], "anatomy_list": [ "直肠" ] } ] }, { "id": 289, "text": "1余月前患者摔倒后胸痛加重，疼痛范围为双侧胸部及肩背部、颈部，呈持续性胀痛，程度重，近1月体重较少约2kg，余情况同前，至某医院就诊查胸片示：左侧第5肋骨骨折。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [ "摔倒后加重" ], "anatomy_list": [ "胸" ] }, { "core_name": "疼痛", "tendency": "", "character": [ "呈持续性胀痛", "程度重" ], "anatomy_list": [ "双侧胸部", "肩", "背部", "颈部" ] }, { "core_name": "体重减少", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "骨折", "tendency": "", "character": [], "anatomy_list": [ "左侧第5肋骨" ] } ] }, { "id": 1682, "text": "入院前2月余，患者以“乙状结肠癌”收入我科，完善相关检查，积极术前准备，在全麻下行“腹腔镜辅助下乙状结肠癌根治术”；术后予以抗感染，止血，补液等对症处理，患者病情逐渐好转。", "event": [ { "core_name": "癌", "tendency": "", "character": [], "anatomy_list": [ "乙状结肠" ] } ] }, { "id": 394, "text": "病人病情恢复可，带管出院，2019-12-11我院局麻下行超选择性肝动脉造影+超选择性肝动脉灌注化疗，术后予以抗感染、护胃、对症支持治疗，术后一直口服靶向药物，定期输入信迪利单抗治疗，5天前患者出现全身乏力，食欲差，无腹痛腹胀等不适，现为求进一步治疗，门诊以“肝癌术后复发”收入我科。", "event": [ { "core_name": "乏力", "tendency": "", "character": [ "全身" ], "anatomy_list": [] }, { "core_name": "食欲", "tendency": "", "character": [ "差" ], "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": "癌", "tendency": "", "character": [ "术后复发" ], "anatomy_list": [ "肝" ] } ] }, { "id": 204, "text": "今为进一步治疗遂来我科，门诊以“食管吻合口狭窄”收住入院。", "event": [ { "core_name": "狭窄", "tendency": "", "character": [], "anatomy_list": [ "食管吻合口" ] } ] }, { "id": 1890, "text": "病程中患者无头痛及头晕，无鼻衄，无咳嗽、咳痰。", "event": [ { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "头" ] }, { "core_name": "头晕", "tendency": "否定", "character": [], "anatomy_list": [ "头" ] }, { "core_name": "鼻衄", "tendency": "否定", "character": [], "anatomy_list": [ "鼻" ] }, { "core_name": "咳嗽", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "否定", "character": [], "anatomy_list": [] } ] }, { "id": 334, "text": "患者自起病以来，精神可，胃纳可，排便困难，小便如常，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": "排便困难", "tendency": "", "character": [], "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": 945, "text": "1周前，患者无诱因出现咳嗽、咳痰，痰为黄色脓痰，无痰中带血丝及咯血，无畏寒、发热。", "event": [ { "core_name": "咳嗽", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "黄色", "脓" ], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "否定", "character": [ "带血丝" ], "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": [] } ] }, { "id": 1198, "text": "患者为求进一步治疗，门诊以“左肾肿瘤”收入我科。", "event": [ { "core_name": "肿瘤", "tendency": "", "character": [], "anatomy_list": [ "左肾" ] } ] }, { "id": 555, "text": "不伴恶心、反酸，无呕吐。", "event": [ { "core_name": "恶心", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "反酸", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "呕吐", "tendency": "否定", "character": [], "anatomy_list": [] } ] }, { "id": 653, "text": "上腹部ct示：肝硬化，弥漫再生结节，门脉高压，脾大，腹腔积液，肝右后叶后上段富血供结节，不典型增生结节？早期肝癌？请结合mri检查；胆囊小结石；腹膜后及腹腔内多发肿大淋巴结；左肾盂肾盂输尿管、左肾结石；左肾积水；双肾囊肿”，无畏寒、发热，无咳嗽、咳痰，无胸闷、气促、呼吸困难，无腹胀、腹痛，未特殊治疗，现为进一步诊疗门诊以“肝硬化失代偿期”收入我科住院治疗。", "event": [ { "core_name": "硬化", "tendency": "", "character": [], "anatomy_list": [ "肝" ] }, { "core_name": "结节", "tendency": "", "character": [ "弥漫", "再生" ], "anatomy_list": [ "肝" ] }, { "core_name": "门脉高压", "tendency": "", "character": [], "anatomy_list": [ "门脉" ] }, { "core_name": "脾大", "tendency": "", "character": [], "anatomy_list": [ "脾" ] }, { "core_name": "积液", "tendency": "", "character": [], "anatomy_list": [ "腹腔" ] }, { "core_name": "结节", "tendency": "", "character": [ "富血供" ], "anatomy_list": [ "肝右后叶后上段" ] }, { "core_name": "结节", "tendency": "不确定", "character": [ "不典型增生" ], "anatomy_list": [ "肝右后叶后上段" ] }, { "core_name": "癌", "tendency": "不确定", "character": [ "早期" ], "anatomy_list": [ "肝" ] }, { "core_name": "结石", "tendency": "", "character": [ "小" ], "anatomy_list": [ "胆囊" ] }, { "core_name": "肿大", "tendency": "", "character": [ "多发" ], "anatomy_list": [ "腹膜后淋巴结", "腹膜内淋巴结" ] }, { "core_name": "结石", "tendency": "", "character": [], "anatomy_list": [ "左肾盂", "输尿管", "左肾" ] }, { "core_name": "积水", "tendency": "", "character": [], "anatomy_list": [ "左肾" ] }, { "core_name": "囊肿", "tendency": "", "character": [], "anatomy_list": [ "双肾" ] }, { "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": "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": "腹胀", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "硬化", "tendency": "", "character": [ "失代偿期" ], "anatomy_list": [ "肝" ] } ] }, { "id": 803, "text": "患者腰背部疼痛伴活动受限，明显影响患者生活质量，为进一步治疗，就诊于我科门诊，行腰椎mr：1、腰椎退行性变；腰2-骶1椎间盘膨出。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [], "anatomy_list": [ "腰背部" ] }, { "core_name": "活动受限", "tendency": "", "character": [ "明显影响患者生活质量" ], "anatomy_list": [ "腰背部" ] }, { "core_name": "病变", "tendency": "", "character": [ "退行性" ], "anatomy_list": [ "腰椎" ] }, { "core_name": "膨出", "tendency": "", "character": [], "anatomy_list": [ "腰2-骶1椎间盘" ] } ] }, { "id": 615, "text": "今日为行放疗来我科，遂以\"左 肺鳞癌 \"收入我科。", "event": [ { "core_name": "鳞癌", "tendency": "", "character": [], "anatomy_list": [ "左肺" ] } ] }, { "id": 264, "text": "体重无明显减轻。", "event": [ { "core_name": "体重减轻", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [] } ] }, { "id": 1121, "text": "入我院妇科治疗，行腹腔探查术,术中冰冻切片示卵巢低分化腺癌，行全子宫切除＋双侧附件切除＋大网膜切除＋阑尾切除术，术后病理报告：1.（右卵巢）低分化浆液性乳头状囊腺癌，子宫未见癌累及；2.（左卵巢）低分化浆液性乳头状腺癌，左输卵管未见癌累及；3.网膜组织见癌转移。", "event": [ { "core_name": "腺癌", "tendency": "", "character": [ "低分化" ], "anatomy_list": [ "卵巢" ] }, { "core_name": "囊腺癌", "tendency": "", "character": [ "低分化", "浆液性", "乳头状" ], "anatomy_list": [ "右卵巢" ] }, { "core_name": "腺癌", "tendency": "", "character": [ "低分化", "浆液性", "乳头状" ], "anatomy_list": [ "左卵巢" ] }, { "core_name": "癌", "tendency": "否定", "character": [ "累及" ], "anatomy_list": [ "左输卵管" ] }, { "core_name": "癌", "tendency": "", "character": [ "转移" ], "anatomy_list": [ "网膜组织" ] } ] }, { "id": 435, "text": "3月前，患者无明显诱因出现左侧腰部腰部胀痛，疼痛不剧烈，能忍受，反复出现，能自行缓解，疼痛和体位、活动无关，无尿频尿急及尿末痛，无恶心呕吐，无寒战发热，无肉眼血尿。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [ "胀痛", "不剧烈", "能忍受", "反复出现", "能自行缓解", "和体位、活动无关" ], "anatomy_list": [ "左侧腰部" ] }, { "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": [ "末" ], "anatomy_list": [] }, { "core_name": "恶心", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "呕吐", "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": "血尿", "tendency": "否定", "character": [], "anatomy_list": [] } ] }, { "id": 890, "text": "入院前1年，患者无明显诱因出现反复咳嗽，伴咯血，以痰中带血为主，量约15ml/日。", "event": [ { "core_name": "咳嗽", "tendency": "", "character": [ "反复" ], "anatomy_list": [] }, { "core_name": "咯血", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "带血" ], "anatomy_list": [] } ] }, { "id": 585, "text": "2.左足未见明显异常。", "event": [ { "core_name": "异常", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [ "左足" ] } ] }, { "id": 1951, "text": "故诊断为“前列腺癌伴骨转移”。", "event": [ { "core_name": "癌", "tendency": "", "character": [], "anatomy_list": [ "前列腺" ] }, { "core_name": "癌", "tendency": "", "character": [ "转移" ], "anatomy_list": [ "骨" ] } ] }, { "id": 670, "text": "入院前3月，患者因诊断为“右侧乳腺癌”。", "event": [ { "core_name": "癌", "tendency": "", "character": [], "anatomy_list": [ "右侧乳腺" ] } ] }, { "id": 1186, "text": "乳腺钼靶：右乳占位，考虑乳腺ca可能大。", "event": [ { "core_name": "占位", "tendency": "", "character": [], "anatomy_list": [ "右乳" ] }, { "core_name": "癌", "tendency": "不确定", "character": [], "anatomy_list": [ "乳腺" ] } ] }, { "id": 901, "text": "体重下降6kg。", "event": [ { "core_name": "体重下降", "tendency": "", "character": [], "anatomy_list": [] } ] }, { "id": 602, "text": "三尖瓣关闭不全（轻度），pasp：35mm。", "event": [ { "core_name": "关闭不全", "tendency": "", "character": [ "轻度" ], "anatomy_list": [ "三尖瓣" ] } ] }, { "id": 1101, "text": "入院前4+年，患者常规体检行胸部ct提示：右下肺块状软组织密度影，呈分叶状，大小约23.5*30.2mm，考虑肺癌。", "event": [ { "core_name": "密度影", "tendency": "", "character": [ "块状", "分叶状" ], "anatomy_list": [ "右下肺", "软组织" ] }, { "core_name": "癌", "tendency": "不确定", "character": [], "anatomy_list": [ "肺" ] } ] }, { "id": 1706, "text": "患者后于某中医院行盆腔ct提示骨盆多处骨转移；胸部ct提示双侧胸腔积液、胸椎多处骨质破坏。", "event": [ { "core_name": "转移", "tendency": "", "character": [ "多处", "骨" ], "anatomy_list": [ "骨盆" ] }, { "core_name": "积液", "tendency": "", "character": [], "anatomy_list": [ "双侧胸腔" ] }, { "core_name": "骨质破坏", "tendency": "", "character": [ "多处" ], "anatomy_list": [ "胸椎" ] } ] }, { "id": 443, "text": "3天前患者因受凉，咳嗽、咳痰加重，咳白色泡沫痰，量多，无臭味。", "event": [ { "core_name": "咳嗽", "tendency": "", "character": [ "因受凉", "加重" ], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "因受凉", "加重" ], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "白色", "泡沫", "量多", "无臭味" ], "anatomy_list": [] } ] }, { "id": 916, "text": "患者入院前3月因颈腰椎间盘突出入某医院住院治疗期间行颈部彩超时发现甲状腺右叶包块，不伴声嘶、吞咽困难，不伴低热、盗汗、高热。", "event": [ { "core_name": "突出", "tendency": "", "character": [], "anatomy_list": [ "颈椎间盘" ] }, { "core_name": "包块", "tendency": "", "character": [], "anatomy_list": [ "甲状腺右叶" ] }, { "core_name": "声嘶", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "吞咽困难", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "发热", "tendency": "否定", "character": [ "低" ], "anatomy_list": [] }, { "core_name": "盗汗", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "发热", "tendency": "否定", "character": [ "高" ], "anatomy_list": [] } ] }, { "id": 1182, "text": "2019年2月初患者自觉头昏、乏力不适，患者就诊于某医院并行骨髓等检查（具体报告未见），遂调整伊马替尼为进口达沙替尼治疗控制病情，但头昏、乏力不适改善不明显，多次复查血常规提示白细胞下降不明显，2019年9月30日患者于某医院复查血常规提示：白细胞总数153.11×109/l，红细胞计数2.97×1012/l，血红蛋白88g/L，血小板28×109/l，建议患者住院治疗，因无床患者遂就诊于我院，门诊以“慢性髓细胞白血病”收住入院。", "event": [ { "core_name": "头昏", "tendency": "", "character": [], "anatomy_list": [ "头" ] }, { "core_name": "乏力", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "头昏", "tendency": "否定", "character": [ "改善明显" ], "anatomy_list": [ "头" ] }, { "core_name": "乏力", "tendency": "否定", "character": [ "改善明显" ], "anatomy_list": [] }, { "core_name": "白细胞下降", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [ "白细胞" ] }, { "core_name": "白血病", "tendency": "", "character": [ "慢性", "髓细胞" ], "anatomy_list": [ "髓细胞" ] } ] }, { "id": 1833, "text": "约半年前于我院住院诊断为“脑供血不足”。", "event": [ { "core_name": "供血不足", "tendency": "", "character": [], "anatomy_list": [ "脑" ] } ] }, { "id": 537, "text": "1年前，患者因血糖控制不佳就诊于我科，完善相关检查，诊断为：“2型糖尿病、糖尿病肾病v期、糖尿病性视网膜病变、糖尿病性周围血管病变、慢性肾衰竭（尿毒症期）、冠状动脉粥样硬化性心脏病、右肺癌伴双肺、胸膜转移、慢性阻塞性肺病、高血压3级很高危、高血压性心脏病、慢性胃炎、颈动脉狭窄”，出院后继续使用：“利格列汀片5mg口服1/日，阿卡波糖片50mg口服3/日，甘精胰岛素注射液34iu皮下1/晚，门冬胰岛素注射液(诺和锐笔芯)12iu皮下1/早、10u皮下1/午、12u皮下1/晚，甘精胰岛素注射液34iu皮下1/晚，”降糖治疗。", "event": [ { "core_name": "血糖", "tendency": "", "character": [ "控制不佳" ], "anatomy_list": [] }, { "core_name": "糖尿病", "tendency": "", "character": [ "2型" ], "anatomy_list": [] }, { "core_name": "肾病", "tendency": "", "character": [ "糖尿病", "v期" ], "anatomy_list": [ "肾" ] }, { "core_name": "病变", "tendency": "", "character": [ "糖尿病性" ], "anatomy_list": [ "视网膜" ] }, { "core_name": "病变", "tendency": "", "character": [ "糖尿病性" ], "anatomy_list": [ "周围血管" ] }, { "core_name": "肾衰竭", "tendency": "", "character": [ "慢性", "尿毒症期" ], "anatomy_list": [ "肾" ] }, { "core_name": "心脏病", "tendency": "", "character": [ "粥样", "硬化性" ], "anatomy_list": [ "冠状动脉", "心脏" ] }, { "core_name": "癌", "tendency": "", "character": [], "anatomy_list": [ "右上肺" ] }, { "core_name": "癌", "tendency": "", "character": [ "转移" ], "anatomy_list": [ "双肺", "胸膜" ] }, { "core_name": "肺病", "tendency": "", "character": [ "慢性", "阻塞性" ], "anatomy_list": [ "肺" ] }, { "core_name": "高血压", "tendency": "", "character": [ "很高危", "3极" ], "anatomy_list": [] }, { "core_name": "心脏病", "tendency": "", "character": [ "高血压性" ], "anatomy_list": [ "心脏" ] }, { "core_name": "胃炎", "tendency": "", "character": [ "慢性" ], "anatomy_list": [ "胃" ] }, { "core_name": "狭窄", "tendency": "", "character": [], "anatomy_list": [ "颈动脉" ] } ] }, { "id": 1577, "text": "患者3+年前同房后出现少量阴道流血，未予重视，未予特殊处理。", "event": [ { "core_name": "出血", "tendency": "", "character": [ "少量", "同房后" ], "anatomy_list": [ "阴道" ] } ] }, { "id": 595, "text": "2、肝内巨大病灶，考虑转移，与前次ct比较肝内病灶明显增大。", "event": [ { "core_name": "病灶", "tendency": "", "character": [ "巨大" ], "anatomy_list": [ "肝内" ] }, { "core_name": "转移", "tendency": "不确定", "character": [], "anatomy_list": [ "肝内" ] }, { "core_name": "病灶", "tendency": "", "character": [ "较前明显增大" ], "anatomy_list": [ "肝内" ] } ] }, { "id": 1900, "text": "患者为进一步明确诊断于2018.07.10在某医院行腰椎穿刺，病理诊断：穿刺（腰椎）见腺癌浸润。", "event": [ { "core_name": "腺癌", "tendency": "", "character": [ "浸润" ], "anatomy_list": [ "腰椎" ] } ] }, { "id": 1957, "text": "患者及家属拒绝行放疗及化疗，拒绝行透析治疗，在我科给予保守治疗后出院；4天前，患者无明显诱因出现活动后喘累，咳嗽、咳痰不明显，不伴咯血、胸痛，无畏寒、发热，为进一步治疗送入我科，遂以“肺癌”收入住院 患者自发病以来，精神、食欲较差，睡眠可，大便如常，小便次数增加，体重减轻约4kg。", "event": [ { "core_name": "喘累", "tendency": "", "character": [ "活动后" ], "anatomy_list": [] }, { "core_name": "咳嗽", "tendency": "", "character": [ "不明显" ], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "不明显" ], "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": "畏寒", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "发热", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "癌", "tendency": "", "character": [], "anatomy_list": [ "肺" ] }, { "core_name": "精神", "tendency": "", "character": [ "较差" ], "anatomy_list": [] }, { "core_name": "食欲", "tendency": "", "character": [ "较差" ], "anatomy_list": [] }, { "core_name": "睡眠", "tendency": "", "character": [ "可" ], "anatomy_list": [] }, { "core_name": "大便", "tendency": "", "character": [ "如常" ], "anatomy_list": [] }, { "core_name": "尿频", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "体重减轻", "tendency": "", "character": [], "anatomy_list": [] } ] }, { "id": 1228, "text": "患病以来，精神、睡眠、食欲可，大小便正常，近期体重下降3Kg。", "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": "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": "", "character": [], "anatomy_list": [] } ] }, { "id": 819, "text": "为避免病情进一步加重，遂于今日来我院急诊科就诊，急诊科以“上消化道出血”收入我科住院治疗。", "event": [ { "core_name": "出血", "tendency": "", "character": [], "anatomy_list": [ "上消化道" ] } ] }, { "id": 1856, "text": "远、近端切缘及环周切缘未见癌累及。", "event": [ { "core_name": "癌", "tendency": "否定", "character": [ "累及" ], "anatomy_list": [ "远、近端切缘及环周切缘" ] } ] }, { "id": 417, "text": "1+年前（2015年7月30日），患者因“左眼卡痛不适3月，肿胀、视力下降2月”于某医院眼科住院治疗，行眼眶ct检查提示：左眼眶左上方见不规则软组织密度。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [ "卡痛不适" ], "anatomy_list": [ "左眼" ] }, { "core_name": "肿胀", "tendency": "", "character": [], "anatomy_list": [ "左眼" ] }, { "core_name": "视力下降", "tendency": "", "character": [], "anatomy_list": [ "左眼" ] }, { "core_name": "密度", "tendency": "", "character": [ "不规则", "软组织" ], "anatomy_list": [ "左眼眶左上方" ] } ] }, { "id": 1930, "text": "患者于2016-2-26因“上腹部隐痛不适1年行肠镜检查发现结肠肿块10天”就诊某医院，完善术前检查及准备后，于2016-2-17在全麻下行根治性右半结肠癌切除术+肝十二指肠淋巴结清扫+胆道探查t管引流术，手术顺利，术后恢复可，术后诊断：右半结肠低分化腺癌合并粘液腺癌伴肝十二指肠肠淋巴结淋巴结转移，iv期。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [ "隐痛" ], "anatomy_list": [ "上腹部" ] }, { "core_name": "上腹部不适", "tendency": "", "character": [], "anatomy_list": [ "上腹部" ] }, { "core_name": "肿块", "tendency": "", "character": [], "anatomy_list": [ "结肠" ] }, { "core_name": "腺癌", "tendency": "", "character": [ "低分化" ], "anatomy_list": [ "右半结肠" ] }, { "core_name": "腺癌", "tendency": "", "character": [ "粘液", "iv期" ], "anatomy_list": [ "右半结肠" ] }, { "core_name": "腺癌", "tendency": "", "character": [ "转移", "iv期" ], "anatomy_list": [ "肝淋巴结", "十二指肠淋巴结" ] } ] }, { "id": 1779, "text": "患者自起病以来，精神、睡眠欠佳，胃纳差，大便正常，小便如上述，体重明显下降（5kg）。", "event": [ { "core_name": "精神", "tendency": "", "character": [ "欠佳" ], "anatomy_list": [] }, { "core_name": "睡眠", "tendency": "", "character": [ "欠佳" ], "anatomy_list": [] }, { "core_name": "纳差", "tendency": "", "character": [], "anatomy_list": [ "胃" ] }, { "core_name": "大便", "tendency": "", "character": [ "正常" ], "anatomy_list": [] }, { "core_name": "小便", "tendency": "", "character": [ "正常" ], "anatomy_list": [] }, { "core_name": "体重下降", "tendency": "", "character": [ "明显" ], "anatomy_list": [] } ] }, { "id": 2028, "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，小便次数增加，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": "尿频", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "体重改变", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [] } ] }, { "id": 1334, "text": "患者自发病以来， 精神、食欲、睡眠较差 ， 大小便如常 ， 体重无明显变化 。", "event": [ { "core_name": "精神", "tendency": "", "character": [ "较差" ], "anatomy_list": [] }, { "core_name": "食欲", "tendency": "", "character": [ "较差" ], "anatomy_list": [] }, { "core_name": "睡眠", "tendency": "", "character": [ "较差" ], "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": 695, "text": "入院前6月，患者因无明显诱因出现阴道不规则点滴出血，色鲜红，伴少量阴道流液，无腹痛、腹胀，不伴畏寒发热、咳嗽咳痰、外阴瘙痒，不伴尿频、尿急等不适症状，患者于当地某医院就诊，给予抗感染等治疗（具体不详）治疗1周，当时上述症状稍缓解，此后未再继续治疗，此后每个月仍出现不规则流血、流液症状，量逐渐增多。", "event": [ { "core_name": "出血", "tendency": "", "character": [ "不规则", "色鲜红", "点滴" ], "anatomy_list": [ "阴道" ] }, { "core_name": "流液", "tendency": "", "character": [ "少量" ], "anatomy_list": [ "阴道" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "腹胀", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "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": "瘙痒", "tendency": "否定", "character": [], "anatomy_list": [ "外阴" ] }, { "core_name": "尿频", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "尿急", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "出血", "tendency": "", "character": [ "不规则", "量逐渐增多" ], "anatomy_list": [ "阴道" ] }, { "core_name": "流液", "tendency": "", "character": [ "不规则", "量逐渐增多" ], "anatomy_list": [ "阴道" ] } ] }, { "id": 1964, "text": "糖尿病病史5年，自诉经药物治疗后血糖恢复正常，已停药，血糖未正规监测。", "event": [ { "core_name": "糖尿病", "tendency": "", "character": [ "5年" ], "anatomy_list": [] }, { "core_name": "血糖", "tendency": "", "character": [ "恢复正常" ], "anatomy_list": [] } ] }, { "id": 1992, "text": "患者本次发病以来，无进食，神志清醒，精神尚可，睡眠尚可，大便如上述，小便正常，近1年体重减少约10kg。", "event": [ { "core_name": "进食", "tendency": "", "character": [ "无" ], "anatomy_list": [] }, { "core_name": "神志", "tendency": "否定", "character": [ "清醒" ], "anatomy_list": [] }, { "core_name": "精神", "tendency": "否定", "character": [ "尚可" ], "anatomy_list": [] }, { "core_name": "睡眠", "tendency": "否定", "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": 93, "text": "末次月经：2016年07月13日，经期约8天，量较前增多，色鲜红，无痛经。", "event": [ { "core_name": "经量", "tendency": "", "character": [ "较前增多" ], "anatomy_list": [] }, { "core_name": "月经", "tendency": "", "character": [ "色鲜红" ], "anatomy_list": [] }, { "core_name": "痛经", "tendency": "否定", "character": [], "anatomy_list": [] } ] }, { "id": 577, "text": "入院前15+月，患者于某妇幼保健院体检行（2018-6-7）乳腺彩超示：1、双乳乳腺轻度增生（bi-rads分类：2类）。", "event": [ { "core_name": "增生", "tendency": "", "character": [ "轻度", "bi-rads分类：2类" ], "anatomy_list": [ "双乳乳腺" ] } ] }, { "id": 466, "text": "半天前患者性交后出现右下腹胀痛，平卧位减轻，无明显加重趋势，有肛门坠胀，无阴道阴道流血、流液，无畏寒、发热，无头晕、头痛，无恶心、呕吐，无心悸、胸闷，无尿频、尿急、尿痛等不适。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [ "胀痛", "平卧位减轻", "无明显加重趋势" ], "anatomy_list": [ "右下腹" ] }, { "core_name": "坠胀", "tendency": "", "character": [], "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": "畏寒", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "发热", "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": "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": "胸闷", "tendency": "否定", "character": [], "anatomy_list": [ "胸" ] }, { "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": [] } ] }, { "id": 1765, "text": "今为求进一步放疗，门诊以“乳腺癌”收入我科住院治疗。", "event": [ { "core_name": "癌", "tendency": "", "character": [], "anatomy_list": [ "乳腺" ] } ] }, { "id": 202, "text": "于我院胸外科行化疗4次，化疗过程中有白细胞降低、恶心、食欲减差、腹泻症状，予以抑酸护胃、升白细胞等治疗后好转。", "event": [ { "core_name": "白细胞降低", "tendency": "", "character": [], "anatomy_list": [ "白细胞" ] }, { "core_name": "恶心", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "食欲", "tendency": "", "character": [ "减差" ], "anatomy_list": [] }, { "core_name": "腹泻", "tendency": "", "character": [], "anatomy_list": [ "腹" ] } ] }, { "id": 1424, "text": "查体左侧颊部见一核桃大小的肿物，表面有溃烂面，疼痛明显，质地硬，活动度差，活检示左颊部鳞癌，请我科会诊后建议完善分期检查并转我科继续治疗，完善头颅mri及胸腹部ct未见确切转移，颌面部ct提示左侧颊癌伴邻近上、下颌骨骨质破坏吸收，周围多发淋巴结肿大淋巴结肿大转移。", "event": [ { "core_name": "肿物", "tendency": "", "character": [ "核桃大小", "表面有溃烂面", "疼痛明显", "质地硬", "活动度差" ], "anatomy_list": [ "左侧颊" ] }, { "core_name": "鳞癌", "tendency": "", "character": [], "anatomy_list": [ "左颊" ] }, { "core_name": "转移", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "癌", "tendency": "", "character": [], "anatomy_list": [ "左侧颊" ] }, { "core_name": "骨质破坏吸收", "tendency": "", "character": [], "anatomy_list": [ "邻近上、下颌骨" ] }, { "core_name": "肿大", "tendency": "", "character": [ "多发", "转移" ], "anatomy_list": [ "周围淋巴结" ] } ] }, { "id": 1844, "text": "具体诊治过程不详，患者为求进一步诊治，转至我院就诊，门诊以“膀胱占位，性质待查？”收入我院泌尿科住院治疗，查ect示：1.全身骨多处异常放射性浓聚，融合骨显像考虑：全身广泛性转移性骨肿瘤。", "event": [ { "core_name": "占位", "tendency": "不确定", "character": [], "anatomy_list": [ "膀胱" ] }, { "core_name": "肿瘤", "tendency": "", "character": [ "广泛性", "转移性" ], "anatomy_list": [ "全身", "骨" ] }, { "core_name": "浓聚", "tendency": "", "character": [ "异常放射性", "多处" ], "anatomy_list": [ "全身", "骨" ] }, { "core_name": "骨融合", "tendency": "", "character": [], "anatomy_list": [ "骨" ] } ] }, { "id": 249, "text": "病程中患者偶感后腰部阵发性疼痛，可耐受，无放射痛，无尿频、尿急、尿痛，疼痛与体位、活动度无关。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [ "偶感", "阵发性", "可耐受" ], "anatomy_list": [ "后腰部" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [ "放射痛" ], "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": "疼痛", "tendency": "", "character": [ "与体位、活动度无关" ], "anatomy_list": [] } ] }, { "id": 1264, "text": "6.双肾囊肿（bosniak Ⅰ级）。", "event": [ { "core_name": "囊肿", "tendency": "", "character": [ "bosniak Ⅰ级" ], "anatomy_list": [ "双肾" ] } ] }, { "id": 1812, "text": "<5、10组，6组，7组，9组，9组，10组，12组>淋巴结未见癌转移（分别为0/2、0/3、0/3、0/1、0/1、0/4、0/3）。", "event": [ { "core_name": "癌", "tendency": "否定", "character": [ "转移" ], "anatomy_list": [ "5、10组，6组，7组，9组，9组，10组，12组淋巴结" ] } ] }, { "id": 1371, "text": "患者入院前7年患者无明显诱因出现多饮、多尿、视物模糊、体重下降，无泡沫尿、手足麻木、间歇性跛行等症状，查血糖升高，诊断为“2型糖尿病”，后长期口服药物降糖治疗，未监测血糖水平。", "event": [ { "core_name": "多饮", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "多尿", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "视物模糊", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "体重下降", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "泡沫尿", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "麻木", "tendency": "否定", "character": [], "anatomy_list": [ "手", "足" ] }, { "core_name": "跛行", "tendency": "否定", "character": [ "间歇性" ], "anatomy_list": [] }, { "core_name": "血糖", "tendency": "", "character": [ "升高" ], "anatomy_list": [] }, { "core_name": "糖尿病", "tendency": "", "character": [ "2型" ], "anatomy_list": [] } ] }, { "id": 980, "text": "患者遂于8月前至我科住院治疗，门诊以“耐药肺结核、胸腔积液待查”收入住院。", "event": [ { "core_name": "结核", "tendency": "", "character": [ "耐药" ], "anatomy_list": [ "肺" ] }, { "core_name": "积液", "tendency": "", "character": [], "anatomy_list": [ "胸腔" ] } ] }, { "id": 1273, "text": "20年前，患者偶测血糖发现血糖升高，无明显口干、多饮、多尿、体重减轻等症状，遂行ogtt检查明确诊断为“2型糖尿病”。", "event": [ { "core_name": "血糖", "tendency": "", "character": [ "升高" ], "anatomy_list": [] }, { "core_name": "口干", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [] }, { "core_name": "多饮", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [] }, { "core_name": "多尿", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [] }, { "core_name": "体重减轻", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [] }, { "core_name": "糖尿病", "tendency": "", "character": [ "2型" ], "anatomy_list": [] } ] }, { "id": 516, "text": "患者自行买药服用后咳嗽稍有好转。", "event": [ { "core_name": "咳嗽", "tendency": "", "character": [ "稍有好转" ], "anatomy_list": [] } ] }, { "id": 1523, "text": "半月前患者受凉后咳嗽、咳痰加重，咳白色粘痰，量多，伴气促，无咯血。", "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", "白色", "粘", "量多" ], "anatomy_list": [] }, { "core_name": "气促", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "咯血", "tendency": "否定", "character": [], "anatomy_list": [] } ] }, { "id": 554, "text": "患者2天前进食辛辣食物后，突发脐周疼痛疼痛不适，呈持续性胀痛，不能缓解，无腰背部放射。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [ "进食辛辣食物后", "突发", "不适", "持续性胀痛", "不能缓解", "无腰背部放射" ], "anatomy_list": [ "脐周" ] } ] }, { "id": 800, "text": "变换体位时疼痛明显。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [ "变换体位时明显" ], "anatomy_list": [] } ] }, { "id": 1157, "text": "患者24小时前无明显诱因出现左侧腰背部疼痛，呈持续性胀痛，疼痛可忍受，休息后可稍缓解，无放射痛，无畏寒、发热，无恶心、呕吐，无尿频、尿痛等不适，就诊于当地医院查尿液检查提示：镜下血尿（患者口诉）。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [ "持续性", "胀痛", "可忍受", "休息后可稍缓解" ], "anatomy_list": [ "左侧腰背部" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [ "放射性" ], "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": "尿频", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "尿痛", "tendency": "否定", "character": [], "anatomy_list": [] } ] }, { "id": 946, "text": "无胸闷、胸痛，夜间喜高枕卧位，无阵发性呼吸困难，患者未行特殊诊治。", "event": [ { "core_name": "胸闷", "tendency": "否定", "character": [], "anatomy_list": [ "胸" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "胸" ] }, { "core_name": "呼吸困难", "tendency": "否定", "character": [ "阵发性" ], "anatomy_list": [] } ] }, { "id": 795, "text": "患者自发病以来，精神、食欲差，睡眠可，大便结燥，小便如常，近半年体重减轻约10kg。", "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": [ "结燥" ], "anatomy_list": [] }, { "core_name": "小便", "tendency": "", "character": [ "如常" ], "anatomy_list": [] }, { "core_name": "体重减轻", "tendency": "", "character": [], "anatomy_list": [] } ] }, { "id": 441, "text": "1年前患者因“咳嗽、咯痰伴呼吸困难”，曾在我院住院明确诊断为“1.肺部感染 2.喉癌术后3气管切开术后 4肺气肿 5.左肺肺大泡 6.亚临床甲状腺功能减退。", "event": [ { "core_name": "咳嗽", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "呼吸困难", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "感染", "tendency": "", "character": [], "anatomy_list": [ "肺部" ] }, { "core_name": "癌", "tendency": "", "character": [ "术后" ], "anatomy_list": [ "喉" ] }, { "core_name": "肺气肿", "tendency": "", "character": [], "anatomy_list": [ "肺" ] }, { "core_name": "肺大疱", "tendency": "", "character": [], "anatomy_list": [ "左肺" ] }, { "core_name": "甲状腺功能减退", "tendency": "", "character": [ "亚临床" ], "anatomy_list": [ "甲状腺" ] } ] }, { "id": 1747, "text": "门诊以“右侧睾丸肿瘤”收入我科。", "event": [ { "core_name": "肿瘤", "tendency": "", "character": [], "anatomy_list": [ "右侧睾丸" ] } ] }, { "id": 953, "text": "入院前2小时患者出现恶心后晕厥，伴有意识丧失，持续时间约1分1分钟，有面色发白、四肢发冷、畏寒等不适，无呕血、血便、粘液脓血便等不适。", "event": [ { "core_name": "恶心", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "晕厥", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "意识丧失", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "发白", "tendency": "", "character": [ "面色" ], "anatomy_list": [] }, { "core_name": "发冷", "tendency": "", "character": [], "anatomy_list": [ "四肢" ] }, { "core_name": "畏寒", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "呕血", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "血便", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "大便", "tendency": "否定", "character": [ "脓血", "粘液" ], "anatomy_list": [] } ] }, { "id": 531, "text": "患者自患病以来精神、食欲及睡眠欠佳，大便正常，尿量减少，自觉体重较前增加。", "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": "大便", "tendency": "", "character": [ "正常" ], "anatomy_list": [] }, { "core_name": "尿量", "tendency": "", "character": [ "减少" ], "anatomy_list": [] }, { "core_name": "体重较前增加", "tendency": "", "character": [], "anatomy_list": [] } ] }, { "id": 1285, "text": "慢性宫颈炎。", "event": [ { "core_name": "宫颈炎", "tendency": "", "character": [ "慢性" ], "anatomy_list": [ "宫颈" ] } ] }, { "id": 361, "text": "予以mri检查提示“膝关节骨性关节炎、半月板损伤、右股骨髁病变性质待定”。", "event": [ { "core_name": "关节炎", "tendency": "", "character": [ "骨性" ], "anatomy_list": [ "膝关节" ] }, { "core_name": "损伤", "tendency": "", "character": [], "anatomy_list": [ "半月板" ] }, { "core_name": "病变", "tendency": "不确定", "character": [], "anatomy_list": [ "右股骨髁" ] } ] }, { "id": 1427, "text": "患者本次发病以来，食欲减退， 神志清醒，精神欠佳，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": [ "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": [ "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": "", "character": [ "明显" ], "anatomy_list": [] } ] }, { "id": 791, "text": "30年来病情进行性加重，咳嗽，咳痰发作渐趋频繁。", "event": [ { "core_name": "咳嗽", "tendency": "", "character": [ "渐趋频繁" ], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "渐趋频繁" ], "anatomy_list": [] } ] }, { "id": 1986, "text": "入院前18小时，患者于服用“头痛粉”后出现呕吐1次，呕吐非喷射样呕吐，呕吐物为鲜血样物，无胆汁样物及隔夜宿食，量约100ml，伴恶心、干呕10余次。", "event": [ { "core_name": "呕吐", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "呕吐", "tendency": "", "character": [ "非喷射样" ], "anatomy_list": [] }, { "core_name": "呕吐物", "tendency": "", "character": [ "鲜血样", "无胆汁样物及隔夜宿食", "量约100ml" ], "anatomy_list": [] }, { "core_name": "恶心", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "干呕", "tendency": "", "character": [], "anatomy_list": [] } ] }, { "id": 1395, "text": "8月22日患者在某妇幼保健院检查阴道镜：宫颈未见明显异常，建议hpv检查。", "event": [ { "core_name": "异常", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [ "宫颈" ] } ] }, { "id": 1843, "text": "10月前，患者无明显诱因出现尿频、尿急、尿痛伴双侧腰痛、便秘，无畏寒、发热，无恶心、呕吐，无腹胀、腹痛，无咳嗽、咳痰，无胸痛、胸闷，无心悸、气促，至某医院行泌尿系彩超检查（2015-03-05），提示：1.右肾积水；2.右肾包膜下少量积液；3.右侧输尿管上段扩张；4.膀胱内弱回声区，内有供血。", "event": [ { "core_name": "尿频", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "尿急", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "尿痛", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "", "character": [], "anatomy_list": [ "双侧腰" ] }, { "core_name": "便秘", "tendency": "", "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": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "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": "心悸", "tendency": "否定", "character": [], "anatomy_list": [ "心" ] }, { "core_name": "气促", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "积水", "tendency": "", "character": [], "anatomy_list": [ "右肾" ] }, { "core_name": "积液", "tendency": "", "character": [ "少量" ], "anatomy_list": [ "右肾包膜下" ] }, { "core_name": "扩张", "tendency": "", "character": [ "扩张" ], "anatomy_list": [ "右侧输尿管上段" ] }, { "core_name": "回声区", "tendency": "", "character": [ "弱" ], "anatomy_list": [ "膀胱内" ] } ] }, { "id": 1086, "text": "今为进一步治疗门诊以“冠状动脉粥样硬化性心脏病”收入我科住院治疗。", "event": [ { "core_name": "冠状动脉粥样硬化性心脏病", "tendency": "", "character": [ "粥样", "硬化性" ], "anatomy_list": [ "冠状动脉", "心脏" ] } ] }, { "id": 219, "text": "患者本次发病以来，食欲下降，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": [ "下降" ], "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": 518, "text": "不伴恶心、呕吐、腹胀、黑便。", "event": [ { "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": "黑便", "tendency": "否定", "character": [], "anatomy_list": [] } ] }, { "id": 1582, "text": "双侧骶韧带未见癌转移。", "event": [ { "core_name": "癌", "tendency": "否定", "character": [ "转移" ], "anatomy_list": [ "双侧骶韧带" ] } ] }, { "id": 1125, "text": "遂于2014-3-5、3-27、2014-4-23、2014-5-15、2014-6-20行五周期化疗（紫杉醇脂质体180mg1+奈达铂50mg1，40mg2 q3w）,患者出现轻度消化道反应，给予对症处理后好转，后复查ca-125持续下降，胸腹部ct未见明显异常。", "event": [ { "core_name": "消化道反应", "tendency": "", "character": [ "轻度" ], "anatomy_list": [ "消化道" ] } ] }, { "id": 1139, "text": "为求进一步诊治今来我院就诊，门诊以“髓母细胞瘤术后化疗”收入院。", "event": [ { "core_name": "髓母细胞瘤", "tendency": "", "character": [ "化疗" ], "anatomy_list": [] } ] }, { "id": 344, "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 ， 体重减轻 。", "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": [ "如常" ], "anatomy_list": [] }, { "core_name": "小便", "tendency": "", "character": [ "如常" ], "anatomy_list": [] }, { "core_name": "体重减轻", "tendency": "", "character": [], "anatomy_list": [] } ] }, { "id": 282, "text": "4.左侧胸腔少量积液，较5+月前病灶明显增大，期间自诉口服中药治疗，症状未缓解，今为求进一步诊治就诊于我科门诊，门诊以“左上肺肺腺癌”收入我科住院治疗。", "event": [ { "core_name": "积液", "tendency": "", "character": [ "少量" ], "anatomy_list": [ "左侧胸腔" ] }, { "core_name": "病灶", "tendency": "", "character": [ "明显增大" ], "anatomy_list": [] }, { "core_name": "腺癌", "tendency": "", "character": [], "anatomy_list": [ "左上肺" ] } ] }, { "id": 997, "text": "目前间断咳嗽，咳少量白色粘痰，偶尔有少量黄痰，无全身乏力、肌肉酸疼，无发热、盗汗，无胸痛、咯血等不适。", "event": [ { "core_name": "咳嗽", "tendency": "", "character": [ "间断" ], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "少量", "白色", "粘" ], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "少量", "黄色", "偶尔" ], "anatomy_list": [] }, { "core_name": "乏力", "tendency": "否定", "character": [], "anatomy_list": [ "全身" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [ "酸痛" ], "anatomy_list": [ "肌肉" ] }, { "core_name": "发热", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "盗汗", "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": [] } ] }, { "id": 1615, "text": "排除放化疗禁忌后于2020-8-3至2020-9-11予以宫颈癌调强放疗，放疗计划：ptv50.40G/28f，放疗期间分别于2020-8-5、8-12、8-19、8-26、9-2予以“顺铂40mg”同步化疗，并于2020-9-4、9-9、9-15、9-18、9-22、9-25予以6次后装治疗。", "event": [ { "core_name": "癌", "tendency": "", "character": [], "anatomy_list": [ "宫颈" ] } ] }, { "id": 349, "text": "患者自发病以来， 精神稍差 ， 食欲稍差 ， 睡眠欠佳 ， 造瘘口排便稍困难 ， 小便如常 ， 体重减轻 。", "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": "排便困难", "tendency": "", "character": [ "稍" ], "anatomy_list": [ "造瘘口" ] }, { "core_name": "小便", "tendency": "", "character": [ "如常" ], "anatomy_list": [] }, { "core_name": "体重减轻", "tendency": "", "character": [], "anatomy_list": [] } ] }, { "id": 1485, "text": "患者自诉2月前无明显诱因出现前胸部胸部疼痛，呈隐痛，不伴牵涉放射痛，阵发，否认发热、盗汗、乏力、咯血，否认胸闷气促、痰中带血、进行性消瘦，无心前区疼痛、心慌等不适，当时未就诊，患者因仍疼痛仍存，2天前遂就诊于我院门诊，行胸部平扫ct示“左肺下叶后基底段段结节，考虑高风险结节，肿瘤性病变可能”，患者为手术治疗入住我院。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [ "隐痛", "不伴牵涉放射痛", "阵发" ], "anatomy_list": [ "前胸部" ] }, { "core_name": "发热", "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": [] }, { "core_name": "咯血", "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": "咳痰", "tendency": "否定", "character": [ "带血" ], "anatomy_list": [] }, { "core_name": "消瘦", "tendency": "否定", "character": [ "进行性" ], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "心前区" ] }, { "core_name": "心慌", "tendency": "否定", "character": [], "anatomy_list": [ "心" ] }, { "core_name": "疼痛", "tendency": "", "character": [], "anatomy_list": [ "前胸部" ] }, { "core_name": "结节", "tendency": "", "character": [ "高风险" ], "anatomy_list": [ "左肺下叶后基底段" ] }, { "core_name": "病变", "tendency": "不确定", "character": [ "肿瘤性" ], "anatomy_list": [] } ] }, { "id": 1020, "text": "上述症状逐渐加重，为求进一步系统治疗来我院，门诊以“1.右侧中耳肿物。", "event": [ { "core_name": "肿物", "tendency": "", "character": [], "anatomy_list": [ "右侧中耳" ] } ] }, { "id": 829, "text": "入院前3+年，患者因“咳嗽咳痰2+年，确诊左下肺肺癌1月”于我院住院治疗，于2016年8月19日在全麻下行胸腔镜中转开胸左下肺癌根治术+胸膜粘连烙断术，手术顺利，术后病理检查（我院，病理号：123456）：<左肺下叶>低分化鳞状细胞癌，支气管切缘未见癌累及。", "event": [ { "core_name": "咳嗽", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "癌", "tendency": "", "character": [], "anatomy_list": [ "左下肺" ] }, { "core_name": "鳞癌", "tendency": "", "character": [ "低分化" ], "anatomy_list": [ "左肺下叶" ] }, { "core_name": "癌", "tendency": "否定", "character": [ "累及" ], "anatomy_list": [ "支气管切缘" ] } ] }, { "id": 286, "text": "自发病以来，精神可，食欲可，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": [ "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": [ "如常" ], "anatomy_list": [] }, { "core_name": "小便", "tendency": "", "character": [ "如常" ], "anatomy_list": [] }, { "core_name": "体重变化", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [] } ] }, { "id": 1095, "text": "入院前半年，患者无明显诱因出现尿频，夜尿次数增多，每晚3-4次，伴排尿困难，表现为：尿线变细，射程变短。", "event": [ { "core_name": "尿频", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "夜尿", "tendency": "", "character": [ "次数增多", "每晚3-4次" ], "anatomy_list": [] }, { "core_name": "排尿困难", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "尿线变细", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "射程变短", "tendency": "", "character": [], "anatomy_list": [] } ] }, { "id": 1610, "text": "2.右肺中叶内侧段及左肺上叶下舌段纤维灶；双肺散在钙化灶。", "event": [ { "core_name": "纤维灶", "tendency": "", "character": [], "anatomy_list": [ "右肺中叶内侧段及左肺上叶下舌段" ] }, { "core_name": "钙化灶", "tendency": "", "character": [ "散在" ], "anatomy_list": [ "双肺" ] } ] }, { "id": 1495, "text": "近1-月以来，患者出现进行性呼吸困难，伴胸闷，伴四肢乏力，伴头晕，伴双下肢水肿，偶有心悸，突发突止，不伴黒朦，不伴意识障碍，不伴发热畏寒，不伴胸痛，不伴放射痛，不伴恶心呕吐，患者就诊于某卫生院，完善胸片检查提示左肺胸腔积液可能，建议患者转上级医院继续治疗，患者遂就诊于我院门诊，门诊以“肺恶性肿瘤”收治我科。", "event": [ { "core_name": "呼吸困难", "tendency": "", "character": [ "进行性" ], "anatomy_list": [] }, { "core_name": "胸闷", "tendency": "", "character": [], "anatomy_list": [ "胸" ] }, { "core_name": "乏力", "tendency": "", "character": [], "anatomy_list": [ "四肢" ] }, { "core_name": "头晕", "tendency": "", "character": [], "anatomy_list": [ "头" ] }, { "core_name": "水肿", "tendency": "", "character": [], "anatomy_list": [ "双下肢" ] }, { "core_name": "心悸", "tendency": "", "character": [ "突发突止" ], "anatomy_list": [ "心" ] }, { "core_name": "黒朦", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "意识障碍", "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": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "胸" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [ "放射性" ], "anatomy_list": [] }, { "core_name": "恶心", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "呕吐", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "积液", "tendency": "不确定", "character": [], "anatomy_list": [ "左肺", "胸腔" ] }, { "core_name": "肿瘤", "tendency": "", "character": [ "恶性" ], "anatomy_list": [ "肺" ] } ] }, { "id": 211, "text": "患者自起病以来，精神略差，胃纳略差，大便次数增多，小便如常，患病期间体重下降约5kg。", "event": [ { "core_name": "精神", "tendency": "", "character": [ "略差" ], "anatomy_list": [] }, { "core_name": "胃纳", "tendency": "", "character": [ "略差" ], "anatomy_list": [ "胃" ] }, { "core_name": "大便", "tendency": "", "character": [ "次数增多" ], "anatomy_list": [] }, { "core_name": "小便", "tendency": "", "character": [ "如常" ], "anatomy_list": [] }, { "core_name": "体重下降", "tendency": "", "character": [], "anatomy_list": [] } ] }, { "id": 694, "text": "患者53岁绝经，绝经前平素月经规则，初潮12岁，周期26-30天，经期3-5天，量中等，无血凝块，偶有痛经，既往白带正常，无异味。", "event": [ { "core_name": "绝经", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "月经", "tendency": "", "character": [ "绝经前", "规则" ], "anatomy_list": [] }, { "core_name": "月经", "tendency": "", "character": [ "量中等", "无血凝块" ], "anatomy_list": [] }, { "core_name": "痛经", "tendency": "", "character": [ "偶尔" ], "anatomy_list": [] }, { "core_name": "白带", "tendency": "", "character": [ "正常", "无异味" ], "anatomy_list": [] } ] }, { "id": 63, "text": "1周前患者于我院门诊复查，完善上腹部腹部ct检查提示肝癌介入术后改变于前片（2014.12.29）比较变化不大，肝左叶外侧段包膜下小结节大小较前无明显改变，肝硬化硬化结节可，甲胎蛋白较前明显升高（未见报告），患者无明显肝区疼痛、乏力、纳差等不适，为求进一步治疗，遂入我院就诊，门诊以“肝细胞癌”收治入院。", "event": [ { "core_name": "癌", "tendency": "", "character": [], "anatomy_list": [ "肝" ] }, { "core_name": "术后改变", "tendency": "", "character": [ "介入术后", "与前片比较变化不大" ], "anatomy_list": [] }, { "core_name": "结节", "tendency": "", "character": [ "小", "大小较前无明显改变" ], "anatomy_list": [ "肝左叶外侧段包膜下" ] }, { "core_name": "硬化", "tendency": "", "character": [], "anatomy_list": [ "肝" ] }, { "core_name": "结节", "tendency": "", "character": [ "硬化" ], "anatomy_list": [ "肝" ] }, { "core_name": "甲胎蛋白", "tendency": "", "character": [ "较前明显升高" ], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [ "肝区" ] }, { "core_name": "乏力", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "纳差", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "癌", "tendency": "", "character": [], "anatomy_list": [ "肝细胞" ] } ] }, { "id": 573, "text": "出院后患者咳嗽、咳痰逐渐好转，未再出现痰中带血，出现脱发，无发热、畏寒，无胸闷、胸痛，无咯血，无头晕、头痛等不适，规律复查血常规，现患者为行第四周期化疗至我院门诊，门诊以“肺恶性肿瘤”收入我科。", "event": [ { "core_name": "咳嗽", "tendency": "", "character": [ "逐渐好转" ], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "逐渐好转" ], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "否定", "character": [ "带血" ], "anatomy_list": [] }, { "core_name": "脱发", "tendency": "", "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": "胸闷", "tendency": "否定", "character": [], "anatomy_list": [ "胸" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "胸部" ] }, { "core_name": "咯血", "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": "肿瘤", "tendency": "", "character": [ "恶性" ], "anatomy_list": [ "肺" ] } ] }, { "id": 542, "text": "患者于入院前1月无明显诱因出现腹痛，为上腹部持续性钝痛，伴阵发性绞痛，偶有恶心、呕吐，无反酸、嗳气，无肩背部放射痛，无心前区压榨感，时有咳嗽，咳中量白色泡沫痰，无鼻塞、流涕，无畏寒、发热，偶有头痛，为前额部胀痛，无畏光、畏声，感全身骨骨痛，四肢乏力，双下肢麻木，不能行走，无关节红肿，无皮肤瘙痒，患者为求进一步诊治，遂于我科就诊。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "疼痛", "tendency": "", "character": [ "持续性", "钝痛", "阵发性", "绞痛" ], "anatomy_list": [ "上腹部" ] }, { "core_name": "恶心", "tendency": "", "character": [ "偶有" ], "anatomy_list": [] }, { "core_name": "呕吐", "tendency": "", "character": [ "偶有" ], "anatomy_list": [] }, { "core_name": "反酸", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "嗳气", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "否定", "character": [ "放射性" ], "anatomy_list": [ "肩", "背部" ] }, { "core_name": "压榨感", "tendency": "否定", "character": [], "anatomy_list": [ "心前区" ] }, { "core_name": "咳嗽", "tendency": "", "character": [ "时有" ], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "中量", "白色", "泡沫痰" ], "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": "畏寒", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "发热", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "", "character": [ "偶有" ], "anatomy_list": [ "头" ] }, { "core_name": "疼痛", "tendency": "", "character": [ "胀痛" ], "anatomy_list": [ "前额部" ] }, { "core_name": "畏光", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "畏声", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "", "character": [], "anatomy_list": [ "骨", "全身" ] }, { "core_name": "乏力", "tendency": "", "character": [], "anatomy_list": [ "四肢" ] }, { "core_name": "麻木", "tendency": "", "character": [], "anatomy_list": [ "双下肢" ] }, { "core_name": "行走", "tendency": "", "character": [ "不能" ], "anatomy_list": [] }, { "core_name": "红肿", "tendency": "否定", "character": [], "anatomy_list": [ "关节" ] }, { "core_name": "瘙痒", "tendency": "否定", "character": [], "anatomy_list": [ "皮肤" ] } ] }, { "id": 36, "text": "患者于当地医院就诊考虑“支气管炎”,给予输液治疗后上述症状能缓解。", "event": [ { "core_name": "支气管炎", "tendency": "不确定", "character": [], "anatomy_list": [ "支气管" ] } ] }, { "id": 1572, "text": "术后分期为：PT3n0M0 iia期；术后给予补充白蛋白、营养支持等治疗；术后患者分别于2019-09-26、2019-11-1按folfox方案化疗2周期（药物总量：奥沙利铂甘露醇：0.14g，奥沙利铂140mg，氟尿嘧啶8.4g）；化疗期间无明显恶心、呕吐、腹胀、腹痛，无骨髓抑制等化疗副反应。患者因个人原因到某地工作，未按时化疗。", "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": "腹胀", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [ "腹" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [ "腹" ] }, { "core_name": "骨髓抑制", "tendency": "否定", "character": [], "anatomy_list": [ "骨髓" ] }, { "core_name": "化疗副反应", "tendency": "否定", "character": [], "anatomy_list": [] } ] }, { "id": 1251, "text": "无恶心、呕吐，无腹痛、腹泻，无畏寒、发热、黄疸，无转移性右下腹痛，无腹胀，无肛门停止排气排便，无呕血、黑便，无咳嗽、咳痰，无胸闷、呼吸困难。", "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": "腹泻", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "畏寒", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "发热", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "黄疸", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "否定", "character": [ "转移性" ], "anatomy_list": [ "右下腹" ] }, { "core_name": "腹胀", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "排气", "tendency": "否定", "character": [ "停止" ], "anatomy_list": [ "肛门" ] }, { "core_name": "排便", "tendency": "否定", "character": [ "停止" ], "anatomy_list": [ "肛门" ] }, { "core_name": "呕血", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "黑便", "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": "呼吸困难", "tendency": "否定", "character": [], "anatomy_list": [] } ] }, { "id": 888, "text": "入院前20天，患者行体检肠镜提示“结肠息肉”，平素排便稍费力，大便结燥，无大便不成形，伴大便次数增多，每日2-3次，无大便带血，无腹痛，偶有腹胀，偶有反酸、烧心，无呃逆、嗳气，无厌油、纳差，无进食梗塞感，无饮水呛咳，间断咳嗽、咳痰，无胸闷、胸痛，无头晕、头痛，无畏寒、发热，伴尿频，无尿急、尿痛，无畏寒、发热，无眼黄、身黄等不适，现患者为进一步行息肉切除入院，门诊以“结肠息肉”收入我科继续治疗。", "event": [ { "core_name": "息肉", "tendency": "", "character": [], "anatomy_list": [ "结肠" ] }, { "core_name": "排便费力", "tendency": "", "character": [ "稍" ], "anatomy_list": [] }, { "core_name": "大便", "tendency": "", "character": [ "结燥" ], "anatomy_list": [] }, { "core_name": "大便", "tendency": "否定", "character": [ "不成形" ], "anatomy_list": [] }, { "core_name": "大便", "tendency": "", "character": [ "次数增多" ], "anatomy_list": [] }, { "core_name": "大便", "tendency": "否定", "character": [ "带血" ], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "腹胀", "tendency": "", "character": [ "偶有" ], "anatomy_list": [ "腹" ] }, { "core_name": "反酸", "tendency": "", "character": [ "偶有" ], "anatomy_list": [] }, { "core_name": "烧心", "tendency": "", "character": [ "偶有" ], "anatomy_list": [] }, { "core_name": "呃逆", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "嗳气", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "厌油", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "纳差", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "梗塞感", "tendency": "否定", "character": [ "进食" ], "anatomy_list": [] }, { "core_name": "呛咳", "tendency": "否定", "character": [ "饮水" ], "anatomy_list": [] }, { "core_name": "咳嗽", "tendency": "", "character": [ "间断" ], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "间断" ], "anatomy_list": [] }, { "core_name": "胸闷", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "胸" ] }, { "core_name": "头晕", "tendency": "否定", "character": [], "anatomy_list": [ "头" ] }, { "core_name": "疼痛", "tendency": "否定", "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": "尿频", "tendency": "", "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": "畏寒", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "发热", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "黄染", "tendency": "否定", "character": [], "anatomy_list": [ "眼" ] }, { "core_name": "黄染", "tendency": "", "character": [], "anatomy_list": [ "身" ] }, { "core_name": "息肉", "tendency": "", "character": [], "anatomy_list": [ "结肠" ] } ] }, { "id": 547, "text": "脑mri增强（2014-10-14）提示：未见明显颅内转移，建议完善骨扫描检查，拟行化疗及粒子植入治疗，患者及家属考虑后拒绝，并要求出院。", "event": [ { "core_name": "转移", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [ "颅内" ] } ] }, { "id": 32, "text": "于入院前1天,患者无明显诱因出现恶心不适,无呕吐,期间无咳嗽、咳痰,无呛咳,无血尿、泡沫尿,无尿频、尿痛,无光过敏,无口腔溃疡,无脱发,无发热、畏寒等不适。", "event": [ { "core_name": "恶心", "tendency": "", "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": [] }, { "core_name": "呛咳", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "血尿", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "泡沫尿", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "尿频", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "尿痛", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "过敏", "tendency": "否定", "character": [ "光" ], "anatomy_list": [] }, { "core_name": "溃疡", "tendency": "否定", "character": [], "anatomy_list": [ "口腔" ] }, { "core_name": "脱发", "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": [] } ] }, { "id": 1603, "text": "患病以来，精神、食欲、睡眠一般，大便正常，排尿频繁，小便量少，排尿困难，近期体重无明显减轻。", "event": [ { "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": [ "一般" ], "anatomy_list": [] }, { "core_name": "大便", "tendency": "", "character": [ "正常" ], "anatomy_list": [] }, { "core_name": "尿频", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "小便", "tendency": "", "character": [ "量少" ], "anatomy_list": [] }, { "core_name": "排尿困难", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "体重减轻", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [] } ] }, { "id": 996, "text": "遂行支气管支架植入术及冷冻治疗，术后喘累、呼吸困难明显缓解，行化疗3周期，放疗1周期。", "event": [ { "core_name": "喘累", "tendency": "", "character": [ "术后", "明显缓解" ], "anatomy_list": [] }, { "core_name": "呼吸困难", "tendency": "", "character": [ "术后", "明显缓解" ], "anatomy_list": [] } ] }, { "id": 737, "text": "后每2-3年左右发作1次，均于打麻将时发生，症状同前，患者否认发作前有胸闷、胸痛、心悸、气促症状，意识恢复后有恶心、呕吐症状。", "event": [ { "core_name": "胸闷", "tendency": "否定", "character": [ "发作前" ], "anatomy_list": [ "胸" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [ "发作前" ], "anatomy_list": [ "胸" ] }, { "core_name": "心悸", "tendency": "否定", "character": [ "发作前" ], "anatomy_list": [ "心" ] }, { "core_name": "气促", "tendency": "否定", "character": [ "发作前" ], "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" ], "anatomy_list": [] } ] }, { "id": 1278, "text": "患者本次发病以来，食欲正常，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": "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": 1298, "text": "入院前40天，患者于某医院体检发现双侧甲状腺结节，建议进一步检查，患者因个人原因未治疗。", "event": [ { "core_name": "结节", "tendency": "", "character": [], "anatomy_list": [ "双侧甲状腺" ] } ] }, { "id": 1494, "text": "患者在当地诊所（具体不详）就诊，症状未见明显改善，患者未予以重视，咳嗽、咳痰较前明显加重，并出现呼吸困难等不适，后转诊至我院，完善气管镜检查，病检回示鳞状细胞癌，标本送常规病检(2019-11-17):（左主气管活检）结合形态学及免疫组化结果，支持鳞状细胞癌。", "event": [ { "core_name": "咳嗽", "tendency": "", "character": [ "较前明显加重" ], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "较前明显加重" ], "anatomy_list": [] }, { "core_name": "呼吸困难", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "癌", "tendency": "", "character": [], "anatomy_list": [ "左主气管" ] }, { "core_name": "鳞癌", "tendency": "", "character": [], "anatomy_list": [ "左主气管" ] } ] }, { "id": 226, "text": "患者自发病以来， 精神稍差 ， 食欲稍差 ， 睡眠欠佳 ， 大便量少 ， 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": [ "量少" ], "anatomy_list": [] }, { "core_name": "小便", "tendency": "", "character": [ "如常" ], "anatomy_list": [] }, { "core_name": "体重变化", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [] } ] }, { "id": 672, "text": "（右乳4点、7点包块）穿刺活检：浸润性导管癌。", "event": [ { "core_name": "包块", "tendency": "", "character": [], "anatomy_list": [ "右乳4点7点" ] }, { "core_name": "导管癌", "tendency": "", "character": [ "浸润性" ], "anatomy_list": [] } ] }, { "id": 2053, "text": "今患者为求复查就诊于我院，以“下段食管癌术后”收入我科。", "event": [ { "core_name": "癌", "tendency": "", "character": [ "术后" ], "anatomy_list": [ "下段食管" ] } ] }, { "id": 1415, "text": "患者家属自行于某医院复查病理切片结果：（卵巢）高级别浆液性腺癌。", "event": [ { "core_name": "腺癌", "tendency": "", "character": [ "高级别", "浆液性" ], "anatomy_list": [ "卵巢" ] } ] }, { "id": 1898, "text": "8月前，患者无明显诱因出现双侧肋骨肋骨疼痛，遂于2018.07.02在某医院行ct检查：1.双肺未见明显异常。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [], "anatomy_list": [ "双侧肋骨" ] } ] }, { "id": 1231, "text": "不伴大汗淋漓，不伴畏寒、发热，无胸闷、心悸，无腹胀，腹泻，无尿频、尿急、尿痛等症状。", "event": [ { "core_name": "出汗", "tendency": "否定", "character": [ "增多" ], "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": "心悸", "tendency": "否定", "character": [], "anatomy_list": [ "心" ] }, { "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": [] } ] }, { "id": 583, "text": "半天前，患者无明显诱因再次出现恶心、呕吐、呕鲜红色血液，伴血凝块，约250ml，伴反酸，无腹痛、腹胀、黑便、腹泻，无黑曚、晕厥、意识丧失，无身黄、眼黄、尿黄，无畏寒、发热，现患者为求进一步治疗，门诊以“上消化道出血”收入我科。", "event": [ { "core_name": "恶心", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "呕吐", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "呕血", "tendency": "", "character": [ "鲜红色", "血凝块" ], "anatomy_list": [] }, { "core_name": "反酸", "tendency": "", "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": "黑便", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "腹泻", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "黒朦", "tendency": "否定", "character": [], "anatomy_list": [ "眼" ] }, { "core_name": "晕厥", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "意识丧失", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "黄染", "tendency": "否定", "character": [], "anatomy_list": [ "全身" ] }, { "core_name": "黄染", "tendency": "否定", "character": [], "anatomy_list": [ "眼" ] }, { "core_name": "尿黄", "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": "", "character": [], "anatomy_list": [ "上消化道" ] } ] }, { "id": 1432, "text": "2018.3.27返院复查膀胱镜见膀胱新生物复发，行新生物电切术后病检示：膀胱底后壁送检散碎组织小灶尿路上皮示高级别尿路上皮癌，另见钙盐沉积及异物肉芽肿；膀胱左侧新生物送检组织衬覆少量尿路上皮伴个别炎症细胞浸润；膀胱颈及三角区送检组织示腺性膀胱炎；左侧输尿管旁送检组织示局灶钙盐沉积，血管扩张充血伴少量慢性炎症细胞浸润。", "event": [ { "core_name": "新生物", "tendency": "", "character": [ "复发" ], "anatomy_list": [ "膀胱" ] }, { "core_name": "癌", "tendency": "", "character": [ "高级别" ], "anatomy_list": [ "膀胱底后壁", "尿路上皮" ] }, { "core_name": "钙盐沉积", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "异物肉芽肿", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "新生物", "tendency": "", "character": [ "衬覆少量尿路上皮", "炎症细胞浸润" ], "anatomy_list": [ "膀胱左侧", "尿路上皮" ] }, { "core_name": "钙盐沉积", "tendency": "", "character": [], "anatomy_list": [ "左侧输尿管旁" ] }, { "core_name": "扩张充血", "tendency": "", "character": [], "anatomy_list": [ "血管" ] }, { "core_name": "浸润", "tendency": "", "character": [ "炎症细胞", "少量", "慢性" ], "anatomy_list": [ "膀胱左侧" ] } ] }, { "id": 1130, "text": "10余天前，患者感右上腹胀较前加重，伴双下肢水肿，小便颜色黄。", "event": [ { "core_name": "腹胀", "tendency": "", "character": [ "加重" ], "anatomy_list": [ "右上腹" ] }, { "core_name": "水肿", "tendency": "", "character": [], "anatomy_list": [ "双下肢" ] }, { "core_name": "小便", "tendency": "", "character": [ "颜色黄" ], "anatomy_list": [] } ] }, { "id": 1367, "text": "患者自发病以来， 精神、食欲、睡眠稍差 ， 二便较少 ， 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": [ "稍差" ], "anatomy_list": [] }, { "core_name": "大便", "tendency": "", "character": [ "较少" ], "anatomy_list": [] }, { "core_name": "小便", "tendency": "", "character": [ "较少" ], "anatomy_list": [] }, { "core_name": "体重改变", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [] } ] }, { "id": 212, "text": "患者于5+月前无明显诱因出现咳嗽、咳痰，痰为白色粘稠痰，伴痰中带血，呈鲜红色，量少，无寒战、发热、胸痛、心悸、呼吸困难，无头晕、头痛、腹痛、腹泻等不适。", "event": [ { "core_name": "咳嗽", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "白色", "粘稠" ], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "带血", "鲜红色", "量少" ], "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": [ "胸" ] }, { "core_name": "心悸", "tendency": "否定", "character": [], "anatomy_list": [ "心" ] }, { "core_name": "呼吸困难", "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": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "腹泻", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] } ] }, { "id": 457, "text": "3.肝内多发囊肿，脾脏小囊肿。", "event": [ { "core_name": "囊肿", "tendency": "", "character": [ "多发" ], "anatomy_list": [ "肝内" ] }, { "core_name": "囊肿", "tendency": "", "character": [ "小" ], "anatomy_list": [ "脾脏" ] } ] }, { "id": 875, "text": "2.前列腺增生。", "event": [ { "core_name": "增生", "tendency": "", "character": [], "anatomy_list": [ "前列腺" ] } ] }, { "id": 936, "text": "无咳嗽、咳痰、喘累等。", "event": [ { "core_name": "咳嗽", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "喘累", "tendency": "否定", "character": [], "anatomy_list": [] } ] }, { "id": 572, "text": "完善头部mr、腹部彩超、全身骨显像等检查后诊断“原发性支气管肺癌右上肺肺小细胞癌并肺内、全身多淋巴结、骨转移t4n3Mm1civ期”，于2018.03.17、2018.04.09、2018.05.04行3周期化疗，方案为：依托泊苷+奈达铂，第三周期复查胸部ct病灶明显吸收，化疗后无特殊不适出院。", "event": [ { "core_name": "癌", "tendency": "", "character": [ "原发性" ], "anatomy_list": [ "支气管", "肺" ] }, { "core_name": "癌", "tendency": "", "character": [], "anatomy_list": [ "右上肺", "小细胞" ] }, { "core_name": "病灶", "tendency": "", "character": [ "明显吸收" ], "anatomy_list": [ "右上肺" ] }, { "core_name": "癌", "tendency": "", "character": [ "转移", "t4n3Mm1civ期" ], "anatomy_list": [ "肺内", "全身多淋巴结", "骨" ] } ] }, { "id": 1543, "text": "4.回肠末段肠管骤热变细、系膜条索影，束带粘连压迫可能，继发近端机械性不全性梗阻。", "event": [ { "core_name": "变细", "tendency": "", "character": [ "骤热" ], "anatomy_list": [ "回肠末端" ] }, { "core_name": "条索影", "tendency": "", "character": [], "anatomy_list": [ "系膜" ] }, { "core_name": "粘连", "tendency": "不确定", "character": [], "anatomy_list": [ "束带" ] }, { "core_name": "压迫", "tendency": "不确定", "character": [], "anatomy_list": [ "束带" ] }, { "core_name": "梗阻", "tendency": "", "character": [ "继发", "机械性", "不完全性" ], "anatomy_list": [ "回肠近端" ] } ] }, { "id": 693, "text": "患者在办入院前，购买卫生巾时出现阴道较多流血，可见鲜血顺双腿流下，自觉阴道有组织物掉出，遂立即于急诊科就诊，由急诊请我科住院总医师会诊，立即转入我科，急诊行超声引导下清宫术。", "event": [ { "core_name": "出血", "tendency": "", "character": [ "较多", "鲜血顺双腿流下" ], "anatomy_list": [ "阴道" ] }, { "core_name": "组织物掉出", "tendency": "", "character": [], "anatomy_list": [ "阴道" ] } ] }, { "id": 794, "text": "1年前住院胸部ct发现肺部结节，考虑肺癌可能，未进一步诊治；4月前患者于我院住院，胸水中查见肿瘤细胞，倾向腺癌细胞，诊断为肺腺癌伴胸膜转移（iv期，t4nxm1），院外口服“吉非替尼”靶向药物治疗。", "event": [ { "core_name": "结节", "tendency": "", "character": [], "anatomy_list": [ "肺部" ] }, { "core_name": "癌", "tendency": "不确定", "character": [], "anatomy_list": [ "肺" ] }, { "core_name": "肿瘤细胞", "tendency": "", "character": [ "胸水中" ], "anatomy_list": [] }, { "core_name": "腺癌细胞", "tendency": "不确定", "character": [ "胸水中" ], "anatomy_list": [] }, { "core_name": "腺癌", "tendency": "", "character": [ "胸膜转移iv期", "t4nxm1" ], "anatomy_list": [ "肺" ] } ] }, { "id": 1814, "text": "2019/11/7ct检查报告：左肺癌肺癌根治术后表现，残余左肺少许炎性改变，左胸及纵隔、双侧胸壁皮下、胸背部、颈部较多积气。", "event": [ { "core_name": "炎性改变", "tendency": "", "character": [ "少许" ], "anatomy_list": [ "残余左肺" ] }, { "core_name": "积气", "tendency": "", "character": [ "较多" ], "anatomy_list": [ "左胸皮下", "左胸纵隔皮下", "左胸双侧胸壁皮下", "胸背部", "颈部" ] } ] }, { "id": 1259, "text": "后患者每年秋冬季节均出现咳嗽、咳痰，均自购“感冒药”服用后好转；2月前患者因“反复心悸、气促1+月”于我院心内科住院，完善相关检查：胸部+上腹部ct(256)检查（2018-03-01，我院）：1.左肺门包绕下叶支气管跨叶生长肿块如上述，考虑肿瘤。", "event": [ { "core_name": "咳嗽", "tendency": "", "character": [ "“感冒药”服用后好转" ], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "“感冒药”服用后好转" ], "anatomy_list": [] }, { "core_name": "心悸", "tendency": "", "character": [ "反复" ], "anatomy_list": [ "心" ] }, { "core_name": "气促", "tendency": "", "character": [ "反复" ], "anatomy_list": [] }, { "core_name": "肿块", "tendency": "", "character": [ "包绕下叶支气管跨叶生长" ], "anatomy_list": [ "左肺门" ] } ] }, { "id": 637, "text": "（吻合口近端、吻合口远端、放射状切缘）未见癌累及。网膜及阑尾组织。", "event": [ { "core_name": "癌", "tendency": "否定", "character": [ "累及" ], "anatomy_list": [ "吻合口近端", "吻合口远端", "放射状切缘" ] } ] }, { "id": 1248, "text": "现患者为求以“右侧胸腔积液；右肺腺癌”，收入我科。", "event": [ { "core_name": "积液", "tendency": "", "character": [], "anatomy_list": [ "右侧胸腔" ] }, { "core_name": "腺癌", "tendency": "", "character": [], "anatomy_list": [ "右肺" ] } ] }, { "id": 1697, "text": "曾因上述症状于外院就诊，查c无明显异常，腹部b超提示：1、脂肪肝；2、脾大；3、右肾周少量积液。", "event": [ { "core_name": "肝功异常", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [ "肝" ] }, { "core_name": "肾功异常", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [ "肾" ] }, { "core_name": "脂肪肝", "tendency": "", "character": [], "anatomy_list": [ "肝" ] }, { "core_name": "脾大", "tendency": "", "character": [], "anatomy_list": [ "脾" ] }, { "core_name": "积液", "tendency": "", "character": [ "少量" ], "anatomy_list": [ "右肾周" ] } ] }, { "id": 779, "text": "院外患者全身疼痛疼痛不适，以腰背部及左侧髋关节处明显，患者自行购买芬必得止痛，效果欠佳，2月前因疼痛加重到我科就诊，建议患者行egfr、alk等基因检测，患者及其家属经慎重考虑后拒绝，自服吉非替尼治疗观察，住院期间根据疼痛调整为羟考酮缓释片 30mg q12h止痛，并予以抗肿瘤、增强免疫、唑来磷酸抗溶骨等处理好转出院。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [], "anatomy_list": [ "全身" ] }, { "core_name": "疼痛", "tendency": "", "character": [ "明显" ], "anatomy_list": [ "腰背部" ] }, { "core_name": "疼痛", "tendency": "", "character": [ "明显" ], "anatomy_list": [ "左侧髋关节" ] }, { "core_name": "疼痛", "tendency": "", "character": [ "加重" ], "anatomy_list": [] } ] }, { "id": 1057, "text": "伴反酸、嗳气、烧心、呃逆，不伴有腹痛、腹泻、尿频、尿急等不适。", "event": [ { "core_name": "反酸", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "嗳气", "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": "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": [] } ] }, { "id": 270, "text": "患者未予以重视，1天前，患者无明显诱因出现腰痛加重，并向双下肢放射，伴双小腿麻木、双下肢乏力；疼痛能忍受，久站、久坐及长距离行走后加重，卧床休息可稍缓解。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [ "加重" ], "anatomy_list": [ "腰" ] }, { "core_name": "疼痛", "tendency": "", "character": [ "放射性" ], "anatomy_list": [ "双下肢" ] }, { "core_name": "麻木", "tendency": "", "character": [], "anatomy_list": [ "双小腿" ] }, { "core_name": "乏力", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "", "character": [ "能忍受", "久站、久坐及长距离行走后加重", "卧床休息可稍缓解" ], "anatomy_list": [] } ] }, { "id": 296, "text": "患者4月前无明显诱因出现右下腹疼痛，为间歇性疼痛，伴烧灼感，无明显加重或缓解因素，无畏寒、发热，无恶心、呕吐，无肉眼血尿，无尿频、尿急，无排尿疼痛，无排尿困难，无双侧腰部胀痛，无双下肢水肿。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [ "间歇性", "伴烧灼感", "无明显加重或缓解因素" ], "anatomy_list": [ "右下腹" ] }, { "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": "血尿", "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": "疼痛", "tendency": "否定", "character": [ "排尿" ], "anatomy_list": [] }, { "core_name": "排尿困难", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "否定", "character": [ "胀痛" ], "anatomy_list": [ "双侧腰部" ] }, { "core_name": "水肿", "tendency": "否定", "character": [], "anatomy_list": [ "双下肢" ] } ] }, { "id": 560, "text": "无胸闷、乏力。", "event": [ { "core_name": "胸闷", "tendency": "否定", "character": [], "anatomy_list": [ "胸" ] }, { "core_name": "乏力", "tendency": "否定", "character": [], "anatomy_list": [] } ] }, { "id": 1062, "text": "发现血压升高18年，最高血压为“200/110mmHg,目前服用“左旋氨氯地平5mg，依那普利5mg”，血压控制可，波动于130-140/80-90mmHg。", "event": [ { "core_name": "血压", "tendency": "", "character": [ "升高" ], "anatomy_list": [] }, { "core_name": "血压", "tendency": "", "character": [ "控制可" ], "anatomy_list": [] }, { "core_name": "血压", "tendency": "", "character": [ "波动" ], "anatomy_list": [] } ] }, { "id": 525, "text": "入院前1年，患者开始偶有静息下呼吸困难，无咯粉红色泡沫痰，伴长期双下肢水肿，无胸痛，无咯血，无恶心呕吐，院外予以“利尿消肿”等治疗可缓解。", "event": [ { "core_name": "呼吸困难", "tendency": "", "character": [ "偶有", "静息下" ], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "否定", "character": [ "粉红色泡沫" ], "anatomy_list": [] }, { "core_name": "水肿", "tendency": "", "character": [ "长期" ], "anatomy_list": [ "双下肢" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "胸" ] }, { "core_name": "咯血", "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": [] } ] }, { "id": 620, "text": "约47岁绝经。", "event": [ { "core_name": "绝经", "tendency": "", "character": [], "anatomy_list": [] } ] }, { "id": 1919, "text": "5+月前患者因“进行性吞咽困难2+月”入我院，我院胃镜检查提示“距门齿21厘米处食管可见一隆起性新生物”，活检提示“食管鳞状细胞癌”；完善相关检查后有手术指征，无绝对手术禁忌，遂于我院行“胸腹腔镜联合食管癌根治+空肠造瘘术”。", "event": [ { "core_name": "吞咽困难", "tendency": "", "character": [ "进行性" ], "anatomy_list": [] }, { "core_name": "新生物", "tendency": "", "character": [ "隆起性" ], "anatomy_list": [ "距门齿21厘米处食管" ] }, { "core_name": "鳞癌", "tendency": "", "character": [], "anatomy_list": [ "食管" ] } ] }, { "id": 1355, "text": "亚砷酸化疗两个疗程后，复查骨髓涂片：增生性骨髓象，化疗过程中，查脑脊液：细胞总数 1401.0*10＾6/L，单个核细胞比率 100.00%，脑脊液生化报告：蛋白 1158.6mg/L，遂多次行地塞米松、甲氨蝶呤、阿糖胞苷鞘内药物注射，患者病情好转出院。", "event": [ { "core_name": "骨髓象", "tendency": "", "character": [ "增生性" ], "anatomy_list": [ "骨髓" ] } ] }, { "id": 280, "text": "2.双肺上叶、右肺下叶背段小结节影，转移瘤或其他病变，建议随访复查。", "event": [ { "core_name": "结节影", "tendency": "", "character": [ "小" ], "anatomy_list": [ "双肺上叶", "右肺下叶背段" ] }, { "core_name": "转移瘤", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "病变", "tendency": "", "character": [ "其他" ], "anatomy_list": [] } ] }, { "id": 897, "text": "病程中患者反复出现颜面及双下肢重度水肿在我科住院治疗，血肌酐在168-425umol/l之间波动，因患者不能平卧平卧休息，伴明显活动后心累气促，考虑心衰，予以血液透析、改善心功能等处理后好转出院。", "event": [ { "core_name": "水肿", "tendency": "", "character": [ "重度", "反复出现" ], "anatomy_list": [ "颜面" ] }, { "core_name": "水肿", "tendency": "", "character": [ "重度", "反复出现" ], "anatomy_list": [ "双下肢" ] }, { "core_name": "平卧休息", "tendency": "否定", "character": [ "不能" ], "anatomy_list": [] }, { "core_name": "心累", "tendency": "", "character": [ "明显活动后" ], "anatomy_list": [] }, { "core_name": "气促", "tendency": "", "character": [ "明显活动后" ], "anatomy_list": [] }, { "core_name": "心力衰竭", "tendency": "不确定", "character": [], "anatomy_list": [ "心" ] } ] }, { "id": 30, "text": "入院前8天余,患者无明显诱因出现声嘶,鼻阻,伴少量透明流涕,自行服用“阿莫西林”等药物后,流涕、鼻塞症状稍有缓解,但仍声嘶明显。", "event": [ { "core_name": "声嘶", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "鼻阻", "tendency": "", "character": [], "anatomy_list": [ "鼻" ] }, { "core_name": "流涕", "tendency": "", "character": [ "透明", "少量" ], "anatomy_list": [] }, { "core_name": "流涕", "tendency": "", "character": [ "症状稍有缓解" ], "anatomy_list": [] }, { "core_name": "鼻塞", "tendency": "", "character": [ "稍有缓解" ], "anatomy_list": [ "鼻" ] }, { "core_name": "声嘶", "tendency": "", "character": [ "明显" ], "anatomy_list": [] } ] }, { "id": 254, "text": "门诊以“颈部包块待查”收入我科住院治疗。", "event": [ { "core_name": "包块", "tendency": "", "character": [], "anatomy_list": [ "颈部" ] } ] }, { "id": 655, "text": "入院前1+周，患者无意中扪及双侧乳腺肿物，约蚕豆大小，不伴有乳房疼痛，不伴有乳头溢血溢液，无局部红肿热痛。", "event": [ { "core_name": "肿物", "tendency": "", "character": [ "约蚕豆大小" ], "anatomy_list": [ "双侧乳腺" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "乳房" ] }, { "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": "发红", "tendency": "否定", "character": [ "局部" ], "anatomy_list": [ "乳房" ] }, { "core_name": "肿", "tendency": "否定", "character": [ "局部" ], "anatomy_list": [ "乳房" ] }, { "core_name": "热", "tendency": "否定", "character": [ "局部" ], "anatomy_list": [ "乳房" ] }, { "core_name": "痛", "tendency": "否定", "character": [ "局部" ], "anatomy_list": [ "乳房" ] } ] }, { "id": 1220, "text": "2017年6月7日宫颈活检提示：（宫颈）见大片异型细胞，倾向恶性肿瘤，建议免疫组化10项协助诊断。", "event": [ { "core_name": "异型细胞", "tendency": "", "character": [ "大片" ], "anatomy_list": [ "宫颈" ] }, { "core_name": "肿瘤", "tendency": "不确定", "character": [ "恶性" ], "anatomy_list": [ "宫颈" ] } ] }, { "id": 582, "text": "入院前1天，患者因服用“头痛粉”后出现恶心、呕吐，呕吐物为胃内容物，无喷射样呕吐，无呕血，伴乏力，无腹痛、腹胀、黑便、腹泻，无畏寒、发热，未引起重视，未进行诊治。", "event": [ { "core_name": "恶心", "tendency": "", "character": [ "服用头痛粉" ], "anatomy_list": [] }, { "core_name": "呕吐", "tendency": "", "character": [ "呕吐物为胃内容物", "服用头痛粉" ], "anatomy_list": [] }, { "core_name": "呕吐", "tendency": "否定", "character": [ "喷射样" ], "anatomy_list": [] }, { "core_name": "呕血", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "乏力", "tendency": "", "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": "黑便", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "腹泻", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "畏寒", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "发热", "tendency": "否定", "character": [], "anatomy_list": [] } ] }, { "id": 869, "text": "患者发病以来，神志 清晰，精神可，胃纳可，大便如上，小便如常，体重未见明显下降。", "event": [ { "core_name": "神志", "tendency": "", "character": [ "清晰" ], "anatomy_list": [] }, { "core_name": "精神", "tendency": "", "character": [ "可" ], "anatomy_list": [] }, { "core_name": "胃纳", "tendency": "", "character": [ "可" ], "anatomy_list": [ "胃" ] }, { "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": 1920, "text": "术后病理结果提示：食管高分化鳞状细胞癌，侵及深肌层，食管切缘、胃切缘未见癌累及，右喉返旁淋巴结见癌转移（2/7），（胃周围、食管旁、胃左、隆突下）淋巴结未见癌转移。", "event": [ { "core_name": "鳞癌", "tendency": "", "character": [ "高分化" ], "anatomy_list": [ "食管" ] }, { "core_name": "鳞癌", "tendency": "", "character": [ "侵及" ], "anatomy_list": [ "深肌层" ] }, { "core_name": "癌", "tendency": "否定", "character": [ "累及" ], "anatomy_list": [ "食管切缘", "胃切缘" ] }, { "core_name": "癌", "tendency": "", "character": [ "转移" ], "anatomy_list": [ "右喉返旁淋巴结" ] }, { "core_name": "癌", "tendency": "否定", "character": [ "转移" ], "anatomy_list": [ "胃周围淋巴结", "食管旁淋巴结", "胃左淋巴结", "隆突下淋巴结" ] } ] }, { "id": 1904, "text": "3.全身多处骨质破坏，fdg代谢增高，考虑转移。", "event": [ { "core_name": "骨质破坏", "tendency": "", "character": [ "多处" ], "anatomy_list": [ "全身" ] }, { "core_name": "fdg代谢", "tendency": "", "character": [ "增高" ], "anatomy_list": [] }, { "core_name": "转移", "tendency": "不确定", "character": [], "anatomy_list": [] } ] }, { "id": 312, "text": "”经对症治疗后，患者症状较前缓解后出院，未行放化疗及去趋势治疗，经为进一步治疗遂到我院就诊，门诊以“前列腺癌”收入我科继续治疗。", "event": [ { "core_name": "癌", "tendency": "", "character": [], "anatomy_list": [ "前列腺" ] } ] }, { "id": 1935, "text": "2、轻度脂肪肝，脾稍大；3、右侧髂骨内骨岛。", "event": [ { "core_name": "脂肪肝", "tendency": "", "character": [ "轻度" ], "anatomy_list": [ "肝" ] }, { "core_name": "脾大", "tendency": "", "character": [ "稍" ], "anatomy_list": [ "脾" ] } ] }, { "id": 892, "text": "到某中医院就诊，经检查考虑肺癌可能，后于某医院就诊，经胸部ct检查后考虑诊断肺癌可能，建议完善肺穿刺活检，患者拒绝并出院。", "event": [ { "core_name": "癌", "tendency": "不确定", "character": [], "anatomy_list": [ "肺" ] }, { "core_name": "癌", "tendency": "不确定", "character": [], "anatomy_list": [ "肺" ] } ] }, { "id": 1469, "text": "入院前5+月，患儿因面色苍白、乏力、皮肤瘀斑瘀点在我院经骨髓micm分型确诊为急性普通b淋巴细胞淋巴细胞白血病l11型（低危，crlf2高表达）。", "event": [ { "core_name": "面色苍白", "tendency": "", "character": [], "anatomy_list": [ "面" ] }, { "core_name": "乏力", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "瘀斑", "tendency": "", "character": [], "anatomy_list": [ "皮肤" ] }, { "core_name": "瘀点", "tendency": "", "character": [], "anatomy_list": [ "皮肤" ] }, { "core_name": "白血病", "tendency": "", "character": [ "b淋巴细胞", "crlf2高表达", "普通", "低危", "急性", "l11型" ], "anatomy_list": [] } ] }, { "id": 1347, "text": "予以患者经皮经肝穿刺置管引流后黄疸较前明显好转后出院。", "event": [ { "core_name": "黄疸", "tendency": "", "character": [ "明显好转" ], "anatomy_list": [] } ] }, { "id": 1517, "text": "患者高血压病，高血压性心脏病10+年，既往最高血压180+/？mmhg，现服用硝苯地平控释片30mg口服qd控制血压。", "event": [ { "core_name": "高血压", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "心脏病", "tendency": "", "character": [ "高血压" ], "anatomy_list": [ "心脏" ] } ] }, { "id": 1914, "text": "遂到在某医院行支气管镜活检，病理提示肺鳞癌。", "event": [ { "core_name": "鳞癌", "tendency": "", "character": [], "anatomy_list": [ "肺" ] } ] }, { "id": 446, "text": "患者10余年前因朋友及家人发现睡眠时打鼾，不伴有夜间憋醒，自诉睡眠时伴有多梦，无心慌、胸闷，无心前区压榨感，无呼吸困难等不适。患者未予以进一步重视及治疗。", "event": [ { "core_name": "打鼾", "tendency": "", "character": [ "睡眠时" ], "anatomy_list": [] }, { "core_name": "憋醒", "tendency": "否定", "character": [ "夜间" ], "anatomy_list": [] }, { "core_name": "多梦", "tendency": "", "character": [ "睡眠时" ], "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": "压榨感", "tendency": "否定", "character": [], "anatomy_list": [ "心前区" ] }, { "core_name": "呼吸困难", "tendency": "否定", "character": [], "anatomy_list": [] } ] }, { "id": 1434, "text": "6月前患者复查再次于我院就诊，膀胱镜检见膀胱内一新生物由于病变极小，取组织后如为恶性肿瘤手术时无法找到病变所在位置，与患者家属沟通后患者家属要求暂不取组织活检要求行诊断性电切术，故于2018年10月18日在硬膜外麻醉下行膀胱病损电切术，术后给予患者表柔比星50mg膀胱灌注治疗。", "event": [ { "core_name": "新生物", "tendency": "", "character": [ "病变极小" ], "anatomy_list": [ "膀胱内" ] }, { "core_name": "肿瘤", "tendency": "不确定", "character": [ "恶性" ], "anatomy_list": [] } ] }, { "id": 2056, "text": "2019-06-03行全面下开腹探查：肿瘤位于回盲部，肿瘤侵犯侵犯右侧盆壁肌肉，肠系膜可见肿大淋巴结。", "event": [ { "core_name": "肿瘤", "tendency": "", "character": [], "anatomy_list": [ "回盲部" ] }, { "core_name": "肿瘤", "tendency": "", "character": [ "侵犯" ], "anatomy_list": [ "右侧盆壁肌" ] }, { "core_name": "肿大", "tendency": "", "character": [], "anatomy_list": [ "肠系膜淋巴结" ] } ] }, { "id": 887, "text": "于患者家属商量后于2020-04-29至2020-06-09给于（贝伐珠单抗350mg1静滴,卡培他滨1.5g连用14天,休息7天）化疗3周期，2020-07-07入院复查按recist1.1提示疾病进展（pd），考虑治疗治疗耐药，于2020-07-8至2020-08-13行贝伐珠单抗350mg1静滴+伊立替康200mg1静滴+亚叶酸钙500mg静滴d1+氟尿嘧啶0.5g静推d1+氟尿嘧啶2.8g持续泵入48h化疗3周期,2020-8-31复查按recist1.1标准评估病情稳定（sd）患者多次化疗后骨髓抑制，于患者交流后拟给于，2020-08-31于（贝伐珠单抗400mg1静滴+伊立替康160mg1静滴+亚叶酸钙500mg静滴d1+氟尿嘧啶0.5g静推d1+氟尿嘧啶2.5g持续泵入48h，患者既往行基因检查提示egfr19外显子突变，给于厄洛替尼靶向治疗，后服用靶向药物后出现严重口腔溃疡停用。现患者为行进一步治疗，门诊以“结肠癌”收入我科患者本次发病以来，食欲下降，神志清醒，精神欠佳，睡眠尚可，大便正常，小便正常，体重无明显变化。", "event": [ { "core_name": "骨髓抑制", "tendency": "", "character": [], "anatomy_list": [ "骨髓" ] }, { "core_name": "溃疡", "tendency": "", "character": [ "严重" ], "anatomy_list": [ "口腔" ] }, { "core_name": "癌", "tendency": "", "character": [], "anatomy_list": [ "结肠" ] }, { "core_name": "食欲", "tendency": "", "character": [ "下降" ], "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": [ "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": 2020, "text": "出院后未行正规内分泌治疗，口服“康士得50mg qd”治疗，后复查行骨扫描检查提示全身多发骨转移。", "event": [ { "core_name": "转移", "tendency": "", "character": [ "骨", "多发" ], "anatomy_list": [ "全身" ] } ] }, { "id": 1365, "text": "入院前 10年 ，患者受凉后咳嗽， 咯白色泡沫痰 ，以晨起明显。", "event": [ { "core_name": "咳嗽", "tendency": "", "character": [ "受凉后" ], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "白色", "泡沫痰", "以晨起明显" ], "anatomy_list": [] } ] }, { "id": 154, "text": "诊断为：1.原发性肝癌，伴肝内转移，肺转移性肿瘤？2.慢性乙型病毒性肝炎（轻度）；3.高血压病3级高危组；4.肝囊肿；5.肾囊肿；6.双侧附睾囊肿。", "event": [ { "core_name": "癌", "tendency": "", "character": [ "原发性" ], "anatomy_list": [ "肝" ] }, { "core_name": "癌", "tendency": "", "character": [ "转移" ], "anatomy_list": [ "肝内" ] }, { "core_name": "肿瘤", "tendency": "不确定", "character": [ "转移性" ], "anatomy_list": [ "肺" ] }, { "core_name": "肝炎", "tendency": "", "character": [ "慢性", "乙型", "轻度", "病毒性" ], "anatomy_list": [ "肝" ] }, { "core_name": "高血压", "tendency": "", "character": [ "3级高危组" ], "anatomy_list": [] }, { "core_name": "囊肿", "tendency": "", "character": [], "anatomy_list": [ "肝" ] }, { "core_name": "囊肿", "tendency": "", "character": [], "anatomy_list": [ "肾" ] }, { "core_name": "囊肿", "tendency": "", "character": [], "anatomy_list": [ "双侧附睾" ] } ] }, { "id": 643, "text": "半年前患者因停经后反复阴道不规则流血就诊于我院，诊断葡萄胎，行清宫术处理，术后病检：（宫内）部分性水泡状胎块。", "event": [ { "core_name": "出血", "tendency": "", "character": [ "停经后", "反复", "不规则" ], "anatomy_list": [ "阴道" ] }, { "core_name": "葡萄胎", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "胎块", "tendency": "", "character": [ "部分性", "水泡状" ], "anatomy_list": [ "宫内" ] } ] }, { "id": 2010, "text": "盗汗，无咳大量脓痰、咯血、喘息症状，但未规范治疗。", "event": [ { "core_name": "盗汗", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "否定", "character": [ "大量", "脓痰" ], "anatomy_list": [] }, { "core_name": "咯血", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "气喘", "tendency": "否定", "character": [], "anatomy_list": [] } ] }, { "id": 529, "text": "心包腔少量积液。", "event": [ { "core_name": "积液", "tendency": "", "character": [ "少量" ], "anatomy_list": [ "心包腔" ] } ] }, { "id": 388, "text": "乳头及皮肤未见癌累及，腋窝淋巴结9枚，均未见癌转移（0/9）。", "event": [ { "core_name": "癌", "tendency": "否定", "character": [ "累及" ], "anatomy_list": [ "乳头", "皮肤" ] }, { "core_name": "癌", "tendency": "否定", "character": [ "转移" ], "anatomy_list": [ "腋窝淋巴结" ] } ] }, { "id": 1046, "text": "7天前，患者无明显诱因出现腹胀，进食后加重，食欲下降、厌油，饭量减少约1/3，伴尿量减少，减少约1/3（具体量患者记不清），尿黄如浓茶色，伴双下肢轻度水肿，全身乏力，无恶心、呕吐，无畏寒、发热，无腹痛，遂于当地诊所购买“阿莫西林、扑炎痛”治疗（具体剂量不详），病情无明显好转。", "event": [ { "core_name": "腹胀", "tendency": "", "character": [ "进食后加重" ], "anatomy_list": [ "腹" ] }, { "core_name": "食欲", "tendency": "", "character": [ "下降" ], "anatomy_list": [] }, { "core_name": "厌油", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "饭量减少", "tendency": "", "character": [ "约1/3" ], "anatomy_list": [] }, { "core_name": "尿量减少", "tendency": "", "character": [ "约1/3" ], "anatomy_list": [] }, { "core_name": "尿黄", "tendency": "", "character": [ "茶色" ], "anatomy_list": [] }, { "core_name": "水肿", "tendency": "", "character": [ "轻度" ], "anatomy_list": [ "双下肢" ] }, { "core_name": "乏力", "tendency": "", "character": [], "anatomy_list": [ "全身" ] }, { "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": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] } ] }, { "id": 1762, "text": "（左乳包块2袋）腺病。", "event": [ { "core_name": "包块", "tendency": "", "character": [], "anatomy_list": [ "左乳" ] }, { "core_name": "腺病", "tendency": "", "character": [], "anatomy_list": [ "左乳" ] } ] }, { "id": 968, "text": "入院4月余前，患者无明显诱因出现右乳头溢液，自诉为淡黄色清亮液体，自诉扪及右乳外上鸡蛋黄大小包块，无乳头凹陷、双乳胀痛，局部皮肤无红肿、破溃、皮温升高，无橘皮样改变、酒窝征，无畏寒、发热、盗汗等不适，患者遂至某医院行乳腺彩超提示：“右乳见多个弱回声，最大位于3点钟距乳头0.6cm处，大小约2.6*0.92cm，bi-rads 4a类”，患者未予以特殊治疗。", "event": [ { "core_name": "溢液", "tendency": "", "character": [ "淡黄色", "清亮液体" ], "anatomy_list": [ "右乳头" ] }, { "core_name": "包块", "tendency": "", "character": [ "鸡蛋黄大小" ], "anatomy_list": [ "右乳外上" ] }, { "core_name": "凹陷", "tendency": "否定", "character": [], "anatomy_list": [ "乳头" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [ "胀痛" ], "anatomy_list": [ "双乳房" ] }, { "core_name": "红肿", "tendency": "否定", "character": [ "局部" ], "anatomy_list": [ "双乳房皮肤" ] }, { "core_name": "破溃", "tendency": "否定", "character": [], "anatomy_list": [ "双乳房皮肤" ] }, { "core_name": "皮温", "tendency": "否定", "character": [ "升高" ], "anatomy_list": [ "双乳房" ] }, { "core_name": "改变", "tendency": "否定", "character": [ "橘皮样" ], "anatomy_list": [ "双乳房" ] }, { "core_name": "酒窝征", "tendency": "否定", "character": [], "anatomy_list": [ "双乳房" ] }, { "core_name": "畏寒", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "发热", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "盗汗", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "回声", "tendency": "", "character": [ "弱", "多个", "最大位于3点钟距乳头0.6cm处", "bi-rads 4a类" ], "anatomy_list": [ "右乳" ] } ] }, { "id": 1721, "text": "患者自诉无腹痛、腹胀，无恶心、呕吐，无厌油、乏力，无呕血、黑便等情况，无白陶土样大便，患者未予以相应治疗。", "event": [ { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "腹胀", "tendency": "否定", "character": [], "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": "厌油", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "乏力", "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": "大便", "tendency": "否定", "character": [ "白陶土样" ], "anatomy_list": [] } ] }, { "id": 190, "text": "2余月前患者再次出现咳嗽，咳白色泡沫痰，痰不易咳出，伴气促，走平路速度低于同类人。", "event": [ { "core_name": "咳嗽", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "白色", "泡沫痰", "不易咳出" ], "anatomy_list": [] }, { "core_name": "气促", "tendency": "", "character": [], "anatomy_list": [] } ] }, { "id": 1394, "text": "4月前患者因“两癌筛查”在当地卫生院检查tct提示宫颈细胞异常（未见检查报告），转诊患者到某妇幼保健院进一步筛查。", "event": [ { "core_name": "细胞异常", "tendency": "", "character": [], "anatomy_list": [ "宫颈" ] } ] }, { "id": 1753, "text": "2016-10-20术后复查ct示腹腔包裹性积液，遂于2016-10-25于超声引导下行腹腔穿刺置管引流术，后带腹腔引流管出院。", "event": [ { "core_name": "积液", "tendency": "", "character": [ "包裹性" ], "anatomy_list": [ "腹腔" ] } ] }, { "id": 824, "text": "患者有痛经症状，程度不重，偶需服止痛药，平素无自觉症状，平素无同房出血、异常阴道排液、性交痛症状。", "event": [ { "core_name": "痛经", "tendency": "", "character": [ "程度不重" ], "anatomy_list": [] }, { "core_name": "出血", "tendency": "否定", "character": [ "同房" ], "anatomy_list": [ "阴道" ] }, { "core_name": "排液", "tendency": "否定", "character": [ "异常" ], "anatomy_list": [ "阴道" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [ "性交" ], "anatomy_list": [] } ] }, { "id": 1870, "text": "1月余前患者无明显诱因出现下腹部隐痛，持续约4分4分钟，无肩背部放射痛，无返酸、嗳气，无恶心、呕吐、腹痛，无畏寒、发热、心慌、气促，无尿频、尿急、尿不尽，夜尿1次，解大便后症状可缓解，未正规诊治。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [ "持续4分钟", "隐痛" ], "anatomy_list": [ "下腹部" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [ "放射性" ], "anatomy_list": [ "肩", "背部" ] }, { "core_name": "返酸", "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": [ "腹部" ] }, { "core_name": "畏寒", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "发热", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "心慌", "tendency": "否定", "character": [], "anatomy_list": [ "心" ] }, { "core_name": "气促", "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": "尿不尽", "tendency": "", "character": [ "夜间" ], "anatomy_list": [] } ] }, { "id": 418, "text": "增强mri回示：左眼眶左上方见不规则信号影，大约4.8cmx3.4cmx2.7cm，以稍长t1影长t2信号影，增强扫描呈明显强化，尚均匀，邻近骨质破坏、吸收，左侧眼球、上直肌、外直肌、视神经及泪腺受压，与左侧泪腺分界欠清，肿块向后蔓延至颅内，左眼轻度突出。", "event": [ { "core_name": "信号影", "tendency": "", "character": [ "不规则", "稍长t1", "长t2" ], "anatomy_list": [ "左眼眶左上方" ] }, { "core_name": "增强扫描", "tendency": "", "character": [ "呈明显强化，尚均匀" ], "anatomy_list": [] }, { "core_name": "骨质破坏", "tendency": "", "character": [], "anatomy_list": [ "邻近" ] }, { "core_name": "骨质吸收", "tendency": "", "character": [], "anatomy_list": [ "邻近" ] }, { "core_name": "受压", "tendency": "", "character": [], "anatomy_list": [ "左侧眼球", "上直肌", "外直肌", "视神经", "泪腺" ] }, { "core_name": "肿块", "tendency": "", "character": [ "向后蔓延" ], "anatomy_list": [ "颅内" ] }, { "core_name": "突出", "tendency": "", "character": [ "轻度" ], "anatomy_list": [ "左眼" ] } ] }, { "id": 1199, "text": "患者于8年前起出现反复头痛、头晕，伴心慌、气促，无发热畏寒、腹胀腹痛、尿频尿急等症状，发作无规律性，疼痛持续数十分钟后缓解。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [ "反复", "发作无规律性" ], "anatomy_list": [ "头" ] }, { "core_name": "头晕", "tendency": "", "character": [ "发作无规律性" ], "anatomy_list": [ "头" ] }, { "core_name": "心慌", "tendency": "", "character": [ "发作无规律性" ], "anatomy_list": [ "心" ] }, { "core_name": "气促", "tendency": "", "character": [ "发作无规律性" ], "anatomy_list": [] }, { "core_name": "发热", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "畏寒", "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": "尿频", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "尿急", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "", "character": [ "持续数十分钟后缓解" ], "anatomy_list": [ "头" ] } ] }, { "id": 534, "text": "3年前，患者出现少尿、全身肿胀等，至某医院就诊，诊断“右上肺肺癌伴双肺、胸膜转移，copd急性加重期，冠心病，心功能iii级，2型糖尿病，糖尿病肾病，糖尿病视网膜病变，肾衰竭尿毒症期”，开始透析治疗至今，每周2次。", "event": [ { "core_name": "少尿", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "肿胀", "tendency": "", "character": [], "anatomy_list": [ "全身" ] }, { "core_name": "癌", "tendency": "", "character": [], "anatomy_list": [ "右上肺" ] }, { "core_name": "癌", "tendency": "", "character": [ "转移" ], "anatomy_list": [ "双肺", "胸膜" ] }, { "core_name": "copd", "tendency": "", "character": [ "急性加重期" ], "anatomy_list": [] }, { "core_name": "冠心病", "tendency": "", "character": [], "anatomy_list": [ "心" ] }, { "core_name": "心功能", "tendency": "", "character": [ "iii级" ], "anatomy_list": [ "心" ] }, { "core_name": "糖尿病", "tendency": "", "character": [ "2型" ], "anatomy_list": [] }, { "core_name": "肾病", "tendency": "", "character": [ "糖尿病" ], "anatomy_list": [ "肾" ] }, { "core_name": "病变", "tendency": "", "character": [ "糖尿病" ], "anatomy_list": [ "视网膜" ] }, { "core_name": "肾衰竭", "tendency": "", "character": [ "尿毒症期" ], "anatomy_list": [ "肾" ] } ] }, { "id": 2059, "text": "至我科门诊行ct检查:右侧腰大肌、髂腰肌异常密度，考虑转移，排除治疗禁忌后于2020-12-9，2020-12-29行化疗:贝伐珠单抗300mg1静滴+mfolfox6(奥沙利铂0.12g静滴d1+亚叶酸钙500mg静滴d1+氟尿嘧啶500mg静推+氟尿嘧啶3.3g静滴48h),14天/周期治疗2周期，患者为行进一步治疗,门诊以\"结肠癌复发\"收入我科.", "event": [ { "core_name": "异常密度", "tendency": "", "character": [], "anatomy_list": [ "右侧腰大肌", "髂腰肌" ] }, { "core_name": "转移", "tendency": "不确定", "character": [], "anatomy_list": [] }, { "core_name": "癌", "tendency": "", "character": [ "复发" ], "anatomy_list": [ "结肠" ] } ] }, { "id": 600, "text": "主动脉瓣关闭不全（轻度）。", "event": [ { "core_name": "关闭不全", "tendency": "", "character": [ "轻度" ], "anatomy_list": [ "主动脉瓣" ] } ] }, { "id": 1850, "text": "并定期在我科行抗溶骨治疗，患者于2015年6月复查ect提示骨转移病灶较前增多，考虑病情进展，于6月14日、7月18日予以多西他赛120mg化疗，过程顺利，化疗后予以帕米磷酸二钠抗溶骨治疗，行抗溶骨治疗后，患者骨痛加重，考虑为血钙再沉积有关，予以对症处理后好转出院休息。", "event": [ { "core_name": "病灶", "tendency": "", "character": [ "骨转移", "较前增多" ], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "", "character": [ "加重" ], "anatomy_list": [ "骨" ] }, { "core_name": "血钙", "tendency": "不确定", "character": [ "再沉积" ], "anatomy_list": [] } ] }, { "id": 223, "text": "我院门诊 腹部ct示：急诊报告：结肠脾区处管壁明显不均匀性增厚，考虑结肠ca可能性大，病变所累及处管腔狭窄，至其近端肠管梗阻；且伴腹膜及大网膜大网膜转移可能性大。", "event": [ { "core_name": "增厚", "tendency": "", "character": [ "明显", "不均匀性" ], "anatomy_list": [ "结肠脾区处管壁" ] }, { "core_name": "癌", "tendency": "不确定", "character": [], "anatomy_list": [ "结肠" ] }, { "core_name": "狭窄", "tendency": "", "character": [], "anatomy_list": [ "病变所累及处管腔" ] }, { "core_name": "梗阻", "tendency": "", "character": [], "anatomy_list": [ "近端肠管" ] }, { "core_name": "转移", "tendency": "不确定", "character": [], "anatomy_list": [ "腹膜", "大网膜" ] } ] }, { "id": 308, "text": "患者诉17天前于我科在全麻下行胸腔镜下右肺上叶切除+淋巴结清扫术，术后常规病理示：右上肺肺浸润浸润性腺癌，第10组淋巴结见癌转移，余支气管、肺切缘、送检淋巴结均未见癌灶。", "event": [ { "core_name": "腺癌", "tendency": "", "character": [ "浸润性" ], "anatomy_list": [ "右上肺" ] }, { "core_name": "癌", "tendency": "", "character": [ "转移" ], "anatomy_list": [ "第10组淋巴结" ] }, { "core_name": "癌灶", "tendency": "否定", "character": [], "anatomy_list": [ "支气管" ] }, { "core_name": "癌灶", "tendency": "否定", "character": [], "anatomy_list": [ "肺切缘" ] }, { "core_name": "癌灶", "tendency": "否定", "character": [], "anatomy_list": [ "送检淋巴结" ] } ] }, { "id": 1219, "text": "2.双侧附件区低回声，考虑肿大淋巴结回声。", "event": [ { "core_name": "回声", "tendency": "", "character": [ "低" ], "anatomy_list": [ "双侧附件区" ] }, { "core_name": "回声", "tendency": "不确定", "character": [ "肿大" ], "anatomy_list": [ "淋巴结" ] } ] }, { "id": 1028, "text": "患者自发病以来，精神可，食欲欠佳，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": [ "可" ], "anatomy_list": [] }, { "core_name": "食欲", "tendency": "", "character": [ "欠佳" ], "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": 2027, "text": "入院前10余天，患者咳黄色粘液痰，可见血丝，伴潮热、胸部紧缩感、活动后气促，再次到某医院就诊，行胸部ct检查发现右肺包块，为求进一步诊治，今日到我院就诊，门诊以“右肺包块”收入我科。", "event": [ { "core_name": "咳痰", "tendency": "", "character": [ "黄色", "粘液", "可见血丝" ], "anatomy_list": [] }, { "core_name": "潮热", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "紧缩感", "tendency": "", "character": [], "anatomy_list": [ "胸部" ] }, { "core_name": "气促", "tendency": "", "character": [ "活动后" ], "anatomy_list": [] }, { "core_name": "包块", "tendency": "", "character": [], "anatomy_list": [ "右肺" ] }, { "core_name": "包块", "tendency": "", "character": [], "anatomy_list": [ "右肺" ] } ] }, { "id": 1275, "text": "病程中患者无口干、多饮、多尿、体重减轻，无泡沫尿、视物模糊、四肢冰凉等症状，定期于我科门诊随访调整降糖药。", "event": [ { "core_name": "口干", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "多饮", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "多尿", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "体重减轻", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "泡沫尿", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "视物模糊", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "冰凉", "tendency": "否定", "character": [], "anatomy_list": [ "四肢" ] } ] }, { "id": 876, "text": "3.右肾囊肿。", "event": [ { "core_name": "囊肿", "tendency": "", "character": [], "anatomy_list": [ "右肾" ] } ] }, { "id": 165, "text": "部分肠切除术后，术区未见明显异常。", "event": [ { "core_name": "异常", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [ "术区" ] } ] }, { "id": 1311, "text": "半月前于起床时再次出现头晕，明显视物旋转，发生一次耳鸣，无明显恶心呕吐、大汗淋漓，无明显头痛，无黑蒙、晕厥，无明显听力减退，无肢体无力、走路不稳。", "event": [ { "core_name": "头晕", "tendency": "", "character": [ "起床时" ], "anatomy_list": [ "头" ] }, { "core_name": "视物旋转", "tendency": "", "character": [ "明显" ], "anatomy_list": [] }, { "core_name": "耳鸣", "tendency": "", "character": [ "一次" ], "anatomy_list": [ "耳" ] }, { "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": "出汗", "tendency": "否定", "character": [ "大汗" ], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [ "头" ] }, { "core_name": "黑朦", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "晕厥", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "听力减退", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [] }, { "core_name": "无力", "tendency": "否定", "character": [], "anatomy_list": [ "肢体" ] }, { "core_name": "走路不稳", "tendency": "否定", "character": [], "anatomy_list": [] } ] }, { "id": 1892, "text": "入院前1周，患者因服用“结核药物”后出现食欲下降，由每餐进食2两减为1两，厌油，返酸，嗳气，腹胀，无腹痛及腹泻，无明显恶心及呕吐，精神变差，双下肢乏力，患者未重视，未治疗，仍继续服用结核药物治疗。", "event": [ { "core_name": "食欲", "tendency": "", "character": [ "下降" ], "anatomy_list": [] }, { "core_name": "厌油", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "返酸", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "嗳气", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "腹胀", "tendency": "", "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": "恶心", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [] }, { "core_name": "呕吐", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "精神", "tendency": "否定", "character": [ "变差" ], "anatomy_list": [] }, { "core_name": "乏力", "tendency": "否定", "character": [], "anatomy_list": [ "双下肢" ] } ] }, { "id": 49, "text": "彩超检查(2016-02-24):双侧锁骨上窝、腋窝及腹股沟区可见淋巴结回声。", "event": [ { "core_name": "回声", "tendency": "", "character": [], "anatomy_list": [ "双侧锁骨上窝", "腋窝", "腹股沟区", "淋巴结" ] } ] }, { "id": 689, "text": "近1月自觉恶心、乏力、疲惫，偶有心慌，无头晕、头痛、气促，无呕吐，无腹痛、腹胀，无腰骶部胀痛，无肛门坠胀，二便正常。", "event": [ { "core_name": "恶心", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "乏力", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "疲惫", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "心慌", "tendency": "", "character": [ "偶有" ], "anatomy_list": [ "心" ] }, { "core_name": "头晕", "tendency": "否定", "character": [], "anatomy_list": [ "头" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "头" ] }, { "core_name": "气促", "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": "疼痛", "tendency": "否定", "character": [ "胀痛" ], "anatomy_list": [ "腰骶部" ] }, { "core_name": "坠胀", "tendency": "否定", "character": [], "anatomy_list": [ "肛门" ] }, { "core_name": "大便", "tendency": "", "character": [ "正常" ], "anatomy_list": [] }, { "core_name": "小便", "tendency": "", "character": [ "正常" ], "anatomy_list": [] } ] }, { "id": 290, "text": "右上肺肺团块影，建议ct检查。", "event": [ { "core_name": "团块影", "tendency": "", "character": [], "anatomy_list": [ "右上肺" ] } ] }, { "id": 277, "text": "遂进一步就诊于某医院，完善颅脑平扫ct以及骨扫描检查未见异常，腹部彩超提示肝脏血管瘤及囊肿，未行特殊治疗。", "event": [ { "core_name": "血管瘤", "tendency": "", "character": [], "anatomy_list": [ "肝脏" ] }, { "core_name": "囊肿", "tendency": "", "character": [], "anatomy_list": [ "肝脏" ] } ] }, { "id": 1879, "text": "8年前，患者因血糖控制不佳于某医院就诊，调整降糖方案为胰岛素诺和灵30r早餐前6u，晚餐前6u控制血糖，未规律监测血糖，血糖控制情况不佳。", "event": [ { "core_name": "血糖", "tendency": "", "character": [ "控制不佳" ], "anatomy_list": [] }, { "core_name": "血糖", "tendency": "", "character": [ "控制情况不佳" ], "anatomy_list": [] } ] }, { "id": 1025, "text": "2019-04-20再次出现阴道出血，为鲜红色，每次量少，无血凝块，无腹痛、腹胀，无阴道阴道坠胀，无尿频、尿急、尿痛、血尿，无呕血、黑便，无畏寒、发热，遂于我院复查盆腔mri示：宫颈癌术后放化疗后：盆腔偏左侧见两个略长t1略长t2信号团块状影及周围结节影，结合病史，考虑肿瘤转移。请结合临床。", "event": [ { "core_name": "出血", "tendency": "", "character": [ "量少", "鲜红色", "无血凝块" ], "anatomy_list": [ "阴道" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "腹胀", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "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": [ "红色" ], "anatomy_list": [] }, { "core_name": "呕血", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "黑便", "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": "癌", "tendency": "", "character": [ "术后", "化放疗后" ], "anatomy_list": [ "宫颈" ] }, { "core_name": "团块影", "tendency": "", "character": [ "略长t1", "略长t2信号" ], "anatomy_list": [ "盆腔偏左侧" ] }, { "core_name": "结节影", "tendency": "", "character": [ "略长t1", "略长t2信号" ], "anatomy_list": [ "盆腔周围" ] }, { "core_name": "肿瘤", "tendency": "不确定", "character": [ "转移" ], "anatomy_list": [] } ] }, { "id": 1118, "text": "患者从发病至今未行任何诊治，今日为明确水肿原因，故就诊于我院，门诊以“水肿原因待查”收入我科。", "event": [ { "core_name": "水肿", "tendency": "不确定", "character": [], "anatomy_list": [] } ] }, { "id": 273, "text": "患者自患病以来，精神、饮食、睡眠可，大小便正常，体重无明显变化。", "event": [ { "core_name": "精神", "tendency": "", "character": [ "可" ], "anatomy_list": [] }, { "core_name": "饮食", "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": "体重变化", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [] } ] }, { "id": 83, "text": "遂于2017-02-08开始行新辅助化疗（方案：表柔比星 100mg 环磷酰胺 600mg 多西他赛 120mg），于2017-02-23行第二次辅助化疗化疗，方案更改为tp+曲妥珠单抗（多西他赛 120mg；洛铂 50mg；曲妥珠单抗首剂 440mg，后330mg）化疗后无剧烈恶心、呕吐等不适，有轻度骨髓抑制，白细胞最低为1.84×109/l，予以升白细胞治疗后好转。", "event": [ { "core_name": "恶心", "tendency": "否定", "character": [ "剧烈" ], "anatomy_list": [] }, { "core_name": "呕吐", "tendency": "否定", "character": [ "剧烈" ], "anatomy_list": [] }, { "core_name": "骨髓抑制", "tendency": "", "character": [ "轻度" ], "anatomy_list": [ "骨髓" ] } ] }, { "id": 256, "text": "1天前右眼出现眼红，无视力下降，无视物变形，无视物重影，3小时前突发视力骤降，遂来我院，门诊检眼左眼视力数指/10cm，眼底血管动脉变细，测血压154/70mmHg，30分钟前视力骤降至仅为光感，建议立即住院积极治疗挽救视功能，急诊以“右眼急性球后视神经炎、缺血性视神经病变？”收住我科。", "event": [ { "core_name": "眼红", "tendency": "", "character": [], "anatomy_list": [ "右眼" ] }, { "core_name": "视力下降", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "视物变形", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "视物重影", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "视力下降", "tendency": "", "character": [ "突发" ], "anatomy_list": [] }, { "core_name": "变细", "tendency": "", "character": [], "anatomy_list": [ "眼底血管", "动脉" ] }, { "core_name": "视力骤降", "tendency": "", "character": [ "骤", "仅为光感" ], "anatomy_list": [] }, { "core_name": "神经炎", "tendency": "不确定", "character": [ "急性" ], "anatomy_list": [ "右眼", "球后视神经" ] }, { "core_name": "病变", "tendency": "不确定", "character": [ "缺血性" ], "anatomy_list": [ "视神经" ] } ] }, { "id": 1147, "text": "患者于6月前因“进行性吞咽困难”，在某医院诊断为“食道癌”。", "event": [ { "core_name": "吞咽困难", "tendency": "", "character": [ "进行性" ], "anatomy_list": [] }, { "core_name": "癌", "tendency": "", "character": [], "anatomy_list": [ "食道" ] } ] }, { "id": 281, "text": "3.所示肝实质内多个结节影，请结合腹部增强检查。", "event": [ { "core_name": "结节影", "tendency": "", "character": [ "多个" ], "anatomy_list": [ "肝实质内" ] } ] }, { "id": 1091, "text": "肠壁上淋巴结未见癌转移（0/12）。", "event": [ { "core_name": "癌", "tendency": "否定", "character": [ "转移" ], "anatomy_list": [ "肠壁上淋巴结" ] } ] }, { "id": 1114, "text": "患者发病自今未行特殊诊治，今日患者自感头昏、心悸有所加重，遂就诊于我院急诊科，测血压为130/92mmHg，未行其余特殊检查，为进一步诊治，患者遂收入我科。", "event": [ { "core_name": "头昏", "tendency": "", "character": [ "加重" ], "anatomy_list": [ "头" ] }, { "core_name": "心悸", "tendency": "", "character": [ "加重" ], "anatomy_list": [ "心" ] } ] }, { "id": 284, "text": "鼻中隔偏曲，双侧下鼻甲及右侧中鼻甲鼻甲肥大；3.右侧中鼻道似见增多软组织影。", "event": [ { "core_name": "偏曲", "tendency": "", "character": [], "anatomy_list": [ "鼻中隔" ] }, { "core_name": "肥大", "tendency": "", "character": [], "anatomy_list": [ "双侧下鼻甲", "右侧中鼻甲" ] }, { "core_name": "软组织影", "tendency": "不确定", "character": [ "增多" ], "anatomy_list": [ "右侧中鼻道" ] } ] }, { "id": 721, "text": "患者于入院前３年余无明显诱因出现排便困难，为黄绿色稀便，大便表面可见少量鲜血，量约50-100g/次，1-2次/天，伴里急后重感，遂到某医院行肠镜发现直肠距肛缘10cm处有一新生物，考虑直肠癌可能，行全腹部增强ct提示：直肠壁增厚伴强化，未见明显肿大淋巴结，遂行直肠癌根治术，术后病检示：直肠中分化腺癌，浸及浅肌层，近切、远切未见癌组织，局部淋巴结未见癌转移，病理分期（t2n0M0，i期）。", "event": [ { "core_name": "排便", "tendency": "", "character": [ "困难" ], "anatomy_list": [] }, { "core_name": "大便", "tendency": "", "character": [ "黄绿色", "稀便" ], "anatomy_list": [] }, { "core_name": "大便", "tendency": "", "character": [ "少量鲜血" ], "anatomy_list": [] }, { "core_name": "腹泻", "tendency": "", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "里急后重感", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "新生物", "tendency": "", "character": [], "anatomy_list": [ "直肠距肛缘10cm处" ] }, { "core_name": "癌", "tendency": "不确定", "character": [], "anatomy_list": [ "直肠" ] }, { "core_name": "增厚", "tendency": "", "character": [], "anatomy_list": [ "直肠壁" ] }, { "core_name": "强化", "tendency": "", "character": [], "anatomy_list": [ "直肠壁" ] }, { "core_name": "肿大", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [ "淋巴结" ] }, { "core_name": "腺癌", "tendency": "", "character": [ "中分化", "浸及浅肌层", "t2n0M0，i期" ], "anatomy_list": [ "直肠" ] }, { "core_name": "癌组织", "tendency": "否定", "character": [], "anatomy_list": [ "直肠近切", "直肠远切" ] }, { "core_name": "癌", "tendency": "否定", "character": [ "转移", "局部" ], "anatomy_list": [ "淋巴结" ] } ] }, { "id": 680, "text": "入院前40+天，患者因胸及肩部疼痛，就诊于我院行胸部ct（2016-10-25 我院）提示：1.前纵隔占位性病变，考虑肿瘤，胸腺瘤或其它？2.符合慢性支气管炎、肺气肿表现，左肺上叶舌段纤维灶。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [], "anatomy_list": [ "肩部" ] }, { "core_name": "疼痛", "tendency": "", "character": [], "anatomy_list": [ "胸" ] }, { "core_name": "病变", "tendency": "", "character": [ "占位性" ], "anatomy_list": [ "前纵隔" ] }, { "core_name": "肿瘤", "tendency": "不确定", "character": [], "anatomy_list": [ "前纵隔" ] }, { "core_name": "瘤", "tendency": "不确定", "character": [], "anatomy_list": [ "胸腺" ] }, { "core_name": "支气管炎", "tendency": "不确定", "character": [ "慢性" ], "anatomy_list": [ "支气管" ] }, { "core_name": "肺气肿", "tendency": "不确定", "character": [], "anatomy_list": [ "肺" ] }, { "core_name": "纤维灶", "tendency": "", "character": [], "anatomy_list": [ "左肺上叶舌段" ] } ] }, { "id": 763, "text": "2019-07患者因气促入院，彩超检查(2019-07-17):右侧胸腔大量积液。", "event": [ { "core_name": "气促", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "积液", "tendency": "", "character": [ "大量" ], "anatomy_list": [ "右侧胸腔" ] } ] }, { "id": 431, "text": "患者21个月前，因大便带血在当地医院治疗，诊断为“直肠癌”，在当地医院行腹腔镜下直肠癌根治术+回肠造瘘术，术后予对症、支持治疗，于2016年2月26日开始予“奥沙利铂+卡培他滨”8个疗程规律化疗，化疗过程顺利，2016年8月行回肠造瘘口还纳术，患者10月21号出现腹泻不适，伴大便带血丝，再次入当地医院治疗，肠镜检查提示：吻合口溃疡，病检提示：结肠粘膜慢性炎，患者为求进一步治疗，来我院以“直肠吻合口溃疡”收入我科患者本次发病以来，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": "大便", "tendency": "", "character": [ "带血" ], "anatomy_list": [] }, { "core_name": "癌", "tendency": "", "character": [], "anatomy_list": [ "直肠" ] }, { "core_name": "腹泻", "tendency": "", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "大便", "tendency": "", "character": [ "带血丝" ], "anatomy_list": [] }, { "core_name": "溃疡", "tendency": "", "character": [], "anatomy_list": [ "吻合口" ] }, { "core_name": "炎", "tendency": "", "character": [ "慢性" ], "anatomy_list": [ "结肠粘膜" ] }, { "core_name": "溃疡", "tendency": "", "character": [], "anatomy_list": [ "直肠吻合口" ] }, { "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": "睡眠质量", "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": 709, "text": "<左侧髂血管血管旁、右侧髂血管血管旁、腹壁>送检淋巴结均未见肿瘤转移（分别为0/4、0/6、0/2）、<肠脂垂结节>送检为脂肪组织，密切随访。", "event": [ { "core_name": "肿瘤", "tendency": "否定", "character": [ "转移" ], "anatomy_list": [ "左侧髂血管旁淋巴结", "右侧髂血管旁淋巴结", "腹壁淋巴结" ] }, { "core_name": "结节", "tendency": "", "character": [ "肠脂垂", "脂肪组织" ], "anatomy_list": [] } ] }, { "id": 1548, "text": "半年前，患者开始出现头痛，主要为头顶部疼痛，为持续性跳痛，为中-重度，每次持续时间约数小时至1天左右可缓解，每次间隔数天发作，发作时无恶心呕吐，无视物模糊以及肢体麻木无力，2天前，患者再次出现头痛，症状同前。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [], "anatomy_list": [ "头顶部" ] }, { "core_name": "疼痛", "tendency": "", "character": [ "可缓解", "持续性", "跳痛", "中-重度", "每次间隔数天发作" ], "anatomy_list": [ "头顶部" ] }, { "core_name": "恶心", "tendency": "否定", "character": [ "发作时" ], "anatomy_list": [] }, { "core_name": "呕吐", "tendency": "否定", "character": [ "发作时" ], "anatomy_list": [] }, { "core_name": "视物模糊", "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": "疼痛", "tendency": "", "character": [], "anatomy_list": [ "头" ] } ] }, { "id": 333, "text": "患者为求进一步治疗，急诊以“不完全性肠梗阻”收入我科。", "event": [ { "core_name": "梗阻", "tendency": "", "character": [ "不完全性" ], "anatomy_list": [ "肠" ] } ] }, { "id": 811, "text": "入院前7年患者于受凉后开始出现咳嗽、咳痰，为白色粘痰，易咳出，每年持续3月以上，呈反复发作，每于冬春季节及受凉后好发作。", "event": [ { "core_name": "咳嗽", "tendency": "", "character": [ "受凉后", "呈反复发作", "每于冬春季节及受凉后好发作" ], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "受凉后", "白色粘痰", "易咳出", "呈反复发作", "每于冬春季节及受凉后好发作" ], "anatomy_list": [] } ] }, { "id": 1331, "text": "曾因咳嗽，喘息加重多次在当地门诊治疗（不详）。", "event": [ { "core_name": "咳嗽", "tendency": "", "character": [ "加重" ], "anatomy_list": [] }, { "core_name": "喘息", "tendency": "", "character": [ "加重" ], "anatomy_list": [] } ] }, { "id": 723, "text": "2010年7月27日开始口服卡培他滨（1g bid d1-d14）后，无明显恶心、呕吐、腹泻、腹痛等不适，随后在我科共行5个周期化疗（奥沙利铂 90mg d1+卡培他滨 1g bid d1-d14）,每21天为1周期，化疗过程顺利，无明显消化道反应及骨髓抑制，好转出院，但仍有每日排便2-4次，为黄色稀便，无肛门坠胀、大便失禁等，末次化疗于2010年11月5日结束。", "event": [ { "core_name": "恶心", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [] }, { "core_name": "呕吐", "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": "消化道反应", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [ "消化道" ] }, { "core_name": "骨髓抑制", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [ "骨髓" ] }, { "core_name": "大便", "tendency": "", "character": [ "黄色", "稀便" ], "anatomy_list": [] }, { "core_name": "坠胀", "tendency": "否定", "character": [], "anatomy_list": [ "肛门" ] }, { "core_name": "大便", "tendency": "否定", "character": [ "失禁" ], "anatomy_list": [] } ] }, { "id": 1800, "text": "近期体重变化不明显。", "event": [ { "core_name": "体重改变", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [] } ] }, { "id": 1541, "text": "2.双肾多发囊肿，较前比较未见变化。", "event": [ { "core_name": "囊肿", "tendency": "", "character": [ "多发" ], "anatomy_list": [ "双肾" ] } ] }, { "id": 629, "text": "患者本次发病以来，食欲减退， 神志清醒，精神尚可，睡眠欠佳，大便正常，小便正常，体重无明显变化。", "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": "睡眠质量", "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": 775, "text": "体重无明显变化。", "event": [ { "core_name": "体重改变", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [] } ] }, { "id": 1867, "text": "术后予sox方案行了三周期化疗，化疗期间无恶心、呕吐、皮肤巩膜黄染、手足麻木疼痛等不适，查血常规、肝肾功未见异常。", "event": [ { "core_name": "恶心", "tendency": "否定", "character": [ "化疗期间" ], "anatomy_list": [] }, { "core_name": "呕吐", "tendency": "否定", "character": [ "化疗期间" ], "anatomy_list": [] }, { "core_name": "黄染", "tendency": "否定", "character": [ "化疗期间" ], "anatomy_list": [ "皮肤", "巩膜" ] }, { "core_name": "麻木", "tendency": "否定", "character": [ "化疗期间" ], "anatomy_list": [ "手", "足" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [ "化疗期间" ], "anatomy_list": [ "手", "足" ] }, { "core_name": "肝功能异常", "tendency": "否定", "character": [], "anatomy_list": [ "肝" ] }, { "core_name": "血常规异常", "tendency": "否定", "character": [], "anatomy_list": [] } ] }, { "id": 1172, "text": "入院前10+天，患者无意中发现右侧颈部一包块，可扪及大小约3xxx3cm，质软，边界清楚，无压痛，随吞咽上下移动，无怕热、多汗、全身乏力、易疲劳、咳嗽等症状，无声嘶、饮水呛咳，无食欲亢进，无恶心、呕吐，无吞咽困难、呼吸困难。", "event": [ { "core_name": "包块", "tendency": "", "character": [ "质软", "边界清楚", "无压痛", "随吞咽上下移动" ], "anatomy_list": [ "右侧颈部" ] }, { "core_name": "怕热", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "出汗", "tendency": "否定", "character": [ "多汗" ], "anatomy_list": [] }, { "core_name": "乏力", "tendency": "否定", "character": [ "全身" ], "anatomy_list": [] }, { "core_name": "疲劳", "tendency": "否定", "character": [ "易" ], "anatomy_list": [] }, { "core_name": "咳嗽", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "声嘶", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "食欲", "tendency": "否定", "character": [ "亢进" ], "anatomy_list": [] }, { "core_name": "恶心", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "呕吐", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "吞咽困难", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "呼吸困难", "tendency": "否定", "character": [], "anatomy_list": [] } ] }, { "id": 744, "text": "今患者为求进一步化疗治疗，遂入我科，门诊以“非霍奇金淋巴瘤”收入我科。", "event": [ { "core_name": "瘤", "tendency": "", "character": [ "非霍奇金氏" ], "anatomy_list": [ "淋巴" ] } ] }, { "id": 614, "text": "近期偶有咳嗽，为刺激性干咳，偶感左胸部游走样针刺样疼痛，向左侧腋下放射，不影响睡眠，可忍受。", "event": [ { "core_name": "咳嗽", "tendency": "", "character": [ "偶尔" ], "anatomy_list": [] }, { "core_name": "咳嗽", "tendency": "", "character": [ "刺激性", "干" ], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "", "character": [ "游走样", "针刺样", "不影响睡眠", "可忍受", "偶尔" ], "anatomy_list": [ "左胸部" ] }, { "core_name": "疼痛", "tendency": "", "character": [ "放射性" ], "anatomy_list": [ "左侧腋下" ] } ] }, { "id": 558, "text": "无肛门坠胀感。", "event": [ { "core_name": "坠胀感", "tendency": "否定", "character": [], "anatomy_list": [ "肛门" ] } ] }, { "id": 221, "text": "伴腹胀 ， 伴恶心、呕吐,呕吐物为胃内容物 ， 发病 以来肛门少量排气排便。", "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": "排便", "tendency": "", "character": [ "少量" ], "anatomy_list": [ "肛门" ] }, { "core_name": "排气", "tendency": "", "character": [ "少量" ], "anatomy_list": [ "肛门" ] } ] }, { "id": 1796, "text": "出院后患者间断来院行抗溶骨及内分泌治疗，院外仍感全身多处骨痛。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [ "多处" ], "anatomy_list": [ "全身", "骨" ] } ] }, { "id": 1188, "text": "术后病检示：（右乳）浸润性导管癌（Ⅱ级，7分），免疫组化：er（±） pr（+）5%cerbb-2（－） ki-67散在（+）。", "event": [ { "core_name": "导管癌", "tendency": "", "character": [ "浸润性", "Ⅱ级", "7分" ], "anatomy_list": [ "右乳" ] } ] }, { "id": 1097, "text": "2月前，患者因“肺气肿”于我院呼吸科住院治疗，当时患者排尿困难加重，予以口服“坦索罗辛”治疗，治疗有缓解，后患者持续服用该药物。", "event": [ { "core_name": "肺气肿", "tendency": "", "character": [], "anatomy_list": [ "肺" ] }, { "core_name": "排尿困难", "tendency": "", "character": [ "加重" ], "anatomy_list": [] } ] }, { "id": 1752, "text": "胆囊胆固醇沉积症，慢性胆囊炎。", "event": [ { "core_name": "胆固醇沉积症", "tendency": "", "character": [], "anatomy_list": [ "胆囊" ] }, { "core_name": "胆囊炎", "tendency": "", "character": [ "慢性" ], "anatomy_list": [ "胆囊" ] } ] }, { "id": 1175, "text": "缘于2014年5月患者自行发现左腹部肋下包块，约苹果大小，无进行性增大表现，伴左腹部胀痛、乏力，偶解黑色大便，无血便，无反酸、恶心、呕吐及腹泻等不适。", "event": [ { "core_name": "包块", "tendency": "", "character": [ "约苹果大小", "进行性增大" ], "anatomy_list": [ "左腹部肋下" ] }, { "core_name": "疼痛", "tendency": "", "character": [ "胀痛" ], "anatomy_list": [ "左腹部" ] }, { "core_name": "乏力", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "大便颜色", "tendency": "", "character": [ "发黑" ], "anatomy_list": [] }, { "core_name": "血便", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "返酸", "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": "腹泻", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] } ] }, { "id": 456, "text": "2.肝硬化，脾稍大，胃底静脉曲张。", "event": [ { "core_name": "硬化", "tendency": "", "character": [], "anatomy_list": [ "肝" ] }, { "core_name": "脾大", "tendency": "", "character": [ "稍" ], "anatomy_list": [ "脾" ] }, { "core_name": "静脉曲张", "tendency": "", "character": [], "anatomy_list": [ "胃底静脉" ] } ] }, { "id": 89, "text": "患者自发病以来，精神可，食欲一般，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": [ "可" ], "anatomy_list": [] }, { "core_name": "食欲", "tendency": "", "character": [ "一般" ], "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": "体重变化", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [] } ] }, { "id": 1368, "text": "患者40+天于我院诊断为：原发性肝癌伴肝内转移，于2015-3-2行tace，术后恢复可，院外服用华蟾素抗肿瘤治疗。", "event": [ { "core_name": "癌", "tendency": "", "character": [ "原发性", "肝内转移" ], "anatomy_list": [ "肝" ] } ] }, { "id": 1315, "text": "6月前，患者因“大便习惯改变半年余”入院，完善检查后诊断为直肠癌，遂行腹腔镜直肠癌根治术（dixon）+放射性粒子置入术，术后病理提示：（直肠）中分化腺癌（含粘液腺癌成份）浸及肠壁全层，未见明确血管、神经侵犯，切端未见癌累及，肠壁淋巴结见癌转移（1/14）。", "event": [ { "core_name": "大便", "tendency": "", "character": [ "习惯改变" ], "anatomy_list": [] }, { "core_name": "癌", "tendency": "", "character": [], "anatomy_list": [ "直肠" ] }, { "core_name": "腺癌", "tendency": "", "character": [ "中分化", "含粘液腺癌成份", "浸及肠壁全层" ], "anatomy_list": [ "直肠", "肠壁全层" ] }, { "core_name": "癌", "tendency": "否定", "character": [ "明确", "侵犯" ], "anatomy_list": [ "血管", "神经" ] }, { "core_name": "癌", "tendency": "否定", "character": [ "切端", "累及" ], "anatomy_list": [] }, { "core_name": "癌", "tendency": "", "character": [ "转移" ], "anatomy_list": [ "肠壁淋巴结" ] } ] }, { "id": 1107, "text": "3+月前，患者自行发现颈部包块，直径约2cm，质硬，轻压痛，不活动，边界不清，表面无红肿溃烂，无咳嗽、咯痰，无活动后心累、气促，无胸闷、胸痛、咯血、呼吸困难，无畏寒、发热。", "event": [ { "core_name": "包块", "tendency": "", "character": [ "质硬", "轻压痛", "不活动", "边界不清", "表面无红肿溃烂" ], "anatomy_list": [ "颈部" ] }, { "core_name": "咳嗽", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "心累", "tendency": "否定", "character": [ "活动后" ], "anatomy_list": [ "心" ] }, { "core_name": "气促", "tendency": "否定", "character": [ "活动后" ], "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": "咯血", "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": [] } ] }, { "id": 6, "text": "在我院住院期间行“胸部ct示：慢支炎伴双下肺感染或间质性炎症,肺气肿征。", "event": [ { "core_name": "支气管炎", "tendency": "", "character": [ "慢性" ], "anatomy_list": [ "支气管" ] }, { "core_name": "感染", "tendency": "", "character": [], "anatomy_list": [ "双下肺" ] }, { "core_name": "炎症", "tendency": "", "character": [ "间质性" ], "anatomy_list": [ "双下肺" ] }, { "core_name": "肺气肿征", "tendency": "", "character": [], "anatomy_list": [ "肺" ] } ] }, { "id": 522, "text": "患者此次患病以来，精神状态尚可，小便正常，便秘。", "event": [ { "core_name": "精神", "tendency": "", "character": [ "尚可" ], "anatomy_list": [] }, { "core_name": "小便", "tendency": "", "character": [ "正常" ], "anatomy_list": [] }, { "core_name": "便秘", "tendency": "", "character": [], "anatomy_list": [] } ] }, { "id": 454, "text": "3月前来我院就诊，2017-8-1414Mmr检查报告：腹部mr增强 1.肝癌hifu术后改变，与前片（2017.02.15）比较，肝右叶后段段结节较前范围稍增大，未见明显强化；肝右叶后下段包膜下肿块较前稍增大，病灶内缘可见少许延迟强化；肝右叶膈顶顶区病灶较前无明显变化；肝左叶外侧段包膜下结节，较前无明显变化。", "event": [ { "core_name": "术后改变", "tendency": "", "character": [ "肝癌", "hifu" ], "anatomy_list": [ "肝" ] }, { "core_name": "结节", "tendency": "", "character": [ "较前范围稍增大", "未见明显强化" ], "anatomy_list": [ "肝右叶后段" ] }, { "core_name": "肿块", "tendency": "", "character": [ "较前稍增大", "病灶内缘可见少许延迟强化" ], "anatomy_list": [ "肝右叶后下段包膜下" ] }, { "core_name": "病灶", "tendency": "", "character": [ "较前无明显变化" ], "anatomy_list": [ "肝右叶膈顶区" ] }, { "core_name": "结节", "tendency": "", "character": [ "较前无明显变化" ], "anatomy_list": [ "肝左叶外侧段包膜下" ] } ] }, { "id": 1045, "text": "20天前，患者无明显诱因出现大便次数增多，约3-4次/天，约50-80g/次，为黄色成形大便，无腹痛、腹泻，无里急后重，无恶心、呕吐，无畏寒、发热，患者未予重视，未治疗。", "event": [ { "core_name": "大便", "tendency": "", "character": [ "次数增多" ], "anatomy_list": [] }, { "core_name": "大便", "tendency": "", "character": [ "黄色", "成形" ], "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": "里急后重", "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": "畏寒", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "发热", "tendency": "否定", "character": [], "anatomy_list": [] } ] }, { "id": 1173, "text": "患者为求进一步治疗，遂来我院门诊就诊，彩超（2018-04-16我院）示：甲状腺右侧叶囊肿。", "event": [ { "core_name": "囊肿", "tendency": "", "character": [], "anatomy_list": [ "甲状腺右侧叶" ] } ] }, { "id": 1375, "text": "5月前患者再次出现气促，无咳嗽、咳痰，无胸痛，入我院肾内科，诊断为”1.慢性肾功能不全（肾衰竭期）ckd5期 糖尿病肾病 肾性贫血； 2.急性左心衰；3.2型糖尿病糖尿病糖尿病肾病 糖尿病周围神经病变 糖尿病视网膜病变；4.原发性高血压3级高血压3级极高危极高危组 高血压性心脏病 心脏增大 心功能iv级；5.脑梗塞后遗症”。", "event": [ { "core_name": "气促", "tendency": "", "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": "肾功能不全", "tendency": "", "character": [ "慢性", "肾衰竭期" ], "anatomy_list": [ "肾" ] }, { "core_name": "肾病", "tendency": "", "character": [ "糖尿病" ], "anatomy_list": [ "肾" ] }, { "core_name": "贫血", "tendency": "", "character": [ "肾性" ], "anatomy_list": [] }, { "core_name": "心力衰竭", "tendency": "", "character": [ "急性" ], "anatomy_list": [ "左心" ] }, { "core_name": "糖尿病", "tendency": "", "character": [ "2型" ], "anatomy_list": [] }, { "core_name": "肾病", "tendency": "", "character": [ "糖尿病" ], "anatomy_list": [ "肾" ] }, { "core_name": "病变", "tendency": "", "character": [ "糖尿病" ], "anatomy_list": [ "周围神经" ] }, { "core_name": "病变", "tendency": "", "character": [ "糖尿病" ], "anatomy_list": [ "视网膜" ] }, { "core_name": "高血压", "tendency": "", "character": [ "原发性", "3级", "极高危" ], "anatomy_list": [] }, { "core_name": "心脏病", "tendency": "", "character": [ "高血压性" ], "anatomy_list": [ "心脏" ] }, { "core_name": "增大", "tendency": "", "character": [], "anatomy_list": [ "心脏" ] }, { "core_name": "心功能", "tendency": "", "character": [ "iv级" ], "anatomy_list": [ "心" ] }, { "core_name": "脑梗塞", "tendency": "", "character": [], "anatomy_list": [ "脑" ] } ] }, { "id": 751, "text": "后患者上述症状较前呈进行性加重，行胸部ct检查(2015-01-14)提示右肺中央型占位病变，考虑肺癌可能行大。", "event": [ { "core_name": "占位性病变", "tendency": "", "character": [ "中央型" ], "anatomy_list": [ "右肺" ] }, { "core_name": "癌", "tendency": "不确定", "character": [], "anatomy_list": [ "肺" ] } ] }, { "id": 73, "text": "入院前2年患儿下楼梯摔倒后出现左侧髋关节疼痛，不伴肿胀，先后累及左膝、左踝、右髋关节、右膝，有活动障碍，未行特殊处理，可自行缓解，双侧非对称分布。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [], "anatomy_list": [ "左侧髋关节" ] }, { "core_name": "肿胀", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "累及", "tendency": "", "character": [], "anatomy_list": [ "左膝", "左踝", "右髋关节", "右膝" ] }, { "core_name": "活动障碍", "tendency": "", "character": [ "双侧非对称分布" ], "anatomy_list": [] } ] }, { "id": 1896, "text": "入院前5年，患者无明显诱因出现小便不能自解，于某医院行导尿处理，拔除尿管后自解小便尚通畅，其后间断口服坦索罗辛及非那雄胺治疗。", "event": [ { "core_name": "小便", "tendency": "", "character": [ "不能自解" ], "anatomy_list": [] }, { "core_name": "排尿", "tendency": "", "character": [ "通畅" ], "anatomy_list": [] } ] }, { "id": 1480, "text": "于2017.2.13环磷酰胺700mg d1+多柔比星 70mg d1+奈达铂 120mg d1 全身静脉化疗，行奈达铂全身静脉化疗时，输注约5-10分时患者自诉出现胸闷伴呼吸困难，面色潮红，皮肤瘙痒，考虑奈达铂化疗药引起等过敏反应，立即停药，并予以地塞米松5mg静推后症状立即缓解。", "event": [ { "core_name": "胸闷", "tendency": "", "character": [], "anatomy_list": [ "胸" ] }, { "core_name": "呼吸困难", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "面色潮红", "tendency": "", "character": [], "anatomy_list": [ "面" ] }, { "core_name": "瘙痒", "tendency": "", "character": [], "anatomy_list": [ "皮肤" ] }, { "core_name": "过敏反应", "tendency": "不确定", "character": [ "奈达铂化疗药" ], "anatomy_list": [] } ] }, { "id": 925, "text": "今为进一步诊治来我科，以“ 1.双侧输尿管梗阻伴双肾积水 ”收入我科。", "event": [ { "core_name": "梗阻", "tendency": "", "character": [], "anatomy_list": [ "双侧输尿管" ] }, { "core_name": "积水", "tendency": "", "character": [], "anatomy_list": [ "双肾" ] } ] }, { "id": 1988, "text": "无嗳气、烧心、胸骨后疼痛，无腹痛、腹胀，无厌油、黄疸，大便无粘液及脓血，无畏寒、发热，无头昏、心悸、耳鸣、全身乏力。", "event": [ { "core_name": "嗳气", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "烧心", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "胸骨后" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "腹胀", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "厌油", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "黄疸", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "大便", "tendency": "否定", "character": [ "粘液", "脓血" ], "anatomy_list": [] }, { "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": "心悸", "tendency": "否定", "character": [], "anatomy_list": [ "心" ] }, { "core_name": "耳鸣", "tendency": "否定", "character": [], "anatomy_list": [ "耳" ] }, { "core_name": "乏力", "tendency": "否定", "character": [], "anatomy_list": [ "全身" ] } ] }, { "id": 188, "text": "无发热、盗汗、咯血、胸闷、胸痛、心悸、双下肢水肿等，每次予以抗感染、止咳祛痰等治疗后可好转。", "event": [ { "core_name": "发热", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "盗汗", "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": "心悸", "tendency": "否定", "character": [], "anatomy_list": [ "心" ] }, { "core_name": "水肿", "tendency": "否定", "character": [], "anatomy_list": [ "双下肢" ] } ] }, { "id": 1300, "text": "入院前8+年，患者在某医院体检发现右肺占位，无咳嗽、咯血，无呼吸困难，无胸痛，无潮热、盗汗、疲乏、消瘦，无畏寒、发热，行纤支镜及病检提示肺鳞癌（未见报告），行肺癌根治术及辅助化疗（具体情况不详），于7+年前复查胸部ct提示肿瘤复发，建议手术治疗，但患者本人拒绝，在某医院行姑息性放疗及化疗（情况不详），此后一直在家休养。", "event": [ { "core_name": "占位", "tendency": "", "character": [], "anatomy_list": [ "右肺" ] }, { "core_name": "咳嗽", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "咯血", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "呼吸困难", "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": "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": [] }, { "core_name": "鳞癌", "tendency": "", "character": [], "anatomy_list": [ "肺" ] }, { "core_name": "肿瘤", "tendency": "", "character": [ "复发" ], "anatomy_list": [ "肺" ] } ] }, { "id": 1123, "text": "并于2012-6-2以“卡铂500mg d1+紫杉醇240mg d1\"方案行第四周期化疗，化疗后复查血常规提示贫血，行骨穿后诊断为“巨幼红细胞性贫血”，考虑为卡铂所致，随后将卡铂改为奥沙利铂。", "event": [ { "core_name": "贫血", "tendency": "", "character": [ "化疗后" ], "anatomy_list": [] }, { "core_name": "贫血", "tendency": "", "character": [ "巨幼红细胞" ], "anatomy_list": [] } ] }, { "id": 1454, "text": "遂入我科，予以全脑姑息性放疗，以2.2G/f照射4次后，患者头痛加重，予以对症处理后，症状无明显缓解，考虑患者颅内病灶多且较分散，颅脑单次剂量过高，经全科讨论后，改为全脑放疗2.0G/f照射16次+2.2G/f照射2次，患者头痛、呕吐症状明显缓解，院外休息，自服索拉菲尼，未诉特殊不适。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [ "加重" ], "anatomy_list": [ "头" ] }, { "core_name": "病灶", "tendency": "", "character": [ "多", "较分散" ], "anatomy_list": [ "颅内病灶" ] }, { "core_name": "疼痛", "tendency": "", "character": [ "明显缓解" ], "anatomy_list": [ "头" ] }, { "core_name": "呕吐", "tendency": "", "character": [ "明显缓解" ], "anatomy_list": [] } ] }, { "id": 1668, "text": "院后饮食、睡眠、精神均可。", "event": [ { "core_name": "饮食", "tendency": "", "character": [ "可" ], "anatomy_list": [] }, { "core_name": "睡眠", "tendency": "", "character": [ "可" ], "anatomy_list": [] }, { "core_name": "精神", "tendency": "", "character": [ "可" ], "anatomy_list": [] } ] }, { "id": 1676, "text": "患者于30余年前，因感冒受凉后出现咳嗽咳痰、痰为白色泡沫痰、量多、无脓臭味，无咯血，无畏寒发热、无潮热盗汗等不适；于外院经抗感染、止咳祛痰等对症处理后症状好转。", "event": [ { "core_name": "感冒", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "咳嗽", "tendency": "", "character": [ "受凉后" ], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "白色", "泡沫痰", "量多", "无脓臭味" ], "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": "潮热", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "盗汗", "tendency": "否定", "character": [], "anatomy_list": [] } ] }, { "id": 1538, "text": "经肿瘤科、肝胆外科、胸外科多科会诊后，结论：患者直肠癌诊断明确，且肝转移可能性大，建议先行新辅助化疗，后期评估后再行手术，遂于2016-01-22、2016-02-04、2016-02-19日分别以“奥沙利铂+5-氟尿嘧啶（folfox4）”行新辅助化疗3次；复查胸腹部ct(2016-03-14 某医院): 1.符合慢支炎、肺气肿改变； 2.主动脉弓钙化； 3.肝左叶内侧段钙化灶；肝内低密度结节影 请随访复查。", "event": [ { "core_name": "癌", "tendency": "", "character": [], "anatomy_list": [ "直肠" ] }, { "core_name": "癌", "tendency": "不确定", "character": [ "转移" ], "anatomy_list": [ "肝" ] }, { "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": "钙化", "tendency": "", "character": [], "anatomy_list": [ "主动脉弓" ] }, { "core_name": "钙化灶", "tendency": "", "character": [], "anatomy_list": [ "肝左叶内侧段" ] }, { "core_name": "结节影", "tendency": "", "character": [ "低密度" ], "anatomy_list": [ "肝内" ] } ] }, { "id": 2044, "text": "3天前患者中腹部阵发隐痛不适，伴黄色稀便，2次/天，每次量少，今日为进一步治疗入我院，急诊以\"白血病\"收入我科住院治疗。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [ "阵发", "隐痛" ], "anatomy_list": [ "中腹部" ] }, { "core_name": "腹部不适", "tendency": "", "character": [], "anatomy_list": [ "中腹部" ] }, { "core_name": "大便", "tendency": "", "character": [ "黄色", "每次量少", "稀" ], "anatomy_list": [] }, { "core_name": "白血病", "tendency": "", "character": [], "anatomy_list": [] } ] }, { "id": 1574, "text": "无禁忌症，于01月17日开始给予folfox方案（奥沙利铂200mg d1，氟尿嘧啶.075g1-d5）化疗1周期，过程顺利，患者出现恶心i度及手足麻木麻木不适，无明显骨髓抑制，给予营养神经、对症等治疗后腹痛及手足麻木好转。", "event": [ { "core_name": "恶心", "tendency": "", "character": [ "i度" ], "anatomy_list": [] }, { "core_name": "麻木", "tendency": "", "character": [], "anatomy_list": [ "手", "足" ] }, { "core_name": "手足不适", "tendency": "", "character": [], "anatomy_list": [ "手", "足" ] }, { "core_name": "骨髓抑制", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [ "骨髓" ] }, { "core_name": "疼痛", "tendency": "", "character": [ "好转" ], "anatomy_list": [ "腹" ] }, { "core_name": "麻木", "tendency": "", "character": [ "好转" ], "anatomy_list": [ "手", "足" ] } ] }, { "id": 999, "text": "入院前8天，患者无明显诱因右上腹疼痛，为“压榨样”疼痛，无肩背部放射痛，间断发作，弯腰屈膝位可缓解，无明显加重因素，伴发热，最高高体温不详，无畏寒、寒战，无胸痛、胸闷，无恶心、呕吐、腹泻，无咳嗽、咳痰，无皮肤、黏膜黄染，小便未见明显异常，未予重视，自行口服药物（具体不详）治疗无效。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [], "anatomy_list": [ "右上腹" ] }, { "core_name": "疼痛", "tendency": "", "character": [ "压榨样", "间歇发作", "弯腰屈膝位可缓解", "无明显加重因素" ], "anatomy_list": [ "右上腹" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [ "放射性" ], "anatomy_list": [ "肩背部" ] }, { "core_name": "发热", "tendency": "", "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": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "胸" ] }, { "core_name": "胸闷", "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": "腹泻", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "咳嗽", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "黄染", "tendency": "否定", "character": [], "anatomy_list": [ "皮肤", "黏膜" ] }, { "core_name": "小便异常", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [] } ] }, { "id": 1891, "text": "病程中患者无头痛及头晕，患者长期于院外复查，患者为复查了解机体情况，今日以“鼻咽癌”收入我科。", "event": [ { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "头" ] }, { "core_name": "头晕", "tendency": "否定", "character": [], "anatomy_list": [ "头" ] }, { "core_name": "癌", "tendency": "", "character": [], "anatomy_list": [ "鼻咽" ] } ] }, { "id": 1606, "text": "2020-7-28行宫颈活检（123456）示：（宫颈上唇、下唇）浸润性鳞状细胞癌；（阴道壁组织）鳞状上皮高级别异型增生，不除外鳞状细胞癌。", "event": [ { "core_name": "鳞癌", "tendency": "", "character": [ "浸润性" ], "anatomy_list": [ "宫颈上唇、下唇" ] }, { "core_name": "增生", "tendency": "", "character": [ "鳞状上皮", "高级别", "异型" ], "anatomy_list": [ "阴道壁组织" ] }, { "core_name": "鳞癌", "tendency": "不确定", "character": [], "anatomy_list": [ "阴道壁" ] } ] }, { "id": 257, "text": "1月前患者无明显诱因出现间断中上腹隐痛上腹隐痛不适，感腹胀，解可疑成形黑便，精神欠佳，无明显反酸、烧心、嗳气，无恶心、呕吐、呕血，无头晕、黑曚，无胸闷、胸痛、心悸，无咳嗽、气促，无腹泻。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [ "间断", "隐痛" ], "anatomy_list": [ "中上腹" ] }, { "core_name": "疼痛", "tendency": "", "character": [ "隐痛不适" ], "anatomy_list": [ "上腹" ] }, { "core_name": "腹胀", "tendency": "", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "黑便", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "精神", "tendency": "", "character": [ "欠佳" ], "anatomy_list": [] }, { "core_name": "返酸", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [] }, { "core_name": "烧心", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [] }, { "core_name": "嗳气", "tendency": "否定", "character": [ "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": "呕血", "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": "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": "咳嗽", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "气促", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "腹泻", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] } ] }, { "id": 1960, "text": "患病以来，患者精神、食欲、睡眠可，二便基本正常，体重无明显改变。", "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": [ "基本正常" ], "anatomy_list": [] }, { "core_name": "体重改变", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [] } ] }, { "id": 767, "text": "2019-11-20患者为求进一步治疗入院，复查ct提示患者病情进展，前期患者胸水基因检测提示egfr基因T790M和19-del突变，积极与患者及家属沟通，建议可申购正版奥西替尼或行化疗，患者及家属经商议后决定于11月27日行培美曲塞0.7g+奈达铂100mg化疗，化疗结束后出院。", "event": [ { "core_name": "胸水", "tendency": "", "character": [], "anatomy_list": [ "胸" ] } ] }, { "id": 1113, "text": "患者无明显头痛、胸痛，无视物模糊、视物旋转，无畏寒发热、喘累气促、呼吸困难等不适。", "event": [ { "core_name": "疼痛", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [ "头" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [ "胸" ] }, { "core_name": "视物模糊", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "视物旋转", "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": "呼吸困难", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "气促", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "喘累", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "呼吸困难", "tendency": "否定", "character": [], "anatomy_list": [] } ] }, { "id": 1784, "text": "术后病理示<直肠>中分化腺癌，侵及肠壁全层及肠周脂肪组织中，脂肪中见癌结节1枚。", "event": [ { "core_name": "腺癌", "tendency": "", "character": [ "中分化" ], "anatomy_list": [ "直肠" ] }, { "core_name": "侵及", "tendency": "", "character": [], "anatomy_list": [ "肠壁全层", "肠周脂肪组织" ] }, { "core_name": "结节", "tendency": "", "character": [ "癌" ], "anatomy_list": [ "肠周脂肪组织中" ] } ] }, { "id": 373, "text": "今为求进一步诊治，入我科就诊，门诊以“间质性肺炎”收入我院。", "event": [ { "core_name": "肺炎", "tendency": "", "character": [ "间质性" ], "anatomy_list": [ "肺" ] } ] }, { "id": 424, "text": "患者于入院前10余年前反复无明显诱因出现腹痛伴大便不通，腹痛部位不定，为间歇性隐痛，大便次数约3", "event": [ { "core_name": "疼痛", "tendency": "", "character": [ "反复" ], "anatomy_list": [ "腹" ] }, { "core_name": "大便", "tendency": "", "character": [ "不通" ], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "", "character": [ "部位不定", "间歇性", "隐痛" ], "anatomy_list": [ "腹" ] } ] }, { "id": 400, "text": "患者于入院2个月前（2015.11.19）于我院在全麻下行左乳包块切除+术中冰冻活检+左腋窝前哨淋巴结探查活检+左乳癌改良根治术，术后病理诊断：（左）乳浸润性癌；免疫组化示：er（++）70%pr（+）10%cerbb-2（±） ki-67（－）；腋窝淋巴结癌转移12/16。", "event": [ { "core_name": "癌", "tendency": "", "character": [ "浸润性" ], "anatomy_list": [ "左乳" ] }, { "core_name": "癌", "tendency": "", "character": [ "转移" ], "anatomy_list": [ "腋窝淋巴结" ] } ] }, { "id": 1464, "text": "2+年患者自觉心前区不适症状加重，就诊于某医院，行冠脉造影后于前降支植入支架2枚，右冠植入支架1枚。", "event": [ { "core_name": "心前区不适", "tendency": "", "character": [ "加重" ], "anatomy_list": [ "心前区" ] } ] }, { "id": 798, "text": "1月前患者来我科行第一次化疗，化疗后患者一般清况尚可，无畏寒发热、无皮肤巩膜黄染、无恶心呕吐、无腹胀腹痛、无头晕气促、无食欲减退等不适，现患者为行第二次化疗来我院收住我科。", "event": [ { "core_name": "畏寒", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "发热", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "黄染", "tendency": "否定", "character": [], "anatomy_list": [ "皮肤", "巩膜" ] }, { "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": "头晕", "tendency": "否定", "character": [], "anatomy_list": [ "头" ] }, { "core_name": "气促", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "食欲减退", "tendency": "否定", "character": [], "anatomy_list": [] } ] }, { "id": 1977, "text": "入院前7月余，患者无明显诱因出现胸痛、咳嗽，胸痛为阵发性牵扯样疼痛，咳嗽为阵发性，白昼无明显差别，伴有少量白色泡沫痰，易咳出，伴有乏力、喘息、胸闷，无夜间阵发性呼吸困难、夜间端坐呼吸、无双下肢水肿，无发热、盗汗、纳差，无心悸、反酸、嗳气等不适。患者未予重视，后患者感上述症状无明显改善。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [], "anatomy_list": [ "胸" ] }, { "core_name": "咳嗽", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "", "character": [ "阵发性", "牵扯样" ], "anatomy_list": [ "胸" ] }, { "core_name": "咳嗽", "tendency": "", "character": [ "阵发性" ], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "少量", "白色", "泡沫痰", "易咳出" ], "anatomy_list": [] }, { "core_name": "乏力", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "喘息", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "胸闷", "tendency": "", "character": [], "anatomy_list": [ "胸" ] }, { "core_name": "呼吸困难", "tendency": "否定", "character": [ "阵发性", "夜间" ], "anatomy_list": [] }, { "core_name": "端坐呼吸", "tendency": "否定", "character": [ "夜间" ], "anatomy_list": [] }, { "core_name": "水肿", "tendency": "否定", "character": [], "anatomy_list": [ "双下肢" ] }, { "core_name": "发热", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "盗汗", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "纳差", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "心悸", "tendency": "否定", "character": [], "anatomy_list": [ "心" ] }, { "core_name": "反酸", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "嗳气", "tendency": "否定", "character": [], "anatomy_list": [] } ] }, { "id": 1453, "text": "67天前，患者无明显诱因出现头痛，为持续性隐痛，伴呕吐，非喷射性，呕吐物为胃内容物，呕吐后症状无明显好转，伴头晕、视物模糊，伴厌油，无腹痛、腹泻，无畏寒、发热等不适，于我院门诊行颅脑ct示颅内多发占位，考虑转移。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [ "持续性", "隐痛" ], "anatomy_list": [ "头" ] }, { "core_name": "呕吐", "tendency": "", "character": [ "非喷射性", "呕吐物为胃内容物", "呕吐后症状无明显好转" ], "anatomy_list": [] }, { "core_name": "头晕", "tendency": "", "character": [], "anatomy_list": [ "头" ] }, { "core_name": "视物模糊", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "厌油", "tendency": "", "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": "畏寒", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "发热", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "占位", "tendency": "", "character": [ "多发" ], "anatomy_list": [ "颅内" ] }, { "core_name": "转移", "tendency": "不确定", "character": [ "转移" ], "anatomy_list": [] } ] }, { "id": 346, "text": "术后患者出现排尿困难，二次导尿后好转，经积极治疗，于2020年01月20日出院。", "event": [ { "core_name": "排尿困难", "tendency": "", "character": [], "anatomy_list": [] } ] }, { "id": 380, "text": "入院前1+年，患者受凉后出现咳嗽，为刺激性咳嗽，痰量少，不易咳出，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": [ "受凉后" ], "anatomy_list": [] }, { "core_name": "咳嗽", "tendency": "", "character": [ "刺激性" ], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "量少", "不易咳出" ], "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": "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": 687, "text": "随后于停经58天（2020-5-18）就诊于我院，查血hcg23126.3m/ml，孕酮：21.13ng/ml。", "event": [ { "core_name": "停经", "tendency": "", "character": [], "anatomy_list": [] } ] }, { "id": 540, "text": "病程中，患者逐渐出现手足麻木、疼痛，间断泡沫尿及间断性跛行，多次于我院就诊，诊断为“2型糖尿病、糖尿病周围神经病变、糖尿病肾病”，予以皮下注射胰岛素（诺和锐30早12iu 晚12iu qd）、服用瑞格列奈 1mg午餐前qd。", "event": [ { "core_name": "麻木", "tendency": "", "character": [], "anatomy_list": [ "手", "足" ] }, { "core_name": "疼痛", "tendency": "", "character": [], "anatomy_list": [ "手", "足" ] }, { "core_name": "泡沫尿", "tendency": "", "character": [ "间断" ], "anatomy_list": [] }, { "core_name": "跛行", "tendency": "", "character": [ "间断性" ], "anatomy_list": [] }, { "core_name": "糖尿病", "tendency": "", "character": [ "2型" ], "anatomy_list": [] }, { "core_name": "病变", "tendency": "", "character": [ "糖尿病" ], "anatomy_list": [ "周围神经" ] }, { "core_name": "肾病", "tendency": "", "character": [ "糖尿病" ], "anatomy_list": [ "肾" ] } ] }, { "id": 72, "text": "2天前患者于体检时行胸部ct检查提示：左肺占位性病变伴阻塞性肺炎，无低热盗汗、畏寒寒战、咯血、痰中带血、胸闷胸痛、恶心呕吐等不适，患者为求进一步诊治，遂入我院，门诊以“左肺占位”收治入科。", "event": [ { "core_name": "病变", "tendency": "", "character": [ "占位性" ], "anatomy_list": [ "左肺" ] }, { "core_name": "肺炎", "tendency": "", "character": [ "阻塞性" ], "anatomy_list": [ "肺" ] }, { "core_name": "发热", "tendency": "否定", "character": [ "低" ], "anatomy_list": [] }, { "core_name": "盗汗", "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": "咯血", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "否定", "character": [ "带血" ], "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": "占位", "tendency": "", "character": [], "anatomy_list": [ "左肺" ] } ] }, { "id": 203, "text": "病程中有反酸、进粗食哽噎感，目前患者无畏寒、发热，无恶心、呕吐，无腹痛、腹泻，无鼻塞、流涕表现，近1周来，患者感进食梗阻较前频繁，2016年3月23日来我院门诊检查胃镜示：食管癌术后；食管吻合口炎吻合口炎伴糜烂；食管吻合口狭窄。", "event": [ { "core_name": "反酸", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "哽噎感", "tendency": "", "character": [ "进粗食" ], "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": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "腹泻", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "鼻塞", "tendency": "否定", "character": [], "anatomy_list": [ "鼻" ] }, { "core_name": "流涕", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "进食梗阻", "tendency": "", "character": [ "较前频繁" ], "anatomy_list": [] }, { "core_name": "癌", "tendency": "", "character": [ "术后" ], "anatomy_list": [ "食管" ] }, { "core_name": "食管吻合口炎", "tendency": "", "character": [], "anatomy_list": [ "食管吻合口" ] }, { "core_name": "吻合口炎", "tendency": "", "character": [], "anatomy_list": [ "吻合口" ] }, { "core_name": "糜烂", "tendency": "", "character": [], "anatomy_list": [ "食管吻合口" ] }, { "core_name": "狭窄", "tendency": "", "character": [], "anatomy_list": [ "食管吻合口" ] } ] }, { "id": 408, "text": "患者于2018年12月24日转诊某医院，腹部ct提示直肠新生物伴周围淋巴结淋巴结增大，行pet/ct提示：直肠下段管壁增厚，fdg代谢增高，倾向肿瘤；盆腔淋巴结肿大，fdg代谢增高，倾向转移；左肾上腺增大，fdg代谢增高，可疑转移；右肾上腺增大，fdg代谢增高，建议随访；双肺小结节，fdg代谢未见异常增高，倾向良性病变。", "event": [ { "core_name": "新生物", "tendency": "", "character": [], "anatomy_list": [ "直肠" ] }, { "core_name": "淋巴结增大", "tendency": "", "character": [], "anatomy_list": [ "直肠周围淋巴结" ] }, { "core_name": "增厚", "tendency": "", "character": [], "anatomy_list": [ "直肠下段管壁" ] }, { "core_name": "fdg", "tendency": "", "character": [ "代谢增高" ], "anatomy_list": [] }, { "core_name": "肿瘤", "tendency": "不确定", "character": [], "anatomy_list": [ "直肠下段" ] }, { "core_name": "肿大", "tendency": "", "character": [], "anatomy_list": [ "盆腔淋巴结" ] }, { "core_name": "fdg", "tendency": "", "character": [ "代谢增高" ], "anatomy_list": [] }, { "core_name": "转移", "tendency": "不确定", "character": [], "anatomy_list": [] }, { "core_name": "增大", "tendency": "", "character": [], "anatomy_list": [ "左肾上腺" ] }, { "core_name": "fdg", "tendency": "", "character": [ "代谢增高" ], "anatomy_list": [] }, { "core_name": "转移", "tendency": "不确定", "character": [], "anatomy_list": [] }, { "core_name": "增大", "tendency": "", "character": [], "anatomy_list": [ "右肾上腺" ] }, { "core_name": "fdg", "tendency": "", "character": [ "代谢增高" ], "anatomy_list": [] }, { "core_name": "结节", "tendency": "", "character": [ "小" ], "anatomy_list": [ "双肺" ] }, { "core_name": "fdg", "tendency": "否定", "character": [ "代谢异常增高" ], "anatomy_list": [] }, { "core_name": "病变", "tendency": "不确定", "character": [ "良性" ], "anatomy_list": [] } ] }, { "id": 1218, "text": "2017.06，患者无明显诱因出现阴道大量流血，呈鲜红色，一天可浸湿三张卫生巾，伴下腹部疼痛，难以忍受，遂至某医院就诊，给予止血、止痛等对症治疗后（具体治疗不详）症状未缓解，患者为进一步治疗到我院妇科门诊就诊，行妇科检查提示宫颈表面可见大量菜花样组织，有活动性出血，妇科彩超提示：1.宫颈偏低回声，考虑宫颈ca。", "event": [ { "core_name": "出血", "tendency": "", "character": [ "大量", "呈鲜红色", "一天可浸湿三张卫生巾" ], "anatomy_list": [ "阴道" ] }, { "core_name": "疼痛", "tendency": "", "character": [ "难以忍受" ], "anatomy_list": [ "下腹部" ] }, { "core_name": "菜花样组织", "tendency": "", "character": [ "大量", "有活动性出血" ], "anatomy_list": [ "宫颈表面" ] }, { "core_name": "回声", "tendency": "", "character": [ "偏低" ], "anatomy_list": [ "宫颈" ] }, { "core_name": "癌", "tendency": "不确定", "character": [], "anatomy_list": [ "宫颈" ] } ] }, { "id": 1193, "text": "患者于2016-07-18在局麻超声引导下行右乳包块麦默通旋切术+快速冰冻活检术，术后病理提示：（右乳）浸润性小叶癌，免疫组化提示：er（－） pr（－） cerbb-2（－） ki-67（++）。", "event": [ { "core_name": "癌", "tendency": "", "character": [ "浸润性" ], "anatomy_list": [ "右乳小叶" ] } ] }, { "id": 1855, "text": "术后病理报告（123456）：（直肠）中分化腺癌，侵及深肌层。", "event": [ { "core_name": "腺癌", "tendency": "", "character": [ "中分化" ], "anatomy_list": [ "直肠" ] }, { "core_name": "腺癌", "tendency": "", "character": [ "侵及" ], "anatomy_list": [ "深肌层" ] } ] }, { "id": 135, "text": "术后病理示：（右乳）浸润性癌（倾向小叶癌合并小管癌），免疫组化：er（+）10%pr（－） ck（++） cr（－） cerbb-2（+） ki-67（+）＜10%。", "event": [ { "core_name": "癌", "tendency": "", "character": [ "浸润性" ], "anatomy_list": [ "右乳" ] }, { "core_name": "小叶癌", "tendency": "不确定 ", "character": [], "anatomy_list": [ "右乳" ] }, { "core_name": "小管癌", "tendency": "不确定 ", "character": [], "anatomy_list": [ "右乳" ] } ] }, { "id": 1362, "text": "患者感左侧胸痛进行性加重，夜间影响睡眠，于2016-09-23于某医院完善骨扫描：右前第2肋、左侧髋关节髋关节异常放射性增多。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [ "进行性加重", "夜间影响睡眠" ], "anatomy_list": [ "左侧胸" ] }, { "core_name": "增多", "tendency": "", "character": [ "异常放射性" ], "anatomy_list": [ "右前2肋", "左侧髋关节" ] } ] }, { "id": 66, "text": "遂于我院就诊，完善相关检查示：hcv-dna定量为1.1*107IU/ml,甲胎蛋白示163.10ug/L，上腹部mr提示肝右叶肝癌可能，肝硬化。", "event": [ { "core_name": "癌", "tendency": "不确定", "character": [], "anatomy_list": [ "肝右叶" ] }, { "core_name": "硬化", "tendency": "", "character": [], "anatomy_list": [ "肝" ] } ] }, { "id": 1144, "text": "子宫颈管见癌累及。建议住院行进一步诊治。", "event": [ { "core_name": "癌", "tendency": "", "character": [], "anatomy_list": [ "子宫颈管" ] } ] }, { "id": 688, "text": "妇科超声提示宫内早孕，卵黄囊可见，直径3.1mm，胎芽可见，长径约3mm，原始心管搏动可见。", "event": [ { "core_name": "早孕", "tendency": "", "character": [], "anatomy_list": [ "宫内" ] }, { "core_name": "卵黄囊", "tendency": "", "character": [ "可见" ], "anatomy_list": [ "宫内" ] }, { "core_name": "胎芽", "tendency": "", "character": [ "可见" ], "anatomy_list": [] }, { "core_name": "搏动", "tendency": "", "character": [ "原始", "可见" ], "anatomy_list": [ "心管" ] } ] }, { "id": 1191, "text": "给予药物治疗（具体用药不详），中上腹疼痛症状稍缓解。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [ "稍缓解" ], "anatomy_list": [ "中上腹" ] } ] }, { "id": 438, "text": "今日再次来我院就诊，门诊以“左侧输尿管扩张”收住入院。", "event": [ { "core_name": "扩张", "tendency": "", "character": [], "anatomy_list": [ "左侧输尿管" ] } ] }, { "id": 159, "text": "患“糖尿病”1+年，现仍在皮下注射胰岛素，血糖控制可。", "event": [ { "core_name": "糖尿病", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "血糖", "tendency": "", "character": [ "控制可" ], "anatomy_list": [] } ] }, { "id": 156, "text": "入院前2天，患者到我院门诊随访，胸部+上腹部ct平扫+增强示：左肺上叶尖后段及下叶外基底段胸膜下类圆形结节结节影，考虑转移可能，较前比较，左肺上叶尖后段胸膜下结节结节影稍增大，肝ca介入术后改变。", "event": [ { "core_name": "结节影", "tendency": "", "character": [ "类圆形" ], "anatomy_list": [ "左肺上叶尖后段胸膜下", "左肺下叶外基底段胸膜下" ] }, { "core_name": "转移", "tendency": "不确定", "character": [], "anatomy_list": [] }, { "core_name": "结节影", "tendency": "", "character": [ "稍增大" ], "anatomy_list": [ "左肺上叶尖后段胸膜下" ] }, { "core_name": "癌", "tendency": "", "character": [], "anatomy_list": [ "肝" ] }, { "core_name": "改变", "tendency": "", "character": [ "介入术后" ], "anatomy_list": [ "肝" ] } ] }, { "id": 1381, "text": "3.左冠状动脉壁钙化。", "event": [ { "core_name": "钙化", "tendency": "", "character": [], "anatomy_list": [ "左冠状动脉壁" ] } ] }, { "id": 480, "text": "至某口腔医院就诊，因肺部检查异常（具体不详）无法麻醉，未行手术切除。", "event": [ { "core_name": "异常", "tendency": "", "character": [], "anatomy_list": [ "肺部" ] } ] }, { "id": 1566, "text": "入院前4月，患者进食后出现胸骨后哽咽感，无腹痛，无恶心、呕吐，无咯血、黑便，无腹胀，近期无异物吞咽史，病后于某医院行食管钡餐及喉镜检查，结果提示“未见明显实质性病变”，未行特殊治疗；入院前2月，患者出现进食哽咽加重伴吞咽困难，进食干硬及大块食物时明显，大量进食后呕吐，呕吐物为食物残渣，患者未重视，未行特殊治疗；现患者吞咽困难仍明显，为进一步诊治于某医院行胃镜检查，结果提示“食管上段鳞癌”，为进一步治疗入我院，门诊以“食管癌”收入我科。", "event": [ { "core_name": "哽噎感", "tendency": "", "character": [ "进食后" ], "anatomy_list": [ "胸骨后" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "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": "咯血", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "黑便", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "腹胀", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "异物吞咽", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "病变", "tendency": "否定", "character": [ "明显实质性" ], "anatomy_list": [] }, { "core_name": "哽噎感", "tendency": "", "character": [ "进食加重", "进食干硬大块食物明显" ], "anatomy_list": [] }, { "core_name": "吞咽困难", "tendency": "", "character": [ "进食干硬大块食物明显" ], "anatomy_list": [] }, { "core_name": "呕吐", "tendency": "", "character": [ "大量进食后", "呕吐物为食物残渣" ], "anatomy_list": [] }, { "core_name": "吞咽困难", "tendency": "", "character": [ "明显" ], "anatomy_list": [] }, { "core_name": "鳞癌", "tendency": "", "character": [], "anatomy_list": [ "食管上段" ] }, { "core_name": "癌", "tendency": "", "character": [], "anatomy_list": [ "食管" ] } ] }, { "id": 1939, "text": "因无手术指征，于2017.04.02、04.26以tp方案（药物总量：紫杉醇480mg+奈达铂260mg）姑息性化疗2周期，化疗期间感全身酸痛，后自行缓解，患者因第三周期化疗时出现奈达铂过敏，于6月1日行tp方案（紫杉醇210mg+卡铂450mg）化疗第3周期，病程中因患者腰部胀痛明显，于2017年4月-66月行腰55椎体转移肿瘤放射治疗，放疗后患者腰部胀痛较前缓解，现口服盐酸吗啡缓释片4片q12h口服止痛治疗，现疼痛评分：2分。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [ "化疗期间", "后自行缓解", "酸痛" ], "anatomy_list": [ "全身" ] }, { "core_name": "过敏", "tendency": "", "character": [ "奈达铂" ], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "", "character": [ "明显", "胀痛" ], "anatomy_list": [ "腰部" ] }, { "core_name": "疼痛", "tendency": "", "character": [ "较前缓解", "放疗后", "胀痛" ], "anatomy_list": [ "腰部" ] } ] }, { "id": 1522, "text": "2月前患者受凉后喘累明显，平路活动即感气促，间断白色粘痰，间断可咳暗红色血，稍活动伴心悸、心累，有纳差，剑突下隐痛，反酸、嗳气，不消化感，大便干结，6-7天/次，颗粒大便，给予抗感染、止咳平喘、护胃治疗好转出院。", "event": [ { "core_name": "喘累", "tendency": "", "character": [ "明显", "受凉后" ], "anatomy_list": [] }, { "core_name": "气促", "tendency": "", "character": [ "平路活动" ], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "间断", "白色", "粘" ], "anatomy_list": [] }, { "core_name": "咳血", "tendency": "", "character": [ "间断", "暗红色" ], "anatomy_list": [] }, { "core_name": "心悸", "tendency": "", "character": [ "稍活动" ], "anatomy_list": [ "心" ] }, { "core_name": "心累", "tendency": "", "character": [ "稍活动" ], "anatomy_list": [ "心" ] }, { "core_name": "纳差", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "", "character": [ "隐痛" ], "anatomy_list": [ "剑突下" ] }, { "core_name": "反酸", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "嗳气", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "不消化感", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "大便", "tendency": "", "character": [ "干结", "颗粒", "6-7天/次" ], "anatomy_list": [] } ] }, { "id": 783, "text": "急诊以“眩晕待诊”收入我院。", "event": [ { "core_name": "眩晕", "tendency": "", "character": [], "anatomy_list": [] } ] }, { "id": 539, "text": "患者于入院前10+年无明显诱因出现口干、多尿、体重减轻（具体数值不详），晕厥1次，遂于“某医院”就诊，查随机血糖大于30mmol/L，诊断为“糖尿病”，予以胰岛素泵强化治疗后好转出院，院外使用一段时间胰岛素后改为口服“达美康”及“中药”（具体不详）等治疗，血糖控制情况不详。", "event": [ { "core_name": "口干", "tendency": "", "character": [], "anatomy_list": [ "口" ] }, { "core_name": "多尿", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "体重减轻", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "晕厥", "tendency": "", "character": [ "1次" ], "anatomy_list": [] }, { "core_name": "糖尿病", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "血糖", "tendency": "", "character": [ "控制不详" ], "anatomy_list": [] } ] }, { "id": 1377, "text": "2天前患者出现咳嗽、咳痰，咳黄白色粘稠痰，无咯血及痰中带血，无发热，未予重视治疗，入院前2小时突发呼吸困难，伴大汗淋漓，无畏寒、发热、头痛、胸痛、恶心、呕吐、抽搐等。", "event": [ { "core_name": "咳嗽", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "黄白色", "粘稠" ], "anatomy_list": [] }, { "core_name": "咯血", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "否定", "character": [ "带血" ], "anatomy_list": [] }, { "core_name": "发热", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "呼吸困难", "tendency": "", "character": [ "突发" ], "anatomy_list": [] }, { "core_name": "出汗", "tendency": "", "character": [ "大汗" ], "anatomy_list": [] }, { "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": "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": "抽搐", "tendency": "否定", "character": [], "anatomy_list": [] } ] }, { "id": 1407, "text": "患者与某医院肝胆外科，行全面下行开腹保留十二指肠的胰头切除术、胆囊切除术和胆总管探查术，术后6天患者出现低血容量性休克，考虑腹腔出血可能性大，予以扩容、输血等对症，无明显好转，局麻下行肝动脉分支假性动脉瘤栓塞止血术，术后经过泰能抗感染、生长抑素泵入、补液、腹腔引流及对症治疗，患者病情平稳后，带腹腔2根引流管+t管引流出院。", "event": [ { "core_name": "休克", "tendency": "", "character": [ "低血容量性" ], "anatomy_list": [] }, { "core_name": "出血", "tendency": "不确定", "character": [], "anatomy_list": [ "腹腔" ] } ] }, { "id": 955, "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，大便如上所诉，小便正常，体重无明显变化。", "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": "小便", "tendency": "", "character": [ "正常" ], "anatomy_list": [] }, { "core_name": "体重改变", "tendency": "", "character": [ "明显" ], "anatomy_list": [] } ] }, { "id": 908, "text": "追问病史，无结核接触史，有卡介苗接种史。", "event": [ { "core_name": "结核", "tendency": "否定", "character": [ "接触史" ], "anatomy_list": [] } ] }, { "id": 581, "text": "门诊建议手术治疗，遂以“左侧乳腺肿瘤”收治入院。", "event": [ { "core_name": "肿瘤", "tendency": "", "character": [], "anatomy_list": [ "左侧乳腺" ] } ] }, { "id": 492, "text": "患者于2016.06.14、2016.07.07、2016.07.29、2016.08.19、2016.09.12、2016.10.10于我院行共6次tac（吡柔比星60mg d1+紫杉醇240mg d2+环磷酰胺800mg d3）方案化疗，化疗过程顺利，化疗后患者出现肢端麻木、感觉异常，给予对症治疗后症状好转。", "event": [ { "core_name": "麻木", "tendency": "", "character": [ "化疗后" ], "anatomy_list": [ "肢端" ] }, { "core_name": "感觉异常", "tendency": "", "character": [ "化疗后" ], "anatomy_list": [ "肢端" ] } ] }, { "id": 1042, "text": "入院前3+月，患者感上腹胀于我科门诊随访完善腹部ct提示肝右叶多发强化病灶，考虑肝转移瘤可能。", "event": [ { "core_name": "腹胀", "tendency": "", "character": [], "anatomy_list": [ "上腹" ] }, { "core_name": "病灶", "tendency": "", "character": [ "多发", "强化" ], "anatomy_list": [ "肝右叶" ] }, { "core_name": "瘤", "tendency": "不确定", "character": [ "转移" ], "anatomy_list": [ "肝" ] } ] }, { "id": 1866, "text": "积极术前准备，于2019年11月10日在手术室全麻下行了腹腔镜辅助下直肠癌直肠前切除术，术后恢复良好出院，术后诊断：直肠腺癌t3n0M0。", "event": [ { "core_name": "腺癌", "tendency": "", "character": [ "t3n0M0" ], "anatomy_list": [ "直肠" ] } ] }, { "id": 568, "text": "2016-12-16行第二次r-chop（长春瑞滨40mg1，吡柔比星30mg1，环磷酰胺1g1，泼尼松100mg1-d5，美罗华500mg6)，化疗顺利，今日为进一步就诊，门诊以“非霍奇金淋巴瘤”收治入院。", "event": [ { "core_name": "瘤", "tendency": "", "character": [ "非霍奇金氏" ], "anatomy_list": [ "淋巴" ] } ] }, { "id": 18, "text": "术后病理诊断（123456）:<右乳>浸润性癌,非特殊类型（iii级,8分）；<右腋窝>淋巴结见癌转移（14/14）；乳头未见癌累及；免疫组化：er(+)70%,pr(+)10%,cerbb-2(0-1+),e-ca(+),p120(+),34βe12(+),p53(-),p63(-),ck5/6(-),calponin部分(+),ki67(+)5%。", "event": [ { "core_name": "癌", "tendency": "", "character": [ "浸润性", "非特殊类型", "8分" ], "anatomy_list": [ "右乳" ] }, { "core_name": "癌", "tendency": "", "character": [ "转移" ], "anatomy_list": [ "右腋窝淋巴结" ] }, { "core_name": "癌", "tendency": "否定", "character": [ "累及" ], "anatomy_list": [ "乳头" ] } ] }, { "id": 1085, "text": "10天患者自感活动后胸痛、心悸、胸闷较前加重，表现为少于之前活动量即可发作，症状持续时间较前延长；伴有咳嗽、咳痰不适，痰液为黄色，较粘稠；为进一步治疗来我院门诊，查血脂：甘油三酯(tg)1.09mmol/l，总胆固醇(cho)6.51mmol/l↑，高密度脂蛋白胆固醇(hdl-c)1.63mmol/l，低密度脂蛋白胆固醇(ldl-c)3.46mmol/l↑；门诊诊断”“冠心病、高脂血症”，予以“阿托伐他钙片20mg、富马酸比索洛尔片2.5mg、阿司匹林肠溶片100mg”口服；患者仍有反复的活动后胸痛、心悸、胸闷发作。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [ "活动后", "较前加重", "少于之前活动量即可发作", "症状持续时间较前延长" ], "anatomy_list": [ "胸" ] }, { "core_name": "心悸", "tendency": "", "character": [ "活动后", "较前加重", "少于之前活动量即可发作", "症状持续时间较前延长" ], "anatomy_list": [ "心" ] }, { "core_name": "胸闷", "tendency": "", "character": [ "活动后", "较前加重", "少于之前活动量即可发作", "症状持续时间较前延长" ], "anatomy_list": [ "胸" ] }, { "core_name": "咳嗽", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "黄色", "较粘稠" ], "anatomy_list": [] }, { "core_name": "心脏病", "tendency": "", "character": [ "粥样", "硬化性" ], "anatomy_list": [ "冠状动脉", "心脏" ] }, { "core_name": "高脂血症", "tendency": "", "character": [], "anatomy_list": [ "全身" ] }, { "core_name": "疼痛", "tendency": "", "character": [ "反复", "活动后" ], "anatomy_list": [ "胸" ] }, { "core_name": "心悸", "tendency": "", "character": [ "反复", "活动后" ], "anatomy_list": [ "心" ] }, { "core_name": "胸闷", "tendency": "", "character": [ "反复", "活动后" ], "anatomy_list": [ "胸" ] } ] }, { "id": 1433, "text": "3月前患者复查完善膀胱镜检，膀胱镜检发现左侧输尿管输尿管口瘢痕组织旁及膀胱左侧顶顶壁见膀胱粘膜炎症、水肿、滤泡样增生，异物钳钳夹左侧输尿管输尿管口附近及左侧顶顶壁粘膜送检后病检示：<左输尿管口附近>低级别非浸润性尿路上皮癌，<左顶壁粘膜>息肉。", "event": [ { "core_name": "炎症", "tendency": "", "character": [ "瘢痕组织旁" ], "anatomy_list": [ "左侧输尿管口", "膀胱左侧顶壁", "膀胱粘膜" ] }, { "core_name": "水肿", "tendency": "", "character": [ "瘢痕组织旁性" ], "anatomy_list": [ "左侧输尿管口", "膀胱左侧顶壁", "膀胱粘膜" ] }, { "core_name": "增生", "tendency": "", "character": [ "滤泡样" ], "anatomy_list": [ "左侧输尿管口", "膀胱左侧顶壁", "膀胱粘膜" ] }, { "core_name": "癌", "tendency": "", "character": [ "低级别", "非浸润性" ], "anatomy_list": [ "左侧输尿管口附近", "尿路上皮" ] }, { "core_name": "息肉", "tendency": "", "character": [ "粘膜" ], "anatomy_list": [ "左顶壁粘膜" ] } ] }, { "id": 1944, "text": "4月余前，患者自觉腰背部疼痛疼痛加重，伴咳嗽、咳痰、乏力多汗等不适。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [], "anatomy_list": [ "腰背部" ] }, { "core_name": "疼痛", "tendency": "", "character": [ "加重" ], "anatomy_list": [ "腰背部" ] }, { "core_name": "咳嗽", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "疲劳", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "多汗", "tendency": "", "character": [], "anatomy_list": [] } ] }, { "id": 1252, "text": "就诊于A医院、B医院予以抗炎等治疗后腹痛无明显缓解。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [ "无明显缓解" ], "anatomy_list": [ "腹" ] } ] }, { "id": 2049, "text": "取活检示：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。", "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" ] } ] }, { "id": 1991, "text": "入院前1月，患者无明显诱因出现咳嗽、咳痰，咳白色粘液痰，无痰中带血、胸痛，于诊所就医后予“硫磺解毒丸、头痛粉”治疗后无好转。", "event": [ { "core_name": "咳嗽", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "白色", "粘液" ], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "否定", "character": [ "带血" ], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "胸" ] } ] }, { "id": 2005, "text": "2.腋窝淋巴结见癌转移（2/20）。", "event": [ { "core_name": "癌", "tendency": "", "character": [ "转移" ], "anatomy_list": [ "腋窝淋巴结" ] } ] }, { "id": 1319, "text": "2013年患者无明显诱因触及左侧腋窝腋窝包块，大小约2*2cm,质硬,无压痛,无发热等不适，于某医院行包块穿刺活检提示:乳腺转移转移性癌,er(+),pr(+),her-2(++),遂行新辅助化疗两个周期ta方案（吡柔比星60mg1+多西他赛120mg2）后于2013年8月22日行左侧乳腺癌改良根治术，术后病理提示：左侧乳腺浸润性导管癌iii期,er(+),pr(+),her-2(+)，腋窝淋巴结6/6。", "event": [ { "core_name": "包块", "tendency": "", "character": [ "质硬", "无压痛" ], "anatomy_list": [ "左侧腋窝" ] }, { "core_name": "发热", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "癌", "tendency": "", "character": [ "转移" ], "anatomy_list": [ "乳腺" ] }, { "core_name": "导管癌", "tendency": "", "character": [ "浸润性", "iii期" ], "anatomy_list": [ "左侧乳腺" ] } ] }, { "id": 414, "text": "化疗期间有骨髓抑制，骨髓毒性程度为Ⅰ度；有胃肠道反应，消化系统毒性程度为Ⅰ度。", "event": [ { "core_name": "骨髓抑制", "tendency": "", "character": [ "化疗期间" ], "anatomy_list": [ "骨髓" ] }, { "core_name": "骨髓毒性", "tendency": "", "character": [ "程度为Ⅰ度" ], "anatomy_list": [ "骨髓" ] }, { "core_name": "胃肠道反应", "tendency": "", "character": [], "anatomy_list": [ "胃肠道" ] }, { "core_name": "消化系统毒性", "tendency": "", "character": [ "程度为Ⅰ度" ], "anatomy_list": [ "消化系统" ] } ] }, { "id": 2062, "text": "患病以来，患者精神、食欲、睡眠差，大便正常，尿频，近期体重无明显改变。", "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": "大便", "tendency": "", "character": [ "正常" ], "anatomy_list": [] }, { "core_name": "尿频", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "体重改变", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [] } ] }, { "id": 915, "text": "为求进一步改善右侧腕部瘢痕及活动情况，今日以“右腕部溃疡25年余”收入我科。", "event": [ { "core_name": "瘢痕", "tendency": "", "character": [], "anatomy_list": [ "右侧腕部" ] }, { "core_name": "溃疡", "tendency": "", "character": [], "anatomy_list": [ "右腕部" ] } ] }, { "id": 865, "text": "患者于12天前无明显诱因出现便血，为鲜红色，约2-3次/天，每次量约几十毫升，伴肛门坠胀感，大便次数及性状正常，表面附着少量鲜血。", "event": [ { "core_name": "便血", "tendency": "", "character": [ "鲜红色", "约2-3次/天", "每次量约几十毫升" ], "anatomy_list": [] }, { "core_name": "坠胀", "tendency": "", "character": [], "anatomy_list": [ "肛门" ] }, { "core_name": "大便", "tendency": "", "character": [ "次数正常" ], "anatomy_list": [] }, { "core_name": "大便", "tendency": "", "character": [ "性状正常" ], "anatomy_list": [] }, { "core_name": "大便", "tendency": "", "character": [ "表面附着少量鲜血" ], "anatomy_list": [] } ] }, { "id": 826, "text": "近2月外院2次妇科彩超均提示双侧附件区巧囊可能。", "event": [ { "core_name": "巧克力囊肿", "tendency": "不确定", "character": [], "anatomy_list": [ "双侧附件" ] } ] }, { "id": 1397, "text": "宫颈6、9、12点慢性炎症伴鳞状上皮增生，上皮内可见挖空细胞。", "event": [ { "core_name": "炎症", "tendency": "", "character": [ "慢性" ], "anatomy_list": [ "宫颈6、9、12点" ] }, { "core_name": "增生", "tendency": "", "character": [ "鳞状上皮" ], "anatomy_list": [ "宫颈6、9、12点" ] } ] }, { "id": 1735, "text": "于2020年2月起，患者反复出现活动后乏力，间断于我科输血治疗。", "event": [ { "core_name": "乏力", "tendency": "", "character": [ "活动后", "反复" ], "anatomy_list": [] } ] }, { "id": 927, "text": "患者于2017-1-21日在某医院行盲肠癌根治术，术后恢复好，病理诊断：（右半结肠）溃疡型低分腺癌，侵及全层；累及阑尾；肠周淋巴结转移（13/15）,见4个癌结节。", "event": [ { "core_name": "腺癌", "tendency": "", "character": [ "溃疡型", "低分化", "侵及全层", "累及阑尾" ], "anatomy_list": [ "右半结肠" ] }, { "core_name": "转移", "tendency": "", "character": [], "anatomy_list": [ "肠周淋巴结" ] }, { "core_name": "结节", "tendency": "", "character": [ "癌", "4个" ], "anatomy_list": [] } ] }, { "id": 1554, "text": "上腹部ct提示胰头部见小片状低密度影，局限性扩张的副胰管？小囊肿？行\"左颈部淋巴结切除活检术\"提示为低分化鳞状细胞癌。", "event": [ { "core_name": "密度影", "tendency": "", "character": [ "低", "小片状" ], "anatomy_list": [ "胰头部" ] }, { "core_name": "扩张", "tendency": "不确定", "character": [ "局限性" ], "anatomy_list": [ "副胰管" ] }, { "core_name": "囊肿", "tendency": "不确定", "character": [ "小" ], "anatomy_list": [ "胰" ] }, { "core_name": "鳞癌", "tendency": "", "character": [ "低分化" ], "anatomy_list": [ "左颈部" ] } ] }, { "id": 123, "text": "患者昨日复查时，发现肿瘤胸壁转移，遂入院治疗 患者自起病以来，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": "肿瘤", "tendency": "", "character": [ "转移" ], "anatomy_list": [ "胸壁" ] }, { "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": 1145, "text": "遂于今日入我院，门诊以“子宫内膜肿瘤”收入入院。", "event": [ { "core_name": "肿瘤", "tendency": "", "character": [], "anatomy_list": [ "子宫内膜" ] } ] }, { "id": 985, "text": "1年前，患者出现咳嗽、咳痰，伴活动后喘息，不伴胸痛、痰中带血、咯血，无声嘶，无吞咽困难，予以常规抗感染治疗及止咳等对症治疗，疗效不明显，我院就诊，胸腔镜结果回示：（右上叶开口）送检支气管粘膜内见单个、散在异型细胞，结合组化腺癌可能性大。", "event": [ { "core_name": "咳嗽", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "喘息", "tendency": "", "character": [ "活动后" ], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "胸" ] }, { "core_name": "咳痰", "tendency": "否定", "character": [ "带血" ], "anatomy_list": [] }, { "core_name": "咯血", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "声嘶", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "吞咽", "tendency": "否定", "character": [ "困难" ], "anatomy_list": [] }, { "core_name": "异形细胞", "tendency": "", "character": [ "单个", "散在" ], "anatomy_list": [ "支气管黏膜" ] }, { "core_name": "腺癌", "tendency": "不确定", "character": [], "anatomy_list": [ "支气管" ] } ] }, { "id": 189, "text": "入院前2年患者开始出现活动后喘累、气促，开始为爬楼感喘累，后进展为快走平路即感喘累。", "event": [ { "core_name": "喘累", "tendency": "", "character": [ "活动后" ], "anatomy_list": [] }, { "core_name": "气促", "tendency": "", "character": [ "活动后" ], "anatomy_list": [] }, { "core_name": "喘累", "tendency": "", "character": [ "爬楼" ], "anatomy_list": [] }, { "core_name": "喘累", "tendency": "", "character": [ "快走平路" ], "anatomy_list": [] } ] }, { "id": 1515, "text": "现患者时有咳嗽咳痰，稍活动即现呼吸喘促，未述发热寒战、头痛胸闷等不适。", "event": [ { "core_name": "咳嗽", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "呼吸喘促", "tendency": "", "character": [ "稍活动" ], "anatomy_list": [] }, { "core_name": "发热", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "寒颤", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "头" ] }, { "core_name": "胸闷", "tendency": "否定", "character": [], "anatomy_list": [ "胸" ] } ] }, { "id": 1234, "text": "3、肝脏少许钙化灶。", "event": [ { "core_name": "钙化灶", "tendency": "", "character": [ "少许" ], "anatomy_list": [ "肝脏" ] } ] }, { "id": 1959, "text": "入院前1天，无明显诱因于休息时再次出现鼻出血，血液由前鼻孔和口腔内流出，伴头部闷胀感，无发热、咳嗽、咳痰、头晕、头痛、恶性、呕吐，无咯血、胸痛，无潮热、盗汗、全身乏力、食欲减退，自行按压鼻部缓解，出血量较多，具体不详，今为求进一步诊治就诊于我科门诊，行电子鼻咽喉镜检查示：鼻出血/鼻咽部新生物/慢性咽炎/慢性扁桃体炎，建议患者住院治疗，患者考虑后同意，即以“鼻咽部新生物”收入院。", "event": [ { "core_name": "出血", "tendency": "", "character": [], "anatomy_list": [ "鼻" ] }, { "core_name": "血液流出", "tendency": "", "character": [], "anatomy_list": [ "前鼻孔", "口腔" ] }, { "core_name": "闷胀感", "tendency": "", "character": [], "anatomy_list": [ "头部" ] }, { "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": "头晕", "tendency": "否定", "character": [], "anatomy_list": [ "头" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "头部" ] }, { "core_name": "恶心", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "呕吐", "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": [] }, { "core_name": "出血", "tendency": "", "character": [ "量较多" ], "anatomy_list": [ "鼻部" ] }, { "core_name": "出血", "tendency": "", "character": [], "anatomy_list": [ "鼻" ] }, { "core_name": "新生物", "tendency": "", "character": [], "anatomy_list": [ "鼻咽部" ] }, { "core_name": "咽炎", "tendency": "", "character": [ "慢性" ], "anatomy_list": [ "咽" ] }, { "core_name": "扁桃体炎", "tendency": "", "character": [ "慢性" ], "anatomy_list": [ "扁桃体" ] }, { "core_name": "新生物", "tendency": "", "character": [], "anatomy_list": [ "鼻咽部" ] } ] }, { "id": 1271, "text": "院外患者偶有受凉后咳嗽，以干咳为主，伴心累、气促，无畏寒、发热，无头晕、头痛，无咯血、痰中带血，无胸闷、胸痛，无腹胀、腹泻，无恶心、呕吐，无四肢关节关节疼痛等表现，今患者因拟行第五次再次就诊于我院，门诊以“右肺癌化疗后”收入我科。", "event": [ { "core_name": "咳嗽", "tendency": "", "character": [ "偶有", "受凉后" ], "anatomy_list": [] }, { "core_name": "咳嗽", "tendency": "", "character": [ "干" ], "anatomy_list": [] }, { "core_name": "心累", "tendency": "", "character": [], "anatomy_list": [ "心" ] }, { "core_name": "气促", "tendency": "", "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": "头晕", "tendency": "否定", "character": [], "anatomy_list": [ "头" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "头" ] }, { "core_name": "咯血", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "否定", "character": [ "带血" ], "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": "腹胀", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "腹泻", "tendency": "否定", "character": [], "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": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "四肢关节" ] }, { "core_name": "癌", "tendency": "", "character": [ "化疗后" ], "anatomy_list": [ "右肺" ] } ] }, { "id": 702, "text": "入院前2+年，患者于无明显诱因出现心悸，无明显诱因，突然发作，自感心跳加快，持续10+分钟后症状缓解，无胸闷、胸痛，无黑蒙、晕厥、意识障碍，无咯血、呼吸困难，患者未重视，未进一步诊治。", "event": [ { "core_name": "心悸", "tendency": "", "character": [ "突然发作" ], "anatomy_list": [ "心" ] }, { "core_name": "心跳", "tendency": "", "character": [ "加快", "持续10+分钟后症状缓解" ], "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": "黑朦", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "晕厥", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "意识障碍", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "咯血", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "呼吸困难", "tendency": "否定", "character": [], "anatomy_list": [] } ] }, { "id": 874, "text": "入院前10天，患者自觉右上肢关节疼痛较前加剧，伴上肢凹陷性水肿，疼痛处皮肤无红、肿，无发热、寒战、畏寒，伴双侧髋关节关节疼痛，活动后明显，平静休息后可缓解，余未见特殊不适，遂至我院就诊，完善肾功示：肌酐 391umol/L、胱抑素c(cysc) 3.50mg/L、α1微球蛋白(α1-mg) 99.4mg/L、尿酸(ua) 387umol/L、尿素(urea) 19.48mmol/L；泌尿系彩超：1.双肾肾缩小，双肾弥漫性病变，请结合临床。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [ "较前加剧" ], "anatomy_list": [ "右上肢关节" ] }, { "core_name": "水肿", "tendency": "", "character": [ "凹陷性" ], "anatomy_list": [ "上肢" ] }, { "core_name": "疼痛", "tendency": "", "character": [ "无皮肤红", "无皮肤肿" ], "anatomy_list": [ "右上肢", "关节" ] }, { "core_name": "发热", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "寒战", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "畏寒", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "", "character": [ "活动后明显", "平静休息后缓解" ], "anatomy_list": [ "双侧髋关节" ] }, { "core_name": "缩小", "tendency": "", "character": [], "anatomy_list": [ "双肾" ] }, { "core_name": "病变", "tendency": "", "character": [ "弥漫性" ], "anatomy_list": [ "双肾" ] } ] }, { "id": 206, "text": "1月前患者无诱因出现咳嗽、干咳为主，无昼夜节律，伴活动后喘累明显，伴右侧肋缘上区持续胸痛，具体性质描述不详，发现体重减轻3斤，无畏寒、发热、咯血等不适，患者于我科住院治疗，完善气管镜检查，找到癌细胞，小细胞未分化癌。", "event": [ { "core_name": "咳嗽", "tendency": "", "character": [ "干性为主", "无昼夜节律" ], "anatomy_list": [] }, { "core_name": "喘累", "tendency": "", "character": [ "活动后明显" ], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "", "character": [ "持续" ], "anatomy_list": [ "右侧肋缘上区", "胸" ] }, { "core_name": "体重减轻", "tendency": "", "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": "咯血", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "癌细胞", "tendency": "", "character": [ "气管镜检查" ], "anatomy_list": [] }, { "core_name": "癌", "tendency": "", "character": [ "未分化", "气管镜检查" ], "anatomy_list": [ "小细胞" ] } ] }, { "id": 1499, "text": "骨髓活检提示：骨髓增生明显活跃，粒系增生，单核细胞增多，需注意慢性粒单核细胞白血病，外送骨髓流式未见异常，bcr-abl基因、calr、jak2v6f阴性。", "event": [ { "core_name": "骨髓增生", "tendency": "", "character": [ "明显活跃" ], "anatomy_list": [ "骨髓" ] }, { "core_name": "白血病", "tendency": "", "character": [ "慢性" ], "anatomy_list": [ "粒单核细胞" ] } ] }, { "id": 1568, "text": "1周前患者再次出现上述症状，伴双下肢抽搐，夜间加重，左下肢从足底沿胫前区放射至膝部，右下肢从足底沿胫前放射至大腿中部，伴喷嚏、流涕，不伴咳嗽、咳痰，伴反酸、嗳气，不伴腹痛、腹胀。", "event": [ { "core_name": "抽搐", "tendency": "", "character": [ "夜间加重" ], "anatomy_list": [ "双下肢" ] }, { "core_name": "疼痛", "tendency": "", "character": [ "放射性" ], "anatomy_list": [ "左下肢从足底沿胫前区至膝部" ] }, { "core_name": "疼痛", "tendency": "", "character": [ "放射性" ], "anatomy_list": [ "右下肢从足底沿胫前至大腿中部" ] }, { "core_name": "喷嚏", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "流涕", "tendency": "", "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": "反酸", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "嗳气", "tendency": "", "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" ] } ] }, { "id": 1428, "text": "1月前，患者体检发现血压升高为：150/？mmhg，无头痛、头晕，无胸闷、心悸，无突眼，无大便次数增多，无怕热，无突发性面色苍白、潮红，无四肢无力，无咳嗽、咳痰，无恶心、呕吐，无腹痛、腹胀、腹泻，无双下肢凹陷性水肿，未重视，未治疗。", "event": [ { "core_name": "血压", "tendency": "", "character": [ "升高" ], "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": "胸闷", "tendency": "否定", "character": [], "anatomy_list": [ "胸" ] }, { "core_name": "心悸", "tendency": "否定", "character": [], "anatomy_list": [ "心" ] }, { "core_name": "突眼", "tendency": "否定", "character": [], "anatomy_list": [ "眼" ] }, { "core_name": "大便", "tendency": "否定", "character": [ "次数增多" ], "anatomy_list": [] }, { "core_name": "怕热", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "面色潮红", "tendency": "否定", "character": [ "突发性" ], "anatomy_list": [ "面" ] }, { "core_name": "面色苍白", "tendency": "否定", "character": [ "突发性" ], "anatomy_list": [ "面" ] }, { "core_name": "无力", "tendency": "", "character": [], "anatomy_list": [ "四肢" ] }, { "core_name": "咳嗽", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "咳痰", "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": "水肿", "tendency": "", "character": [ "凹陷性" ], "anatomy_list": [ "双下肢" ] } ] }, { "id": 676, "text": "30天前患者受凉后出现咳嗽症状加重，夜间及活动后尤甚，伴咳白色黏痰，夜间为主，无明显缓解及加重因素，无畏寒、寒战、咯血、胸痛等不适，发热不详，自行服用药物（具体不详）未见好转，于我院就诊，胸部ct示“1.双肺气肿并双肺间质改变。", "event": [ { "core_name": "咳嗽", "tendency": "", "character": [ "受凉后", "夜间及活动后尤甚" ], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "白色", "粘性", "夜间为主", "无明显缓解及加重因素" ], "anatomy_list": [] }, { "core_name": "畏寒", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "寒颤", "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": "发热", "tendency": "", "character": [ "不详" ], "anatomy_list": [] }, { "core_name": "肺气肿", "tendency": "", "character": [], "anatomy_list": [ "双肺" ] }, { "core_name": "间质改变", "tendency": "", "character": [], "anatomy_list": [ "双肺" ] } ] }, { "id": 69, "text": "入院前1月，患者体检，彩超提示“左甲状腺甲状腺多发结节、右侧乳腺包块”（未见具体报告），左侧颈部包块、左乳包块均未触及，无疼痛，侧颈部包块不随吞咽上下移动，无声嘶、饮水呛咳，无进食哽噎、吞咽困难，无恶心、呕吐，无呼吸困难，患者未引起重视，未予院外行相关诊治，今患者未行进一步诊治，遂至我院就诊，门诊以“左甲状腺甲状腺多发结节”收入我科住院治疗。", "event": [ { "core_name": "结节", "tendency": "", "character": [ "多发" ], "anatomy_list": [ "左甲状腺" ] }, { "core_name": "包块", "tendency": "", "character": [], "anatomy_list": [ "右侧乳腺" ] }, { "core_name": "包块", "tendency": "否定", "character": [], "anatomy_list": [ "左侧颈部" ] }, { "core_name": "包块", "tendency": "否定", "character": [], "anatomy_list": [ "左乳" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "包块", "tendency": "", "character": [ "不随吞咽上下移动" ], "anatomy_list": [ "侧颈部" ] }, { "core_name": "声嘶", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "饮水呛咳", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "进食哽噎", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "吞咽", "tendency": "否定", "character": [ "困难" ], "anatomy_list": [] }, { "core_name": "恶心", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "呕吐", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "呼吸困难", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "结节", "tendency": "", "character": [ "多发" ], "anatomy_list": [ "左甲状腺" ] } ] }, { "id": 1781, "text": "肝脏未见确切占位。", "event": [ { "core_name": "占位", "tendency": "不确定", "character": [], "anatomy_list": [ "肝脏" ] } ] }, { "id": 375, "text": "入院 5年前，患者无明显诱因出现腹胀、乏力、腹围增大， 不伴双下肢水肿 ， 不伴腹痛、腹泻 ，无反酸、恶心、呕吐、呕血、便血、身黄、尿黄、胸痛、腹痛、皮肤粘膜出血、颜面及下肢水肿、意识障碍，患者我院门诊就诊，乙肝标志物阳性，腹部彩超提示肝硬化，诊断为\"乙型肝炎肝硬化\"，长期使用阿德福韦酯10mg抗病毒治疗。", "event": [ { "core_name": "腹胀", "tendency": "", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "乏力", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "腹围", "tendency": "", "character": [ "增大" ], "anatomy_list": [] }, { "core_name": "水肿", "tendency": "否定", "character": [], "anatomy_list": [ "双下肢" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "腹泻", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "反酸", "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": "便血", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "黄染", "tendency": "否定", "character": [], "anatomy_list": [ "身" ] }, { "core_name": "尿黄", "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": "出血", "tendency": "否定", "character": [], "anatomy_list": [ "皮肤粘膜" ] }, { "core_name": "水肿", "tendency": "否定", "character": [], "anatomy_list": [ "颜面" ] }, { "core_name": "水肿", "tendency": "否定", "character": [], "anatomy_list": [ "下肢" ] }, { "core_name": "意识障碍", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "乙肝标志物", "tendency": "", "character": [ "阳性" ], "anatomy_list": [ "肝" ] }, { "core_name": "硬化", "tendency": "", "character": [], "anatomy_list": [ "肝" ] }, { "core_name": "硬化", "tendency": "", "character": [ "乙型肝炎" ], "anatomy_list": [ "肝" ] } ] }, { "id": 1907, "text": "6.肛管局部fdg代谢增高，倾向于炎性病变。", "event": [ { "core_name": "病变", "tendency": "", "character": [ "炎性" ], "anatomy_list": [ "肛管" ] }, { "core_name": "fdg代谢", "tendency": "", "character": [ "局部", "增高" ], "anatomy_list": [ "肛管" ] } ] }, { "id": 778, "text": "ect示：右侧肱骨上段、左侧肩胛下角、左侧第5后肋起始部、多个椎体、骨盆多处放射性浓聚，骨转移？考虑患者右上肺肺腺癌iv期，鉴于患者脱落细胞数量少，不宜行基因监测，建议患者行放化疗，患者及家属拒绝后自动出院。", "event": [ { "core_name": "浓聚", "tendency": "", "character": [ "多处", "放射性" ], "anatomy_list": [ "右侧肱骨上段", "左侧肩胛下角", "左侧第5后肋起始部", "椎体", "骨盆" ] }, { "core_name": "转移", "tendency": "不确定", "character": [], "anatomy_list": [ "骨" ] }, { "core_name": "腺癌", "tendency": "不确定", "character": [ "iv期" ], "anatomy_list": [ "右上肺" ] }, { "core_name": "脱落细胞", "tendency": "", "character": [ "数量少" ], "anatomy_list": [] } ] }, { "id": 478, "text": "缘于2019年5月，患者无明显诱因出现右侧口腔包块，约蚕豆大小，触及时轻微疼痛，同时发现右侧颈部包块，约豌豆大小，伴有瘙痒、刺痛无破溃。", "event": [ { "core_name": "包块", "tendency": "", "character": [ "蚕豆大小", "触及时轻微疼痛" ], "anatomy_list": [ "右侧口腔" ] }, { "core_name": "包块", "tendency": "", "character": [ "约豌豆大小" ], "anatomy_list": [ "右侧颈部" ] }, { "core_name": "瘙痒", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "", "character": [ "刺痛" ], "anatomy_list": [] }, { "core_name": "破溃", "tendency": "否定", "character": [], "anatomy_list": [] } ] }, { "id": 1938, "text": "纤维支气管镜检及病理结果为肺鳞癌，诊断为：肺鳞癌伴骨转移 iv期。", "event": [ { "core_name": "鳞癌", "tendency": "", "character": [], "anatomy_list": [ "肺" ] }, { "core_name": "鳞癌", "tendency": "", "character": [ "iv期" ], "anatomy_list": [ "肺" ] }, { "core_name": "鳞癌", "tendency": "", "character": [ "转移", "iv期" ], "anatomy_list": [ "骨" ] } ] }, { "id": 463, "text": "患者肿瘤稳定，予以保肝、增强免疫、抗肿瘤治疗，患者好转出院。", "event": [ { "core_name": "肿瘤", "tendency": "", "character": [ "稳定" ], "anatomy_list": [] } ] }, { "id": 553, "text": "今患者为求进一步治疗，遂来我院门诊，门诊以“类风湿性关节炎”收入我科住院治疗。", "event": [ { "core_name": "关节炎", "tendency": "", "character": [ "类风湿性" ], "anatomy_list": [ "关节" ] } ] }, { "id": 117, "text": "乳头未见癌累及。", "event": [ { "core_name": "癌", "tendency": "否定", "character": [ "累及" ], "anatomy_list": [ "乳头" ] } ] }, { "id": 356, "text": "入院前3+年，患者无明显诱因出现右膝膝部疼痛，疼痛为间断性胀痛，能忍受，久站及久行后加重，休息后可缓解，双下肢无麻木、乏力，无潮热、盗汗，无咳嗽、咳痰，无胸闷、气促，无大小便失禁等；遂于某医院就诊，诊断“膝关节骨性关节炎”，予以口服药、止痛、玻璃酸钠注射等治疗后好转。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [ "间断性胀痛", "能忍受", "久站及久行后加重", "休息后可缓解" ], "anatomy_list": [ "右膝" ] }, { "core_name": "麻木", "tendency": "否定", "character": [], "anatomy_list": [ "双下肢" ] }, { "core_name": "乏力", "tendency": "否定", "character": [], "anatomy_list": [ "双下肢" ] }, { "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": "大小便", "tendency": "否定", "character": [ "失禁" ], "anatomy_list": [] }, { "core_name": "关节炎", "tendency": "", "character": [ "骨性" ], "anatomy_list": [ "膝关节" ] } ] }, { "id": 1926, "text": "6天前患者患者感吞咽梗阻、困难，进食稀饭顺畅，遂来我院，门诊行胃镜提示：“食管距门齿20cm见吻合口吻合口肛侧端粘膜呈半球形隆起，占据2/3管腔。", "event": [ { "core_name": "吞咽梗阻", "tendency": "", "character": [ "进食稀饭顺畅" ], "anatomy_list": [] }, { "core_name": "吞咽困难", "tendency": "", "character": [ "进食稀饭顺畅" ], "anatomy_list": [] }, { "core_name": "隆起", "tendency": "", "character": [ "占据2/3管腔", "半球形" ], "anatomy_list": [ "吻合口肛侧端粘膜" ] } ] }, { "id": 27, "text": "患者于入院前16月于发现解小便次数及尿量均减少（具体不详）,伴泡沫尿,偶有双侧踝关节轻中度凹陷对称性水肿,无尿急、尿痛,未予以重视,未予以对症治疗。", "event": [ { "core_name": "小便", "tendency": "", "character": [ "次数减少" ], "anatomy_list": [] }, { "core_name": "尿量", "tendency": "", "character": [ "减少" ], "anatomy_list": [] }, { "core_name": "泡沫尿", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "凹陷", "tendency": "", "character": [ "轻中度" ], "anatomy_list": [ "双侧踝关节" ] }, { "core_name": "水肿", "tendency": "", "character": [ "对称性" ], "anatomy_list": [ "双侧踝关节" ] }, { "core_name": "尿急", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "尿痛", "tendency": "否定", "character": [], "anatomy_list": [] } ] }, { "id": 1108, "text": "患者未引起重视，未行进一步诊治，此后颈部包块进行性增大，于2020-09-28到我科住院治疗，行浅表淋巴结彩超:右侧颈部低回声团（考虑转移灶），建议进一步检查。左侧颈部、双侧腋窝、双侧腹股沟区腹股沟区淋巴结可见。", "event": [ { "core_name": "包块", "tendency": "", "character": [ "进行性", "增大" ], "anatomy_list": [ "颈部" ] }, { "core_name": "回声团", "tendency": "", "character": [ "低" ], "anatomy_list": [ "右侧颈部" ] }, { "core_name": "转移灶", "tendency": "不确定", "character": [], "anatomy_list": [ "右侧颈部" ] }, { "core_name": "淋巴结", "tendency": "", "character": [], "anatomy_list": [ "左侧颈部", "双侧腋窝", "双侧腹股沟区" ] } ] }, { "id": 216, "text": "患者及家属因经费原因，拒绝行头颅mri检查，患者诊断左肺鳞癌iib期，因肿瘤紧临肺动脉，手术风险高，术后可能需icu辅助对症治疗，费用昂贵，患者及家属表示费用过高，不能承受。", "event": [ { "core_name": "鳞癌", "tendency": "", "character": [ "iib期" ], "anatomy_list": [ "左肺" ] } ] }, { "id": 1540, "text": "3+月前（2017年7月12日），患者因“腹痛、腹胀伴肛门坠胀”再次就诊于我院胃肠外科；复查ct(2017-07-13 某医院)提示1.肝内多发结节，考虑转移瘤，与前片比较病灶增多、增大；部分肝肝内胆管轻度扩张。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "腹胀", "tendency": "", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "坠胀", "tendency": "", "character": [], "anatomy_list": [ "肛门" ] }, { "core_name": "结节", "tendency": "", "character": [ "多发" ], "anatomy_list": [ "肝内" ] }, { "core_name": "瘤", "tendency": "不确定", "character": [ "转移" ], "anatomy_list": [] }, { "core_name": "病灶", "tendency": "", "character": [ "增多", "增大" ], "anatomy_list": [] }, { "core_name": "扩张", "tendency": "", "character": [ "轻度" ], "anatomy_list": [ "肝内胆管" ] } ] }, { "id": 1562, "text": "入院前4+月，患者无意中发现右乳上方有一“绿豆”大小包块，偶感疼痛。", "event": [ { "core_name": "包块", "tendency": "", "character": [ "绿豆大小" ], "anatomy_list": [ "右乳上方" ] }, { "core_name": "疼痛", "tendency": "", "character": [ "偶感" ], "anatomy_list": [ "右乳上方" ] } ] }, { "id": 1956, "text": "未引起重视，3+月前，患者体检时发现肺部阴影，行支气管镜检查提示“小细胞肺癌”,肾功能：尿素18.4mmol/l，尿酸 616.4umol/l，肌酐 420.9umol/l，肾内科会诊诊断为：慢性肾脏病5期，高尿酸血症。", "event": [ { "core_name": "阴影", "tendency": "", "character": [], "anatomy_list": [ "肺部" ] }, { "core_name": "癌", "tendency": "", "character": [], "anatomy_list": [ "肺", "小细胞" ] }, { "core_name": "肾脏病", "tendency": "", "character": [ "慢性", "5期" ], "anatomy_list": [ "肾脏" ] }, { "core_name": "高尿酸血症", "tendency": "", "character": [], "anatomy_list": [] } ] }, { "id": 1827, "text": "患者自发病以来，精神一般，食欲差，睡眠可，大便正常，小便如常，体重无明显变化。", "event": [ { "core_name": "精神", "tendency": "", "character": [ "一般" ], "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": [ "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": 1791, "text": "今患者为进一步治疗入我科门诊，门诊以“蜂窝组织炎”收入我科。", "event": [ { "core_name": "蜂窝组织炎", "tendency": "", "character": [], "anatomy_list": [] } ] }, { "id": 1185, "text": "彩超示：右乳乳晕区一不规则低回声区（3.5×4.0×0.9cm）。", "event": [ { "core_name": "回声", "tendency": "", "character": [ "不规则", "低" ], "anatomy_list": [ "右乳乳晕区" ] } ] }, { "id": 1392, "text": "1+年患者因宫颈癌化疗术后左输尿管狭窄伴积水，行了左输尿管内支架植入术，术后恢复良好，半年后更换内支架管，患者今来我院，要求更换内支架管，遂门诊以“左输尿管内支架植入术，宫颈癌放化疗术后”入院。", "event": [ { "core_name": "狭窄", "tendency": "", "character": [ "宫颈癌化疗术后" ], "anatomy_list": [ "左输尿管" ] }, { "core_name": "积水", "tendency": "", "character": [ "宫颈癌化疗术后" ], "anatomy_list": [ "左输尿管" ] }, { "core_name": "癌", "tendency": "", "character": [ "放化疗术后" ], "anatomy_list": [ "宫颈" ] } ] }, { "id": 850, "text": "患者于2017年8月无意中发现左侧腹股沟腹股沟包块，质硬，不可活动，无发热、畏寒，无腹痛、腹泻。", "event": [ { "core_name": "包块", "tendency": "", "character": [ "质硬", "不可活动" ], "anatomy_list": [ "左侧腹股沟" ] }, { "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": [ "腹" ] }, { "core_name": "腹泻", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] } ] }, { "id": 662, "text": "半月前，患者无明显诱因出现心累气促加重，伴出汗，伴咳嗽咳痰，咳出白色泡沫痰，量多，以夜间及晨起为重，无咯血、痰中带血，无畏寒、高热，无胸闷、胸痛，无潮热、盗汗，无双下肢水肿，无端坐呼吸及夜间阵发性呼吸困难。", "event": [ { "core_name": "心累", "tendency": "", "character": [ "加重" ], "anatomy_list": [] }, { "core_name": "气促", "tendency": "", "character": [ "加重" ], "anatomy_list": [] }, { "core_name": "出汗", "tendency": "", "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": [ "白色", "泡沫痰", "量多", "以夜间及晨起为重" ], "anatomy_list": [] }, { "core_name": "咯血", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "否定", "character": [ "带血" ], "anatomy_list": [] }, { "core_name": "畏寒", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "发热", "tendency": "否定", "character": [ "高" ], "anatomy_list": [] }, { "core_name": "胸闷", "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": "水肿", "tendency": "否定", "character": [], "anatomy_list": [ "双下肢" ] }, { "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": [] } ] }, { "id": 1492, "text": "患者平素有咳嗽、咳痰、盗汗、头晕、乏力、反酸、烧心等病史，今为求进一步诊治，遂至我科住院治疗。", "event": [ { "core_name": "咳嗽", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "盗汗", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "头晕", "tendency": "", "character": [], "anatomy_list": [ "头" ] }, { "core_name": "乏力", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "反酸", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "烧心", "tendency": "", "character": [], "anatomy_list": [] } ] }, { "id": 432, "text": "患者于入院前6月因发现左乳肿块我院，行微创手术活检确诊为左乳浸润性癌，免疫组化：er（+++）80%pr（+++）90%cerbb-2（+），给予et方案（多西他赛120mg+吡柔比星60mg）化疗半疗程后行了左乳癌根治术，腋窝淋巴结1/9转移。", "event": [ { "core_name": "肿块", "tendency": "", "character": [], "anatomy_list": [ "左乳" ] }, { "core_name": "癌", "tendency": "", "character": [ "浸润性" ], "anatomy_list": [ "左乳" ] }, { "core_name": "转移", "tendency": "", "character": [], "anatomy_list": [ "腋窝淋巴结" ] } ] }, { "id": 151, "text": "为进一步检查，入院前1月患者在我科住院，腹部mr增强示：1.肝右后叶占位及左叶小结节，考虑原发性肝ca伴肝内转移可能。", "event": [ { "core_name": "占位", "tendency": "", "character": [], "anatomy_list": [ "肝右后叶" ] }, { "core_name": "结节", "tendency": "", "character": [ "小" ], "anatomy_list": [ "肝左叶" ] }, { "core_name": "癌", "tendency": "不确定", "character": [ "原发性" ], "anatomy_list": [ "肝" ] }, { "core_name": "癌", "tendency": "不确定", "character": [ "转移" ], "anatomy_list": [ "肝内" ] } ] }, { "id": 2047, "text": "后分别于2010.12.6，2010.12.31，2011.01.21，2011.02.11,2011.03.3，2011.3.24行表柔比星+奈达铂全身静脉化疗，化疗过程较顺利，未见明显化疗相关副反应。", "event": [ { "core_name": "化疗相关副反应", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [] } ] }, { "id": 617, "text": "患者于31年前因臀部疼痛（具体不详），于某医院确诊为神经纤维瘤，予以手术治疗，之后发现盆腔内转移，先后6次于某医院行手术治疗。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [], "anatomy_list": [ "臀部" ] }, { "core_name": "瘤", "tendency": "", "character": [ "神经纤维" ], "anatomy_list": [] }, { "core_name": "瘤", "tendency": "", "character": [ "转移" ], "anatomy_list": [ "盆腔内" ] } ] }, { "id": 1629, "text": "患者于10年前起出现反复头晕、颈部胀痛，疼痛呈持续性，视物模糊，常于活动时发作，每次持续1小时左右，伴有头痛，程度较轻，休息后头昏及头痛症状可自行缓解，曾在多家医院就诊，多次测血压均高于180/100mmHg，诊断“高血压病”，口服“清脑降压片”治疗。", "event": [ { "core_name": "头晕", "tendency": "", "character": [ "反复" ], "anatomy_list": [ "头" ] }, { "core_name": "疼痛", "tendency": "", "character": [ "持续性", "反复", "胀痛" ], "anatomy_list": [ "颈部" ] }, { "core_name": "视物模糊", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "", "character": [ "程度较轻" ], "anatomy_list": [ "头" ] }, { "core_name": "头昏", "tendency": "", "character": [ "休息后可自行缓解" ], "anatomy_list": [ "头" ] }, { "core_name": "疼痛", "tendency": "", "character": [ "休息后可自行缓解" ], "anatomy_list": [ "头" ] }, { "core_name": "血压", "tendency": "", "character": [ "升高" ], "anatomy_list": [] }, { "core_name": "高血压", "tendency": "", "character": [], "anatomy_list": [] } ] }, { "id": 1356, "text": "入院前2+月，患者于外院检查发现宫颈病变，取宫颈多点活检术，病检结果回示：子宫颈（3、6、9、12点）宫颈鳞状细胞癌。", "event": [ { "core_name": "病变", "tendency": "", "character": [], "anatomy_list": [ "宫颈" ] }, { "core_name": "鳞癌", "tendency": "", "character": [], "anatomy_list": [ "子宫颈（3、6、9、12点）" ] } ] }, { "id": 1724, "text": "现患者为求进一步诊治来我院就诊，门诊以“肝占位”收入我科。", "event": [ { "core_name": "占位", "tendency": "", "character": [], "anatomy_list": [ "肝" ] } ] }, { "id": 828, "text": "门诊遂以“卵巢子宫内膜异位囊肿”收住入院。", "event": [ { "core_name": "囊肿", "tendency": "", "character": [ "子宫内膜异位" ], "anatomy_list": [ "卵巢" ] } ] }, { "id": 774, "text": "患者自发病以来，精神、食欲、睡眠差，大便无明显异常，小便可。", "event": [ { "core_name": "精神", "tendency": "", "character": [ "差" ], "anatomy_list": [] }, { "core_name": "食欲", "tendency": "", "character": [ "差" ], "anatomy_list": [] }, { "core_name": "睡眠质量", "tendency": "", "character": [ "差" ], "anatomy_list": [] }, { "core_name": "大便", "tendency": "否定", "character": [ "明显", "异常" ], "anatomy_list": [] }, { "core_name": "小便", "tendency": "", "character": [ "可" ], "anatomy_list": [] } ] }, { "id": 987, "text": "院外患者多次胸部彩超示：1、右侧胸腔大量积液,故多次行胸腔穿刺抽液，并送胸水检验：大量增生活跃的间皮细胞和部分炎细胞。", "event": [ { "core_name": "积液", "tendency": "", "character": [ "大量" ], "anatomy_list": [ "右侧胸腔" ] }, { "core_name": "炎细胞", "tendency": "", "character": [ "部分" ], "anatomy_list": [] } ] }, { "id": 849, "text": "患者发病以来，神志 清晰，精神可，胃纳可，大便如常，小便正常，体重未见明显下降。", "event": [ { "core_name": "神志", "tendency": "", "character": [ "清晰" ], "anatomy_list": [] }, { "core_name": "精神", "tendency": "", "character": [ "可" ], "anatomy_list": [] }, { "core_name": "胃纳", "tendency": "", "character": [ "可" ], "anatomy_list": [] }, { "core_name": "大便", "tendency": "", "character": [ "如常" ], "anatomy_list": [] }, { "core_name": "小便", "tendency": "", "character": [ "正常" ], "anatomy_list": [] }, { "core_name": "体重下降", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [] } ] }, { "id": 170, "text": "于2018-03-20行腹腔镜下左侧腹膜后占位探查术及活检术，术后病理示（左侧腹膜后肿物）癌侵润。", "event": [ { "core_name": "肿物", "tendency": "", "character": [], "anatomy_list": [ "左侧腹膜后" ] }, { "core_name": "癌", "tendency": "", "character": [ "侵润" ], "anatomy_list": [] } ] }, { "id": 111, "text": "患者在某医院上腹部彩超检查发现肝脏占位性病变，为进一步诊治，故来我科就诊。", "event": [ { "core_name": "病变", "tendency": "", "character": [ "占位性" ], "anatomy_list": [ "肝脏" ] } ] }, { "id": 1456, "text": "4月前，患者无明显诱因出现咳嗽、咯血，咳黄色黏痰，咯血为痰中混血，夜间及晨起明显，无发热、畏寒、盗汗，无乏力、纳差，无胸闷、胸痛、心悸、夜间阵发性呼吸困难，无双下肢水肿，未进一步就诊及处理。", "event": [ { "core_name": "咳嗽", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "咯血", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "黄色", "粘痰" ], "anatomy_list": [] }, { "core_name": "咯血", "tendency": "", "character": [ "痰中混血", "夜间及晨起明显" ], "anatomy_list": [] }, { "core_name": "发热", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "畏寒", "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": [] }, { "core_name": "纳差", "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": "心悸", "tendency": "否定", "character": [], "anatomy_list": [ "心" ] }, { "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" ] } ] }, { "id": 229, "text": "患者遂于某医院就诊，胸部彩超提示左侧胸腔大量积液，予以抽胸水化验，结果不详，考虑诊断：胸腔积液原因待查：恶性胸腔积液？结核性胸腔积液？，后予以诊断性抗结核治疗（具体不详），患者服用抗结核药后出现恶心、食欲下降、乏力等不适，患者诉查肝功异常，遂停抗结核药，予以保肝、护胃等对症治疗。", "event": [ { "core_name": "积液", "tendency": "", "character": [ "大量" ], "anatomy_list": [ "左侧胸腔" ] }, { "core_name": "积液", "tendency": "不确定", "character": [], "anatomy_list": [ "胸腔" ] }, { "core_name": "积液", "tendency": "不确定", "character": [ "恶性" ], "anatomy_list": [ "胸腔" ] }, { "core_name": "积液", "tendency": "不确定", "character": [ "结核性" ], "anatomy_list": [ "胸腔" ] }, { "core_name": "恶心", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "食欲", "tendency": "", "character": [ "下降" ], "anatomy_list": [] }, { "core_name": "乏力", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "肝功能异常", "tendency": "", "character": [], "anatomy_list": [ "肝" ] } ] }, { "id": 817, "text": "术前术后共行te方案（吡柔比星40mg d1 30mg d2，多西他赛（艾素）140mg d2））6疗程化疗，化疗过程顺利，患者无明显骨髓抑制等副反应。", "event": [ { "core_name": "骨髓抑制", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [ "骨髓" ] } ] }, { "id": 141, "text": "4+月前因“腰痛”于我院完善腰椎mri提示“腰椎间盘突出”，未予特殊处理。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [], "anatomy_list": [ "腰" ] }, { "core_name": "突出", "tendency": "", "character": [], "anatomy_list": [ "腰椎间盘" ] } ] }, { "id": 1258, "text": "入院前10+年，患者无明显诱因出现咳嗽、咳痰，无明显发热、盗汗，胸闷、胸痛等不适，自行购买感冒药（具体不详）服用后咳嗽、咳痰缓解。", "event": [ { "core_name": "咳嗽", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "发热", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [] }, { "core_name": "盗汗", "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": "咳嗽", "tendency": "", "character": [ "缓解" ], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "缓解" ], "anatomy_list": [] } ] }, { "id": 1038, "text": "出院期间，患者诉四肢乏力，无便血、便秘、稀便、里急后重、腹痛、腹胀，无恶心、呕吐、胸闷、气急等。", "event": [ { "core_name": "乏力", "tendency": "", "character": [], "anatomy_list": [ "四肢" ] }, { "core_name": "便血", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "便秘", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "大便", "tendency": "否定", "character": [ "稀便" ], "anatomy_list": [] }, { "core_name": "里急后重", "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": "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": "气急", "tendency": "否定", "character": [], "anatomy_list": [] } ] }, { "id": 315, "text": "10天前患者无明显诱因出现阴道多量黄白色分泌物，有异味，遂于我院门诊就诊，妇科检查提示阴道多量分泌物，阴道壁充血，白带常规检查提示：清洁度iii，考虑“老年性阴道炎”，给予“硝呋太尔”阴道上药6天，行b超检查提示“宫腔内见范围约37x22mm异常回声，透声差，内见细密点状稍强回声，未探及血流信号，宫腔下段见一横向强回声伴声尾，其右侧达右侧壁肌层，左侧端似达左侧壁浆膜层，考虑：宫腔积血，节育器嵌顿”。", "event": [ { "core_name": "分泌物", "tendency": "", "character": [ "多量", "黄白色", "有异味" ], "anatomy_list": [ "阴道" ] }, { "core_name": "分泌物", "tendency": "", "character": [ "多量" ], "anatomy_list": [ "阴道" ] }, { "core_name": "充血", "tendency": "", "character": [], "anatomy_list": [ "阴道壁" ] }, { "core_name": "阴道炎", "tendency": "不确定", "character": [ "老年性" ], "anatomy_list": [ "阴道" ] }, { "core_name": "异常回声", "tendency": "", "character": [ "透声差", "内见细密点状稍强回声", "未探及血流信号" ], "anatomy_list": [] }, { "core_name": "回声", "tendency": "", "character": [ "强", "伴声尾", "其右侧达右侧壁肌层", "左侧端似达左侧壁浆膜层" ], "anatomy_list": [ "宫腔下段" ] }, { "core_name": "积血", "tendency": "不确定", "character": [], "anatomy_list": [ "宫腔" ] }, { "core_name": "节育器嵌顿", "tendency": "不确定", "character": [], "anatomy_list": [] } ] }, { "id": 690, "text": "停经10+5周（2020-6-4）我院复查妇科超声提示宫内早孕，卵黄囊可见，直径4.3mm，胎芽可见，长径约19mm（相当于8w3d），建议患者1月后来院行nt超声检查。", "event": [ { "core_name": "停经", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "早孕", "tendency": "", "character": [], "anatomy_list": [ "宫内" ] }, { "core_name": "卵黄囊", "tendency": "", "character": [ "可见" ], "anatomy_list": [ "宫内" ] }, { "core_name": "胎芽", "tendency": "", "character": [ "可见" ], "anatomy_list": [ "宫内" ] } ] }, { "id": 2064, "text": "有慢性胃炎病史多年，长期感上腹饱胀，反酸，间断服药治疗，2015.02.06我院行消化道钡餐提示：慢性胃炎，胃底粘膜粘膜聚集，溃疡？占位？，建议进一步检查，十二指肠降部憩室。", "event": [ { "core_name": "胃炎", "tendency": "", "character": [ "慢性" ], "anatomy_list": [ "胃" ] }, { "core_name": "饱胀", "tendency": "", "character": [], "anatomy_list": [ "上腹" ] }, { "core_name": "反酸", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "胃炎", "tendency": "", "character": [ "慢性" ], "anatomy_list": [ "胃" ] }, { "core_name": "聚集", "tendency": "", "character": [ "粘膜" ], "anatomy_list": [ "胃底" ] }, { "core_name": "溃疡", "tendency": "不确定", "character": [], "anatomy_list": [ "胃底" ] }, { "core_name": "占位", "tendency": "不确定", "character": [], "anatomy_list": [ "胃底" ] }, { "core_name": "憩室", "tendency": "", "character": [], "anatomy_list": [ "十二指肠降部" ] } ] }, { "id": 1405, "text": "9月前，患者无明显诱因出现上腹部阵发性隐痛，偶有左上腹牵扯痛，无肩背部及腹股沟区放射痛，进食后可稍加重，弯曲体位时腹痛可稍缓解。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [ "阵发性", "隐痛" ], "anatomy_list": [ "上腹部" ] }, { "core_name": "疼痛", "tendency": "", "character": [ "牵扯痛" ], "anatomy_list": [ "左上腹" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [ "放射痛" ], "anatomy_list": [ "肩背部", "腹股沟区" ] }, { "core_name": "疼痛", "tendency": "", "character": [ "进食后可稍加重", "弯曲体位时可稍缓" ], "anatomy_list": [ "腹" ] } ] }, { "id": 1716, "text": "患者于2月余受凉后出现咳嗽，咯少量白色泡沫痰或粘痰，伴痰中带少量血丝，伴咽喉疼痛，伴肩背酸痛，不伴恶寒发热，无潮热盗汗，无胸闷、气促，无喘息、呼吸困难，无关节疼痛，无消瘦。", "event": [ { "core_name": "咳嗽", "tendency": "", "character": [ "受凉后" ], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "少量", "白色", "泡沫", "粘痰" ], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "少量血丝" ], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "", "character": [], "anatomy_list": [ "咽", "喉" ] }, { "core_name": "疼痛", "tendency": "", "character": [ "酸痛" ], "anatomy_list": [ "肩", "背" ] }, { "core_name": "恶寒", "tendency": "否定", "character": [], "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": "胸闷", "tendency": "否定", "character": [], "anatomy_list": [ "胸" ] }, { "core_name": "气促", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "喘息", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "呼吸困难", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "关节" ] }, { "core_name": "消瘦", "tendency": "否定", "character": [], "anatomy_list": [] } ] }, { "id": 494, "text": "患病以来，精神、食欲可，睡眠欠佳。", "event": [ { "core_name": "精神", "tendency": "", "character": [ "好" ], "anatomy_list": [] }, { "core_name": "食欲", "tendency": "", "character": [ "好" ], "anatomy_list": [] }, { "core_name": "睡眠", "tendency": "", "character": [ "欠佳" ], "anatomy_list": [] } ] }, { "id": 1162, "text": "遂来我院就诊，门诊胸部ct提示：1.左肺上叶结节，肺ca可能性大；2.左肺下叶结节，肺ca或炎症皆不除外。", "event": [ { "core_name": "结节", "tendency": "", "character": [], "anatomy_list": [ "左肺上叶" ] }, { "core_name": "癌", "tendency": "不确定", "character": [], "anatomy_list": [ "肺" ] }, { "core_name": "结节", "tendency": "", "character": [], "anatomy_list": [ "左肺下叶" ] }, { "core_name": "癌", "tendency": "不确定", "character": [], "anatomy_list": [ "肺" ] }, { "core_name": "炎症", "tendency": "不确定", "character": [], "anatomy_list": [ "肺" ] } ] }, { "id": 536, "text": "半年前患者因血糖控制不佳入我科，完善相关检查，诊断为：2型糖尿病、糖尿病性肾病v期、糖尿病性视网膜病变、糖尿病周围血管病变、慢性肾衰竭尿毒症期、冠状动脉性心脏病、心功能Ⅲ级、右上肺肺癌伴双肺、胸膜转移、慢性阻塞性肺病、高血压3极极高危、高血压性心脏病、血脂代谢异常、慢性胃炎、颈动脉狭窄，调整降糖治疗方案为“磷酸西格列汀片0.1g口服qd，伏格列波糖片0.2mg口服tid，门冬胰岛素注射液(诺和锐笔芯)10iu皮下tid，甘精胰岛素34uqn”，自诉院外血糖控制可。", "event": [ { "core_name": "血糖", "tendency": "", "character": [ "控制不佳" ], "anatomy_list": [] }, { "core_name": "糖尿病", "tendency": "", "character": [ "2型" ], "anatomy_list": [] }, { "core_name": "肾病", "tendency": "", "character": [ "糖尿病", "v期" ], "anatomy_list": [ "肾" ] }, { "core_name": "病变", "tendency": "", "character": [ "糖尿病" ], "anatomy_list": [ "视网膜" ] }, { "core_name": "病变", "tendency": "", "character": [ "糖尿病" ], "anatomy_list": [ "周围血管" ] }, { "core_name": "肾功能衰竭", "tendency": "", "character": [ "慢性", "尿毒症期" ], "anatomy_list": [ "肾" ] }, { "core_name": "心脏病", "tendency": "", "character": [ "冠状动脉性" ], "anatomy_list": [ "心脏" ] }, { "core_name": "心功能", "tendency": "", "character": [ "Ⅲ级" ], "anatomy_list": [ "心" ] }, { "core_name": "癌", "tendency": "", "character": [ "转移" ], "anatomy_list": [ "双肺", "胸膜" ] }, { "core_name": "癌", "tendency": "", "character": [], "anatomy_list": [ "右上肺" ] }, { "core_name": "肺病", "tendency": "", "character": [ "慢性", "阻塞性" ], "anatomy_list": [ "肺" ] }, { "core_name": "高血压", "tendency": "", "character": [ "极高危", "3极" ], "anatomy_list": [] }, { "core_name": "心脏病", "tendency": "", "character": [ "高血压性" ], "anatomy_list": [ "心脏" ] }, { "core_name": "血脂", "tendency": "", "character": [ "代谢异常" ], "anatomy_list": [] }, { "core_name": "胃炎", "tendency": "", "character": [ "慢性" ], "anatomy_list": [ "胃" ] }, { "core_name": "狭窄", "tendency": "", "character": [], "anatomy_list": [ "颈动脉" ] }, { "core_name": "血糖", "tendency": "", "character": [ "控制可" ], "anatomy_list": [] } ] }, { "id": 1728, "text": "患儿近期精神食欲可，睡眠好，大小便正常。", "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": [ "好" ], "anatomy_list": [] }, { "core_name": "大小便", "tendency": "", "character": [ "正常" ], "anatomy_list": [] } ] }, { "id": 513, "text": "患者自发病以来， 精神可 ， 食欲尚可 ， 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": [ "好" ], "anatomy_list": [] }, { "core_name": "食欲", "tendency": "", "character": [ "尚可" ], "anatomy_list": [] }, { "core_name": "睡眠", "tendency": "", "character": [ "好" ], "anatomy_list": [] }, { "core_name": "大便", "tendency": "", "character": [ "如常" ], "anatomy_list": [] }, { "core_name": "小便", "tendency": "", "character": [ "如常" ], "anatomy_list": [] }, { "core_name": "体重变化", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [] } ] }, { "id": 633, "text": "<宫颈>hsil累及腺体。", "event": [ { "core_name": "hsil", "tendency": "", "character": [ "累及腺体" ], "anatomy_list": [ "宫颈" ] } ] }, { "id": 760, "text": "2.双肺多发结节影，多系转移，较前变化不明显。", "event": [ { "core_name": "结节影", "tendency": "", "character": [ "多发", "较前变化不明显" ], "anatomy_list": [ "双肺" ] }, { "core_name": "转移", "tendency": "", "character": [ "多系" ], "anatomy_list": [ "双肺" ] } ] }, { "id": 707, "text": "4+年（2016-5-13）前因“卵巢肿瘤”于我科行“腹腔镜下卵巢癌肿瘤细胞减灭术+肠粘连松解术+右侧盆腔淋巴结切除术+大网膜切除术+阑尾切除术+肠修补术”，术前查ca-125>5000U/ml，术后病检结果：（双侧卵巢）高级别浆液性癌；（双侧输卵管）见癌累及；（左宫旁、右宫旁、阴道壁、宫颈、颈管、宫体、肌壁）均见癌累及，脉管内可见癌栓；（子宫浆膜下结节、网膜）见癌结节；（右侧宫旁、右侧髂内淋巴结）见癌转移；（直肠壁）见癌累及，肠周淋巴结见癌转移，术后复查ca-1251160U/ml，诊断分期为“卵巢高级别浆液性癌iiic期”，术后予以“tc方案”（紫杉醇静脉+卡铂腹腔）化疗八次，在第七次化疗前ca-125降至正常（2016-9-29），化疗期间出现iii~iv度骨髓抑制骨髓抑制（粒细胞缺乏），予以对症治疗，于2016-10-22结束第八次化疗，化疗后未遵医嘱定期复查，化疗结束后有全身轻微瘙痒不适，无畏寒、发热、恶心、呕吐、咳嗽、关节疼痛、心慌气短等不适，全身无淤血淤斑、皮疹、口腔溃疡、阴道流血流液等症状。", "event": [ { "core_name": "肿瘤", "tendency": "", "character": [], "anatomy_list": [ "卵巢" ] }, { "core_name": "癌", "tendency": "", "character": [ "高级别", "浆液性" ], "anatomy_list": [ "双侧卵巢" ] }, { "core_name": "癌", "tendency": "", "character": [ "累及" ], "anatomy_list": [ "双侧输卵管" ] }, { "core_name": "癌栓", "tendency": "", "character": [], "anatomy_list": [ "脉管" ] }, { "core_name": "癌", "tendency": "", "character": [ "累及" ], "anatomy_list": [ "左宫旁", "右宫旁", "阴道壁", "宫颈", "颈管", "宫体", "肌壁" ] }, { "core_name": "癌结节", "tendency": "", "character": [], "anatomy_list": [ "子宫浆膜下", "网膜" ] }, { "core_name": "癌", "tendency": "", "character": [ "转移" ], "anatomy_list": [ "右侧髂内淋巴结", "子宫旁" ] }, { "core_name": "癌", "tendency": "", "character": [ "累及" ], "anatomy_list": [ "直肠壁" ] }, { "core_name": "癌", "tendency": "", "character": [ "转移" ], "anatomy_list": [ "肠周淋巴结" ] }, { "core_name": "癌", "tendency": "", "character": [ "高级别", "浆液性", "iiic期" ], "anatomy_list": [ "卵巢" ] }, { "core_name": "骨髓抑制", "tendency": "", "character": [ "iii~iv度" ], "anatomy_list": [ "骨髓" ] }, { "core_name": "缺乏", "tendency": "", "character": [], "anatomy_list": [ "粒细胞" ] }, { "core_name": "瘙痒", "tendency": "", "character": [ "化疗结束后", "轻微" ], "anatomy_list": [ "全身" ] }, { "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": "咳嗽", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "关节" ] }, { "core_name": "心慌", "tendency": "否定", "character": [], "anatomy_list": [ "心" ] }, { "core_name": "气短", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "瘀血", "tendency": "否定", "character": [], "anatomy_list": [ "全身" ] }, { "core_name": "瘀斑", "tendency": "否定", "character": [], "anatomy_list": [ "全身" ] }, { "core_name": "皮疹", "tendency": "否定", "character": [], "anatomy_list": [ "全身" ] }, { "core_name": "溃疡", "tendency": "否定", "character": [], "anatomy_list": [ "口腔" ] }, { "core_name": "出血", "tendency": "否定", "character": [], "anatomy_list": [ "阴道" ] }, { "core_name": "流液", "tendency": "否定", "character": [], "anatomy_list": [ "阴道" ] } ] }, { "id": 917, "text": "入院前两月，患者入某医院就甲状腺包快情况就诊，甲状腺彩超示：甲状腺右叶内囊实混合性结节（3.3*1.3cm）。", "event": [ { "core_name": "包块", "tendency": "", "character": [], "anatomy_list": [ "甲状腺" ] }, { "core_name": "结节", "tendency": "", "character": [ "囊实性", "混合性" ], "anatomy_list": [ "甲状腺右叶内" ] } ] }, { "id": 491, "text": "腋窝淋巴结未见癌转移（0/7）。", "event": [ { "core_name": "癌", "tendency": "否定", "character": [ "转移" ], "anatomy_list": [ "腋窝淋巴结" ] } ] }, { "id": 764, "text": "积极行右侧胸腔穿刺置管引流术，引流出暗红色血性液体，考虑癌性胸水可能性大，胸水送常规、细胞检查符合渗出液特征，送检体液tct(2019-07-22):送检胸水细胞学：血凝块样组织中见少许炎症细胞。", "event": [ { "core_name": "引流", "tendency": "", "character": [ "暗红色血性液体" ], "anatomy_list": [] }, { "core_name": "胸水", "tendency": "不确定", "character": [ "癌性" ], "anatomy_list": [ "胸" ] }, { "core_name": "渗出液", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "炎症细胞", "tendency": "", "character": [ "血凝块样组织中见", "少许" ], "anatomy_list": [] } ] }, { "id": 1718, "text": "咳嗽无减轻，咳嗽较重时伴前胸疼痛。", "event": [ { "core_name": "咳嗽", "tendency": "否定", "character": [ "减轻" ], "anatomy_list": [] }, { "core_name": "咳嗽", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "", "character": [], "anatomy_list": [ "前胸" ] } ] }, { "id": 1924, "text": "4月前患者因“腹胀、纳差”再次入我院，予以诊断“食管恶性肿瘤术后、胃肠功能紊乱、严重营养不良、急性腹膜炎、肺部感染”。", "event": [ { "core_name": "腹胀", "tendency": "", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "纳差", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "肿瘤", "tendency": "", "character": [ "术后", "恶性" ], "anatomy_list": [ "食管" ] }, { "core_name": "功能紊乱", "tendency": "", "character": [], "anatomy_list": [ "胃", "肠" ] }, { "core_name": "营养不良", "tendency": "", "character": [ "严重" ], "anatomy_list": [] }, { "core_name": "腹膜炎", "tendency": "", "character": [ "急性" ], "anatomy_list": [ "腹膜" ] }, { "core_name": "感染", "tendency": "", "character": [], "anatomy_list": [ "肺部" ] } ] }, { "id": 599, "text": "室间隔间隔增厚。", "event": [ { "core_name": "增厚", "tendency": "", "character": [], "anatomy_list": [ "室间隔" ] } ] }, { "id": 1406, "text": "无发热、黄染；无反酸、嗳气；我院行上腹部ct增强提示：胰头癌可能。", "event": [ { "core_name": "发热", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "黄染", "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": "癌", "tendency": "不确定", "character": [], "anatomy_list": [ "胰头" ] } ] }, { "id": 1035, "text": "糖类抗原125：591.10U/ml、人附睾蛋白:186.30pmol/l，请肿瘤多学科会诊后，明确患者为卵巢癌复发伴直肠转移，转我科继续治疗。", "event": [ { "core_name": "癌", "tendency": "", "character": [ "复发" ], "anatomy_list": [ "卵巢" ] }, { "core_name": "癌", "tendency": "", "character": [ "转移" ], "anatomy_list": [ "直肠" ] } ] }, { "id": 2001, "text": "第三次入院记录（2012年12月4日-2012年12月24日） 患者2月余前无明显诱因出现乏力，但不影响正常工作，无纳差、身黄，无发热、畏寒，无腹痛、腹胀，无黑便等不适。", "event": [ { "core_name": "乏力", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "影响正常工作", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "纳差", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "黄染", "tendency": "否定", "character": [], "anatomy_list": [ "身" ] }, { "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": [ "腹部" ] }, { "core_name": "腹胀", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "黑便", "tendency": "否定", "character": [], "anatomy_list": [] } ] }, { "id": 1902, "text": "pet/ct90检查(123456)提示：1.右肺下叶内基底段段结节影，fdg代谢增高，考虑肿瘤。", "event": [ { "core_name": "结节影", "tendency": "", "character": [], "anatomy_list": [ "右肺下叶内基底段" ] }, { "core_name": "fdg代谢", "tendency": "", "character": [ "增高" ], "anatomy_list": [] }, { "core_name": "肿瘤", "tendency": "不确定", "character": [], "anatomy_list": [ "右肺下叶内基底段" ] } ] }, { "id": 2031, "text": "入院前5月于我院行右肩背部肿物彩超检查提示：右肩部肩部皮下皮下脂肪层内可见范围约56mm*13mm中等回声团，考虑脂肪瘤。", "event": [ { "core_name": "肿物", "tendency": "", "character": [], "anatomy_list": [ "右肩背部" ] }, { "core_name": "回声团", "tendency": "", "character": [ "中等" ], "anatomy_list": [ "右肩部皮下皮下脂肪层" ] }, { "core_name": "瘤", "tendency": "不确定", "character": [], "anatomy_list": [ "脂肪" ] } ] }, { "id": 1698, "text": "为求进一步治疗，今日来我院就诊，门诊以“尿频原因待查”收入院。", "event": [ { "core_name": "尿频", "tendency": "不确定", "character": [], "anatomy_list": [] } ] }, { "id": 1504, "text": "半天前患者自觉头昏、双下肢乏力伴耳鸣，轻微活动后心累、气促等不适，无牙龈出血、鼻出血，无恶心、呕吐，无呕血、便血，无畏寒、发热，无咳嗽、咳痰，无血尿等不适，现患者为求进一步诊疗，遂就诊于我科门诊，门诊以“慢性粒单核细胞白血病；化疗后骨髓抑制”收入我科住院治疗。", "event": [ { "core_name": "头昏", "tendency": "", "character": [], "anatomy_list": [ "头" ] }, { "core_name": "乏力", "tendency": "", "character": [], "anatomy_list": [ "双下肢" ] }, { "core_name": "耳鸣", "tendency": "", "character": [], "anatomy_list": [ "耳" ] }, { "core_name": "心累", "tendency": "", "character": [ "轻微活动后" ], "anatomy_list": [ "心" ] }, { "core_name": "气促", "tendency": "", "character": [ "轻微活动后" ], "anatomy_list": [] }, { "core_name": "出血", "tendency": "否定", "character": [], "anatomy_list": [ "牙龈" ] }, { "core_name": "出血", "tendency": "否定", "character": [], "anatomy_list": [ "鼻" ] }, { "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": "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": "咳嗽", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "血尿", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "白血病", "tendency": "", "character": [ "慢性", "粒单核细胞" ], "anatomy_list": [] }, { "core_name": "骨髓抑制", "tendency": "", "character": [ "化疗后" ], "anatomy_list": [ "骨髓" ] } ] }, { "id": 1437, "text": "胸部ct：1.右肺上叶后段占位伴空洞形成，由肺动脉供血，考虑肿瘤性病变；2.纵隔淋巴结肿大，考虑t3椎体转移可能；腰椎磁共振：右髂骨软组织占位，结合病史，考虑转移可能大。", "event": [ { "core_name": "病变", "tendency": "", "character": [ "占位性" ], "anatomy_list": [ "右肺上叶后段" ] }, { "core_name": "空洞形成", "tendency": "", "character": [], "anatomy_list": [ "右肺上叶后段" ] }, { "core_name": "病变", "tendency": "不确定", "character": [ "肿瘤性" ], "anatomy_list": [ "右肺上叶后段" ] }, { "core_name": "肿大", "tendency": "", "character": [], "anatomy_list": [ "纵隔淋巴结" ] }, { "core_name": "转移", "tendency": "不确定", "character": [], "anatomy_list": [ "t3椎体" ] }, { "core_name": "占位", "tendency": "", "character": [], "anatomy_list": [ "右髂骨软组织" ] }, { "core_name": "肿瘤", "tendency": "不确定", "character": [ "转移" ], "anatomy_list": [] } ] }, { "id": 606, "text": "患者因“间断头昏伴呕吐40天，发现颅内占位病变20天”于2012-8-25入院，mri：右侧顶枕叶囊实性占位，于2012-8-31在全麻下行开颅肿瘤切除术，术后病检示：（右枕叶）室管膜母细胞瘤。", "event": [ { "core_name": "头昏", "tendency": "", "character": [ "间断" ], "anatomy_list": [ "头" ] }, { "core_name": "呕吐", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "病变", "tendency": "", "character": [ "占位性" ], "anatomy_list": [ "颅内" ] }, { "core_name": "占位", "tendency": "", "character": [ "囊实性" ], "anatomy_list": [ "右侧顶枕叶" ] }, { "core_name": "瘤", "tendency": "", "character": [], "anatomy_list": [ "右枕叶室管膜", "母细胞" ] } ] }, { "id": 1484, "text": "入院前1周，患者无明显诱因出现咳嗽、咳痰，伴乏力，不伴发热、头昏、心悸、呼吸困难、恶心、呕吐、腹胀、腹痛等，今为求下一疗程化疗来我院住院。", "event": [ { "core_name": "咳嗽", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "乏力", "tendency": "", "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": "心悸", "tendency": "否定", "character": [], "anatomy_list": [ "心" ] }, { "core_name": "呼吸困难", "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": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] } ] }, { "id": 1190, "text": "1+月前，患者因中上腹疼痛疼痛不适于外院求诊，行电子胃镜示：1、食道赘生物性质待定？2、慢性浅表性胃炎。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [], "anatomy_list": [ "中上腹" ] }, { "core_name": "赘生物", "tendency": "不确定", "character": [], "anatomy_list": [ "食道" ] }, { "core_name": "胃炎", "tendency": "", "character": [ "慢性", "浅表性" ], "anatomy_list": [ "胃" ] } ] }, { "id": 1550, "text": "遂于今日就诊于我院神经内科门诊，门诊以“血管性头痛？”收入我科。", "event": [ { "core_name": "疼痛", "tendency": "不确定", "character": [ "血管性" ], "anatomy_list": [ "头" ] } ] }, { "id": 251, "text": "患者本次发病以来，食欲下降， 神志清醒，精神尚可，睡眠欠佳，大便正常，小便正常，体重无明显变化。", "event": [ { "core_name": "食欲", "tendency": "", "character": [ "下降" ], "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": [ "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": "体重变化", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [] } ] }, { "id": 1222, "text": "膀胱两侧多发结节，考虑转移。", "event": [ { "core_name": "结节", "tendency": "", "character": [ "多发" ], "anatomy_list": [ "膀胱两侧" ] }, { "core_name": "转移", "tendency": "不确定", "character": [], "anatomy_list": [] } ] }, { "id": 750, "text": "4+年前，患者无明显诱因出现咳嗽，干咳为主，偶有痰中带血，伴活动后气促，无发热，无盗汗，无明显消瘦，无胸痛，无头晕、头痛，无视物改变，无恶心、呕吐，患者自以为“感冒”，自购药物治疗无明显好转。", "event": [ { "core_name": "咳嗽", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "咳嗽", "tendency": "", "character": [ "干性" ], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "带血", "偶有" ], "anatomy_list": [] }, { "core_name": "气促", "tendency": "", "character": [ "活动后" ], "anatomy_list": [] }, { "core_name": "发热", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "盗汗", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "消瘦", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "胸" ] }, { "core_name": "头晕", "tendency": "否定", "character": [], "anatomy_list": [ "头" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "头" ] }, { "core_name": "视物改变", "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": "感冒", "tendency": "", "character": [], "anatomy_list": [] } ] }, { "id": 292, "text": "自患者起病以来，精神一般，食欲减退为正常时60%，睡眠欠佳，大便费力，尿量从1500ml左右逐渐减少为300ml左右，体重减少。", "event": [ { "core_name": "精神", "tendency": "", "character": [ "一般" ], "anatomy_list": [] }, { "core_name": "食欲", "tendency": "", "character": [ "减退" ], "anatomy_list": [] }, { "core_name": "睡眠", "tendency": "", "character": [ "欠佳" ], "anatomy_list": [] }, { "core_name": "大便", "tendency": "", "character": [ "费力" ], "anatomy_list": [] }, { "core_name": "尿量减少", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "体重减少", "tendency": "", "character": [], "anatomy_list": [] } ] }, { "id": 1487, "text": "进一步就诊我院，门诊查肾功示“尿素15.65mmol/L，肌酐508.5umol/L，腹部彩超：1.肝右叶钙化灶，肝囊肿；2.胆囊切除术后；3.双肾实质回声增强；4.右肾囊肿；5.胆管、胰、脾未见异常。", "event": [ { "core_name": "钙化灶", "tendency": "", "character": [], "anatomy_list": [ "肝右叶" ] }, { "core_name": "囊肿", "tendency": "", "character": [], "anatomy_list": [ "肝" ] }, { "core_name": "切除", "tendency": "", "character": [ "术后" ], "anatomy_list": [ "胆囊" ] }, { "core_name": "回声", "tendency": "", "character": [ "增强" ], "anatomy_list": [ "双肾实质" ] }, { "core_name": "囊肿", "tendency": "", "character": [], "anatomy_list": [ "右肾" ] }, { "core_name": "异常", "tendency": "否定", "character": [], "anatomy_list": [ "胆管", "胰", "脾" ] } ] }, { "id": 2063, "text": "发现血压升高13+年，最高血压达170/？mmhg，既往患者规律服用丹参片降压，平素血压维持在140/？mmhg，平素无头晕、耳鸣、视物模糊，无脑溢血病史，无明显语言肢体活动障碍。", "event": [ { "core_name": "血压", "tendency": "", "character": [ "升高" ], "anatomy_list": [] }, { "core_name": "头晕", "tendency": "否定", "character": [], "anatomy_list": [ "头" ] }, { "core_name": "耳鸣", "tendency": "否定", "character": [], "anatomy_list": [ "耳" ] }, { "core_name": "视物模糊", "tendency": "否定", "character": [], "anatomy_list": [ "眼" ] }, { "core_name": "脑溢血", "tendency": "否定", "character": [], "anatomy_list": [ "脑" ] }, { "core_name": "语言障碍", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [] }, { "core_name": "活动障碍", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [ "肢体" ] } ] }, { "id": 1184, "text": "查体扪及右乳乳晕区约4.0×3.0cm大小质硬肿块，皮肤受累。", "event": [ { "core_name": "肿块", "tendency": "", "character": [ "质硬" ], "anatomy_list": [ "右乳乳晕" ] }, { "core_name": "受累", "tendency": "", "character": [], "anatomy_list": [ "皮肤" ] } ] }, { "id": 52, "text": "两切端未见癌累及。", "event": [ { "core_name": "癌", "tendency": "否定", "character": [ "累及" ], "anatomy_list": [ "两切端" ] } ] }, { "id": 1824, "text": "患者拒绝行第6周期化疗，此后正规复查，肿瘤处于sd，2月前患者无明显诱因出现喘累、气促，活动后明显，休息时稍缓解，于我院住院治疗，胸、腹腔b超提示胸腔积液、腹腔积液，予以胸腔穿刺置管引流后喘累缓解，予以腹腔穿刺置管引流后于2018-05-24行dp方案（多西他赛100mg iv+顺铂100mg腹腔灌注）化疗1周期，化疗后出现轻度恶心、呕吐，予以止吐对症治疗后好转，无明显骨髓抑制，喘累好转。", "event": [ { "core_name": "肿瘤", "tendency": "", "character": [ "sd" ], "anatomy_list": [] }, { "core_name": "喘累", "tendency": "", "character": [ "活动后明显", "休息时稍缓解" ], "anatomy_list": [] }, { "core_name": "气促", "tendency": "", "character": [ "活动后明显", "休息时稍缓解" ], "anatomy_list": [] }, { "core_name": "积液", "tendency": "", "character": [], "anatomy_list": [ "胸腔" ] }, { "core_name": "积液", "tendency": "", "character": [], "anatomy_list": [ "腹腔" ] }, { "core_name": "喘累", "tendency": "", "character": [ "缓解" ], "anatomy_list": [] }, { "core_name": "恶心", "tendency": "", "character": [ "轻度", "化疗后" ], "anatomy_list": [] }, { "core_name": "呕吐", "tendency": "", "character": [ "轻度", "化疗后" ], "anatomy_list": [] }, { "core_name": "骨髓抑制", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [ "骨髓" ] }, { "core_name": "喘累", "tendency": "", "character": [ "好转" ], "anatomy_list": [] } ] }, { "id": 1803, "text": "入院前 3+天 ，患者检修自家瓦房屋顶时不慎从3+米多高处跌落，致头部及左下肢受伤（具体受力方式不详），伤后昏迷约10+分钟，醒转后神萎嗜睡、少语，感头晕头痛及左小腿疼痛，无抽搐及大小便失禁，无口鼻腔及外耳道耳道出血，无呕吐，无肢体活动受限。", "event": [ { "core_name": "受伤", "tendency": "", "character": [ "高处跌落" ], "anatomy_list": [ "头部", "左下肢" ] }, { "core_name": "昏迷", "tendency": "", "character": [ "伤后" ], "anatomy_list": [] }, { "core_name": "神萎", "tendency": "", "character": [ "醒转后" ], "anatomy_list": [] }, { "core_name": "嗜睡", "tendency": "", "character": [ "醒转后" ], "anatomy_list": [] }, { "core_name": "少语", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "头晕", "tendency": "", "character": [], "anatomy_list": [ "头" ] }, { "core_name": "疼痛", "tendency": "", "character": [], "anatomy_list": [ "头" ] }, { "core_name": "疼痛", "tendency": "", "character": [], "anatomy_list": [ "左小腿" ] }, { "core_name": "抽搐", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "大小便失禁", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "出血", "tendency": "否定", "character": [], "anatomy_list": [ "口鼻腔", "外耳道" ] }, { "core_name": "呕吐", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "活动受限", "tendency": "否定", "character": [], "anatomy_list": [ "肢体" ] } ] }, { "id": 1466, "text": "40+年患者发现血压升高，最高血压为190/？mmhg，平时无头昏、头痛不适。", "event": [ { "core_name": "血压", "tendency": "", "character": [ "升高" ], "anatomy_list": [] }, { "core_name": "头昏", "tendency": "否定", "character": [], "anatomy_list": [ "头" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "头" ] } ] }, { "id": 1923, "text": "出院后患者感容易饱胀，多次于当地镇医院输液治疗（具体不详）。", "event": [ { "core_name": "饱胀", "tendency": "", "character": [ "容易" ], "anatomy_list": [] } ] }, { "id": 1400, "text": "无同房出血及性交痛，建议月经期后进一步检查及治疗。", "event": [ { "core_name": "出血", "tendency": "否定", "character": [ "同房" ], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "否定", "character": [ "性交" ], "anatomy_list": [] } ] }, { "id": 403, "text": "2月前，患者无明显诱因出现便血，为鲜血，伴少许粘液，无恶臭，伴大便困难，无明显肛门坠胀，无腹痛、腹泻，无发热、寒战等不适，患者自认为“痔疮”并自行使用外用药物处理（具体不详）后仍反复便血，患者遂就诊于某医院，行ct见直肠下段管壁改变，考虑占位性病变。", "event": [ { "core_name": "便血", "tendency": "", "character": [ "鲜血", "伴少许粘液", "无恶臭" ], "anatomy_list": [] }, { "core_name": "大便困难", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "坠胀", "tendency": "否定", "character": [ "明显" ], "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": "发热", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "寒颤", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "痔疮", "tendency": "不确定", "character": [], "anatomy_list": [] }, { "core_name": "便血", "tendency": "", "character": [ "反复" ], "anatomy_list": [] }, { "core_name": "改变", "tendency": "", "character": [], "anatomy_list": [ "直肠下段管壁" ] }, { "core_name": "病变", "tendency": "不确定", "character": [ "占位性" ], "anatomy_list": [ "直肠下段管壁" ] } ] }, { "id": 304, "text": "15月前，患者因“胸腔积液”再次入院，请心胸外科会诊后考虑转移所致，遂于2014-07-17在我院心胸外科行“剖胸探查术+胸膜部分剥脱术+胸壁包块切除术”，术后患者胸壁切口裂开，切口出现大量渗液，于2014-08-27经引流管向伤口方向注入顺铂30mg，抑制胸膜腔液体渗出，2014-09-02行胸腔闭式引流术，2014-09-04探查切口见引流管脱出，予纱布填塞后纱布很快浸湿，考虑仍有胸腔积液，予重新安置胸腔闭式引流并定期给予换药，后因患者强烈要求拔管遂拔除引流管。", "event": [ { "core_name": "积液", "tendency": "", "character": [], "anatomy_list": [ "胸腔" ] }, { "core_name": "转移", "tendency": "不确定", "character": [], "anatomy_list": [] }, { "core_name": "切口裂开", "tendency": "", "character": [ "术后" ], "anatomy_list": [ "胸壁" ] }, { "core_name": "渗液", "tendency": "", "character": [ "大量" ], "anatomy_list": [ "胸壁切口" ] }, { "core_name": "引流管脱出", "tendency": "", "character": [], "anatomy_list": [ "胸壁" ] }, { "core_name": "积液", "tendency": "不确定", "character": [], "anatomy_list": [ "胸腔" ] } ] }, { "id": 1208, "text": "5.子宫左侧软组织肿块，肿瘤？其它？请结合mri检查。", "event": [ { "core_name": "肿块", "tendency": "", "character": [], "anatomy_list": [ "子宫左侧软组织" ] }, { "core_name": "肿瘤", "tendency": "不确定", "character": [], "anatomy_list": [] } ] }, { "id": 1609, "text": "胸部ct：1.右肺下叶前基底段实性结节。", "event": [ { "core_name": "结节", "tendency": "", "character": [ "实性" ], "anatomy_list": [ "右肺下叶前基底段" ] } ] }, { "id": 1461, "text": "2+年患者在某医院住院期间发现血糖升高，行ogtt提示“空腹血糖6.6mmol/l，餐后60分钟血糖15.1mmol/l，餐后120分钟血糖15.7mmol/l”，诊断为“2型糖尿病”，现使用“阿卡波糖50mg2次/日”降糖，平时未规律监测血糖。", "event": [ { "core_name": "血糖", "tendency": "", "character": [ "升高" ], "anatomy_list": [] }, { "core_name": "糖尿病", "tendency": "", "character": [ "2型" ], "anatomy_list": [] } ] }, { "id": 697, "text": "2.子宫实性占位（符合子宫肌瘤声像图）3.盆腔积液；hpv检查示：hpv11（+）；宫腔镜诊断性刮宫，刮出组织送病检，病检结果（123456）：（宫腔）子宫内膜癌。", "event": [ { "core_name": "占位", "tendency": "", "character": [ "实性" ], "anatomy_list": [ "子宫" ] }, { "core_name": "肌瘤", "tendency": "", "character": [], "anatomy_list": [ "子宫" ] }, { "core_name": "积液", "tendency": "", "character": [], "anatomy_list": [ "盆腔" ] }, { "core_name": "癌", "tendency": "", "character": [ "子宫内膜" ], "anatomy_list": [ "宫腔" ] } ] }, { "id": 1200, "text": "多次测血压收缩压均高于150mm，最高时收缩压达210mm，平素规律服用“奈迪亚”、“非洛地平”、“倍他乐克”等降压药物，自诉血压控制不佳。", "event": [ { "core_name": "血压", "tendency": "", "character": [ "控制不佳" ], "anatomy_list": [] } ] }, { "id": 1742, "text": "患者本次发病以来，食欲不振，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": [ "不振" ], "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": 641, "text": "随后予以“奥沙利铂+雷替曲塞”方案化疗5次，化疗后无恶心、呕吐等不适。", "event": [ { "core_name": "恶心", "tendency": "否定", "character": [ "化疗后" ], "anatomy_list": [] }, { "core_name": "呕吐", "tendency": "否定", "character": [ "化疗后" ], "anatomy_list": [] } ] }, { "id": 704, "text": "于院外行心电图示：窦性心律，室性期前收缩三联律，t波改变。", "event": [ { "core_name": "窦性心律", "tendency": "", "character": [], "anatomy_list": [ "心" ] }, { "core_name": "期前收缩", "tendency": "", "character": [ "室性" ], "anatomy_list": [] }, { "core_name": "三联律", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "t波改变", "tendency": "", "character": [], "anatomy_list": [] } ] }, { "id": 499, "text": "患者男，53岁，2+月前因进行性进食吞咽困难行活组织检查提示贲门食管腺癌，并于08-29日于我院在全麻下行开胸探查+贲门腺癌根治术。", "event": [ { "core_name": "吞咽困难", "tendency": "", "character": [ "进行性", "进食" ], "anatomy_list": [] }, { "core_name": "腺癌", "tendency": "", "character": [], "anatomy_list": [ "贲门", "食管" ] } ] }, { "id": 358, "text": "入院前1+年，患者右膝疼痛再发加重，伴左膝关节胀痛，以长距离行走、爬楼后明显，于当地医院就诊，诊断“双膝关节骨性关节炎”。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [ "再发加重" ], "anatomy_list": [ "右膝" ] }, { "core_name": "疼痛", "tendency": "", "character": [ "胀痛", "长距离行走、爬楼后明显" ], "anatomy_list": [ "左膝关节" ] }, { "core_name": "关节炎", "tendency": "", "character": [ "骨性" ], "anatomy_list": [ "双膝关节" ] } ] }, { "id": 1776, "text": "尿黄、眼黄、身黄持续存在，半月前，患者反复出现畏寒、发热、寒战，伴尿频、尿量增多，无尿急、尿痛及肉眼血尿，无咳嗽、咳痰，无恶心、呕吐，无腹痛、腹泻，自行服用退热药后症状缓解。", "event": [ { "core_name": "尿黄", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "黄染", "tendency": "", "character": [], "anatomy_list": [ "眼" ] }, { "core_name": "黄染", "tendency": "", "character": [], "anatomy_list": [ "身" ] }, { "core_name": "畏寒", "tendency": "", "character": [ "反复" ], "anatomy_list": [] }, { "core_name": "发热", "tendency": "", "character": [ "反复" ], "anatomy_list": [] }, { "core_name": "寒颤", "tendency": "", "character": [ "反复" ], "anatomy_list": [] }, { "core_name": "尿频", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "小便", "tendency": "", "character": [ "量增多" ], "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": "咳嗽", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "咳痰", "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": 1966, "text": "患者2月前在我科住院，诊断为急性上消化道出血，治愈后出院，出院后一直感心累，伴有胸骨后梗阻感，运动后加重，无肩背部放射痛，与饮食无关。", "event": [ { "core_name": "出血", "tendency": "", "character": [ "急性" ], "anatomy_list": [ "上消化道" ] }, { "core_name": "心累", "tendency": "", "character": [ "一直" ], "anatomy_list": [ "心" ] }, { "core_name": "梗阻感", "tendency": "", "character": [ "运动后加重" ], "anatomy_list": [ "胸骨后" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [ "放射性" ], "anatomy_list": [ "肩", "背部" ] }, { "core_name": "疼痛", "tendency": "", "character": [ "与饮食无关" ], "anatomy_list": [ "胸骨后" ] } ] }, { "id": 563, "text": "患者2月前因体检发现脾脏内结节，遂就诊于我院查体发现颈部、腋窝淋巴结有肿大，左侧颈部可扪及一大小约2*2cm大小包块，质地中等，活动度可，无触痛，局部皮肤无红肿、破溃。", "event": [ { "core_name": "结节", "tendency": "", "character": [], "anatomy_list": [ "脾脏内" ] }, { "core_name": "肿大", "tendency": "", "character": [], "anatomy_list": [ "颈部淋巴结", "腋窝淋巴结" ] }, { "core_name": "包块", "tendency": "", "character": [ "质地中等", "活动度可", "无触痛" ], "anatomy_list": [ "左侧颈部" ] }, { "core_name": "红肿", "tendency": "否定", "character": [], "anatomy_list": [ "局部皮肤" ] }, { "core_name": "破溃", "tendency": "否定", "character": [], "anatomy_list": [ "局部皮肤" ] } ] }, { "id": 370, "text": "不伴有发热寒战，不伴有恶心呕吐，不伴有腹痛腹泻。", "event": [ { "core_name": "发热", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "寒颤", "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": 700, "text": "1+月前，患者无明显诱因出现上腹胀，进食后加重，伴纳差，进食约为平素1/3，无腹痛，伴反酸、嗳气，无恶心、呕吐，无腹泻，无呕血，无黑便，无肛门停止排便排气，伴全身乏力，无厌油、眼黄、尿黄，有尿量减少（具体不详），无尿频、尿急、尿痛，无排尿困难，无心悸、胸闷，无咳嗽、咳痰，无发热，有头昏、头痛，无偏瘫、抽搐等不适。", "event": [ { "core_name": "腹胀", "tendency": "", "character": [ "进食后加重" ], "anatomy_list": [ "上腹" ] }, { "core_name": "纳差", "tendency": "", "character": [ "进食约为平素1/3" ], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "反酸", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "嗳气", "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": "腹泻", "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": "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": "乏力", "tendency": "", "character": [], "anatomy_list": [ "全身" ] }, { "core_name": "厌油", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "黄染", "tendency": "否定", "character": [], "anatomy_list": [ "眼" ] }, { "core_name": "尿黄", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "小便", "tendency": "", "character": [ "减少" ], "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": "排尿困难", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "心悸", "tendency": "否定", "character": [], "anatomy_list": [ "心" ] }, { "core_name": "胸闷", "tendency": "否定", "character": [], "anatomy_list": [ "胸" ] }, { "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": "头昏", "tendency": "", "character": [], "anatomy_list": [ "头" ] }, { "core_name": "疼痛", "tendency": "", "character": [], "anatomy_list": [ "头" ] }, { "core_name": "偏瘫", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "抽搐", "tendency": "否定", "character": [], "anatomy_list": [] } ] }, { "id": 1011, "text": "2、脾脏下极异常密度，建议增强扫描进一步明确。", "event": [ { "core_name": "密度", "tendency": "", "character": [ "异常" ], "anatomy_list": [ "脾脏下极" ] } ] }, { "id": 1842, "text": "患者本次发病以来，食欲不振， 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": [ "不振" ], "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": 1201, "text": "8年间头痛反复发作，期间未于外院就诊。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [ "反复" ], "anatomy_list": [ "头" ] } ] }, { "id": 959, "text": "予以右肺中叶及右肺下叶楔形切除+胸壁包块活检术，术中冰冻提示右肺中叶及下叶腺癌，术后病理结果及免疫组化不详，术后分期为t4n2Mm1。", "event": [ { "core_name": "腺癌", "tendency": "", "character": [], "anatomy_list": [ "右肺中叶及下叶" ] }, { "core_name": "腺癌", "tendency": "", "character": [ "术后分期为t4n2Mm1" ], "anatomy_list": [] } ] }, { "id": 1022, "text": "入院前10+年，患者无明显诱因出现阴道不规律出血，为鲜红色，每次量少，无血凝块，无腹痛、腹胀，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，在某医院就诊，完善相关检查（具体不详），考虑\"宫颈癌\"，行子宫全切术，术中取活检，活检报告提示子宫颈癌（未见报告），术后予以6周期化疗（具体用药不详），化疗过程中患者有恶心、呕吐，腹痛、腹胀，全血下降等不适，给予对症处理后缓解。", "event": [ { "core_name": "出血", "tendency": "", "character": [ "不规律", "鲜红色", "量少", "无血凝块" ], "anatomy_list": [ "阴道" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "腹胀", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "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": "体重减轻", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [] }, { "core_name": "癌", "tendency": "不确定", "character": [], "anatomy_list": [ "宫颈" ] }, { "core_name": "癌", "tendency": "", "character": [], "anatomy_list": [ "子宫颈" ] }, { "core_name": "恶心", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "呕吐", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "腹胀", "tendency": "", "character": [], "anatomy_list": [ "腹" ] } ] }, { "id": 1943, "text": "患者9月前无明显诱因出现腰部疼痛，疼痛可忍受，患者未予重视。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [], "anatomy_list": [ "腰部" ] }, { "core_name": "疼痛", "tendency": "", "character": [ "可忍受" ], "anatomy_list": [ "腰部" ] } ] }, { "id": 859, "text": "入院前1天患者有腹泻症状，解数次黄色水样便，伴排便时脐周及脐上隐痛，伴恶心，无畏寒、发热、心悸、呕吐、呕血、黑便，在家口服诺氟沙星治疗后未再腹泻。", "event": [ { "core_name": "腹泻", "tendency": "", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "大便", "tendency": "", "character": [ "黄色", "水样" ], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "", "character": [ "排便时", "隐痛" ], "anatomy_list": [ "脐上", "脐周" ] }, { "core_name": "恶心", "tendency": "", "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": "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": "腹泻", "tendency": "否定", "character": [ "口服诺氟沙星治疗后" ], "anatomy_list": [ "腹" ] } ] }, { "id": 734, "text": "患者自发病以来，精神尚可，食欲可，睡眠可，大便如常，小便如常，体重有减轻（具体不详）。", "event": [ { "core_name": "精神", "tendency": "", "character": [ "尚可" ], "anatomy_list": [] }, { "core_name": "食欲", "tendency": "", "character": [ "可" ], "anatomy_list": [] }, { "core_name": "睡眠质量", "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": "体重减轻", "tendency": "", "character": [], "anatomy_list": [] } ] }, { "id": 801, "text": "伴干咳，无痰液。", "event": [ { "core_name": "咳嗽", "tendency": "", "character": [ "干性" ], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "否定", "character": [], "anatomy_list": [] } ] }, { "id": 1350, "text": "入院前1+年，患者自行发现左侧乳腺1cm*1cm大小包块，质硬，无活动，无压痛，边界不清，乳头无溢液，无腋窝淋巴结肿大，患者未重视。", "event": [ { "core_name": "包块", "tendency": "", "character": [ "质硬", "无活动", "无压痛", "边界不清" ], "anatomy_list": [ "左侧乳腺" ] }, { "core_name": "溢液", "tendency": "否定", "character": [], "anatomy_list": [ "乳头" ] }, { "core_name": "肿大", "tendency": "否定", "character": [], "anatomy_list": [ "腋窝淋巴结" ] } ] }, { "id": 1768, "text": "腋窝淋巴结见癌转移（6/22）。", "event": [ { "core_name": "癌", "tendency": "", "character": [ "转移" ], "anatomy_list": [ "腋窝淋巴结" ] } ] }, { "id": 1205, "text": "2.纵隔淋巴结增大。", "event": [ { "core_name": "增大", "tendency": "", "character": [], "anatomy_list": [ "纵隔淋巴结" ] } ] }, { "id": 1230, "text": "无腰背部放射痛。", "event": [ { "core_name": "疼痛", "tendency": "否定", "character": [ "放射性" ], "anatomy_list": [ "腰", "背部" ] } ] }, { "id": 1872, "text": "今晨患者突然出现下腹部疼痛疼痛加重，仍排气排便，无返酸、嗳气，无恶心、呕吐、腹痛，无心慌气促、无畏寒、发热、无呕血等不适，为求治疗急诊来我院，腹部ct示：1、直乙交界区肠管壁增厚2、前列腺增大伴钙化。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [], "anatomy_list": [ "下腹部" ] }, { "core_name": "疼痛", "tendency": "", "character": [ "加重" ], "anatomy_list": [ "下腹部" ] }, { "core_name": "返酸", "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": [ "腹部" ] }, { "core_name": "心慌", "tendency": "否定", "character": [], "anatomy_list": [ "心" ] }, { "core_name": "气促", "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": "呕血", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "增厚", "tendency": "", "character": [], "anatomy_list": [ "直乙交界区肠管壁" ] }, { "core_name": "钙化", "tendency": "", "character": [], "anatomy_list": [ "前列腺" ] }, { "core_name": "增大", "tendency": "", "character": [], "anatomy_list": [ "前列腺" ] } ] }, { "id": 1807, "text": "（2020-10-24）患者于我院体检中心体检，行胸部ct：双肺多发结节影（未见具体报告），无明显发热、寒颤、咳嗽、咳痰、恶心、呕吐、头痛、头晕、腹痛等不适。", "event": [ { "core_name": "结节影", "tendency": "", "character": [ "多发" ], "anatomy_list": [ "双肺" ] }, { "core_name": "发热", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [] }, { "core_name": "寒颤", "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": "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": "头晕", "tendency": "否定", "character": [], "anatomy_list": [ "头" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] } ] }, { "id": 766, "text": "建议可继续口服奥西替尼（印度版），但鉴于右侧胸腔恶性积液，病情缓慢进展，建议患者可更换为正版奥西替尼，患者及家属拒绝；后征得患者及家属同意后分别于7-22、7-26、7-29、8-01行胸腔灌注注射用重组改构人肿瘤坏死因子300万iu。", "event": [ { "core_name": "积液", "tendency": "", "character": [ "恶性" ], "anatomy_list": [ "右侧胸腔" ] } ] }, { "id": 1591, "text": "自述双乳有肿痛，与月经有关。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [ "月经有关", "肿痛" ], "anatomy_list": [ "双乳" ] } ] }, { "id": 1007, "text": "患者入院8月前无明显诱因出现全腹痛，主要表现为右下腹痛，呈阵发性隐痛，发作无规律性，与进食无关，无放射痛，可忍受，偶有打嗝，完善相关检查诊断为“结肠肿块”，于2016-05-07行剖腹探查+右半结肠根治术，术后病理示：右半结肠圆形细胞恶性肿瘤，两切端及阑尾均未见肿瘤累及。肠壁上淋巴结未见肿瘤转移（0/15）。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [], "anatomy_list": [ "全腹" ] }, { "core_name": "疼痛", "tendency": "", "character": [ "阵发性隐痛", "发作无规律性", "与进食无关", "可忍受" ], "anatomy_list": [ "右下腹" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [ "放射性" ], "anatomy_list": [] }, { "core_name": "打嗝", "tendency": "", "character": [ "偶有" ], "anatomy_list": [] }, { "core_name": "肿块", "tendency": "", "character": [], "anatomy_list": [ "结肠" ] }, { "core_name": "肿瘤", "tendency": "", "character": [ "圆形细胞", "恶性" ], "anatomy_list": [ "右半结肠" ] }, { "core_name": "癌", "tendency": "", "character": [], "anatomy_list": [ "右半结肠" ] }, { "core_name": "肿瘤", "tendency": "否定", "character": [ "累及" ], "anatomy_list": [ "右半结肠两切端", "阑尾" ] }, { "core_name": "肿瘤", "tendency": "否定", "character": [ "转移" ], "anatomy_list": [ "肠壁上淋巴结" ] } ] }, { "id": 392, "text": "患者于5+月前，因腹痛就诊于我院，我院诊断为“原发性肝癌破裂出血”，于2019年09月29日病人于全麻下行了腹腔镜肝中叶切除术+大网膜淋巴结清扫+胆囊切除术，术后给予静脉滴注护胃、静脉滴注维生素改善患者围手术期营养状况、促进机体能量代谢、抗感染、改善肝内胆道淤积症状、预防并发症、补钾、维持电解质平衡等对症治疗。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "破裂出血", "tendency": "", "character": [ "原发性肝癌" ], "anatomy_list": [ "肝" ] } ] }, { "id": 1281, "text": "于2016-03-04行全麻下腹腔镜全子宫双附件切除术+盆腔淋巴结清扫术+腹主动脉旁淋巴结清扫术+盆腔粘连松解术，镜下见：乙状结肠及肠系膜与左侧盆壁致密粘连；子宫体前位，正常大小，表面光滑：双侧附件萎缩、纤维化；盆腹腔内其他脏器表面未见明显异常。", "event": [ { "core_name": "粘连", "tendency": "", "character": [ "致密" ], "anatomy_list": [ "乙状结肠", "肠系膜", "左侧盆壁" ] }, { "core_name": "子宫体前位", "tendency": "", "character": [], "anatomy_list": [ "子宫体" ] }, { "core_name": "萎缩", "tendency": "", "character": [], "anatomy_list": [ "双侧附件" ] }, { "core_name": "纤维化", "tendency": "", "character": [], "anatomy_list": [ "双侧附件" ] }, { "core_name": "异常", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [ "盆腹腔内其他脏器表面" ] } ] }, { "id": 1674, "text": "入院1年余前，患者无明显诱因出现下腹疼痛，左下腹明显，呈阵发性隐痛，无放射痛，无加重缓解因素，大便1-3次/日，为黄色成型软便，无畏寒、发热、盗汗、消瘦，无便秘、腹泻等伴随，遂至我院门诊，于2015年7月查肠镜提示：结肠多发息肉，病检：\"结肠\"腺瘤型息肉，遂在我科住院行肠息肉治疗术，治疗后病情好转出院；2016-06因体检发现癌胚抗原异常升高，遂至我科住院治疗，完善肠镜提示：结肠多发性息肉，同时行了射频治疗；今日患者住院，要求复查肠镜，同时评估有无肠道息肉，故门诊以\"慢性肠炎、结肠息肉？\"收治入院。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [], "anatomy_list": [ "下腹" ] }, { "core_name": "疼痛", "tendency": "", "character": [ "明显" ], "anatomy_list": [ "左下腹" ] }, { "core_name": "疼痛", "tendency": "", "character": [ "阵发性", "隐痛" ], "anatomy_list": [ "下腹" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [ "放射性" ], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "", "character": [ "无加重缓解因素" ], "anatomy_list": [ "下腹" ] }, { "core_name": "大便", "tendency": "", "character": [ "黄色", "成型", "软" ], "anatomy_list": [] }, { "core_name": "畏寒", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "发热", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "盗汗", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "消瘦", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "便秘", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "腹泻", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "息肉", "tendency": "", "character": [ "多发" ], "anatomy_list": [ "结肠" ] }, { "core_name": "息肉", "tendency": "", "character": [ "腺瘤型" ], "anatomy_list": [ "结肠" ] }, { "core_name": "癌胚抗原", "tendency": "", "character": [ "异常升高" ], "anatomy_list": [] }, { "core_name": "肿物", "tendency": "", "character": [], "anatomy_list": [ "肠" ] }, { "core_name": "息肉", "tendency": "", "character": [ "多发性" ], "anatomy_list": [ "结肠" ] }, { "core_name": "息肉", "tendency": "不确定", "character": [], "anatomy_list": [ "肠道" ] }, { "core_name": "肠炎", "tendency": "", "character": [ "慢性" ], "anatomy_list": [ "肠" ] }, { "core_name": "息肉", "tendency": "不确定", "character": [], "anatomy_list": [ "结肠" ] } ] }, { "id": 1709, "text": "复查颅脑ct及骨盆平片见颅骨、骨盆、双股骨多发骨质异常，符合多发性骨髓瘤。", "event": [ { "core_name": "骨质异常", "tendency": "", "character": [ "多发" ], "anatomy_list": [ "颅骨", "骨盆", "双股骨" ] }, { "core_name": "瘤", "tendency": "", "character": [ "多发性" ], "anatomy_list": [ "骨髓" ] } ] }, { "id": 635, "text": "门诊以“宫颈高级别鳞状上皮内病变”收住入院。", "event": [ { "core_name": "病变", "tendency": "", "character": [ "高级别", "鳞状上皮" ], "anatomy_list": [ "宫颈" ] } ] }, { "id": 395, "text": "患者自发病以来，精神可，食欲可，睡眠可，大便如常，小便如常，体重减轻8kg。", "event": [ { "core_name": "精神", "tendency": "", "character": [ "" ], "anatomy_list": [] }, { "core_name": "食欲", "tendency": "", "character": [ "" ], "anatomy_list": [] }, { "core_name": "睡眠", "tendency": "", "character": [ "" ], "anatomy_list": [] }, { "core_name": "大便", "tendency": "", "character": [ "如常" ], "anatomy_list": [] }, { "core_name": "小便", "tendency": "", "character": [ "如常" ], "anatomy_list": [] }, { "core_name": "体重减轻", "tendency": "", "character": [], "anatomy_list": [] } ] }, { "id": 124, "text": "入院4天前，患者于我院体检，行胸部ct提示：“左肺下叶后基底段团块影，考虑肿瘤性病变可能（周围型肺癌？），纵隔、双肺门多发肿大淋巴结，建议进一步检查明确”。", "event": [ { "core_name": "团块影", "tendency": "", "character": [], "anatomy_list": [ "左肺下叶后基底段" ] }, { "core_name": "病变", "tendency": "不确定", "character": [ "肿瘤性" ], "anatomy_list": [ "肺" ] }, { "core_name": "癌", "tendency": "不确定", "character": [ "周围型" ], "anatomy_list": [ "肺" ] }, { "core_name": "肿大", "tendency": "", "character": [ "多发" ], "anatomy_list": [ "纵隔淋巴结", "双肺门淋巴结" ] } ] }, { "id": 469, "text": "患者于30年前体检时发现血压升高（具体不详），未予重视，此后多次测血压均高于正常值，最高达180/120mmHg，长期口服降压药，血压控制不理想，血压波动于160-130/100-70mmHg。", "event": [ { "core_name": "血压", "tendency": "", "character": [ "升高" ], "anatomy_list": [] }, { "core_name": "血压", "tendency": "", "character": [ "控制不理想" ], "anatomy_list": [] }, { "core_name": "血压", "tendency": "", "character": [ "波动" ], "anatomy_list": [] } ] }, { "id": 1648, "text": "于全麻下行“左侧乳腺癌改良根治术”，免疫组化提示:左侧乳腺浸润性导管癌，er(-),pr(-)her-2（3+），ki676710%。", "event": [ { "core_name": "导管癌", "tendency": "", "character": [ "浸润性" ], "anatomy_list": [ "左侧乳腺" ] } ] }, { "id": 15, "text": "入院前5月,患儿因发热,头痛伴反复呕吐入院治疗,ct提示右侧小脑占位性病变、梗阻性脑积水,住院期间先后行了左侧脑室外引流术（储液囊）、后颅窝肿瘤切除术、腰大池引流术,术后恢复可,顺利出院,出院后定期神经外科门诊随访。", "event": [ { "core_name": "发热", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "", "character": [], "anatomy_list": [ "头" ] }, { "core_name": "呕吐", "tendency": "", "character": [ "反复" ], "anatomy_list": [] }, { "core_name": "病变", "tendency": "", "character": [ "占位性" ], "anatomy_list": [ "右侧小脑" ] }, { "core_name": "积水", "tendency": "", "character": [ "梗阻性" ], "anatomy_list": [ "脑" ] } ] }, { "id": 574, "text": "入院前1+月，患者因右下腹痛就诊于某医院，行急诊剖腹探查术，术后病理切片提示：（右卵巢）卵黄囊瘤，术后予以抗感染等对症处理后好转出院。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [], "anatomy_list": [ "右下腹" ] }, { "core_name": "瘤", "tendency": "", "character": [ "卵黄囊" ], "anatomy_list": [ "右卵巢" ] } ] }, { "id": 956, "text": "入院前半年，患者重体力劳动中出现胸骨后疼痛，呈压榨感，伴大汗淋漓，无放射痛，无黑蒙、晕厥，无呼吸困难，持续约3分3分钟，休息后缓解，患者未予以重视，未就医治疗。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [ "重体力劳动中", "压榨感" ], "anatomy_list": [ "胸骨后" ] }, { "core_name": "大汗淋漓", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "否定", "character": [ "放射性" ], "anatomy_list": [] }, { "core_name": "黑朦", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "晕厥", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "呼吸困难", "tendency": "否定", "character": [ "休息后缓解" ], "anatomy_list": [] } ] }, { "id": 194, "text": "半月前患者再次症状反复，出现痰中带血，再次于当地医院治疗咳嗽、咳痰明显缓解，未见痰中带血，患者仍感活动后气促、喘累，1天前患者就诊于某医院，行胸部ct检查提示右肺门增大，见增多软组织，考虑肿瘤性病变可能大。", "event": [ { "core_name": "咳痰", "tendency": "", "character": [ "反复", "带血" ], "anatomy_list": [] }, { "core_name": "咳嗽", "tendency": "", "character": [ "明显缓解" ], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "明显缓解" ], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "否定", "character": [ "带血" ], "anatomy_list": [] }, { "core_name": "气促", "tendency": "", "character": [ "活动后" ], "anatomy_list": [] }, { "core_name": "喘累", "tendency": "", "character": [ "活动后" ], "anatomy_list": [] }, { "core_name": "增大", "tendency": "", "character": [], "anatomy_list": [ "右肺门" ] }, { "core_name": "软组织增多", "tendency": "", "character": [], "anatomy_list": [ "软组织" ] }, { "core_name": "病变", "tendency": "不确定", "character": [ "肿瘤性" ], "anatomy_list": [] } ] }, { "id": 832, "text": "入院前11月患者复查胸部ct示气管占位并双肺多发结节，于某医院就诊，诊断气道狭窄，行活检后诊断为“气管鳞癌”，于某医院行介入治疗（冷冻冻取、电圈套、激光消融、apc，坏死及新生物清理），2019年1月及4月在某医院分别行气道介入治疗 活检钳清理、冷冻冻取清理新生物。", "event": [ { "core_name": "占位", "tendency": "", "character": [], "anatomy_list": [ "气管" ] }, { "core_name": "结节", "tendency": "", "character": [ "多发" ], "anatomy_list": [ "双肺" ] }, { "core_name": "狭窄", "tendency": "", "character": [], "anatomy_list": [ "气道" ] }, { "core_name": "鳞癌", "tendency": "", "character": [], "anatomy_list": [ "气管" ] } ] }, { "id": 684, "text": "6.右侧肾上腺病灶，考虑肿瘤性病变，腺瘤或其它；右肾小囊肿。", "event": [ { "core_name": "病灶", "tendency": "", "character": [], "anatomy_list": [ "右侧肾上腺" ] }, { "core_name": "病变", "tendency": "不确定", "character": [ "肿瘤性" ], "anatomy_list": [ "右侧肾上腺" ] }, { "core_name": "腺瘤", "tendency": "不确定", "character": [], "anatomy_list": [ "右侧肾上腺" ] }, { "core_name": "囊肿", "tendency": "", "character": [ "小" ], "anatomy_list": [ "右肾" ] } ] }, { "id": 104, "text": "包块 逐渐增大 ， 无局部红、肿、热、痒 ， 无烦躁 ， 无失眠 ， 无声痛 ， 无怕热多汗 ， 无心慌气短 ， 无吞咽困难 ， 无呼吸困难 。", "event": [ { "core_name": "包块", "tendency": "", "character": [ "逐渐增大，无局部红，无局部肿，无局部热，无局部痒" ], "anatomy_list": [] }, { "core_name": "烦躁", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "失眠", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "声痛", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "怕热", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "出汗", "tendency": "否定", "character": [ "增多" ], "anatomy_list": [] }, { "core_name": "心慌", "tendency": "否定", "character": [], "anatomy_list": [ "心" ] }, { "core_name": "气短", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "吞咽困难", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "呼吸困难", "tendency": "否定", "character": [], "anatomy_list": [] } ] }, { "id": 447, "text": "5月前患者无明显诱因出现夜间睡眠时憋醒，伴有多梦、偶有梦魇，醒后偶有嗜睡，自诉平时记忆力欠佳，伴有晨起后咽干、咽痒、咽痛、口苦、口干，偶有咽喉部异物感等不适。", "event": [ { "core_name": "憋醒", "tendency": "", "character": [ "夜间睡眠时" ], "anatomy_list": [] }, { "core_name": "多梦", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "梦魇", "tendency": "", "character": [ "偶有" ], "anatomy_list": [] }, { "core_name": "嗜睡", "tendency": "", "character": [ "醒后偶有" ], "anatomy_list": [] }, { "core_name": "记忆力", "tendency": "", "character": [ "欠佳" ], "anatomy_list": [] }, { "core_name": "咽干", "tendency": "", "character": [ "晨起后" ], "anatomy_list": [ "咽" ] }, { "core_name": "咽痒", "tendency": "", "character": [ "晨起后" ], "anatomy_list": [ "咽" ] }, { "core_name": "疼痛", "tendency": "", "character": [ "晨起后" ], "anatomy_list": [ "咽" ] }, { "core_name": "口苦", "tendency": "", "character": [ "晨起后" ], "anatomy_list": [ "口" ] }, { "core_name": "口干", "tendency": "", "character": [ "晨起后" ], "anatomy_list": [ "口" ] }, { "core_name": "异物感", "tendency": "", "character": [ "偶有" ], "anatomy_list": [ "咽喉部" ] } ] }, { "id": 67, "text": "２.肝癌肿瘤滋养动脉超选择性插管化疗栓塞术。", "event": [ { "core_name": "癌", "tendency": "", "character": [], "anatomy_list": [ "肝" ] } ] }, { "id": 786, "text": "入院前30年，患者受凉后出现频繁咳嗽，为非高调金属声样咳嗽及鸡鸣样咳嗽，伴咳痰，为白色泡沫痰，以晨起明显，与体位改变无明显相关。", "event": [ { "core_name": "咳嗽", "tendency": "", "character": [ "受凉后", "频繁" ], "anatomy_list": [] }, { "core_name": "咳嗽", "tendency": "", "character": [ "非高调金属声样" ], "anatomy_list": [] }, { "core_name": "咳嗽", "tendency": "", "character": [ "鸡鸣样" ], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "白色", "泡沫痰", "以晨起明显", "与体位改变无明显相关" ], "anatomy_list": [] } ] }, { "id": 1611, "text": "3.双肺门肺门及纵隔淋巴结淋巴结钙化。", "event": [ { "core_name": "钙化", "tendency": "", "character": [], "anatomy_list": [ "双肺门淋巴结", "纵隔淋巴结" ] } ] }, { "id": 510, "text": "（食管旁淋巴结）未见癌转移（0/1），(胃周脂肪组织内淋巴结)未见癌转移（0/4），8组组淋巴结未见癌转移（0/1），（右喉返神经旁淋巴结）未见癌转移（0/3），术后诊断：1.食管胸中段腺鳞癌pT3n0M3 iib期；2.双肺结节；3.慢性非萎缩性胃炎；4.右肾囊肿。", "event": [ { "core_name": "癌", "tendency": "否定", "character": [ "转移" ], "anatomy_list": [ "食管旁淋巴结" ] }, { "core_name": "癌", "tendency": "否定", "character": [ "转移" ], "anatomy_list": [ "胃周脂肪组织内淋巴结" ] }, { "core_name": "癌", "tendency": "否定", "character": [ "转移" ], "anatomy_list": [ "8组淋巴结" ] }, { "core_name": "癌", "tendency": "否定", "character": [ "转移" ], "anatomy_list": [ "右喉返神经旁淋巴结" ] }, { "core_name": "腺鳞癌", "tendency": "", "character": [ "pT3n0M3", "iib期" ], "anatomy_list": [ "食管胸中段" ] }, { "core_name": "结节", "tendency": "", "character": [], "anatomy_list": [ "双肺" ] }, { "core_name": "胃炎", "tendency": "", "character": [ "慢性", "非萎缩性" ], "anatomy_list": [ "胃" ] }, { "core_name": "囊肿", "tendency": "", "character": [], "anatomy_list": [ "右肾" ] } ] }, { "id": 523, "text": "入院前3年，患者活动后出现呼吸困难（爬楼梯时），无胸痛，无左肩部放射痛，无咯血，无端坐呼吸及咯粉红泡沫样痰，无咳嗽、咳痰，患者未予重视，未治疗。", "event": [ { "core_name": "呼吸困难", "tendency": "", "character": [ "活动后", "爬楼梯时" ], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "胸" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [ "放射性" ], "anatomy_list": [ "左肩部" ] }, { "core_name": "咯血", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "端坐呼吸", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "否定", "character": [ "粉红泡沫样" ], "anatomy_list": [] }, { "core_name": "咳嗽", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "否定", "character": [], "anatomy_list": [] } ] }, { "id": 1978, "text": "1月前，患者无明显诱因出现痰中带血，量少，后到某医院就诊，给予抗炎等对症支持治疗后未再出现咯血，胸痛、咳嗽、喘累、乏力稍有好转。", "event": [ { "core_name": "咳痰", "tendency": "", "character": [ "带血", "量少" ], "anatomy_list": [] }, { "core_name": "咯血", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "", "character": [ "稍有好转" ], "anatomy_list": [ "胸" ] }, { "core_name": "咳嗽", "tendency": "", "character": [ "稍有好转" ], "anatomy_list": [] }, { "core_name": "喘累", "tendency": "", "character": [ "稍有好转" ], "anatomy_list": [] }, { "core_name": "乏力", "tendency": "", "character": [ "稍有好转" ], "anatomy_list": [] } ] }, { "id": 168, "text": "右肺下叶胸膜旁小结节影，fdg代谢未见异常增高。", "event": [ { "core_name": "结节影", "tendency": "", "character": [ "小" ], "anatomy_list": [ "右肺下叶胸膜旁" ] }, { "core_name": "fdg", "tendency": "否定", "character": [ "代谢异常增高" ], "anatomy_list": [] } ] }, { "id": 1196, "text": "3天前患者因车祸伤在我院骨科住院，住院期间彩超示：左肾下极实质稍低回声，肿瘤性病变待排。", "event": [ { "core_name": "车祸伤", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "回声", "tendency": "", "character": [ "稍低" ], "anatomy_list": [ "左肾下极实质" ] }, { "core_name": "病变", "tendency": "不确定", "character": [ "肿瘤性" ], "anatomy_list": [] } ] }, { "id": 648, "text": "为求进一步诊治，今晨急诊以“低血糖症”收治住院。", "event": [ { "core_name": "低血糖症", "tendency": "", "character": [], "anatomy_list": [] } ] }, { "id": 769, "text": "入院半年前，患者无明显诱因出现头昏、乏力，以站立及活动时明显，平卧及休息可缓解，伴纳差，无畏寒、发热、咳嗽、咳痰、咯血，无腹胀、腹痛、黄疸、恶心、呕吐、呕血、黑便，无血尿、皮肤粘膜瘀斑，无胸痛、心前区压榨感，无晕厥、意识障碍等伴随。", "event": [ { "core_name": "头昏", "tendency": "", "character": [ "活动时明显", "平卧及休息可缓解" ], "anatomy_list": [ "头" ] }, { "core_name": "乏力", "tendency": "", "character": [ "活动时明显", "平卧及休息可缓解" ], "anatomy_list": [] }, { "core_name": "纳差", "tendency": "", "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": "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": "腹胀", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "黄疸", "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": "黑便", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "血尿", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "瘀斑", "tendency": "否定", "character": [], "anatomy_list": [ "皮肤黏膜" ] }, { "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": "晕厥", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "意识障碍", "tendency": "否定", "character": [], "anatomy_list": [] } ] }, { "id": 947, "text": "1天前，患者出现颠顶部阵发性疼痛疼痛不适，为阵发性钝痛，疼痛轻度影响睡眠，持续时间长短不等后缓解，无双目凝视及精神意识障碍，无恶心、呕吐，无视物旋转等，今日为进一步治疗来院，遂以“1.肺部感染；2.肺癌脑转移、骨多处转移”收住我科。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [ "阵发性", "钝痛", "轻度影响睡眠", "持续时间长短不等后缓解" ], "anatomy_list": [ "颠顶部" ] }, { "core_name": "凝视", "tendency": "否定", "character": [], "anatomy_list": [ "双目" ] }, { "core_name": "精神障碍", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "意识障碍", "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": "视物旋转", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "感染", "tendency": "", "character": [], "anatomy_list": [ "肺部" ] }, { "core_name": "癌", "tendency": "", "character": [ "脑转移", "骨多处转移" ], "anatomy_list": [ "肺" ] } ] }, { "id": 1500, "text": "考虑诊断为：“慢性粒单核细胞白血病”，予以调节免疫、输血、补液支持等治疗后好转出院。", "event": [ { "core_name": "白血病", "tendency": "", "character": [ "慢性" ], "anatomy_list": [ "粒单核细胞" ] } ] }, { "id": 1620, "text": "2.双肺散在钙化结节。", "event": [ { "core_name": "结节", "tendency": "", "character": [ "散在", "钙化" ], "anatomy_list": [ "双肺" ] } ] }, { "id": 565, "text": "胸部ct平扫+增强：1.双侧肺门、纵隔多发淋巴结显示，双侧腋窝淋巴结肿大。", "event": [ { "core_name": "肿大", "tendency": "", "character": [], "anatomy_list": [ "双侧腋窝淋巴结" ] } ] }, { "id": 150, "text": "入院前2月，患者在某医院体检，腹部彩超示肝内实质性占位病变，肝囊性占位；肝左叶形态饱满，肝实质回声增粗增强，不均匀，胆囊息肉样病变，脾大。", "event": [ { "core_name": "病变", "tendency": "", "character": [ "占位", "实质性" ], "anatomy_list": [ "肝内" ] }, { "core_name": "占位", "tendency": "", "character": [ "囊性" ], "anatomy_list": [ "肝" ] }, { "core_name": "回声", "tendency": "", "character": [ "增粗", "增强", "不均匀" ], "anatomy_list": [ "肝实质" ] }, { "core_name": "病变", "tendency": "", "character": [ "息肉样" ], "anatomy_list": [ "胆囊" ] }, { "core_name": "脾大", "tendency": "", "character": [], "anatomy_list": [ "脾" ] } ] }, { "id": 291, "text": "现患者为进一步诊治来我院，门诊以“ 右上肺肺团块影待查”收入我院我科。", "event": [ { "core_name": "团块影", "tendency": "不确定", "character": [], "anatomy_list": [ "右上肺" ] } ] }, { "id": 231, "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。", "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": 758, "text": "院外不规律随访，疗效sd。", "event": [ { "core_name": "SD", "tendency": "", "character": [], "anatomy_list": [] } ] }, { "id": 1909, "text": "综上诊断为:右肺腺癌 iv期 骨转移，予以口服吉非替尼治疗4个多月后，患者诉自行ct复查提示：肋骨转移病灶较之前有所缩小，肺部病灶稳定。", "event": [ { "core_name": "腺癌", "tendency": "", "character": [ "iv期" ], "anatomy_list": [ "右肺" ] }, { "core_name": "腺癌", "tendency": "", "character": [ "转移" ], "anatomy_list": [ "骨" ] }, { "core_name": "病灶", "tendency": "", "character": [ "较之前有所缩小", "转移" ], "anatomy_list": [ "肋骨" ] }, { "core_name": "病灶", "tendency": "", "character": [ "稳定" ], "anatomy_list": [ "肺部" ] } ] }, { "id": 1516, "text": "患者肾上腺良性肿瘤、原发性醛固酮增多症、低钾血症10+年，平时反复全身乏力、恶心、纳差等症状，患者因手术风险高未行手术治疗，多次于当地医院就诊予以补钾治疗后好转。", "event": [ { "core_name": "肿瘤", "tendency": "", "character": [ "良性" ], "anatomy_list": [ "肾上腺" ] }, { "core_name": "醛固酮增多症", "tendency": "", "character": [ "原发性" ], "anatomy_list": [] }, { "core_name": "低钾血症", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "乏力", "tendency": "", "character": [ "反复" ], "anatomy_list": [ "全身" ] }, { "core_name": "恶心", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "纳差", "tendency": "", "character": [], "anatomy_list": [] } ] }, { "id": 1053, "text": "4年前患者我院常规体检发现cea达正常值高限，未做特殊处理，无乏力、纳差、腹痛、黑便等不适，无咳嗽、咳痰、胸痛等。", "event": [ { "core_name": "乏力", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "纳差", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "黑便", "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" ] } ] }, { "id": 1695, "text": "无尿急、肉眼血尿。", "event": [ { "core_name": "尿急", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "血尿", "tendency": "否定", "character": [], "anatomy_list": [] } ] }, { "id": 1418, "text": "患者入院前因“咳嗽、咳痰8月，加重伴声嘶、消瘦10余天”于2009年6月住我院呼吸内科就诊，后经检查诊断为“左肺中央型肺癌伴纵膈膈胸膜、骨转移”。", "event": [ { "core_name": "咳嗽", "tendency": "", "character": [ "加重" ], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "加重" ], "anatomy_list": [] }, { "core_name": "声嘶", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "消瘦", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "癌", "tendency": "", "character": [ "中央型" ], "anatomy_list": [ "左肺" ] }, { "core_name": "癌", "tendency": "", "character": [ "转移" ], "anatomy_list": [ "纵膈", "胸膜", "骨" ] } ] }, { "id": 1323, "text": "结合曾患乳癌病史及免疫组化gata-2阳性，考虑乳腺癌转移。", "event": [ { "core_name": "癌", "tendency": "不确定", "character": [ "转移" ], "anatomy_list": [ "乳腺" ] } ] }, { "id": 911, "text": "半月前，患者诉进食油腻食物后出现上腹疼痛，伴恶心，无腹胀、腹泻、发热等不适，服用消炎利胆片后缓解，1周前，患者再次出现右上腹不适，无腹痛、腹胀、腹泻、发热，现患者为求进一步治疗来我院就诊，门诊以“胆囊结石伴急性胆囊炎”收入我科。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [ "进食油腻食物后" ], "anatomy_list": [ "上腹" ] }, { "core_name": "恶心", "tendency": "", "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": "发热", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "不适", "tendency": "", "character": [], "anatomy_list": [ "右上腹" ] }, { "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": "发热", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "结石", "tendency": "", "character": [], "anatomy_list": [ "胆囊" ] }, { "core_name": "胆囊炎", "tendency": "", "character": [ "急性" ], "anatomy_list": [ "胆囊" ] } ] }, { "id": 1177, "text": "行骨髓穿刺提示：慢性髓细胞白血病。", "event": [ { "core_name": "白血病", "tendency": "", "character": [ "慢性" ], "anatomy_list": [ "髓细胞" ] } ] }, { "id": 1240, "text": "入院前3天，患者出现上述症状加重，为求进一步治疗，今日来我科门诊就诊，完善“血常规：红细胞计数 2.91*10^12/L、血红蛋白 98g/L、白细胞计数 13.1*10^12/L、n% 83%；肝功：门冬氨酸氨基转移酶:133U/L、丙氨酸氨基转移酶75U/L、γ谷氨酰基转移酶:570U/L、胆碱脂酶:1731U/L、清蛋白:26.6g/L、球蛋白:49.7g/L、直接胆红素:20umol/L、总胆红素:34.5umol/L；乙肝标志物定量、hcv报告未回；腹部彩超：肝脏弥漫性病变，肝内多发实性占位（考虑肝ca）伴门静脉栓子形成，胆囊壁水肿，脾大（中度），腹腔积液”，门诊以“原发性肝癌？”收入我科住院治疗。", "event": [ { "core_name": "病变", "tendency": "", "character": [ "弥漫性" ], "anatomy_list": [ "肝脏" ] }, { "core_name": "占位", "tendency": "", "character": [ "多发", "实性" ], "anatomy_list": [ "肝内" ] }, { "core_name": "癌", "tendency": "不确定", "character": [], "anatomy_list": [ "肝" ] }, { "core_name": "栓子形成", "tendency": "", "character": [], "anatomy_list": [ "门静脉" ] }, { "core_name": "水肿", "tendency": "", "character": [], "anatomy_list": [ "胆囊壁" ] }, { "core_name": "增大", "tendency": "", "character": [ "中度" ], "anatomy_list": [ "脾" ] }, { "core_name": "积液", "tendency": "", "character": [], "anatomy_list": [ "腹腔" ] }, { "core_name": "癌", "tendency": "不确定", "character": [ "原发性" ], "anatomy_list": [ "肝" ] } ] }, { "id": 616, "text": "患者自发病以来， 精神可 ， 食欲尚可 ， 睡眠可 ， 大便如常 ， 小便如常 ， 体重近1月下降明显 。", "event": [ { "core_name": "精神", "tendency": "", "character": [ "可" ], "anatomy_list": [] }, { "core_name": "食欲", "tendency": "", "character": [ "尚可" ], "anatomy_list": [] }, { "core_name": "睡眠质量", "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": "体重下降", "tendency": "", "character": [ "明显" ], "anatomy_list": [] } ] }, { "id": 524, "text": "病程中，患者反复活动后呼吸困难，活动耐量逐渐下降，伴间断双下肢水肿，均当地诊所予以对症治疗后好转。", "event": [ { "core_name": "呼吸困难", "tendency": "", "character": [ "反复", "活动后" ], "anatomy_list": [] }, { "core_name": "活动耐量", "tendency": "", "character": [ "逐渐下降" ], "anatomy_list": [] }, { "core_name": "水肿", "tendency": "", "character": [ "间断" ], "anatomy_list": [ "双下肢" ] } ] }, { "id": 1888, "text": "入院前3+年，患者出现头昏、头痛，无鼻衄，无耳鸣及听力减退，无视物旋转及视物模糊，无恶心、呕吐，无反酸、嗳气，无腹痛、腹泻，无全身酸痛及骨痛，无畏寒、发热，无潮热、盗汗等，无体重明显下降。", "event": [ { "core_name": "头昏", "tendency": "", "character": [], "anatomy_list": [ "头" ] }, { "core_name": "疼痛", "tendency": "", "character": [], "anatomy_list": [ "头" ] }, { "core_name": "鼻衄", "tendency": "否定", "character": [], "anatomy_list": [ "鼻" ] }, { "core_name": "耳鸣", "tendency": "否定", "character": [ "减退" ], "anatomy_list": [ "耳" ] }, { "core_name": "听力减退", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "视物旋转", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "视物模糊", "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": "返酸", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "嗳气", "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": [ "酸痛" ], "anatomy_list": [ "全身" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "骨" ] }, { "core_name": "畏寒", "tendency": "否定", "character": [], "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": "体重减轻", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [] } ] }, { "id": 1052, "text": "期间包块一直存在，大小如前，有触痛，不伴纳差、腹痛、体重下降，不伴咳嗽、咳痰、胸痛等。", "event": [ { "core_name": "包块", "tendency": "", "character": [ "一直存在", "有触痛", "大小如前" ], "anatomy_list": [] }, { "core_name": "纳差", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "体重下降", "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" ] } ] }, { "id": 1838, "text": "继之出现双侧掌指、近端指间关节关节肿胀，伴疼痛，肿胀可于数小时内缓解，诉夜间双肩、双肘、双膝等全身多处关节及腰背部疼痛明显，无明显晨僵，否认光过敏、皮疹、反复口腔溃疡、双手遇冷后变白变紫变红，为进一步诊治于我院我科住院治疗，予以甲强龙40mg qd静滴（2017.01.06-2017.01.20），羟氯喹 200mg bid（2017.01.06-2017.01.28）、帕夫林0.6g qd控制狼疮（2017.01.22-2017.01.28），服用碳酸钙、骨化三醇抗骨质疏松及护胃治疗，熊去氧胆酸250mg tid治疗原发性胆汁性肝硬化，及输白蛋白、血浆等对症支持治疗，疼痛症状明显好转后出院。", "event": [ { "core_name": "肿胀", "tendency": "", "character": [], "anatomy_list": [ "双侧掌关节", "指关节", "近端指间关节关节" ] }, { "core_name": "疼痛", "tendency": "", "character": [], "anatomy_list": [ "双侧掌关节", "指关节", "近端指间关节关节" ] }, { "core_name": "肿胀", "tendency": "", "character": [ "可于数小时内缓解" ], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "", "character": [ "夜间", "明显" ], "anatomy_list": [ "双肩、双肘、双膝等全身多处关节" ] }, { "core_name": "疼痛", "tendency": "", "character": [ "明显" ], "anatomy_list": [ "腰背部" ] }, { "core_name": "晨僵", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [] }, { "core_name": "过敏", "tendency": "否定", "character": [ "光" ], "anatomy_list": [] }, { "core_name": "皮疹", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "溃疡", "tendency": "否定", "character": [ "反复" ], "anatomy_list": [ "口腔" ] }, { "core_name": "变白", "tendency": "否定", "character": [ "遇冷后" ], "anatomy_list": [ "双手" ] }, { "core_name": "变紫", "tendency": "否定", "character": [ "遇冷后" ], "anatomy_list": [ "双手" ] }, { "core_name": "变红", "tendency": "否定", "character": [ "遇冷后" ], "anatomy_list": [ "双手" ] }, { "core_name": "狼疮", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "硬化", "tendency": "", "character": [ "原发性", "胆汁性" ], "anatomy_list": [ "肝" ] }, { "core_name": "疼痛", "tendency": "", "character": [ "明显", "好转" ], "anatomy_list": [] } ] }, { "id": 1733, "text": "2019年5月复查骨髓形态学示“与2018.11.5比，粒红两系无明显变化，巨核增多”。", "event": [ { "core_name": "增多", "tendency": "", "character": [ "增多" ], "anatomy_list": [ "巨核" ] } ] }, { "id": 1037, "text": "术后病理：（部分直肠）组织中见浸润，结合病史，免疫表型符合卵巢高级别浆液性癌侵犯直肠。", "event": [ { "core_name": "浸润", "tendency": "", "character": [ "组织" ], "anatomy_list": [ "直肠" ] }, { "core_name": "癌", "tendency": "", "character": [ "高级别", "浆液性", "侵犯直肠" ], "anatomy_list": [ "卵巢" ] } ] }, { "id": 1265, "text": "因患者住院期间有心房纤颤病史，故未行纤支镜检查，予以强心、利尿纠正心衰，抗凝、对症等治疗后病情好转后出院。", "event": [ { "core_name": "心房纤颤", "tendency": "", "character": [], "anatomy_list": [ "心房" ] }, { "core_name": "心力衰竭", "tendency": "", "character": [], "anatomy_list": [ "心" ] } ] }, { "id": 106, "text": "今日为进一步治疗入我院，门诊以“甲状腺肿物”收入我科。", "event": [ { "core_name": "肿物", "tendency": "", "character": [], "anatomy_list": [ "甲状腺" ] } ] }, { "id": 1137, "text": "患者本次发病以来，食欲下降，神志清醒，精神欠佳，睡眠尚可，大便正常，，体重减少3kg。", "event": [ { "core_name": "食欲", "tendency": "", "character": [ "下降" ], "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": [ "尚可" ], "anatomy_list": [] }, { "core_name": "大便", "tendency": "", "character": [ "正常" ], "anatomy_list": [] }, { "core_name": "体重", "tendency": "", "character": [ "减轻" ], "anatomy_list": [] } ] }, { "id": 728, "text": "患者为进一步复查遂入我院，门诊以“直肠癌术后化疗后”收治入我科。", "event": [ { "core_name": "癌", "tendency": "", "character": [ "术后化疗后" ], "anatomy_list": [ "直肠" ] } ] }, { "id": 382, "text": "因无手术指征，遂给予 ‘紫杉醇脂质体240mg+卡铂400mg+贝伐珠单抗400mg’方案姑息性化疗 8周期，化疗期间及化疗后无明显胃肠道反应、神经毒性、骨髓抑制等毒副症状。", "event": [ { "core_name": "胃肠道反应", "tendency": "否定", "character": [ "化疗期间及化疗后", "明显" ], "anatomy_list": [ "胃肠道" ] }, { "core_name": "毒副症状", "tendency": "否定", "character": [ "化疗期间及化疗后", "明显", "神经毒性" ], "anatomy_list": [] }, { "core_name": "骨髓抑制", "tendency": "否定", "character": [ "化疗期间及化疗后", "明显" ], "anatomy_list": [ "骨髓" ] } ] }, { "id": 1168, "text": "患者５天前无明显诱因下出现持续性右上腹痛，程度不剧烈，可忍受，伴恶心、呕吐，呕吐物为胃内容物或胆汁，不伴肩、背部放射痛、发热、畏寒、心慌、胸闷、眼黄、身黄等。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [ "持续性", "不剧烈", "可忍受" ], "anatomy_list": [ "右上腹" ] }, { "core_name": "恶心", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "呕吐", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "呕吐", "tendency": "", "character": [ "呕吐物为胃内容物或胆汁" ], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "否定", "character": [ "放射性" ], "anatomy_list": [ "肩部", "背部" ] }, { "core_name": "发热", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "畏寒", "tendency": "否定", "character": [], "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": "眼黄", "tendency": "否定", "character": [], "anatomy_list": [ "眼" ] }, { "core_name": "黄染", "tendency": "否定", "character": [], "anatomy_list": [ "身" ] } ] }, { "id": 1472, "text": "近期患儿精神、食欲可，睡眠好，大小便未见异常。", "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": [ "好" ], "anatomy_list": [] }, { "core_name": "小便", "tendency": "", "character": [ "未见异常" ], "anatomy_list": [] }, { "core_name": "大便", "tendency": "", "character": [ "未见异常" ], "anatomy_list": [] } ] }, { "id": 1820, "text": "就诊于某医院阴道彩超示：子宫大小月8.6*6.2*5.6cm，肌层回声欠均质，前部较后壁增厚，宫内膜厚约0.6cm，子宫后方见一无回声，大小约6.1*4.9cm,提示：1.子宫后方囊性占位占位性病变 2.子宫稍增大，肌层回声欠均质：腺肌症？阑尾彩超、血常规未见明显异常，血hcg＜2.0m/ml,给予止痛治疗未见明显效果。", "event": [ { "core_name": "回声", "tendency": "", "character": [ "欠均质" ], "anatomy_list": [ "子宫肌层" ] }, { "core_name": "增厚", "tendency": "", "character": [ "前部较后壁" ], "anatomy_list": [] }, { "core_name": "病变", "tendency": "", "character": [ "囊性", "占位性" ], "anatomy_list": [ "子宫后方" ] }, { "core_name": "增大", "tendency": "", "character": [ "稍" ], "anatomy_list": [ "子宫" ] }, { "core_name": "回声", "tendency": "", "character": [ "欠均质" ], "anatomy_list": [ "子宫肌层" ] }, { "core_name": "腺肌症", "tendency": "不确定", "character": [], "anatomy_list": [ "腺肌" ] } ] }, { "id": 1982, "text": "入院前4年，患者无明显原因出现言语不清，无头痛、恶心、呕吐，无意识障碍、肢体活动障碍、肢体抽搐、大小便失禁，患者家属将患者送至当地医院就诊，予以他汀、抗血小板聚集及对症治疗后言语不清好转，但未恢复至发病前。", "event": [ { "core_name": "言语不清", "tendency": "", "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": "意识障碍", "tendency": "否定", "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": [] }, { "core_name": "言语不清", "tendency": "", "character": [ "好转" ], "anatomy_list": [] } ] }, { "id": 1508, "text": "；精神食欲一般，睡眠好；大小便正常。", "event": [ { "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": "大便", "tendency": "", "character": [ "正常" ], "anatomy_list": [] }, { "core_name": "小便", "tendency": "", "character": [ "正常" ], "anatomy_list": [] } ] }, { "id": 1821, "text": "遂急诊“卵巢囊肿蒂扭转？”收入我科。", "event": [ { "core_name": "囊肿蒂扭转", "tendency": "不确定", "character": [], "anatomy_list": [ "卵巢" ] } ] }, { "id": 1357, "text": "原发性肝癌，患者于2020-02-23在某医院在全麻下行腹腔镜探查+开腹左半肝切除术+胆囊切除术，术后病理组织检查报告示：“肝脏”中分化细胞肝癌，包膜见癌组织侵犯；切缘未见癌组织累及。", "event": [ { "core_name": "癌", "tendency": "", "character": [ "原发性" ], "anatomy_list": [ "肝" ] }, { "core_name": "癌", "tendency": "", "character": [ "中分化细胞", "包膜见癌组织侵犯", "切缘未见癌组织累及" ], "anatomy_list": [ "肝脏", "包膜", "切缘" ] } ] }, { "id": 79, "text": "无发热、寒战，无双乳胀胀痛，无乳头溢液，无皮肤红肿，无皮肤破溃，无气促、呼吸困难等不适。", "event": [ { "core_name": "发热", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "寒颤", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "否定", "character": [ "胀痛" ], "anatomy_list": [ "双乳" ] }, { "core_name": "溢液", "tendency": "否定", "character": [], "anatomy_list": [ "乳头" ] }, { "core_name": "红肿", "tendency": "否定", "character": [], "anatomy_list": [ "皮肤" ] }, { "core_name": "破溃", "tendency": "否定", "character": [], "anatomy_list": [ "皮肤" ] }, { "core_name": "气促", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "呼吸困难", "tendency": "否定", "character": [], "anatomy_list": [] } ] }, { "id": 1449, "text": "32月前（2014年5月）患者复查ct见肝内原结节处病灶，复查afp持续升高（最高达113.7ug/L），再次到重医附二院就诊，腹部mri示：肝癌介入术后改变，肝右前叶强化小结节小结节影，与2014年6月9日病灶稍增大；肝门区淋巴结淋巴结肿大。", "event": [ { "core_name": "病灶", "tendency": "", "character": [ "原结节处" ], "anatomy_list": [ "肝内" ] }, { "core_name": "改变", "tendency": "", "character": [ "肝癌介入术后" ], "anatomy_list": [ "肝" ] }, { "core_name": "结节影", "tendency": "", "character": [ "强化", "小" ], "anatomy_list": [ "肝右前叶" ] }, { "core_name": "病灶", "tendency": "", "character": [ "稍增大" ], "anatomy_list": [] }, { "core_name": "肿大", "tendency": "", "character": [], "anatomy_list": [ "肝门区淋巴结" ] } ] }, { "id": 374, "text": "患者自起病以来，精神略差，胃纳略差，大便如常，小便如常，体重未见明显下降。", "event": [ { "core_name": "精神", "tendency": "", "character": [ "略差" ], "anatomy_list": [] }, { "core_name": "胃纳", "tendency": "", "character": [ "略差" ], "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": 1383, "text": "无畏寒、发热，无咳嗽、咳痰、无心慌、胸闷，无头晕、头痛，无潮热、盗汗等不适。", "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": "否定", "character": [], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "否定", "character": [], "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": "头晕", "tendency": "否定", "character": [], "anatomy_list": [ "头" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "头" ] }, { "core_name": "潮热", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "盗汗", "tendency": "否定", "character": [], "anatomy_list": [] } ] }, { "id": 1928, "text": "为进一步诊治，门诊以“食管癌术后”收入我科。", "event": [ { "core_name": "癌", "tendency": "", "character": [ "术后" ], "anatomy_list": [ "食管" ] } ] }, { "id": 1979, "text": "出院后一直于当地医院输液治疗，后患者感上述症状无明显改善，7天前再次到某医院就诊，行胸部ct检查提示“左肺结节影”，并出现多次咯血，血为暗红色，每次量约2ml，多于晨起发生，予以抗炎等治疗后无明显改善，现到我院就诊。", "event": [ { "core_name": "结节影", "tendency": "", "character": [], "anatomy_list": [ "左肺" ] }, { "core_name": "咯血", "tendency": "", "character": [ "多次", "暗红色", "多于晨起发生" ], "anatomy_list": [] } ] }, { "id": 371, "text": "在我院入院后予以止咳、化痰、解痉、平喘、抗感染等对症支持治疗，咳嗽、咳痰好转出院。", "event": [ { "core_name": "咳嗽", "tendency": "", "character": [ "好转" ], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "好转" ], "anatomy_list": [] } ] }, { "id": 711, "text": "于2018-11开始出现左下肢下肢骨骨痛，2019-1-4起开始于某医院随访及治疗，ca-1252951u/ml、he4256.1pmol/l，全腹ct提示：考虑右肺下叶结节影、腹腔及腹腔后多发淋巴结转移、左侧骶翼骨转移，2019-1-9予以“奥沙利铂+多西他赛”静脉化疗1次，并间断予以“唑来磷酸”改善骨质破坏治疗，治疗期间ca125持续上升，患者拒绝化疗，2019-5-15ca-1253238u/ml，全腹ct提示：考虑双侧骶翼骨转移，予以“多西他赛+奈达铂”静脉化疗1次，2019-7-11ca-1251733u/ml，2019-8-14ca-1254242u/ml，8-15予以“多西他赛+奈达铂”静脉化疗1次，2019-9-5ca-1252953u/ml，予以“多西他赛+奈达铂”静脉化疗1次，2019-9-9ca-1251755u/ml，2019-10-11ca-1251750u/ml，2019-12-10ca-1254193u/ml，予以“吉西他滨+奈达铂”静脉化疗1次，2020-1-3ca-1252228u/ml，予以“吉西他滨+奈达铂”静脉化疗1次，后失访3月。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [], "anatomy_list": [ "左下肢", "肢骨" ] }, { "core_name": "结节影", "tendency": "不确定", "character": [], "anatomy_list": [ "右肺下叶" ] }, { "core_name": "转移", "tendency": "不确定", "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": [ "左侧骶翼骨" ] }, { "core_name": "骨质破坏", "tendency": "", "character": [ "改善" ], "anatomy_list": [ "左侧骶翼骨" ] }, { "core_name": "转移", "tendency": "不确定", "character": [], "anatomy_list": [ "双侧骶翼骨" ] } ] }, { "id": 74, "text": "2+月前再次出现右侧髋关节关节阵发性疼痛，伴活动障碍，不伴肿胀，无皮肤发红，不伴皮疹、光过敏、面部蝶形红斑，遂于2017.05.11～2017.05.20我院住院治疗，住院期间行相关检查，结合外院淋巴细胞b27阳性，诊断为幼年特发性关节炎（与附着点炎症相关的关节炎）。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [ "阵发性" ], "anatomy_list": [ "右侧髋关节" ] }, { "core_name": "活动障碍", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "肿胀", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "发红", "tendency": "否定", "character": [], "anatomy_list": [ "皮肤" ] }, { "core_name": "皮疹", "tendency": "否定", "character": [], "anatomy_list": [ "皮肤" ] }, { "core_name": "过敏", "tendency": "否定", "character": [ "光" ], "anatomy_list": [] }, { "core_name": "红斑", "tendency": "", "character": [ "蝶形" ], "anatomy_list": [ "面部" ] }, { "core_name": "关节炎", "tendency": "", "character": [ "幼年", "特发性", "与附着点炎症相关的关节炎" ], "anatomy_list": [ "关节" ] } ] }, { "id": 962, "text": "2015-09-21于某医院行培美曲塞900mg（具体治疗不详）维持治疗，自诉有头晕、食欲下降，无骨髓抑制，予以对症处理后好转出院。", "event": [ { "core_name": "头晕", "tendency": "", "character": [], "anatomy_list": [ "头" ] }, { "core_name": "食欲", "tendency": "", "character": [ "下降" ], "anatomy_list": [] }, { "core_name": "骨髓抑制", "tendency": "否定", "character": [], "anatomy_list": [ "骨髓" ] } ] }, { "id": 1127, "text": "2015年04月患者出现肿瘤标志物进行性升高，遂于我院就诊，并于2015-4-21行一周期紫杉醇脂质体210mg ivgtt d1+奈达铂50mg d1、40mg2方案化疗，化疗后出现口腔及咽喉部溃疡及iv度骨髓抑制，予以对症处理后好转出院。", "event": [ { "core_name": "肿瘤标志物", "tendency": "", "character": [ "进行性升高" ], "anatomy_list": [] }, { "core_name": "溃疡", "tendency": "", "character": [], "anatomy_list": [ "口腔", "咽喉部" ] }, { "core_name": "骨髓抑制", "tendency": "", "character": [ "iv度" ], "anatomy_list": [ "骨髓" ] } ] }, { "id": 293, "text": "患者10余年前无明显诱因出现尿频，白天约10-30分/次，尿急，夜尿次数增多，7-8次/夜，此后上述症状持续不缓解，无尿量、尿液颜色异常，无尿痛、排尿困难、尿不尽，无泡沫尿、肉眼血尿，无腰痛不适，未见皮疹、口腔溃疡、光敏、脱发及关节痛。患者未予以重视，未行任何治疗。", "event": [ { "core_name": "尿频", "tendency": "", "character": [ "白天约10-30分/次" ], "anatomy_list": [] }, { "core_name": "尿急", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "夜尿次数增多", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "尿量异常", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "尿液颜色异常", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "尿痛", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "排尿困难", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "尿不尽", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "泡沫尿", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "血尿", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "腰" ] }, { "core_name": "皮疹", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "溃疡", "tendency": "否定", "character": [], "anatomy_list": [ "口腔" ] }, { "core_name": "光敏", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "脱发", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "关节" ] } ] }, { "id": 1436, "text": "入院2月前，患者因“右侧肩背部疼痛1周”于我院住院治疗，完善相关检查，肺癌肿瘤标志物：癌胚抗原(cea)110.00ng/ml↑，细胞角蛋白19片段(cyfra21-1)8.78ng/ml↑，神经元特异性烯醇化酶(nse)27.16ng/ml↑。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [], "anatomy_list": [ "右侧肩", "右侧背部" ] }, { "core_name": "癌", "tendency": "", "character": [], "anatomy_list": [ "肺" ] } ] }, { "id": 1846, "text": "右侧输尿管及右肾盂积水。", "event": [ { "core_name": "积水", "tendency": "", "character": [], "anatomy_list": [ "右侧输尿管", "右肾盂" ] } ] }, { "id": 1754, "text": "10余天前，患者无明显诱因出现右上腹疼痛，为持续性隐痛，程度尚可忍受，无明显加重及缓解因素，与体位及进食无明显关系，无明显放射性疼痛，伴活动后气促，伴纳差，伴巩膜轻度黄染，无恶心、呕吐、呕血、黑便，无畏寒、发热、寒战，无白陶土样大便，无全身皮肤瘙痒。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [], "anatomy_list": [ "右上腹" ] }, { "core_name": "疼痛", "tendency": "", "character": [ "持续性隐痛", "程度尚可忍受", "无明显加重及缓解因素", "与体位及进食无明显关系" ], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "否定", "character": [ "明显放射性" ], "anatomy_list": [] }, { "core_name": "气促", "tendency": "", "character": [ "活动后" ], "anatomy_list": [] }, { "core_name": "纳差", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "黄染", "tendency": "", "character": [ "轻度" ], "anatomy_list": [ "巩膜" ] }, { "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": "畏寒", "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": "大便", "tendency": "否定", "character": [ "白陶土样" ], "anatomy_list": [] }, { "core_name": "瘙痒", "tendency": "否定", "character": [], "anatomy_list": [ "全身皮肤" ] } ] }, { "id": 1560, "text": "放疗结束后患者出现咳嗽，阵时咳痰，痰液为白色泡沫痰，感进食梗阻较前稍有缓解，无畏寒、发热，无饮水呛咳，无声嘶等不适，为进一步治疗，故来我院，以“左下肺鳞癌伴肺门、纵膈、锁骨上淋巴结转移、胸膜转移（ct3n3Mm1a iva期）、食管癌放疗后”收入我科。", "event": [ { "core_name": "咳嗽", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "阵时", "白色", "泡沫痰" ], "anatomy_list": [] }, { "core_name": "梗阻", "tendency": "", "character": [ "进食", "稍有缓解" ], "anatomy_list": [] }, { "core_name": "畏寒", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "发热", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "呛咳", "tendency": "否定", "character": [ "饮水" ], "anatomy_list": [] }, { "core_name": "声嘶", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "鳞癌", "tendency": "", "character": [ "转移", "ct3n3Mm1a iva期" ], "anatomy_list": [ "左下肺" ] }, { "core_name": "癌", "tendency": "", "character": [ "转移", "ct3n3Mm1a iva期" ], "anatomy_list": [ "肺门淋巴结 " ] }, { "core_name": "癌", "tendency": "", "character": [ "转移", "ct3n3Mm1a iva期" ], "anatomy_list": [ "纵隔淋巴结" ] }, { "core_name": "癌", "tendency": "", "character": [ "转移", "ct3n3Mm1a iva期" ], "anatomy_list": [ "锁骨上淋巴结" ] }, { "core_name": "癌", "tendency": "", "character": [ "转移", "ct3n3Mm1a iva期" ], "anatomy_list": [ "胸膜" ] }, { "core_name": "癌", "tendency": "", "character": [ "放疗后" ], "anatomy_list": [ "食管" ] } ] }, { "id": 1974, "text": "患者半月前无明显诱因出现无痛性肉眼血尿，呈全程血尿，未见血凝块，无畏寒、发热，无恶心、呕吐，无腰腹部疼痛，无尿频、尿痛等不适，就诊于某医院，行彩超提示：前列腺增生，双侧睾丸鞘膜积液（患者自诉，未见报告）。", "event": [ { "core_name": "血尿", "tendency": "", "character": [ "无痛性" ], "anatomy_list": [] }, { "core_name": "血尿", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "血凝块", "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": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "腰部", "腹部" ] }, { "core_name": "尿频", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "尿痛", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "增生", "tendency": "", "character": [], "anatomy_list": [ "前列腺" ] }, { "core_name": "积液", "tendency": "", "character": [], "anatomy_list": [ "双侧睾丸鞘膜" ] } ] }, { "id": 161, "text": "患者患病以来精神一般，食欲可，睡眠可，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": [ "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": 1813, "text": "术后患者行基因检测提示egfr19号外显子缺失。", "event": [ { "core_name": "egfr19号外显子缺失", "tendency": "", "character": [], "anatomy_list": [] } ] }, { "id": 827, "text": "3天前至我院就诊，查妇科彩超提示：右侧附件区见两枚囊性回声，较大者大小约22mm×19mm，左侧附件区见一大小约63mm×27mm囊性回声，考虑巧囊，要求手术。", "event": [ { "core_name": "回声", "tendency": "", "character": [ "两枚", "囊性" ], "anatomy_list": [ "右侧附件" ] }, { "core_name": "回声", "tendency": "", "character": [ "囊性" ], "anatomy_list": [ "左侧附件" ] }, { "core_name": "巧克力囊肿", "tendency": "不确定", "character": [], "anatomy_list": [] } ] }, { "id": 1795, "text": "入院前1年，患者因双肩部及双上臂疼痛，ect:右侧肱骨头异常放射性浓聚结合，融合图像考虑：转移性骨肿瘤。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [], "anatomy_list": [ "双肩部", "双上臂" ] }, { "core_name": "浓聚结合", "tendency": "", "character": [ "异常放射性" ], "anatomy_list": [ "右侧肱骨头" ] }, { "core_name": "肿瘤", "tendency": "", "character": [ "转移性" ], "anatomy_list": [ "右侧肱骨头" ] } ] }, { "id": 1865, "text": "患者4+月前因“大便次数增多伴便血2月”到我院就诊，我院行肠镜及病检123456提示：直肠腺癌(距肛门8-14cm)，大肠多发息肉。", "event": [ { "core_name": "大便", "tendency": "", "character": [ "次数增多" ], "anatomy_list": [] }, { "core_name": "便血", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "腺癌", "tendency": "", "character": [], "anatomy_list": [ "直肠" ] }, { "core_name": "息肉", "tendency": "", "character": [ "多发" ], "anatomy_list": [ "大肠" ] } ] }, { "id": 1056, "text": "患者于3年前无明显诱因出现排大便困难，排大便1次/3天,大便外观正常,成形便，无粘液脓血，无血便。", "event": [ { "core_name": "排便困难", "tendency": "", "character": [ "1次/3天" ], "anatomy_list": [] }, { "core_name": "大便", "tendency": "", "character": [ "外观正常", "成形" ], "anatomy_list": [] }, { "core_name": "大便", "tendency": "否定", "character": [ "脓血", "粘液" ], "anatomy_list": [] }, { "core_name": "血便", "tendency": "否定", "character": [], "anatomy_list": [] } ] }, { "id": 110, "text": "无身黄、眼黄，无呕血及黑便；体重未见明显消瘦。", "event": [ { "core_name": "黄染", "tendency": "否定", "character": [], "anatomy_list": [ "身" ] }, { "core_name": "黄染", "tendency": "否定", "character": [], "anatomy_list": [ "眼" ] }, { "core_name": "呕血", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "黑便", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "消瘦", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [] } ] }, { "id": 144, "text": "入院前1+年，患者因“1.右肾萎缩；2.左肾重度积水；3.双肾结石；4.左侧输尿管支架置入术后”于我科行“经输尿管镜左侧输尿管支架取出术+左侧输尿管镜检+经输尿管镜钬激光碎石术+左侧输尿管支架植入术”，术后患者带管回家，病程中患者无尿频、尿急、尿痛、血尿，无反酸、嗳气，无恶心、呕吐，无畏寒、发热，无明显腹胀、腹泻、转移性疼痛。", "event": [ { "core_name": "萎缩", "tendency": "", "character": [], "anatomy_list": [ "右肾" ] }, { "core_name": "积水", "tendency": "", "character": [ "重度" ], "anatomy_list": [ "左肾" ] }, { "core_name": "结石", "tendency": "", "character": [], "anatomy_list": [ "双肾" ] }, { "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": "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": "畏寒", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "发热", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "腹胀", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [ "腹" ] }, { "core_name": "腹泻", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [ "腹" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [ "转移性" ], "anatomy_list": [] } ] }, { "id": 1660, "text": "2017-02-08予以予以吡柔比星 70mg ivgtt qd+维a酸 10mg po tid+阿糖胞苷75mg q12h 微量泵入，辅以碱化尿液、水化、增强免疫力等对症治疗，阿糖胞苷50mg+地塞米松磷酸钠5mg+甲氨蝶呤15mg鞘内注射第3次化疗，化疗期间患者出现血象下降、感染，予以输入血小板、升血、抗感染等治疗好转出院。", "event": [ { "core_name": "感染", "tendency": "", "character": [ "血象" ], "anatomy_list": [] }, { "core_name": "血象", "tendency": "", "character": [ "下降" ], "anatomy_list": [] } ] }, { "id": 44, "text": "3月前患者于我院复查彩超提示“左附件区大小约70×48×38mm的异常回声,考虑畸胎瘤可能”。", "event": [ { "core_name": "异常回声", "tendency": "", "character": [], "anatomy_list": [ "左附件" ] }, { "core_name": "畸胎瘤", "tendency": "不确定", "character": [], "anatomy_list": [] } ] }, { "id": 213, "text": "随后咳嗽咳痰症状逐渐加重，为求进一步诊治，于某医院就诊，完善胸部增强ct检查（2020-03-09）：双肺肺气肿，左肺上叶支气管腔内稍低密度影，肿瘤性病变不完全除外，建议结合纤支镜检查。", "event": [ { "core_name": "咳嗽", "tendency": "", "character": [ "逐渐加重" ], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "逐渐加重" ], "anatomy_list": [] }, { "core_name": "肺气肿", "tendency": "", "character": [], "anatomy_list": [ "双肺" ] }, { "core_name": "密度影", "tendency": "", "character": [ "稍低" ], "anatomy_list": [ "左肺上叶支气管腔内" ] }, { "core_name": "病变", "tendency": "不确定", "character": [ "肿瘤性" ], "anatomy_list": [] } ] }, { "id": 103, "text": "患者于5年前，无意中发现左侧颈部包块，最初发现时包块约花生米大小， 无压痛 ， 无吞咽不适 ，未作特殊处理。", "event": [ { "core_name": "包块", "tendency": "", "character": [], "anatomy_list": [ "左侧颈部" ] }, { "core_name": "包块", "tendency": "", "character": [ "花生米大小" ], "anatomy_list": [] }, { "core_name": "压痛", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "吞咽不适", "tendency": "否定", "character": [], "anatomy_list": [] } ] }, { "id": 1426, "text": "患者于3天前无明显诱因感双下肢乏力、纳差，无咳嗽咳痰，无畏寒发热，无头痛头昏，无恶心呕吐，无反酸、烧心，无腹痛、腹泻、黑便，精神萎，时有谵语，期间未行相应治疗，以“乏力待查”收入院。", "event": [ { "core_name": "乏力", "tendency": "", "character": [], "anatomy_list": [ "双下肢" ] }, { "core_name": "纳差", "tendency": "", "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": "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": "反酸", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "烧心", "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": "黑便", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "精神", "tendency": "否定", "character": [ "萎" ], "anatomy_list": [] }, { "core_name": "谵语", "tendency": "", "character": [ "时有" ], "anatomy_list": [] }, { "core_name": "乏力", "tendency": "不确定", "character": [], "anatomy_list": [] } ] }, { "id": 1260, "text": "左肺下叶少许炎症，左肺下叶外侧基底段小结节。随访。", "event": [ { "core_name": "炎症", "tendency": "", "character": [ "少许" ], "anatomy_list": [ "左肺下叶" ] }, { "core_name": "结节", "tendency": "", "character": [ "小" ], "anatomy_list": [ "左肺下叶外侧基底段" ] } ] }, { "id": 580, "text": "入院前4天，患者为求进一步治疗，遂前往我院就诊，门诊行乳腺彩超示：左侧乳腺3点钟方向占位，超声bi-rads分类：3类，乳腺纤维腺瘤可能，建议6月后再次超声检查。", "event": [ { "core_name": "占位", "tendency": "", "character": [ "超声bi-rads分类：3类" ], "anatomy_list": [ "左侧乳腺3点钟方向" ] }, { "core_name": "腺瘤", "tendency": "不确定", "character": [ "纤维" ], "anatomy_list": [ "乳腺" ] } ] }, { "id": 1476, "text": "患者入院前1天无明显诱因出现视物双影，伴轻度倾斜。", "event": [ { "core_name": "视物双影", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "视物倾斜", "tendency": "", "character": [ "轻度" ], "anatomy_list": [] } ] }, { "id": 1672, "text": "3天前，患者因再次受凉后感咳嗽、咳痰加重，痰为白色粘稠痰、量多，并出现活动后呼吸困难，休息及自服“铝碳酸镁片”后稍缓解，现患者仍存在咳嗽、咳痰，痰为白色粘稠痰，量多，不易咳出，轻微活动后即感呼吸困难，为进一步诊治，遂至我院，我科以“肺部感染、食道ca术后”收入院。", "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", "粘稠" ], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "增多" ], "anatomy_list": [] }, { "core_name": "呼吸困难", "tendency": "", "character": [ "活动后" ], "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", "粘稠" ], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "增多", "不易咳出" ], "anatomy_list": [] }, { "core_name": "呼吸困难", "tendency": "", "character": [ "轻微活动后" ], "anatomy_list": [] }, { "core_name": "感染", "tendency": "", "character": [], "anatomy_list": [ "肺部" ] }, { "core_name": "癌", "tendency": "", "character": [ "术后" ], "anatomy_list": [ "食道" ] } ] }, { "id": 28, "text": "入院前15月余因“唾液中带血”于我院耳鼻喉科就诊,查肾功示：尿素50.96mmol/L↑,肌酐1654.9umol/L↑,尿酸472.1umol/L↑,行彩超示：双肾减小,诊断为“尿毒症”,后转入我科,诊断为“慢性肾功不全 尿毒症期 高血压肾病 肾性贫血”,行左上肢动静脉造瘘术,并予以透析治疗。", "event": [ { "core_name": "唾液", "tendency": "", "character": [ "带血" ], "anatomy_list": [] }, { "core_name": "肾减小", "tendency": "", "character": [ "减小" ], "anatomy_list": [ "双肾" ] }, { "core_name": "尿毒症", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "肾功能不全", "tendency": "", "character": [ "慢性" ], "anatomy_list": [ "肾" ] }, { "core_name": "高血压肾病", "tendency": "", "character": [ "高血压" ], "anatomy_list": [ "肾" ] }, { "core_name": "贫血", "tendency": "", "character": [ "肾性" ], "anatomy_list": [ "肾" ] } ] }, { "id": 1001, "text": "4年余前,患者于某医院体检,行b超检查发现肝右前叶异常回声结节,脾大。", "event": [ { "core_name": "结节", "tendency": "", "character": [ "异常回声" ], "anatomy_list": [ "肝右前叶" ] }, { "core_name": "脾大", "tendency": "", "character": [ "大" ], "anatomy_list": [ "脾" ] } ] }, { "id": 1249, "text": "患者自发病以来， 精神差 ， 食欲差 ， 睡眠差 ， 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": [ "差" ], "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": 279, "text": "期间自诉口服中药治疗，未特殊诊治，10+天前，患者因感冒后感咳嗽、咳痰症状加重，伴左侧胸背部胸背部疼痛，与体位、呼吸无相关性，偶有痰中带血丝，无鼻塞、流涕、头昏、头痛，无心悸、胸闷、气促，无腹痛、腹泻，就诊于某医院复查胸部ct（2018年12月29日）：1.左肺上叶舌段示软组织块块影，考虑肺ca可能，建议进一步行增强检查。", "event": [ { "core_name": "感冒", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "咳嗽", "tendency": "", "character": [ "感冒后", "加重" ], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "感冒后", "加重" ], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "", "character": [ "与体位、呼吸无相关性" ], "anatomy_list": [ "左侧胸背部" ] }, { "core_name": "咳痰", "tendency": "", "character": [ "偶有", "痰中带血" ], "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": "头昏", "tendency": "否定", "character": [], "anatomy_list": [ "头" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "头" ] }, { "core_name": "心悸", "tendency": "否定", "character": [], "anatomy_list": [ "心" ] }, { "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": "块影", "tendency": "", "character": [], "anatomy_list": [ "左肺上叶舌段", "软组织" ] }, { "core_name": "癌", "tendency": "不确定", "character": [], "anatomy_list": [ "肺" ] } ] }, { "id": 926, "text": "患者自发病以来， 精神可 ， 食欲可 ， 睡眠可 ， 大便如常 ，小便如上述，体力、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": "睡眠质量", "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": "体力改变", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [] }, { "core_name": "体重改变", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [] } ] }, { "id": 1999, "text": "第二次入院记录（2012年2月13日-2012年3月8日） 患者于1年前于我院再次复查，腹部mri提示：肝右叶小结节，给予保肝对症治疗，于2012.2.21行介入治疗，手术顺利。", "event": [ { "core_name": "结节", "tendency": "", "character": [ "小" ], "anatomy_list": [ "肝右叶" ] } ] }, { "id": 785, "text": "入院1+年 前 ，患者无明显诱因出现头昏，伴有头闷胀不适，呈持续性，以双侧颞部及额部为主，伴有四肢麻木，无视物旋转、恶心、呕吐，耳鸣、听力下降等，无肢体偏瘫、失语、吞咽困难、饮水呛咳等，无意识障碍、四肢抽搐、口吐白沫、大小便失禁等，无胸闷、气促、心前区压榨感等，无畏寒、发热、咳嗽、咳痰等，患者自行在个体医师处治疗（具体不详），患者症状无明显缓解，入院3月前，患者感头昏、头胀较前加重，并伴有双眼胀痛，为进一步治疗，遂来我科，门诊以“后循环缺血”收入我院。", "event": [ { "core_name": "头昏", "tendency": "", "character": [], "anatomy_list": [ "头" ] }, { "core_name": "闷胀", "tendency": "", "character": [ "持续性" ], "anatomy_list": [ "头", "双侧颞部", "额部" ] }, { "core_name": "麻木", "tendency": "", "character": [], "anatomy_list": [ "四肢" ] }, { "core_name": "视物旋转", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "呕吐", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "耳鸣", "tendency": "", "character": [], "anatomy_list": [ "耳" ] }, { "core_name": "听力下降", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "偏瘫", "tendency": "否定", "character": [], "anatomy_list": [ "肢体" ] }, { "core_name": "失语", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "吞咽困难", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "呛咳", "tendency": "否定", "character": [ "饮水" ], "anatomy_list": [] }, { "core_name": "意识障碍", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "抽搐", "tendency": "否定", "character": [], "anatomy_list": [ "四肢" ] }, { "core_name": "口吐白沫", "tendency": "否定", "character": [], "anatomy_list": [ "口" ] }, { "core_name": "大小便", "tendency": "否定", "character": [ "失禁" ], "anatomy_list": [] }, { "core_name": "憋闷", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "气促", "tendency": "否定", "character": [], "anatomy_list": [] }, { "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": "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": "症状", "tendency": "否定", "character": [ "明显缓解" ], "anatomy_list": [] }, { "core_name": "头昏", "tendency": "", "character": [ "加重" ], "anatomy_list": [ "头" ] }, { "core_name": "发胀", "tendency": "", "character": [ "加重" ], "anatomy_list": [ "头" ] }, { "core_name": "疼痛", "tendency": "", "character": [ "胀痛" ], "anatomy_list": [ "双眼" ] }, { "core_name": "缺血", "tendency": "", "character": [], "anatomy_list": [ "后循环" ] } ] }, { "id": 352, "text": "病程中患者无腹痛、腹胀、腹泻,无恶心、呕吐,无畏寒、发热，无阴道阴道流血流液，无同房接触性出血，无排便习惯及性状改变，无头晕、头痛，无胸闷、心悸，无尿频、尿急等不适,考虑盆腔包块，建议住院手术治疗，今日患者为求手术就诊我院，故门诊以“盆腔包块性质待查”收入院。", "event": [ { "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": "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": "出血", "tendency": "否定", "character": [], "anatomy_list": [ "阴道" ] }, { "core_name": "流液", "tendency": "否定", "character": [], "anatomy_list": [ "阴道" ] }, { "core_name": "出血", "tendency": "否定", "character": [ "同房接触性" ], "anatomy_list": [] }, { "core_name": "排便", "tendency": "", "character": [ "习惯及性状改变" ], "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": "心悸", "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": "包块", "tendency": "不确定", "character": [], "anatomy_list": [ "盆腔" ] }, { "core_name": "包块", "tendency": "不确定", "character": [], "anatomy_list": [ "盆腔" ] } ] }, { "id": 65, "text": "入院前35天，患者于当地常规体检时发现转氨酶增高（具体值不详），不伴发热、畏寒、寒战、咳嗽、咳痰、恶心、呕吐、腹痛、腹泻、皮肤瘙痒、尿黄、眼黄、身黄等不适。", "event": [ { "core_name": "转氨酶", "tendency": "", "character": [ "增高" ], "anatomy_list": [] }, { "core_name": "发热", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "畏寒", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "寒颤", "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": "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" ] }, { "core_name": "瘙痒", "tendency": "否定", "character": [], "anatomy_list": [ "皮肤" ] }, { "core_name": "尿黄", "tendency": "", "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" ] } ] }, { "id": 255, "text": "患者于3天前无明显诱因右眼突发眼胀胀痛不适，无视力下降、视物变形、视物重影，无眼红、分泌物增多，至我院就诊，双眼视神经萎缩，建议完善检查。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [ "突发", "胀痛不适" ], "anatomy_list": [ "右眼" ] }, { "core_name": "视力下降", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "视物变形", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "视物重影", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "眼红", "tendency": "否定", "character": [], "anatomy_list": [ "眼" ] }, { "core_name": "分泌物增多", "tendency": "否定", "character": [], "anatomy_list": [ "眼" ] }, { "core_name": "萎缩", "tendency": "", "character": [], "anatomy_list": [ "双眼视神经" ] } ] }, { "id": 879, "text": "2天前，患者上诉症状再发，夜间高枕卧位，伴夜间阵发性呼吸困难，无双下肢水肿，伴有咳嗽、咳痰,为白色泡沫痰,无畏寒、发热，无胸闷、胸痛、心悸，无恶心、呕吐，无出汗等不适，为进一步诊治入我院，门诊以“心力衰竭”收入我科。", "event": [ { "core_name": "呼吸困难", "tendency": "", "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": [], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "白色", "泡沫痰" ], "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": "心悸", "tendency": "否定", "character": [], "anatomy_list": [ "心" ] }, { "core_name": "恶心", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "呕吐", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "出汗", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "心力衰竭", "tendency": "", "character": [], "anatomy_list": [ "心" ] } ] }, { "id": 1911, "text": "1周前，患者诉骶尾部疼痛，影响夜间睡眠，未诊治入我科，门诊以\"右肺腺癌”收入我科。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [ "影响夜间睡眠" ], "anatomy_list": [ "骶尾部" ] }, { "core_name": "腺癌", "tendency": "", "character": [], "anatomy_list": [ "右肺" ] } ] }, { "id": 51, "text": "5+月前患者因“大便习惯改变”于我院就诊,经检查后诊断为乙状结肠肿瘤,于07.16在全麻下行腹腔镜下乙状结肠肿瘤根治术,手术顺利,术后病检：（乙状结肠）溃疡型中-低分化管状腺癌,浸及肠壁深肌层,癌侵犯神经。", "event": [ { "core_name": "大便", "tendency": "", "character": [ "习惯改变" ], "anatomy_list": [] }, { "core_name": "肿瘤", "tendency": "", "character": [], "anatomy_list": [ "乙状结肠" ] }, { "core_name": "管状腺癌", "tendency": "", "character": [ "溃疡型", "浸及肠壁深肌层", "侵犯神经" ], "anatomy_list": [ "乙状结肠" ] } ] }, { "id": 1446, "text": "患者发病以来，神志 清晰，精神可，胃纳可，大便次数增多，小便如常，体重未见明显下降。", "event": [ { "core_name": "神志", "tendency": "", "character": [ "清晰" ], "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": [ "次数增多" ], "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": 1570, "text": "入院前5+月，患者无明显诱因出现大便次数增加，由1次/天，增加至10次/天，为稀糊样大便，大便无明显变细、变形，大便表面或大便中混有暗红色血液，伴轻度肛门坠胀坠胀不适，偶有下腹部隐痛不适，发作无规律，可自行解除或排除后缓解，无脓性便、果酱样便，无腹胀、恶心、呕吐等不适。", "event": [ { "core_name": "大便", "tendency": "", "character": [ "次数增加" ], "anatomy_list": [] }, { "core_name": "大便", "tendency": "", "character": [ "稀糊样" ], "anatomy_list": [] }, { "core_name": "大便", "tendency": "", "character": [ "明显变细" ], "anatomy_list": [] }, { "core_name": "大便", "tendency": "", "character": [ "明显变形" ], "anatomy_list": [] }, { "core_name": "大便", "tendency": "", "character": [ "表面或大便中暗红色血液" ], "anatomy_list": [] }, { "core_name": "坠胀", "tendency": "", "character": [ "轻度" ], "anatomy_list": [ "肛门" ] }, { "core_name": "疼痛", "tendency": "", "character": [ "发作无规律", "偶有", "隐痛", "自行解除", "排除后缓解" ], "anatomy_list": [ "下腹部" ] }, { "core_name": "大便", "tendency": "否定", "character": [ "脓性" ], "anatomy_list": [] }, { "core_name": "大便", "tendency": "否定", "character": [ "果酱样" ], "anatomy_list": [] }, { "core_name": "腹胀", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "恶心", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "呕吐", "tendency": "否定", "character": [], "anatomy_list": [] } ] }, { "id": 1391, "text": "自患病以来，患者精神、食欲、睡眠可，大小便基本正常，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": [ "基本正常" ], "anatomy_list": [] }, { "core_name": "小便", "tendency": "", "character": [ "基本正常" ], "anatomy_list": [] }, { "core_name": "体重改变", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [] } ] }, { "id": 391, "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，1月余体重减少约2Kg。", "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": 1419, "text": "该次入院前3月发现左侧锁骨上锁骨上肿块约花生米粒大小，伴有胸痛，咳嗽，粘痰，无发热、无痰血、及头痛、头晕、恶心、呕吐及骨关节关节疼痛。", "event": [ { "core_name": "肿块", "tendency": "", "character": [ "花生米粒大小" ], "anatomy_list": [ "左侧锁骨上" ] }, { "core_name": "疼痛", "tendency": "", "character": [], "anatomy_list": [ "胸" ] }, { "core_name": "咳嗽", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "粘痰" ], "anatomy_list": [] }, { "core_name": "发热", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "否定", "character": [ "痰血" ], "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": "呕吐", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "骨关节" ] } ] }, { "id": 840, "text": "患者自起病以来，精神可，睡眠可，胃纳可，大便如常，小便如常，体重未见明显下降。", "event": [ { "core_name": "精神", "tendency": "", "character": [ "可" ], "anatomy_list": [] }, { "core_name": "睡眠", "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": 64, "text": "患者自起病以来，精神可，胃纳可，大便如常，尿急，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": "尿急", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "体重下降", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [] } ] }, { "id": 873, "text": "予以护肾、降尿酸、抑酸、改善循环、营养神经、营养心肌、降压等处理后好转出院；4年前患者在体检时发现血肌酐肌酐升高（约100+umol/l），但患者未予重视，院外不规律服用“金水宝、尿毒清颗粒”护肾治疗，不定期随访肾功，均提示血肌酐呈上升趋势，伴夜尿增多，不伴尿量减少、浮肿，不伴恶心、呕吐等不适。", "event": [ { "core_name": "血肌酐肌酐升高", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "血肌酐上升趋势", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "夜尿增多", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "小便", "tendency": "否定", "character": [ "量减少" ], "anatomy_list": [] }, { "core_name": "浮肿", "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": [] } ] }, { "id": 1098, "text": "3天前，出现上述症状进行性加重，表现为：排尿费力，尿分叉，尿线变细，排尿滴沥，尿不尽感。", "event": [ { "core_name": "排尿费力", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "尿分叉", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "尿线变细", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "排尿滴沥", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "尿不尽感", "tendency": "", "character": [], "anatomy_list": [] } ] }, { "id": 1431, "text": "两次手术病检分别为：<膀胱>高级别尿路上皮癌，膀胱肿瘤及基底部高级别乳头状尿路上皮癌；<左输尿管近膀胱处>高级别浸润性尿路上皮癌，侵及浅肌层，<左侧>肾脏组织未见癌累及，<左肾门>淋巴结未见癌转移（0/12）。", "event": [ { "core_name": "癌", "tendency": "", "character": [ "高级别" ], "anatomy_list": [ "膀胱", "尿路上皮" ] }, { "core_name": "肿瘤", "tendency": "", "character": [], "anatomy_list": [ "膀胱" ] }, { "core_name": "癌", "tendency": "", "character": [ "高级别", "乳头状" ], "anatomy_list": [ "膀胱基底部", "尿路上皮" ] }, { "core_name": "癌", "tendency": "", "character": [ "左侧肾脏组织未见癌累及", "高级别", "浸润性", "侵及浅肌层" ], "anatomy_list": [ "左输尿管近膀胱处", "尿路上皮" ] }, { "core_name": "癌", "tendency": "否定", "character": [ "转移" ], "anatomy_list": [ "左肾门淋巴结" ] } ] }, { "id": 1384, "text": "今患者为行进一步诊治来我院，门诊以“双肺多发结节待查？”收入我科住院治疗。", "event": [ { "core_name": "结节", "tendency": "不确定", "character": [ "多发" ], "anatomy_list": [ "双肺" ] } ] }, { "id": 1691, "text": "4月前于我科诊断为“双眼糖尿病视网膜病变，右眼黄斑水肿”，后先后于我科行右眼玻璃体腔注药术（康柏西普），后患者觉视物模糊较前缓解。", "event": [ { "core_name": "病变", "tendency": "", "character": [ "糖尿病" ], "anatomy_list": [ "双眼", "视网膜" ] }, { "core_name": "水肿", "tendency": "", "character": [], "anatomy_list": [ "右眼" ] }, { "core_name": "黄斑", "tendency": "", "character": [], "anatomy_list": [ "右眼" ] }, { "core_name": "视物模糊", "tendency": "", "character": [ "较前缓解" ], "anatomy_list": [] } ] }, { "id": 1903, "text": "2.右肺门、纵膈、右侧锁骨锁骨区淋巴结淋巴结增大，fdg代谢增高，考虑转移。", "event": [ { "core_name": "转移", "tendency": "不确定", "character": [], "anatomy_list": [] }, { "core_name": "肿大", "tendency": "", "character": [], "anatomy_list": [ "右肺门淋巴结", "纵膈淋巴结", "右侧锁骨淋巴结" ] }, { "core_name": "fdg代谢", "tendency": "", "character": [ "增高" ], "anatomy_list": [] } ] }, { "id": 1801, "text": "患者4月前，开始出现进食后哽咽感，有进食停顿感，有胸骨后疼痛疼痛不适，无胸骨后烧灼感，无恶心，无呕吐，无返酸，无嗳气，无呕血，无黑便，无心悸、胸闷等不适，无发热、抽搐等症。", "event": [ { "core_name": "哽噎感", "tendency": "", "character": [ "进食后" ], "anatomy_list": [] }, { "core_name": "停顿感", "tendency": "", "character": [ "进食" ], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "", "character": [], "anatomy_list": [ "胸骨后" ] }, { "core_name": "胸骨后不适", "tendency": "", "character": [], "anatomy_list": [ "胸骨后" ] }, { "core_name": "烧灼感", "tendency": "否定", "character": [], "anatomy_list": [ "胸骨后" ] }, { "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": "呕血", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "黑便", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "心悸", "tendency": "否定", "character": [], "anatomy_list": [ "心" ] }, { "core_name": "胸闷", "tendency": "否定", "character": [], "anatomy_list": [ "胸" ] }, { "core_name": "发热", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "抽搐", "tendency": "否定", "character": [], "anatomy_list": [] } ] }, { "id": 307, "text": "其后分别于2015-8-15、2015-9-18、2015-10-17行伊立替康 320mg1化疗，术后好转出院，现患者为行复查来我院，门诊以“左肺癌术后”收入我科。", "event": [ { "core_name": "癌", "tendency": "", "character": [ "术后" ], "anatomy_list": [ "左肺" ] } ] }, { "id": 1748, "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，小便如上述，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": "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": 423, "text": "现患者遵嘱来我院化疗，门诊以“颅底颅眶沟通腺样性癌”收住我科。", "event": [ { "core_name": "癌", "tendency": "", "character": [ "颅底颅眶沟通", "腺样性" ], "anatomy_list": [] } ] }, { "id": 823, "text": "1年前于某中医院体检，行妇科彩超检查提示：左附件区包块，直径约6cm，考虑巧囊可能（未见报告），建议手术，患者未做。", "event": [ { "core_name": "包块", "tendency": "", "character": [], "anatomy_list": [ "左附件" ] }, { "core_name": "巧克力囊肿", "tendency": "不确定", "character": [], "anatomy_list": [] } ] }, { "id": 1116, "text": "7天前患者无明显诱因出现双下肢水肿，呈进行性加重，最初水肿局限在双侧脚背，后逐渐扩大到双侧小腿，其余部位暂无明显水肿。", "event": [ { "core_name": "水肿", "tendency": "", "character": [ "进行性加重" ], "anatomy_list": [ "双下肢" ] }, { "core_name": "水肿", "tendency": "", "character": [ "局限" ], "anatomy_list": [ "双侧脚背" ] }, { "core_name": "水肿", "tendency": "", "character": [ "扩大" ], "anatomy_list": [ "双侧小腿" ] }, { "core_name": "水肿", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [] } ] }, { "id": 762, "text": "予以抗感染、增强免疫、辅助抗肿瘤等处理，患者发热等症状逐渐好转，患者及家属不考虑化疗等其他特殊治疗，自动出院。", "event": [ { "core_name": "发热", "tendency": "", "character": [ "逐渐好转" ], "anatomy_list": [] } ] }, { "id": 1000, "text": "6天前，患者在上述症状基础上出现恶心、呕吐非咖啡色胃内容物，遂就诊于某医院，予以糖尿病饮食、抗感染、护肝、改善循环、对症等治疗，患者未再发热，腹痛无明显改善，遂完善上腹部ct提示：1.肝右叶占位性病变，性质待定，肝脓肿？新生物？2.肝大；3.左肾小囊肿；4.右下肺炎症；5.右侧胸腔积液；诊断为：1.肝右叶占位：肝脓肿？肝癌?2.肺部感染；3.肝功能异常；4.急性冠脉综合征；5.急性胃黏膜病变；6.2型糖尿病；7.颈椎骨质增生，遂于今日转入我院，就诊于我院急诊科，请我科会诊后以“肝脏占位待查”收入我科住院治疗。", "event": [ { "core_name": "恶心", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "呕吐", "tendency": "", "character": [ "非咖啡色胃内容物" ], "anatomy_list": [] }, { "core_name": "发热", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "否定", "character": [ "明显改善" ], "anatomy_list": [ "腹" ] }, { "core_name": "病变", "tendency": "", "character": [ "占位性" ], "anatomy_list": [ "肝右叶" ] }, { "core_name": "脓肿", "tendency": "不确定", "character": [], "anatomy_list": [ "肝" ] }, { "core_name": "新生物", "tendency": "不确定", "character": [], "anatomy_list": [ "肝" ] }, { "core_name": "肝大", "tendency": "", "character": [ "大" ], "anatomy_list": [ "肝" ] }, { "core_name": "囊肿", "tendency": "", "character": [ "小" ], "anatomy_list": [ "左肾" ] }, { "core_name": "炎症", "tendency": "", "character": [], "anatomy_list": [ "右下肺" ] }, { "core_name": "积液", "tendency": "", "character": [], "anatomy_list": [ "右侧胸腔" ] }, { "core_name": "占位", "tendency": "", "character": [], "anatomy_list": [ "肝右叶" ] }, { "core_name": "脓肿", "tendency": "不确定", "character": [], "anatomy_list": [ "肝" ] }, { "core_name": "癌", "tendency": "不确定", "character": [], "anatomy_list": [ "肝" ] }, { "core_name": "感染", "tendency": "", "character": [], "anatomy_list": [ "肺部" ] }, { "core_name": "肝功能异常", "tendency": "", "character": [], "anatomy_list": [ "肝" ] }, { "core_name": "冠脉综合征", "tendency": "", "character": [ "急性" ], "anatomy_list": [] }, { "core_name": "病变", "tendency": "", "character": [ "急性", "粘膜" ], "anatomy_list": [ "胃部" ] }, { "core_name": "糖尿病", "tendency": "", "character": [ "2型" ], "anatomy_list": [] }, { "core_name": "骨质增生", "tendency": "", "character": [], "anatomy_list": [ "颈椎" ] }, { "core_name": "占位", "tendency": "", "character": [], "anatomy_list": [ "肝脏" ] } ] }, { "id": 1023, "text": "4年前，患者于我院复查时发现腹腔包块，包块接近血管部位，考虑宫颈癌复发，故再次予以包块部分切除术，术后予以4周期化疗（具体不详），化疗中患者出现恶心、呕吐、腹痛、腹胀，全血下降等不适，给予对症处理后缓解。", "event": [ { "core_name": "包块", "tendency": "", "character": [ "接近血管部位" ], "anatomy_list": [ "腹腔" ] }, { "core_name": "癌", "tendency": "不确定", "character": [ "复发" ], "anatomy_list": [ "宫颈" ] }, { "core_name": "恶心", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "呕吐", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "腹胀", "tendency": "", "character": [], "anatomy_list": [ "腹" ] } ] }, { "id": 71, "text": "病程中反复出现咳嗽、咳痰症状，程度及频次较前均减少，未再咯血，患者均予以对症治疗，未行进一步处理及治疗。", "event": [ { "core_name": "咳嗽", "tendency": "", "character": [ "反复", "程度及频次较前均减少" ], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "反复", "程度及频次较前均减少" ], "anatomy_list": [] }, { "core_name": "咯血", "tendency": "否定", "character": [], "anatomy_list": [] } ] }, { "id": 449, "text": "今为求进一步治疗，遂于我院就诊，门诊以“鼾症”收拾入院。", "event": [ { "core_name": "鼾症", "tendency": "", "character": [], "anatomy_list": [] } ] }, { "id": 1330, "text": "入院前 5年 ，患者渐感劳力性呼吸困难，以上楼、上坡或剧烈活动后明显，不伴夜间阵发性呼吸困难及端坐呼吸，不伴双下肢肿。", "event": [ { "core_name": "呼吸困难", "tendency": "", "character": [ "劳力性", "以上楼、上坡或剧烈活动后明显" ], "anatomy_list": [] }, { "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": "肿", "tendency": "否定", "character": [], "anatomy_list": [ "双下肢" ] } ] }, { "id": 1353, "text": "21月前患者无明显诱因出现咽痛，服用抗生素（具体不详）后无明显缓解，未予重视，其后患者反复出现咽痛，伴间断发热，最高高体温达39℃，伴乏力，至某医院，查血图：hb67g/L，wbc3.34*10＾9/L，plt15*10＾9/L，d-二聚体最高时>5.0mg/L，凝血象：凝血酶原标准化比值1.14，凝血酶原时间12.5秒，活化部分凝血活酶时间>190秒,鱼精蛋白试验：阳性，铁蛋白：1942ng/ml，本周氏蛋白、甲功、贫血组合、抗人球蛋白试验正常，考虑为“急性髓系白血病（m3型），弥漫性血管内凝血（dic）”，因凝血功能极差未完善骨髓涂片及骨髓活检 ,予以输注红细胞、人纤维蛋白原等对症支持治疗，治疗过程中，患者全身乏力症状未见明显缓解，并伴发牙龈出血及全身皮肤瘀斑，后患者入我院。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [], "anatomy_list": [ "咽" ] }, { "core_name": "疼痛", "tendency": "", "character": [ "反复" ], "anatomy_list": [ "咽" ] }, { "core_name": "发热", "tendency": "", "character": [ "间断" ], "anatomy_list": [] }, { "core_name": "乏力", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "白血病", "tendency": "不确定", "character": [ "急性", "髓系", "m3型" ], "anatomy_list": [] }, { "core_name": "弥漫性血管内凝血", "tendency": "不确定", "character": [], "anatomy_list": [] }, { "core_name": "凝血功能极差", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "乏力", "tendency": "否定", "character": [ "明显缓解" ], "anatomy_list": [ "全身" ] }, { "core_name": "出血", "tendency": "", "character": [], "anatomy_list": [ "牙龈" ] }, { "core_name": "瘀斑", "tendency": "", "character": [], "anatomy_list": [ "全身皮肤" ] } ] }, { "id": 661, "text": "出院时患者出现心累气促，遂到某职工医院输液3天，经抗炎治疗（具体不详）后，心累气促减轻后出院。", "event": [ { "core_name": "心累", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "气促", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "心累", "tendency": "", "character": [ "减轻" ], "anatomy_list": [] }, { "core_name": "气促", "tendency": "", "character": [ "减轻" ], "anatomy_list": [] } ] }, { "id": 1468, "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，大便不成形，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": [ "不成形" ], "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": 1901, "text": "2018.07.16于某医院，行肋骨螺旋ct检查：1.右肺下叶内基底段新生物可能；2.右肺中叶及左下肺小结节肺小结节影，转移不除外；3.纵膈内肿大淋巴结；4.右侧第4及左侧第9、10肋骨转移。", "event": [ { "core_name": "新生物", "tendency": "不确定", "character": [], "anatomy_list": [ "右肺下叶内基底段" ] }, { "core_name": "结节影", "tendency": "", "character": [ "转移不除外", "小" ], "anatomy_list": [ "右肺中叶" ] }, { "core_name": "结节影", "tendency": "", "character": [ "转移不除外", "小" ], "anatomy_list": [ "左下肺" ] }, { "core_name": "肿大", "tendency": "", "character": [], "anatomy_list": [ "纵膈内淋巴结" ] }, { "core_name": "转移", "tendency": "", "character": [ "骨" ], "anatomy_list": [ "右侧第4肋骨", "左侧第9、10肋骨" ] } ] }, { "id": 353, "text": "患者于2个多月前（2013.02.28）因诊断为右乳浸润性导管癌，在我院行右乳癌改良根治术，受体情况为er(++) pr（++） cerbb-2(+++)。", "event": [ { "core_name": "导管癌", "tendency": "", "character": [ "浸润性" ], "anatomy_list": [ "右乳" ] } ] }, { "id": 623, "text": "查hpv：16型阳性；妇科彩超未见明显异常，今日患者至我院就诊，门诊以“宫颈鳞状细胞癌”收治入院。", "event": [ { "core_name": "hpv16型", "tendency": "", "character": [ "阳性" ], "anatomy_list": [] }, { "core_name": "鳞癌", "tendency": "", "character": [], "anatomy_list": [ "宫颈" ] } ] }, { "id": 157, "text": "故门诊以“肝癌”收入我科室。", "event": [ { "core_name": "癌", "tendency": "", "character": [], "anatomy_list": [ "肝" ] } ] }, { "id": 416, "text": "门诊以“乳腺癌术后”收入我科。", "event": [ { "core_name": "癌", "tendency": "", "character": [ "术后" ], "anatomy_list": [ "乳腺" ] } ] }, { "id": 421, "text": "之后患者于2015年10月5日于某医院行放射治疗（pgtvnx 69.96G/33f；pgtv2 66G/33f），2015年10月14日、2015年11月16日于华西医院行2周期化疗（化疗方案为顺铂30mg d1-?），出院后回家休养，间断出现呕吐，呈喷射状，呕吐物为胃内容物，自感颈部僵硬，无明显头痛，无四肢乏力等症状。", "event": [ { "core_name": "呕吐", "tendency": "", "character": [ "间断出现", "呈喷射状", "呕吐物为胃内容物" ], "anatomy_list": [] }, { "core_name": "僵硬", "tendency": "", "character": [], "anatomy_list": [ "颈部" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [ "头" ] }, { "core_name": "乏力", "tendency": "否定", "character": [], "anatomy_list": [ "四肢" ] } ] }, { "id": 1204, "text": "右侧胸膜增厚。", "event": [ { "core_name": "增厚", "tendency": "", "character": [], "anatomy_list": [ "右侧胸膜" ] } ] }, { "id": 1423, "text": "2余月前（2019年4月）患者因院外查血糖高就诊于我院内分泌科，反复头晕，偶有耳鸣，无头痛，无肢体偏瘫，无意识障碍、视物旋转、视力下降，无畏寒、发热，无咳嗽、咳痰，无胸闷、心慌，无恶心、呕吐，无腹痛、腹胀、腹泻，无肢体麻木、肢体活动障碍。", "event": [ { "core_name": "血糖", "tendency": "", "character": [ "高" ], "anatomy_list": [] }, { "core_name": "头晕", "tendency": "", "character": [ "反复" ], "anatomy_list": [ "头" ] }, { "core_name": "耳鸣", "tendency": "", "character": [], "anatomy_list": [ "耳" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "头" ] }, { "core_name": "偏瘫", "tendency": "否定", "character": [], "anatomy_list": [ "肢体" ] }, { "core_name": "意识障碍", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "视物旋转", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "视力下降", "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": "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": "心慌", "tendency": "否定", "character": [], "anatomy_list": [ "心" ] }, { "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": "麻木", "tendency": "否定", "character": [], "anatomy_list": [ "肢体" ] }, { "core_name": "活动障碍", "tendency": "否定", "character": [], "anatomy_list": [ "肢体" ] } ] }, { "id": 978, "text": "8月前，患者到某医院就诊，行胸片：1.双肺尖改变，考虑陈旧性肺结核可能，建议胸部ct+查痰；2.双肺慢性感染；3.两肋膈角变钝，考虑双侧胸腔积液；4.胸腰椎骨质增生。", "event": [ { "core_name": "改变", "tendency": "", "character": [], "anatomy_list": [ "双肺尖" ] }, { "core_name": "结核", "tendency": "不确定", "character": [ "陈旧性" ], "anatomy_list": [ "肺" ] }, { "core_name": "感染", "tendency": "", "character": [ "慢性" ], "anatomy_list": [ "双肺" ] }, { "core_name": "变钝", "tendency": "", "character": [], "anatomy_list": [ "两肋膈角" ] }, { "core_name": "积液", "tendency": "不确定", "character": [], "anatomy_list": [ "双侧胸腔" ] }, { "core_name": "骨质增生", "tendency": "", "character": [], "anatomy_list": [ "胸椎", "腰椎" ] } ] }, { "id": 2070, "text": "病后患者精神、饮食、睡眠尚可，大小便基本正常，体重无明显变化。", "event": [ { "core_name": "精神", "tendency": "", "character": [ "尚可" ], "anatomy_list": [] }, { "core_name": "进食", "tendency": "", "character": [ "尚可" ], "anatomy_list": [] }, { "core_name": "睡眠", "tendency": "", "character": [ "尚可" ], "anatomy_list": [] }, { "core_name": "大小便", "tendency": "", "character": [ "基本正常" ], "anatomy_list": [] }, { "core_name": "体重改变", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [] } ] }, { "id": 657, "text": "现为行进一步诊治，遂来我院就诊，门诊以“双侧乳房肿物”收入住院。", "event": [ { "core_name": "肿物", "tendency": "", "character": [], "anatomy_list": [ "双侧乳房" ] } ] }, { "id": 842, "text": "病程中患者无明显颈部疼痛、颈部异物感、咽痛、发热，无怕热、多汗、心悸、凸眼，无食欲改变、明显脱发、颜面部及下肢水肿，无大便性状及频率改变等不适。此次患者为进一步诊治入院。", "event": [ { "core_name": "疼痛", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [ "颈部" ] }, { "core_name": "异物感", "tendency": "否定", "character": [], "anatomy_list": [ "颈部" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "咽" ] }, { "core_name": "发热", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "怕热", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "出汗", "tendency": "否定", "character": [ "增多" ], "anatomy_list": [] }, { "core_name": "心悸", "tendency": "否定", "character": [], "anatomy_list": [ "心" ] }, { "core_name": "凸眼", "tendency": "否定", "character": [], "anatomy_list": [ "眼" ] }, { "core_name": "食欲改变", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "脱发", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [] }, { "core_name": "水肿", "tendency": "否定", "character": [], "anatomy_list": [ "颜面部" ] }, { "core_name": "水肿", "tendency": "否定", "character": [], "anatomy_list": [ "下肢" ] }, { "core_name": "大便性状改变", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "大便频率改变", "tendency": "否定", "character": [], "anatomy_list": [] } ] }, { "id": 1586, "text": "于3月前（07-22）行第一次tp方案化疗，化疗期间患者感轻微恶心，有明显脱发，无腹痛、腹泻等不适。", "event": [ { "core_name": "恶心", "tendency": "", "character": [ "轻微" ], "anatomy_list": [] }, { "core_name": "脱发", "tendency": "", "character": [ "明显" ], "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": 1160, "text": "患者入院前10天，无明显诱因下出现干咳，伴发热、气促，发热时大汗淋漓，无胸闷胸痛，无呼吸困难，自服川贝止咳糖浆后无好转。", "event": [ { "core_name": "咳嗽", "tendency": "", "character": [ "干性" ], "anatomy_list": [] }, { "core_name": "发热", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "气促", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "发热", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "出汗", "tendency": "", "character": [ "大汗" ], "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": "呼吸困难", "tendency": "否定", "character": [], "anatomy_list": [] } ] }, { "id": 741, "text": "为进一步，门诊以“意识丧失待查”收入我科。", "event": [ { "core_name": "意识丧失", "tendency": "", "character": [], "anatomy_list": [] } ] }, { "id": 437, "text": "2、左肾积水伴左输尿管全程扩张，不除外输尿管末段狭窄。", "event": [ { "core_name": "积水", "tendency": "", "character": [], "anatomy_list": [ "左肾" ] }, { "core_name": "扩张", "tendency": "", "character": [], "anatomy_list": [ "左输尿管全程" ] }, { "core_name": "狭窄", "tendency": "不确定", "character": [], "anatomy_list": [ "输尿管末段" ] } ] }, { "id": 43, "text": "入院前1年,患者体检超声发现“左侧附件区7.2×5.5cm混合性包块”,考虑畸胎瘤可能,无畏寒、发热,无恶心、呕吐,无腹胀、腹痛、腹泻,无大便隐血,无肛门坠胀,无尿频、尿急、尿痛,无阴道阴道流血、流液等不适,嘱患者密切随访,随后患者多次行腹部b超检查,包块未见明显增大,患者未予重视、未做特殊处理。", "event": [ { "core_name": "包块", "tendency": "", "character": [ "混合性" ], "anatomy_list": [ "左侧附件" ] }, { "core_name": "畸胎瘤", "tendency": "不确定", "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": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "腹泻", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "大便", "tendency": "", "character": [ "无隐血" ], "anatomy_list": [] }, { "core_name": "坠胀", "tendency": "否定", "character": [], "anatomy_list": [ "肛门" ] }, { "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": "出血", "tendency": "否定", "character": [], "anatomy_list": [ "阴道" ] }, { "core_name": "流液", "tendency": "否定", "character": [], "anatomy_list": [ "阴道" ] }, { "core_name": "包块增大", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [ "左侧附件" ] } ] }, { "id": 1815, "text": "右肺中叶结节。", "event": [ { "core_name": "结节", "tendency": "", "character": [], "anatomy_list": [ "右肺中叶" ] } ] }, { "id": 1628, "text": "患者近期无发热、咳嗽、咳痰、呼吸困难病史，无疫区接触史，无新冠肺炎患者及疑似患者接触史。", "event": [ { "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": "呼吸困难", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "新冠肺炎", "tendency": "否定", "character": [], "anatomy_list": [ "肺" ] } ] }, { "id": 2008, "text": "自患病以来，患者精神、食欲尚可，睡眠欠佳，大小便正常，近期体重无明显改变。", "event": [ { "core_name": "精神", "tendency": "", "character": [ "尚可" ], "anatomy_list": [] }, { "core_name": "食欲", "tendency": "", "character": [ "尚可" ], "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": "体重改变", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [] } ] }, { "id": 1055, "text": "近期无恶心、呕吐，腹痛、腹胀，无咳嗽、咳痰，胸痛、咯血等，患者为求进一步诊治遂来我院，以“右下颌下颌包块待查”收入我科。", "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": "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": "包块", "tendency": "不确定", "character": [], "anatomy_list": [ "右下颌" ] } ] }, { "id": 1969, "text": "右手拇指及食指麻木。", "event": [ { "core_name": "麻木", "tendency": "", "character": [], "anatomy_list": [ "右手拇指", "右手食指" ] } ] }, { "id": 1839, "text": "入院前1天，患者行走后出现，双下肢对称性凹陷性水肿，无心悸、气促，无端坐呼吸，无眼睑水肿，无尿频、尿急、尿痛等不适，未予特殊处理，今为进一步诊治来我院，门诊拟“系统性红斑狼疮”收入院。", "event": [ { "core_name": "水肿", "tendency": "", "character": [ "行走后", "对称性", "凹陷性" ], "anatomy_list": [ "双下肢" ] }, { "core_name": "心悸", "tendency": "否定", "character": [], "anatomy_list": [ "心" ] }, { "core_name": "气促", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "端坐呼吸", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "水肿", "tendency": "否定", "character": [], "anatomy_list": [ "眼睑" ] }, { "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": "红斑狼疮", "tendency": "不确定", "character": [ "系统性" ], "anatomy_list": [] } ] }, { "id": 214, "text": "纤支镜（2020-03-23）：左上升支支气管开口被肿物完全阻塞，于此处行活检及刷检，病理诊断：左上升支磷状细胞ca，灌洗液未找到抗酸杆菌。", "event": [ { "core_name": "阻塞", "tendency": "", "character": [ "完全" ], "anatomy_list": [ "左上升支支气管开口" ] }, { "core_name": "肿物", "tendency": "", "character": [], "anatomy_list": [ "左上升支支气管开口" ] }, { "core_name": "鳞癌", "tendency": "", "character": [], "anatomy_list": [ "左上升支" ] } ] }, { "id": 1450, "text": "患者后于2014年09月15日入某医院行“剖腹探查术+肝癌切除术+放射离子植入术”（具体不详）；取肝组织病检示：肝脏微小癌癌结节，免疫组化支持腺癌。", "event": [ { "core_name": "结节", "tendency": "", "character": [ "癌", "微小" ], "anatomy_list": [ "肝脏" ] }, { "core_name": "腺癌", "tendency": "", "character": [], "anatomy_list": [ "肝脏" ] } ] }, { "id": 120, "text": "患者于2016年9月08日我院行右乳房乳癌麦默通切除术，术中冰冻电话报告：（右乳）恶性肿瘤，于2016年9月12日已行右腋窝前哨淋巴结活检+术中冰冻+右乳癌改良根治术术后辅助化疗，化疗方案为（化疗方案为吡柔比星粉针40mg+多西他赛注射液100mg+环磷酰胺粉针0.8g）。", "event": [ { "core_name": "肿瘤", "tendency": "", "character": [ "恶性" ], "anatomy_list": [ "右乳" ] } ] }, { "id": 863, "text": "入院前1+年患者无明显诱因开始出现颈部、咽喉部疼痛，为间断性，无咳嗽、咳痰，无咽喉疼痛、咯血、胸痛、呼吸困难、吞咽梗阻、吞咽疼痛等症状，自行口服药物（具体不详）治疗，效果欠佳。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [ "间断性" ], "anatomy_list": [ "颈部" ] }, { "core_name": "疼痛", "tendency": "", "character": [ "间断性" ], "anatomy_list": [ "咽喉部" ] }, { "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": [ "咽喉部" ] }, { "core_name": "咯血", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "胸部" ] }, { "core_name": "呼吸困难", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "梗阻", "tendency": "否定", "character": [ "吞咽" ], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "否定", "character": [ "吞咽" ], "anatomy_list": [] } ] }, { "id": 427, "text": "到某医院就诊， 胸部增强ct 提示 尘肺，双肺上叶团块病灶有强化 。", "event": [ { "core_name": "尘肺", "tendency": "", "character": [], "anatomy_list": [ "肺" ] }, { "core_name": "团块", "tendency": "", "character": [ "病灶有强化" ], "anatomy_list": [ "双肺上叶" ] } ] }, { "id": 1176, "text": "患者遂于2014年7月1日就诊于某医院胃肠外科，入院查血常规提示：白细胞总数383.40×109/l，红细胞计数2.53×1012/l，血红蛋白79g/L，血小板492×109/l，幼稚细胞百分比45%；腹部超声：胆囊息肉样病变；脾大；左肾囊性占位性病变（囊肿）；左上腹上腹部“包块”处探及增大的脾脏。", "event": [ { "core_name": "病变", "tendency": "", "character": [ "息肉样" ], "anatomy_list": [ "胆囊" ] }, { "core_name": "增大", "tendency": "", "character": [], "anatomy_list": [ "脾" ] }, { "core_name": "病变", "tendency": "", "character": [ "囊性", "占位性" ], "anatomy_list": [ "左肾" ] }, { "core_name": "囊肿", "tendency": "", "character": [], "anatomy_list": [ "左肾" ] }, { "core_name": "包块", "tendency": "", "character": [], "anatomy_list": [ "左上腹部" ] }, { "core_name": "增大", "tendency": "", "character": [], "anatomy_list": [ "脾脏" ] } ] }, { "id": 1344, "text": "术后出现小肝综合征，予以静脉营养支持、保肝利胆、输注人血白蛋白、间断小剂量输注新鲜冰冻血浆后肝功能逐渐恢复正常，其后患者无胸闷和心悸，无腹胀和腹痛，无腹泻和便血，无畏寒和发热，无眼黄、身黄，无闷油、乏力、纳差。", "event": [ { "core_name": "小肝综合征", "tendency": "", "character": [], "anatomy_list": [ "肝" ] }, { "core_name": "肝功能", "tendency": "", "character": [ "逐渐恢复正常" ], "anatomy_list": [ "肝" ] }, { "core_name": "胸闷", "tendency": "否定", "character": [], "anatomy_list": [ "胸" ] }, { "core_name": "心悸", "tendency": "否定", "character": [], "anatomy_list": [ "心" ] }, { "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": "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": "黄染", "tendency": "否定", "character": [], "anatomy_list": [ "眼" ] }, { "core_name": "黄染", "tendency": "否定", "character": [], "anatomy_list": [ "身" ] }, { "core_name": "乏力", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "闷油", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "纳差", "tendency": "否定", "character": [], "anatomy_list": [] } ] }, { "id": 906, "text": "为求进一步治疗，今来我院就诊，门诊以“右侧髋关节滑膜炎？”入院。", "event": [ { "core_name": "滑膜炎", "tendency": "不确定", "character": [], "anatomy_list": [ "右侧髋关节滑膜" ] } ] }, { "id": 1533, "text": "入院前20+年，患者无明显诱因出现咳嗽、咳痰，咳白色泡沫痰，并逐年加重，伴心累、气促，稍活动后明显，无胸痛、胸闷、无咯血等，于院外诊断为\"慢性阻塞性肺疾病\"，未规范治疗，8+月前，患者因受凉后出现声音嘶哑，患者遂于肿瘤医院行胸部ct、纤支镜+活检检查，诊断为\"左肺鳞癌\"；建议患者住院进一步治疗，患者回家安排后分别于06月02日、06月29日，在我科住院，予以\"tp\"方案化疗第1、2周期（药物总量：紫杉醇 400mg 顺铂 160mg），化疗过程中患者无明显恶心、呕吐、发热、身痛等不适，门诊随访血常规未见明显异常，建议其可规律化疗，但患者本人拒绝。", "event": [ { "core_name": "咳嗽", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "白色", "泡沫", "逐年加重" ], "anatomy_list": [] }, { "core_name": "心累", "tendency": "", "character": [ "稍活动后", "明显" ], "anatomy_list": [ "心" ] }, { "core_name": "气促", "tendency": "", "character": [ "稍活动后", "明显" ], "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": "咯血", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "慢性阻塞性肺疾病", "tendency": "", "character": [ "慢性", "阻塞性" ], "anatomy_list": [ "肺" ] }, { "core_name": "声音嘶哑", "tendency": "", "character": [ "受凉后" ], "anatomy_list": [] }, { "core_name": "鳞癌", "tendency": "", "character": [], "anatomy_list": [ "左肺" ] }, { "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": "发热", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [ "身" ] } ] }, { "id": 1136, "text": "患者本次发病以来，食欲下降，神志清醒，精神欠佳，睡眠尚可，大便正常，体重减少3kg。", "event": [ { "core_name": "食欲", "tendency": "", "character": [ "下降" ], "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": [ "尚可" ], "anatomy_list": [] }, { "core_name": "大便", "tendency": "", "character": [ "正常" ], "anatomy_list": [] }, { "core_name": "体重", "tendency": "", "character": [ "减轻" ], "anatomy_list": [] } ] }, { "id": 495, "text": "二便正常，体重无明显减轻。", "event": [ { "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": 319, "text": "患者1+年前于我科在局部浸润麻醉下行前列腺活检穿刺，病检回示：前列腺癌。", "event": [ { "core_name": "癌", "tendency": "", "character": [], "anatomy_list": [ "前列腺" ] } ] }, { "id": 2032, "text": "现患者为求进一步治疗右肩背部肿物而来我院入我科。", "event": [ { "core_name": "肿物", "tendency": "", "character": [], "anatomy_list": [ "右肩背部" ] } ] }, { "id": 1549, "text": "起病前无受凉感冒。", "event": [ { "core_name": "感冒", "tendency": "否定", "character": [], "anatomy_list": [] } ] }, { "id": 54, "text": "另送（腹主动脉旁及肠系膜下）淋巴结均见癌转移（均为1/1）。", "event": [ { "core_name": "癌", "tendency": "", "character": [ "转移" ], "anatomy_list": [ "腹主动脉旁淋巴结", "肠系膜下淋巴结" ] } ] }, { "id": 1463, "text": "15+年患者出现心前区不适，呈紧缩感，发作时伴有呼吸困难，间断使用药物治疗（具体不详），但症状反复。", "event": [ { "core_name": "心前区不适", "tendency": "", "character": [ "呈紧缩感" ], "anatomy_list": [ "心前区" ] }, { "core_name": "呼吸困难", "tendency": "", "character": [], "anatomy_list": [] } ] }, { "id": 244, "text": "腰椎mri(我院，2016-07-26）提示：腰4-5水平椎管内占位性病变，其上方椎管内可见较多迂曲血管影，请结合增强mri检查。", "event": [ { "core_name": "病变", "tendency": "", "character": [ "占位性" ], "anatomy_list": [ "腰椎L4-5水平椎管内" ] }, { "core_name": "血管影", "tendency": "", "character": [ "较多", "迂曲" ], "anatomy_list": [ "腰椎L4-5水平上方椎管内" ] } ] }, { "id": 393, "text": "术后患者胆漏，引流管无液体引出，于10月15日局麻下行了腹腔穿刺引流术，术后恢复可；未促进瘘口好转，于10月25日咽部局麻下行了ercp术，但患者瘘口偏外，支架自行脱出，患者胆汁引流少。", "event": [ { "core_name": "胆漏", "tendency": "", "character": [ "术后" ], "anatomy_list": [ "胆" ] }, { "core_name": "液体引出", "tendency": "否定", "character": [ "引流管" ], "anatomy_list": [] }, { "core_name": "瘘口", "tendency": "", "character": [ "未促进", "好转" ], "anatomy_list": [] }, { "core_name": "瘘口", "tendency": "", "character": [ "偏外" ], "anatomy_list": [] }, { "core_name": "支架脱出", "tendency": "", "character": [ "自行" ], "anatomy_list": [] }, { "core_name": "引流", "tendency": "", "character": [ "胆汁", "少" ], "anatomy_list": [] } ] }, { "id": 1614, "text": "请我院妇科妇检会诊后诊断“宫颈鳞癌iia期”。", "event": [ { "core_name": "鳞癌", "tendency": "", "character": [ "iia期" ], "anatomy_list": [ "宫颈" ] } ] }, { "id": 179, "text": "某医院行脊柱mri（2020-1-22）：颈33/4-6/7椎间盘变性、突出；腰33/4椎间盘变性、突出；胸椎部分黄韧带增厚；腰2、3椎体及腹膜后异常信号，考虑转移；左侧中下腹部腹部占位性病变，考虑恶性肿瘤并腹膜后淋巴结转移可能，左肾积水。", "event": [ { "core_name": "变性", "tendency": "", "character": [], "anatomy_list": [ "颈椎C3/4-6/7椎间盘" ] }, { "core_name": "突出", "tendency": "", "character": [], "anatomy_list": [ "颈椎C3/4-6/7椎间盘" ] }, { "core_name": "变性", "tendency": "", "character": [], "anatomy_list": [ "腰椎L3/4椎间盘" ] }, { "core_name": "突出", "tendency": "", "character": [], "anatomy_list": [ "腰椎L3/4椎间盘" ] }, { "core_name": "增厚", "tendency": "", "character": [ "部分" ], "anatomy_list": [ "胸椎部分黄韧带" ] }, { "core_name": "信号异常", "tendency": "", "character": [], "anatomy_list": [ "腰椎L2、3椎体", "腹膜后" ] }, { "core_name": "转移", "tendency": "不确定", "character": [], "anatomy_list": [] }, { "core_name": "病变", "tendency": "", "character": [ "占位性" ], "anatomy_list": [ "左侧中下腹部" ] }, { "core_name": "肿瘤", "tendency": "不确定", "character": [ "恶性" ], "anatomy_list": [] }, { "core_name": "转移", "tendency": "不确定", "character": [], "anatomy_list": [ "腹膜后淋巴结" ] }, { "core_name": "积水", "tendency": "", "character": [], "anatomy_list": [ "左肾" ] } ] }, { "id": 1090, "text": "2.（直肠）溃疡型中-低分化管状腺癌，浸及肠壁深肌层，脉管内见癌栓。", "event": [ { "core_name": "腺癌", "tendency": "", "character": [ "溃疡型", "管状", "中-低分化", "浸及肠壁深肌层" ], "anatomy_list": [ "直肠", "直肠壁深肌层" ] }, { "core_name": "癌栓", "tendency": "", "character": [], "anatomy_list": [ "脉管内" ] } ] }, { "id": 1766, "text": "入院1+年前，患者洗澡时扪及右侧腋窝腋窝下一大小约4x5cm大小包块，质硬，表面光滑，活动度差，无压痛、分泌物，就诊于某医院，诊断乳腺癌并行右乳癌改良根治术。", "event": [ { "core_name": "包块", "tendency": "", "character": [ "质硬", "表面光滑", "活动度差", "无压痛", "分泌物" ], "anatomy_list": [ "右侧腋窝下" ] }, { "core_name": "癌", "tendency": "", "character": [], "anatomy_list": [ "乳腺" ] } ] }, { "id": 797, "text": "患者于2012-3-30日在全麻下行剖腹探查+胰十二指肠切除术，手术顺利，术后病理提示：1.壶腹部中分化腺癌，浸及肌层，脉管、神经未见癌侵犯，十二指肠、胰腺、胃未见癌累及，胃大弯淋巴结未见癌转移（0/1）；2.（胆总管）未见癌累及；3.慢性胆囊炎急性发作，胆囊多发性胆固醇性息肉，胆囊腺肌症；4.（肝门部淋巴结）未见癌转移（0/1）。", "event": [ { "core_name": "腺癌", "tendency": "", "character": [ "中分化", "浸及肌层" ], "anatomy_list": [ "壶腹部" ] }, { "core_name": "癌", "tendency": "否定", "character": [ "侵犯" ], "anatomy_list": [ "脉管", "神经" ] }, { "core_name": "癌", "tendency": "否定", "character": [ "累及" ], "anatomy_list": [ "十二指肠", "胰腺", "胃" ] }, { "core_name": "癌", "tendency": "否定", "character": [ "转移" ], "anatomy_list": [ "胃大弯淋巴结" ] }, { "core_name": "癌", "tendency": "否定", "character": [ "累及" ], "anatomy_list": [ "胆总管" ] }, { "core_name": "胆囊炎", "tendency": "", "character": [ "慢性", "急性发作" ], "anatomy_list": [ "胆囊" ] }, { "core_name": "息肉", "tendency": "", "character": [ "多发性", "胆固醇性" ], "anatomy_list": [ "胆囊" ] }, { "core_name": "腺肌症", "tendency": "", "character": [], "anatomy_list": [ "胆囊" ] }, { "core_name": "癌", "tendency": "否定", "character": [ "转移" ], "anatomy_list": [ "肝门淋巴结" ] } ] }, { "id": 550, "text": "入院前3+年，患者无明显有诱因出现全身多关节肿痛，偶有晨僵，无明显皮肤潮红、皮温升高，无面部蝶形红斑、光敏反应，无雷诺现象，无反复口腔溃疡，无明显脱发，无畏寒、发热、寒战，无胸闷、心悸，无活动后心累、气促、夜间阵发性呼吸困难，无腰痛、少尿、肉眼血尿，无肢体水肿等表现，患者遂间断口服中药调理，关节肿痛可缓解，但反复发作，关节肿痛逐渐加重。", "event": [ { "core_name": "肿痛", "tendency": "", "character": [ "多" ], "anatomy_list": [ "全身", "关节" ] }, { "core_name": "晨僵", "tendency": "", "character": [ "偶有" ], "anatomy_list": [ "全身", "关节" ] }, { "core_name": "潮红", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [ "皮肤" ] }, { "core_name": "皮温", "tendency": "否定", "character": [ "升高", "明显" ], "anatomy_list": [] }, { "core_name": "红斑", "tendency": "否定", "character": [ "蝶形" ], "anatomy_list": [ "面部" ] }, { "core_name": "光敏反应", "tendency": "否定", "character": [], "anatomy_list": [ "面部" ] }, { "core_name": "雷诺现象", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "溃疡", "tendency": "否定", "character": [ "反复" ], "anatomy_list": [ "口腔" ] }, { "core_name": "脱发", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [] }, { "core_name": "畏寒", "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": "胸闷", "tendency": "否定", "character": [], "anatomy_list": [ "胸" ] }, { "core_name": "心悸", "tendency": "否定", "character": [], "anatomy_list": [ "心" ] }, { "core_name": "心累", "tendency": "否定", "character": [ "活动后" ], "anatomy_list": [] }, { "core_name": "气促", "tendency": "否定", "character": [ "活动后" ], "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": [ "腰" ] }, { "core_name": "少尿", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "血尿", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "水肿", "tendency": "否定", "character": [], "anatomy_list": [ "肢体" ] }, { "core_name": "肿痛", "tendency": "", "character": [ "可缓解" ], "anatomy_list": [ "关节" ] }, { "core_name": "肿痛", "tendency": "", "character": [ "逐渐加重", "反复发作" ], "anatomy_list": [ "关节" ] } ] }, { "id": 1069, "text": "为进一步诊疗，患者于某医院复核提示：（左腹股沟）非霍奇金淋巴瘤，结合免疫组化符合弥漫大b细胞淋巴瘤（生发中心型），免疫组化：ck（-）、plap（-）、cd3散（+）、bcl-6（-）、mum-1散在（+）、cd20（+）、ki676760%（+）、ema（-）、alk（-）、melana（-）、s100（-）、cd30（-）、cd10（+）、lca（+）。", "event": [ { "core_name": "瘤", "tendency": "", "character": [ "非霍奇金" ], "anatomy_list": [ "左腹股沟", "淋巴" ] }, { "core_name": "瘤", "tendency": "", "character": [ "弥漫性", "生发中心型" ], "anatomy_list": [ "左腹股沟", "淋巴", "大B细胞" ] } ] }, { "id": 884, "text": "于2020-03-07就诊于我院感染科，肿瘤标志物ca19-9、cea明显升高，考虑胃肠道肿瘤，进一步完善全胸腹部增强ct：1、升结肠占位，考虑肿瘤性病变可能性大：结肠癌？伴肝内多发转移、邻近右侧膈肌膈肌受侵可能，腹膜后多发淋巴结显示伴部分增大，盆腔积液。", "event": [ { "core_name": "肿瘤标志物ca19-9", "tendency": "", "character": [ "明显升高" ], "anatomy_list": [] }, { "core_name": "肿瘤标志物cea", "tendency": "", "character": [ "" ], "anatomy_list": [] }, { "core_name": "肿瘤", "tendency": "不确定", "character": [], "anatomy_list": [ "胃肠道" ] }, { "core_name": "占位", "tendency": "", "character": [], "anatomy_list": [ "升结肠" ] }, { "core_name": "病变", "tendency": "不确定", "character": [ "肿瘤性" ], "anatomy_list": [ "升结肠" ] }, { "core_name": "癌", "tendency": "不确定", "character": [], "anatomy_list": [ "结肠" ] }, { "core_name": "转移", "tendency": "", "character": [ "多发" ], "anatomy_list": [ "肝内" ] }, { "core_name": "受侵", "tendency": "不确定", "character": [], "anatomy_list": [ "近邻右侧膈肌" ] }, { "core_name": "增大", "tendency": "", "character": [ "部分" ], "anatomy_list": [ "腹膜后淋巴结" ] }, { "core_name": "积液", "tendency": "", "character": [], "anatomy_list": [ "盆腔" ] } ] }, { "id": 485, "text": "建议至我科就诊，今日门诊以“结外边缘区淋巴瘤”收住院。", "event": [ { "core_name": "瘤", "tendency": "", "character": [], "anatomy_list": [ "结外边缘区", "淋巴" ] } ] }, { "id": 1019, "text": "一个多月前患者感时有头昏、视物模糊，活动时加重，3天前晚上患者发作眩晕，视物旋转，伴右耳痛，休息后眩晕好转，但活动后仍感行走不稳。", "event": [ { "core_name": "头昏", "tendency": "", "character": [ "时有", "活动时加重" ], "anatomy_list": [ "头" ] }, { "core_name": "视物模糊", "tendency": "", "character": [ "时有", "活动时加重" ], "anatomy_list": [] }, { "core_name": "眩晕", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "视物旋转", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "", "character": [], "anatomy_list": [ "右耳" ] }, { "core_name": "眩晕", "tendency": "", "character": [ "休息后好转" ], "anatomy_list": [] }, { "core_name": "行走", "tendency": "", "character": [ "不稳", "活动后" ], "anatomy_list": [] } ] }, { "id": 476, "text": "患者平素日常活动后无明显气促、喘累，无夜间阵发性呼吸困难，不咳粉红色泡沫痰。", "event": [ { "core_name": "气促", "tendency": "否定", "character": [ "活动后", "明显" ], "anatomy_list": [] }, { "core_name": "喘累", "tendency": "否定", "character": [ "活动后", "明显" ], "anatomy_list": [] }, { "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": [] } ] }, { "id": 341, "text": "伴肛门坠胀 ， 不伴肛门肿物脱出 ， 不伴眩晕、黑蒙 ， 患者不伴纳差、乏力 ， 不伴恶心、呕吐 ， 不伴畏寒、发热 ， 不伴反酸、嗳气 ， 无咳嗽、咳痰 ， 无胸闷、心悸 ， 无尿频、尿急、尿痛 ， 不伴腹胀等症状 。", "event": [ { "core_name": "坠胀", "tendency": "", "character": [], "anatomy_list": [ "肛门" ] }, { "core_name": "肿物脱出", "tendency": "否定", "character": [], "anatomy_list": [ "肛门" ] }, { "core_name": "眩晕", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "黑朦", "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": [] }, { "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": "反酸", "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": "胸闷", "tendency": "否定", "character": [], "anatomy_list": [ "胸" ] }, { "core_name": "心悸", "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": "尿痛", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "腹胀", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] } ] }, { "id": 90, "text": "5年前患者于外院行辅助检查提示“肝硬化”诊断（具体不详），遵医嘱予以“替比夫定”抗病毒治疗，后患者于我院门诊复诊后调整为口服“恩替卡韦”抗病毒治疗。", "event": [ { "core_name": "硬化", "tendency": "", "character": [], "anatomy_list": [ "肝" ] } ] }, { "id": 1834, "text": "4月前患者感头昏症状加重，每日早晨及午睡后头昏较轻，此后1-2小时后头昏症状逐渐加重，感夜间头昏症状最明显，偶有自觉行走站立不稳，并诉头昏严重时自测血压159/95mmHg，头昏缓解时血压139/85mmHg，无恶心、呕吐、眩晕、耳鸣、头痛、单侧肢体乏力、黑蒙、手抖、饮水呛咳等，今日患者仍感上诉症状无明显缓解，未进一步治疗，遂入我科。", "event": [ { "core_name": "头昏", "tendency": "", "character": [ "加重" ], "anatomy_list": [ "头" ] }, { "core_name": "头昏", "tendency": "", "character": [ "早晨及午睡后较轻", "此后1-2小时后逐渐加重" ], "anatomy_list": [ "头" ] }, { "core_name": "头昏", "tendency": "", "character": [ "夜间最明显" ], "anatomy_list": [ "头" ] }, { "core_name": "站立不稳", "tendency": "", "character": [ "偶有" ], "anatomy_list": [] }, { "core_name": "行走不稳", "tendency": "", "character": [ "偶有" ], "anatomy_list": [] }, { "core_name": "恶心", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "呕吐", "tendency": "否定", "character": [], "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": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "头" ] }, { "core_name": "乏力", "tendency": "否定", "character": [], "anatomy_list": [ "单侧肢体" ] }, { "core_name": "黑朦", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "手抖", "tendency": "否定", "character": [], "anatomy_list": [ "手" ] }, { "core_name": "呛咳", "tendency": "否定", "character": [ "饮水" ], "anatomy_list": [] } ] }, { "id": 570, "text": "纤支镜检查：右上叶支气管被新生物完全阻塞，新生物表现血管迂曲、丰富，周围粘膜呈浸润样改变，累计右侧亚隆突、中间支气管，于镜下活检，病理活检及免疫组化：<右支气管>恶性肿瘤，结合组织学形态，倾向于小细胞癌，免疫组化：ck（+），ema（+），napsina（-），p63（-），p40（-），cga（+），syn（+），cd56（+），ki6790%（+），ttf-1（+）。", "event": [ { "core_name": "阻塞", "tendency": "", "character": [ "完全", "被新生物" ], "anatomy_list": [ "右上叶支气管" ] }, { "core_name": "新生物", "tendency": "", "character": [ "血管迂曲", "血管丰富", "累及右侧亚隆突、中间支气管" ], "anatomy_list": [ "右上叶支气管" ] }, { "core_name": "改变", "tendency": "", "character": [ "浸润样" ], "anatomy_list": [ "右上叶支气管周围粘膜" ] }, { "core_name": "肿瘤", "tendency": "", "character": [ "恶性" ], "anatomy_list": [ "右支气管" ] }, { "core_name": "癌", "tendency": "不确定", "character": [], "anatomy_list": [ "右支气管", "小细胞" ] } ] }, { "id": 938, "text": "入院前2+年，患者无明显诱因出现右下肢不自主抖动、麻木、僵硬，无头痛、呕吐，无肢体活动障碍，无意识障碍、大小便失禁，无失语、幻听等不适，后患者觉上述症状加重，2018-6-6就诊于某医院，行头颅ct示左侧额、顶叶占位，2018-6-9就诊于某医院行胸部ct示：右肺上叶新生物，大小约2.0*2.4cm，纵膈内见稍大淋巴结。", "event": [ { "core_name": "抖动", "tendency": "", "character": [ "不自主" ], "anatomy_list": [ "右下肢" ] }, { "core_name": "麻木", "tendency": "", "character": [], "anatomy_list": [ "右下肢" ] }, { "core_name": "僵硬", "tendency": "", "character": [], "anatomy_list": [ "右下肢" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "头" ] }, { "core_name": "呕吐", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "活动障碍", "tendency": "否定", "character": [], "anatomy_list": [ "肢体" ] }, { "core_name": "意识障碍", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "大小便", "tendency": "否定", "character": [ "失禁" ], "anatomy_list": [] }, { "core_name": "失语", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "幻听", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "占位", "tendency": "", "character": [], "anatomy_list": [ "左侧额叶" ] }, { "core_name": "占位", "tendency": "", "character": [], "anatomy_list": [ "左侧顶叶" ] }, { "core_name": "新生物", "tendency": "", "character": [], "anatomy_list": [ "右肺上叶" ] }, { "core_name": "淋巴结大", "tendency": "", "character": [ "稍大" ], "anatomy_list": [ "纵膈内" ] } ] }, { "id": 753, "text": "完善ect检查提示骨转移，征得患者及其家属同意后，分别于2015-01-22、2015-02-12、2015-03-11、2015-04-01、2015-04-22、2015-05-13、2015-06-10、2015-07-08予以tp方案化疗8周期，期间曾复查提示肿瘤较前缩小，但未达cr，评估为sd，8期化疗结束后复查ct(2015-07-12):1.右下肺肺门肿块影，考虑肿瘤性病变，伴阻塞性肺炎。", "event": [ { "core_name": "转移", "tendency": "", "character": [ "转移" ], "anatomy_list": [ "骨" ] }, { "core_name": "肿瘤", "tendency": "", "character": [ "较前缩小", "未达cr", "评估为sd" ], "anatomy_list": [] }, { "core_name": "肿块影", "tendency": "", "character": [], "anatomy_list": [ "右下肺门" ] }, { "core_name": "病变", "tendency": "不确定", "character": [ "肿瘤性" ], "anatomy_list": [ "右下肺门" ] }, { "core_name": "肺炎", "tendency": "", "character": [ "阻塞性" ], "anatomy_list": [ "肺" ] } ] }, { "id": 1875, "text": "15天前，患者无明显诱因出现中上腹上腹痛，为阵发性隐痛，疼痛程度较轻，患者尚可忍受，疼痛持续时间约1分1分钟后自行缓解，与体位变化、进食无关，伴后背部放射痛，伴恶心、嗳气，无呕吐、呃逆，无胸痛、胸闷、心前区压榨感，无烧心、反酸、腹胀，无呕血、黑便、血便，无畏寒、发热、黄疸等症状，患者未重视。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [], "anatomy_list": [ "中上腹" ] }, { "core_name": "疼痛", "tendency": "", "character": [ "阵发性", "隐痛" ], "anatomy_list": [ "中上腹" ] }, { "core_name": "疼痛", "tendency": "", "character": [ "程度较轻", "可忍受" ], "anatomy_list": [ "腹部" ] }, { "core_name": "疼痛", "tendency": "", "character": [ "约1分钟后自行缓解", "与体位变化、进食无关" ], "anatomy_list": [ "腹部" ] }, { "core_name": "疼痛", "tendency": "", "character": [ "放射性" ], "anatomy_list": [ "后背部" ] }, { "core_name": "恶心", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "嗳气", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "呕吐", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "打嗝", "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": "压榨感", "tendency": "否定", "character": [], "anatomy_list": [ "心前区" ] }, { "core_name": "烧心", "tendency": "否定", "character": [], "anatomy_list": [ "心" ] }, { "core_name": "返酸", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "腹胀", "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": "血便", "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": "黄疸", "tendency": "否定", "character": [], "anatomy_list": [] } ] }, { "id": 489, "text": "术后病检（123456）结果回报：（左乳）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": [ "左乳" ] } ] }, { "id": 1340, "text": "<门静脉右支血管壁>未见癌组织。", "event": [ { "core_name": "癌组织", "tendency": "否定", "character": [], "anatomy_list": [ "门静脉右支血管壁" ] } ] }, { "id": 1799, "text": "自发病以来，患者精神、食欲尚可，嗜睡，大便、大便正常，小便夜尿次数多，约4~5次。", "event": [ { "core_name": "精神", "tendency": "", "character": [ "尚可" ], "anatomy_list": [] }, { "core_name": "食欲", "tendency": "", "character": [ "尚可" ], "anatomy_list": [] }, { "core_name": "嗜睡", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "大便", "tendency": "", "character": [ "正常" ], "anatomy_list": [] }, { "core_name": "小便", "tendency": "", "character": [ "正常" ], "anatomy_list": [] }, { "core_name": "夜尿次数多", "tendency": "", "character": [], "anatomy_list": [] } ] }, { "id": 1235, "text": "急诊科请我科会诊后以“肠扭转”收入我科。", "event": [ { "core_name": "扭转", "tendency": "", "character": [], "anatomy_list": [ "肠" ] } ] }, { "id": 921, "text": "无明显腰腹部疼痛，无畏寒、发热，无尿频、尿急、尿痛，无血尿，无恶心、呕吐，无腹胀、腹泻等临床表现。", "event": [ { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "腰", "腹" ] }, { "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": "血尿", "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" ] } ] }, { "id": 1133, "text": "2、肝内外胆管多发结石，胆囊增大伴胆囊底部结石可能。", "event": [ { "core_name": "结石", "tendency": "", "character": [ "多发" ], "anatomy_list": [ "肝内外胆管" ] }, { "core_name": "增大", "tendency": "不确定", "character": [], "anatomy_list": [ "胆囊" ] }, { "core_name": "结石", "tendency": "不确定", "character": [], "anatomy_list": [ "胆囊底部" ] } ] }, { "id": 1878, "text": "入院前10年，患者无明显诱因出现烦渴、多饮、多尿，每日饮水量3000ml，饮水量与尿量相当，伴全身乏力乏力不适，无双下肢麻木，无易饥多食，无视物模糊，无腹痛、腹泻，无心前区疼痛、活动后心累、气促，大便正常，患者于某医院就诊，查得血糖高（具体不详），诊断为2型糖尿病（具体不详），给予二甲双胍、消渴丸等降糖治疗(具体方案及剂量不详），服药期间未规律监测血糖，期间患者偶测得血糖偏高。", "event": [ { "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": "乏力", "tendency": "", "character": [], "anatomy_list": [ "全身" ] }, { "core_name": "全身不适", "tendency": "", "character": [], "anatomy_list": [ "全身" ] }, { "core_name": "麻木", "tendency": "", "character": [], "anatomy_list": [ "双下肢" ] }, { "core_name": "易饥多食", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "视物模糊", "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": [ "心前区" ] }, { "core_name": "心累", "tendency": "否定", "character": [ "活动后" ], "anatomy_list": [ "心" ] }, { "core_name": "气促", "tendency": "否定", "character": [ "活动后" ], "anatomy_list": [] }, { "core_name": "大便", "tendency": "", "character": [ "正常" ], "anatomy_list": [] }, { "core_name": "血糖", "tendency": "", "character": [ "偏高" ], "anatomy_list": [] }, { "core_name": "糖尿病", "tendency": "", "character": [ "2型" ], "anatomy_list": [] }, { "core_name": "血糖", "tendency": "", "character": [ "高" ], "anatomy_list": [] } ] }, { "id": 1496, "text": "入院前6+月，患者无明显诱因出现头昏、乏力，伴活动后心累、气促，伴视物模糊，无头痛、晕厥，无牙龈出血、鼻出血，无恶心、呕吐，无呕血、便血，无畏寒、发热，无咳嗽、咳痰，无血尿等不适，于某医院就诊，完善血常规考虑诊断为“重度贫血原因待查”，予以输血等对症治疗（具体不详）后患者头昏、乏力症状稍好转，但贫血原因未明确，建议转上级医院治疗。", "event": [ { "core_name": "头昏", "tendency": "", "character": [], "anatomy_list": [ "头" ] }, { "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": [] }, { "core_name": "视物模糊", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "头" ] }, { "core_name": "晕厥", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "出血", "tendency": "否定", "character": [], "anatomy_list": [ "牙龈" ] }, { "core_name": "出血", "tendency": "否定", "character": [], "anatomy_list": [ "鼻" ] }, { "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": "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": "咳嗽", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "血尿", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "贫血", "tendency": "不确定", "character": [ "重度" ], "anatomy_list": [] }, { "core_name": "头昏", "tendency": "", "character": [ "稍好转" ], "anatomy_list": [ "头" ] }, { "core_name": "乏力", "tendency": "", "character": [ "稍好转" ], "anatomy_list": [] }, { "core_name": "贫血", "tendency": "", "character": [], "anatomy_list": [] } ] }, { "id": 2023, "text": "症状未见明显好转，于今日来我院就诊，门诊以“前列腺癌”收入我科治疗。", "event": [ { "core_name": "癌", "tendency": "", "character": [], "anatomy_list": [ "前列腺" ] } ] }, { "id": 1619, "text": "胸部ct平扫：1.右肺下叶前基底段实性结节，右肺中叶血管旁及胸膜下、右肺下叶背段微结节，建议随诊。", "event": [ { "core_name": "结节", "tendency": "", "character": [ "实性" ], "anatomy_list": [ "右肺下叶前基底段" ] }, { "core_name": "结节", "tendency": "", "character": [ "微" ], "anatomy_list": [ "右肺旁下下叶背段" ] }, { "core_name": "结节", "tendency": "", "character": [ "微" ], "anatomy_list": [ "右肺中叶血管旁" ] }, { "core_name": "结节", "tendency": "", "character": [ "微" ], "anatomy_list": [ "胸膜下" ] } ] }, { "id": 1696, "text": "否认关节疼痛、脱发、皮疹病史。", "event": [ { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "关节" ] }, { "core_name": "脱发", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "皮疹", "tendency": "否定", "character": [], "anatomy_list": [ "皮" ] } ] }, { "id": 1666, "text": "常规病理检查报告：肝组织内恶性肿瘤，待免疫组化进一步检查确诊。周围肝组织部分区域脂肪变。", "event": [ { "core_name": "肿瘤", "tendency": "", "character": [ "恶性" ], "anatomy_list": [ "肝组织内" ] }, { "core_name": "脂肪变", "tendency": "", "character": [ "部分区域" ], "anatomy_list": [ "周围肝组织" ] } ] }, { "id": 1505, "text": "入院前2+月患儿因出血、贫血及发热在我院经骨髓micm分型确诊为确诊急性普通b淋巴细胞淋巴细胞白血病l11型（tel/aml1阳性，低危）。", "event": [ { "core_name": "出血", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "贫血", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "发热", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "白血病", "tendency": "", "character": [ "急性", "普通", "l11型", "tel/aml1阳性", "低危" ], "anatomy_list": [ "b淋巴细胞" ] } ] }, { "id": 84, "text": "术后病理示：左乳浸润性导管癌（Ⅲ级，8分）腋窝淋巴结未见癌转移（0/13）。", "event": [ { "core_name": "导管癌", "tendency": "", "character": [ "浸润性" ], "anatomy_list": [ "左乳" ] }, { "core_name": "癌", "tendency": "否定", "character": [ "转移" ], "anatomy_list": [ "腋窝淋巴结" ] } ] }, { "id": 127, "text": "入院前3月，患者因“发现左乳包块2+年”入院。", "event": [ { "core_name": "包块", "tendency": "", "character": [], "anatomy_list": [ "左乳" ] } ] }, { "id": 158, "text": "3+年患者无明显诱因出现腰臀部阵发性胀痛，久行、弯腰可诱发疼痛加重，休息后减轻，无双下肢麻木、疼痛和乏力，无尿频、尿急及肉眼血尿，当时曾在我科就诊，经行腰椎mri等检查后，诊断为“腰椎间盘突出症”，自行在外理疗后缓解，7天前，患者上述症状无明显诱因加重，并伴左下肢疼痛，于今日来我科诊治，门诊以\"胸背部疼痛待查\"收入住院。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [ "阵发性", "胀痛", "久行弯腰可诱发加重", "休息后减轻" ], "anatomy_list": [ "腰部", "臀部" ] }, { "core_name": "麻木", "tendency": "否定", "character": [], "anatomy_list": [ "双下肢" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "双下肢" ] }, { "core_name": "乏力", "tendency": "否定", "character": [], "anatomy_list": [ "双下肢" ] }, { "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": "否定", "character": [], "anatomy_list": [] }, { "core_name": "突出", "tendency": "", "character": [], "anatomy_list": [ "腰椎间盘" ] }, { "core_name": "疼痛", "tendency": "", "character": [], "anatomy_list": [ "左下肢" ] }, { "core_name": "疼痛", "tendency": "不确定", "character": [], "anatomy_list": [ "胸背部" ] } ] }, { "id": 1374, "text": "后患者双下肢水肿反复发作。", "event": [ { "core_name": "水肿", "tendency": "", "character": [ "反复发作" ], "anatomy_list": [ "双下肢" ] } ] }, { "id": 1210, "text": "7.双侧盆壁、腹股沟区淋巴结肿大。", "event": [ { "core_name": "肿大", "tendency": "", "character": [], "anatomy_list": [ "双侧盆壁淋巴结", "腹股沟区淋巴结" ] } ] }, { "id": 1388, "text": "入院前3+月患者因受凉后开始出现声嘶，为间断性，伴咽喉部不适、咽喉部异物感，无咳嗽、咳痰，无咽喉疼痛、咯血、胸痛、呼吸困难、吞咽梗阻、吞咽疼痛等症状，声嘶在长时间说话加重，休息后声嘶可稍缓解。", "event": [ { "core_name": "声嘶", "tendency": "", "character": [ "间断性" ], "anatomy_list": [] }, { "core_name": "咽喉部不适", "tendency": "", "character": [], "anatomy_list": [ "咽喉部" ] }, { "core_name": "异物感", "tendency": "", "character": [], "anatomy_list": [ "咽喉部" ] }, { "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": [ "咽喉" ] }, { "core_name": "咯血", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "胸" ] }, { "core_name": "呼吸困难", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "梗阻", "tendency": "否定", "character": [ "吞咽" ], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "否定", "character": [ "吞咽" ], "anatomy_list": [] }, { "core_name": "声嘶", "tendency": "", "character": [ "休息后稍缓解", "长时间说话加重" ], "anatomy_list": [] } ] }, { "id": 332, "text": "患者昨日已解出大便4次。", "event": [ { "core_name": "大便", "tendency": "", "character": [ "4次" ], "anatomy_list": [] } ] }, { "id": 799, "text": "3天前，患者无明显诱因出现腰背部疼痛，呈持续性胀痛，疼痛明显，翻身、起床、睡下困难。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [], "anatomy_list": [ "腰背部" ] }, { "core_name": "疼痛", "tendency": "", "character": [ "持续性", "胀痛" ], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "", "character": [ "明显" ], "anatomy_list": [] }, { "core_name": "翻身困难", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "起床困难", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "睡下困难", "tendency": "", "character": [], "anatomy_list": [] } ] }, { "id": 1451, "text": "2016年6月患者随访复查ct提示局部病灶增大，afp异常升高（具体不详），遂入某医院，行肝右叶肿瘤切除术（具体不详），术后病检提示原发性肝细胞性腺癌（未见原报告）。", "event": [ { "core_name": "病灶", "tendency": "", "character": [ "局部", "增大" ], "anatomy_list": [] }, { "core_name": "腺癌", "tendency": "", "character": [ "原发性", "肝细胞性" ], "anatomy_list": [ "肝" ] } ] }, { "id": 1535, "text": "2+月前，患者出现胸痛，为持续性胀痛，无明显加重及缓解因素，伴咳嗽、咳痰，考虑诊断为“左肺鳞癌4周期化疗后伴纵膈淋巴结、肺内、骨转移”，给予口服“羟考酮”对症处理，患者仍诉胸痛明显，“羟考酮”剂量逐日增加至240mg q12h，其胸痛仍缓解不明显，后于我院住院治疗给予皮下注射“盐酸吗啡注射液 50mg q12h”后疼痛缓解。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [ "持续性胀痛", "无明显加重及缓解因素" ], "anatomy_list": [ "胸" ] }, { "core_name": "咳嗽", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "鳞癌", "tendency": "不确定", "character": [ "化疗后" ], "anatomy_list": [ "左肺" ] }, { "core_name": "癌", "tendency": "不确定", "character": [ "转移" ], "anatomy_list": [ "纵膈淋巴结", "肺内", "骨" ] }, { "core_name": "疼痛", "tendency": "", "character": [ "明显" ], "anatomy_list": [ "胸" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [ "明显缓解" ], "anatomy_list": [ "胸" ] }, { "core_name": "疼痛", "tendency": "", "character": [ "缓解" ], "anatomy_list": [ "胸" ] } ] }, { "id": 845, "text": "病程中否认四肢麻木、疼痛、感觉异常、腹泻与便秘交替，间断足靴区溃疡，无意识丧失，无头晕、头痛、胡言乱语，无胸闷、胸痛、心悸等不适。", "event": [ { "core_name": "麻木", "tendency": "否定", "character": [], "anatomy_list": [ "四肢" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "四肢" ] }, { "core_name": "感觉", "tendency": "否定", "character": [ "异常" ], "anatomy_list": [ "四肢" ] }, { "core_name": "腹泻", "tendency": "否定", "character": [ "与便秘交替" ], "anatomy_list": [ "腹" ] }, { "core_name": "便秘", "tendency": "否定", "character": [ "与腹泻交替" ], "anatomy_list": [] }, { "core_name": "溃疡", "tendency": "", "character": [ "间断" ], "anatomy_list": [ "足靴区" ] }, { "core_name": "意识丧失", "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": "胡言乱语", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "胸闷", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "胸" ] }, { "core_name": "心悸", "tendency": "否定", "character": [], "anatomy_list": [ "心" ] } ] }, { "id": 1413, "text": "左右淋巴结未见癌转移。", "event": [ { "core_name": "癌", "tendency": "否定", "character": [ "转移" ], "anatomy_list": [ "左右淋巴结" ] } ] }, { "id": 1622, "text": "4.双肺门肺门及纵隔淋巴结淋巴结钙化。较2020-07-39片变化不明显。", "event": [ { "core_name": "钙化", "tendency": "", "character": [], "anatomy_list": [ "双肺门淋巴结", "纵隔淋巴结" ] } ] }, { "id": 654, "text": "起病以来，患者精神、食欲、睡眠可，大便正常，小便量少，体重未见明显下降。", "event": [ { "core_name": "精神", "tendency": "", "character": [ "可" ], "anatomy_list": [] }, { "core_name": "食欲", "tendency": "", "character": [ "可" ], "anatomy_list": [] }, { "core_name": "睡眠质量", "tendency": "", "character": [ "可" ], "anatomy_list": [] }, { "core_name": "大便", "tendency": "", "character": [ "正常" ], "anatomy_list": [] }, { "core_name": "小便", "tendency": "", "character": [ "量少" ], "anatomy_list": [] }, { "core_name": "体重下降", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [] } ] }, { "id": 1422, "text": "入院前5余月，患者无明显诱因出现左侧牙龈疼痛，伴左侧一颗下磨牙松动，患者自行拔除，疼痛缓解，但疼痛反复，于当地医院间断输液治疗，疗效差，期间逐渐出现张口受限，仍未重视。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [], "anatomy_list": [ "左侧牙龈" ] }, { "core_name": "松动", "tendency": "", "character": [ "一颗" ], "anatomy_list": [ "左侧下磨牙" ] }, { "core_name": "疼痛", "tendency": "", "character": [ "缓解", "反复" ], "anatomy_list": [] }, { "core_name": "张口受限", "tendency": "", "character": [ "逐渐出现" ], "anatomy_list": [] } ] }, { "id": 1723, "text": "遂至我院就诊，行上腹部ct提示“小肝癌”，遂于2017-12-12行肝肿瘤射频消融术，术后予以保肝、止血、抑酸等治疗，患者恢复可，遂出院。出院期间患者未出现何不适。", "event": [ { "core_name": "癌", "tendency": "", "character": [ "小" ], "anatomy_list": [ "肝" ] } ] }, { "id": 1084, "text": "半余年前患者无明显诱因下开始出现活动后胸痛、心悸、胸闷不适症状，爬坡、爬楼、快走、劳动等中等量体力活动后出现上述不适加重，每次持续约5-10分钟，休息后可缓解；当时无肩背部放射痛、乏力、端坐呼吸，无头晕、头痛，无恶心、呕吐、反酸、烧心等不适症状；患者未重视，未正规治疗。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [ "活动后加重", "爬坡、爬楼、快走、劳动等中等量体力活动后加重", "休息后缓解", "每次持续约5-10分钟" ], "anatomy_list": [ "胸" ] }, { "core_name": "心悸", "tendency": "", "character": [ "活动后加重", "爬坡、爬楼、快走、劳动等中等量体力活动后加重", "休息后缓解", "每次持续约5-10分钟" ], "anatomy_list": [ "心" ] }, { "core_name": "胸闷", "tendency": "", "character": [ "活动后加重", "爬坡、爬楼、快走、劳动等中等量体力活动后加重", "休息后缓解", "每次持续约5-10分钟" ], "anatomy_list": [ "胸" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [ "放射性" ], "anatomy_list": [ "肩背部" ] }, { "core_name": "乏力", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "端坐呼吸", "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": "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": "烧心", "tendency": "否定", "character": [], "anatomy_list": [] } ] }, { "id": 652, "text": "肝功示：谷丙转氨酶71U/L，谷草转氨酶88U/L，谷酰转肽酶94U/L，总胆汁酸80.6umol/L，总胆红素46.5umol/L，白蛋白28.9g/L；泌尿系彩超：左侧输尿管上段结石伴左肾重度积水。", "event": [ { "core_name": "结石", "tendency": "", "character": [], "anatomy_list": [ "左侧输尿管上段" ] }, { "core_name": "积水", "tendency": "", "character": [ "重度" ], "anatomy_list": [ "左肾" ] } ] }, { "id": 1793, "text": "于2013年9月13日入我院泌尿外科行下腹部增强ct:前列腺右侧外腺区肿块考虑前列腺癌并精囊腺侵犯，盆腔淋巴结转移；全身骨骨扫描spect/ct图像融合提示：右肱骨上段放射性浓聚区见局部骨密度明显增强，局部骨皮质中断；胸椎及肋骨放射性浓聚区见局部骨密度明显增强。", "event": [ { "core_name": "肿块", "tendency": "", "character": [], "anatomy_list": [ "前列腺右侧外腺区" ] }, { "core_name": "癌", "tendency": "不确定", "character": [], "anatomy_list": [ "前列腺" ] }, { "core_name": "侵犯", "tendency": "不确定", "character": [], "anatomy_list": [ "精囊腺" ] }, { "core_name": "转移", "tendency": "", "character": [], "anatomy_list": [ "盆腔淋巴结" ] }, { "core_name": "骨密度增强", "tendency": "", "character": [ "明显", "局部" ], "anatomy_list": [ "右肱骨上段放射性浓聚区" ] }, { "core_name": "骨皮质中断", "tendency": "", "character": [ "局部" ], "anatomy_list": [ "右肱骨上段局部骨皮质" ] }, { "core_name": "骨密度增强", "tendency": "", "character": [ "放射性浓聚区", "明显增强", "局部" ], "anatomy_list": [ "胸椎放射性浓聚区", "肋骨放射性浓聚区" ] } ] }, { "id": 448, "text": "近期患者自觉症状明显，并伴有右侧耳前耳前疼痛疼痛不适，可触及肿大包块，不伴有面颊部麻木，口角歪斜，无发热、咳嗽，无口角流涎等不适。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [], "anatomy_list": [ "右侧耳前" ] }, { "core_name": "肿大包块", "tendency": "", "character": [], "anatomy_list": [ "右侧耳前" ] }, { "core_name": "麻木", "tendency": "否定", "character": [], "anatomy_list": [ "面颊" ] }, { "core_name": "歪斜", "tendency": "", "character": [], "anatomy_list": [ "口角" ] }, { "core_name": "发热", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "咳嗽", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "流涎", "tendency": "否定", "character": [], "anatomy_list": [ "口角" ] } ] }, { "id": 904, "text": "无明确外伤史，右下肢稍肿，无关节红肿。", "event": [ { "core_name": "肿", "tendency": "", "character": [ "稍" ], "anatomy_list": [ "右下肢" ] }, { "core_name": "红肿", "tendency": "否定", "character": [], "anatomy_list": [ "关节" ] } ] }, { "id": 1832, "text": "入院前10+年患者无明显诱因反复感头昏不适，头部昏沉感，发作时伴有肢体乏力表现，自诉既往于重医诊断为“腔隙性脑梗死”，平素口服“强力定眩片”等药物治疗。", "event": [ { "core_name": "头昏", "tendency": "", "character": [ "反复" ], "anatomy_list": [ "头" ] }, { "core_name": "头不适", "tendency": "", "character": [ "反复" ], "anatomy_list": [ "头" ] }, { "core_name": "昏沉感", "tendency": "", "character": [], "anatomy_list": [ "头部" ] }, { "core_name": "乏力", "tendency": "", "character": [ "发作时" ], "anatomy_list": [ "肢体" ] }, { "core_name": "梗死", "tendency": "", "character": [ "腔隙性" ], "anatomy_list": [ "脑" ] } ] }, { "id": 1149, "text": "为进一步明确诊治患者就诊于某医院行“化疗”，此后半年间患者先后3次就诊于某医院进行相关化疗（具体不详），吞咽困难逐渐加重，现仅能进流质，今日患者因自身原因就诊我院门诊，门诊以“食道癌”收入我科。", "event": [ { "core_name": "吞咽困难", "tendency": "", "character": [ "逐渐加重" ], "anatomy_list": [] }, { "core_name": "癌", "tendency": "", "character": [], "anatomy_list": [ "食道" ] } ] }, { "id": 669, "text": "患者本次发病以来，食欲欠佳，神志、精神可，睡眠欠佳，大便如常，夜尿次数增多，体重无明显改变。", "event": [ { "core_name": "食欲", "tendency": "", "character": [ "欠佳" ], "anatomy_list": [] }, { "core_name": "神志", "tendency": "", "character": [ "可" ], "anatomy_list": [] }, { "core_name": "精神", "tendency": "", "character": [ "可" ], "anatomy_list": [] }, { "core_name": "睡眠质量", "tendency": "", "character": [ "欠佳" ], "anatomy_list": [] }, { "core_name": "大便", "tendency": "", "character": [ "如常" ], "anatomy_list": [] }, { "core_name": "夜尿次数增多", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "体重改变", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [] } ] }, { "id": 716, "text": "患者目前病情稳定，患者出院后无明显恶心呕吐、胃寒发热，患者拟行第一次术后化疗入院。", "event": [ { "core_name": "恶心", "tendency": "否定", "character": [ "明显" ], "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": [] } ] }, { "id": 1363, "text": "患者本人及家属要求回当地医院治疗，故来我院，以“左肺非小细胞癌”收入我科。", "event": [ { "core_name": "癌", "tendency": "", "character": [ "非小细胞" ], "anatomy_list": [ "左肺" ] } ] }, { "id": 1087, "text": "入院前1月患者于无明显诱因出现进食辛辣食物后不适，表现为上腹轻微胀痛，伴反酸烧心，偶有黑便，无恶心、呕吐，无腹泻及大便次数改变,无畏寒发热，无咯血胸痛、无胸闷心悸、气促，无双下肢水肿，入院前2天，患者受凉出现咳嗽、咳痰，可咳出少量白色粘液痰，伴双下肢水肿，伴纳差乏力，无四肢酸痛，无消瘦乏力，无咯血胸痛，于今日来我院就诊，为进一步治疗，门诊以\"上腹不适待查\"收入我科住院治疗。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [ "轻微", "胀痛" ], "anatomy_list": [ "上腹" ] }, { "core_name": "反酸", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "烧心", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "黑便", "tendency": "", "character": [ "偶有" ], "anatomy_list": [] }, { "core_name": "恶心", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "呕吐", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "腹泻", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "大便", "tendency": "否定", "character": [ "次数改变" ], "anatomy_list": [] }, { "core_name": "畏寒", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "发热", "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": "胸闷", "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": "水肿", "tendency": "否定", "character": [], "anatomy_list": [ "双下肢" ] }, { "core_name": "咳嗽", "tendency": "", "character": [ "受凉" ], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "白色", "少量", "粘液", "受凉" ], "anatomy_list": [] }, { "core_name": "水肿", "tendency": "", "character": [], "anatomy_list": [ "双下肢" ] }, { "core_name": "纳差", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "乏力", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "否定", "character": [ "酸痛" ], "anatomy_list": [ "四肢" ] }, { "core_name": "消瘦", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "乏力", "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": "上腹不适", "tendency": "", "character": [], "anatomy_list": [ "上腹" ] } ] }, { "id": 1853, "text": "入院前20天，患者因“大便习惯改变伴大便带血6月，加重2月。", "event": [ { "core_name": "大便习惯改变", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "大便", "tendency": "", "character": [ "带血" ], "anatomy_list": [] }, { "core_name": "大便习惯改变", "tendency": "", "character": [ "加重" ], "anatomy_list": [] }, { "core_name": "大便", "tendency": "", "character": [ "带血", "加重" ], "anatomy_list": [] } ] }, { "id": 866, "text": "无粘液血便、呕血，无恶心、呕吐，无反酸、嗳气，无腹胀、腹痛，无黑朦、乏力等不适。", "event": [ { "core_name": "血便", "tendency": "否定", "character": [ "粘液" ], "anatomy_list": [] }, { "core_name": "呕血", "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": "反酸", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "嗳气", "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": "黑朦", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "乏力", "tendency": "否定", "character": [], "anatomy_list": [] } ] }, { "id": 864, "text": "4+天患者自诉上述症状加重，伴声嘶不适，患者为进一步诊治遂就诊我科门诊行电子鼻咽喉镜检查提示：鼻中隔偏曲/鼻咽部膨隆待查/慢性咽喉炎/双侧声带息肉，建议住院治疗，患者因自身原因未住院，今日患者再次就诊我科要求住院，门诊即以\"喉新生物、鼻咽部新生物\"收入院治疗。", "event": [ { "core_name": "声嘶", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "偏曲", "tendency": "", "character": [], "anatomy_list": [ "鼻中隔" ] }, { "core_name": "膨隆", "tendency": "", "character": [], "anatomy_list": [ "鼻咽部" ] }, { "core_name": "咽喉炎", "tendency": "", "character": [ "慢性" ], "anatomy_list": [ "咽", "喉" ] }, { "core_name": "息肉", "tendency": "", "character": [], "anatomy_list": [ "双侧声带" ] }, { "core_name": "新生物", "tendency": "", "character": [], "anatomy_list": [ "喉" ] }, { "core_name": "新生物", "tendency": "", "character": [], "anatomy_list": [ "鼻咽部" ] } ] }, { "id": 557, "text": "今晨院外自行使用“开塞露”，能解少量大便，无黑便、血便、粘液便。", "event": [ { "core_name": "大便", "tendency": "", "character": [ "少量" ], "anatomy_list": [] }, { "core_name": "黑便", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "血便", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "大便", "tendency": "否定", "character": [ "粘液性" ], "anatomy_list": [] } ] }, { "id": 1916, "text": "5+月前，患者上述症状反复出现并加重，并出现喘息、咳痰，痰不易咳出，遂到我科就诊，ct检查（123456):右侧枕叶结节，结合病史，考虑转移性肿瘤；左肺门区占位性病变，考虑肺癌伴左肺阻塞性肺不张、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；肝脏多发环形强化强化结节，系转移性肿瘤；右肾占位性病变，考虑肿瘤性病变，肾癌？；左肾小结石；左侧肾上腺结节，结合病史，考虑转移性肿瘤。", "event": [ { "core_name": "气喘", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "不易咳出" ], "anatomy_list": [] }, { "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": [ "左肺门区" ] }, { "core_name": "癌", "tendency": "", "character": [], "anatomy_list": [ "肺" ] }, { "core_name": "肺不张", "tendency": "", "character": [ "阻塞性" ], "anatomy_list": [ "左肺" ] }, { "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": [ "多发", "环形", "强化" ], "anatomy_list": [ "肝脏" ] }, { "core_name": "肿瘤", "tendency": "", "character": [ "转移性" ], "anatomy_list": [ "肝脏" ] }, { "core_name": "病变", "tendency": "", "character": [ "占位性" ], "anatomy_list": [ "右肾" ] }, { "core_name": "病变", "tendency": "不确定", "character": [ "肿瘤性" ], "anatomy_list": [ "右肾" ] }, { "core_name": "癌", "tendency": "不确定", "character": [], "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": 88, "text": "3天前，患者受凉后出现流清涕，伴胸闷及耳鸣，活动后心累、气促症状较前加重，无明显咳嗽咳痰，无畏寒寒战，无腹痛腹泻，无尿频尿急尿痛，无皮下出血及皮肤瘀点瘀斑，患者于小渡中心卫生院差血常规提示白细胞高及血红蛋白低，今日拟输血及进一步治疗来院，遂以“骨髓增生异常综合症”收住入院。", "event": [ { "core_name": "流涕", "tendency": "", "character": [ "受凉后", "清" ], "anatomy_list": [] }, { "core_name": "胸闷", "tendency": "", "character": [], "anatomy_list": [ "胸" ] }, { "core_name": "耳鸣", "tendency": "", "character": [], "anatomy_list": [ "耳" ] }, { "core_name": "心累", "tendency": "", "character": [ "活动后", "症状较前加重" ], "anatomy_list": [ "心" ] }, { "core_name": "气促", "tendency": "", "character": [ "活动后", "症状较前加重" ], "anatomy_list": [] }, { "core_name": "咳嗽", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [] }, { "core_name": "畏寒", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "寒颤", "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": [] }, { "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": "出血", "tendency": "否定", "character": [], "anatomy_list": [ "皮下" ] }, { "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": "白细胞高", "tendency": "", "character": [], "anatomy_list": [ "白细胞" ] }, { "core_name": "血红蛋白", "tendency": "", "character": [ "低" ], "anatomy_list": [] }, { "core_name": "骨髓增生异常综合症", "tendency": "", "character": [], "anatomy_list": [ "骨髓" ] } ] }, { "id": 169, "text": "脂肪肝、肝右叶钙化灶；左肾肾盂肾盏及左侧输尿管上段稍积水扩张；脊柱退行性变。", "event": [ { "core_name": "脂肪肝", "tendency": "", "character": [], "anatomy_list": [ "肝" ] }, { "core_name": "钙化灶", "tendency": "", "character": [], "anatomy_list": [ "肝右叶" ] }, { "core_name": "积水扩张", "tendency": "", "character": [ "稍" ], "anatomy_list": [ "左肾肾盂", "左肾肾盏", "左侧输尿管上段" ] }, { "core_name": "改变", "tendency": "", "character": [ "退行性" ], "anatomy_list": [ "脊柱" ] } ] }, { "id": 950, "text": "其后上述症状反复发作，后逐渐出现食欲减退。", "event": [ { "core_name": "食欲", "tendency": "", "character": [ "减退" ], "anatomy_list": [] } ] }, { "id": 526, "text": "入院前5月前，患者受凉后呼吸困难加重，伴双下肢水肿，于某医院治疗后好转出院（具体诊疗不详）。", "event": [ { "core_name": "呼吸困难", "tendency": "", "character": [ "受凉后加重" ], "anatomy_list": [] }, { "core_name": "水肿", "tendency": "", "character": [], "anatomy_list": [ "双下肢" ] } ] }, { "id": 467, "text": "遂于我院就诊，查超声示“子宫周围探及异常回声，范围约98×46mm的异常无回声区，主要位于子宫右后方，边界不清，形态不规则，以低回声为主，cdfi:其周边未探及血流信号；腹腔探及片状无回声区，最深处约56mm；盆腔内可见片状的不规则无回声区，最深处位于子宫后方，约7mm，内透声差，可见点状弱回声浮动”。", "event": [ { "core_name": "回声", "tendency": "", "character": [ "异常" ], "anatomy_list": [ "子宫周围" ] }, { "core_name": "异常无回声", "tendency": "", "character": [ "边界不清", "形态不规则" ], "anatomy_list": [ "子宫右后方" ] }, { "core_name": "血流信号", "tendency": "否定", "character": [ "周边探及" ], "anatomy_list": [] }, { "core_name": "无回声区", "tendency": "", "character": [ "片状" ], "anatomy_list": [ "腹腔" ] }, { "core_name": "回声", "tendency": "", "character": [ "最深处位于子宫后方", "片状", "不规则", "内透声差", "可见点状弱回声浮动", "弱" ], "anatomy_list": [ "盆腔内" ] } ] }, { "id": 628, "text": "于“某医院”就诊，诊断为copd急性加重期，经治疗（具体不详）后症状无明显好转，为求进一步治疗遂于我院就诊，我院门诊以“慢性阻塞性肺疾病急性加重期”收入我科。", "event": [ { "core_name": "copd", "tendency": "", "character": [ "急性加重期" ], "anatomy_list": [] }, { "core_name": "肺疾病", "tendency": "", "character": [ "慢性", "阻塞性", "急性加重期" ], "anatomy_list": [ "肺" ] } ] }, { "id": 1782, "text": "盆腹腔内未见明显转移结节。", "event": [ { "core_name": "结节", "tendency": "否定", "character": [ "明显", "转移" ], "anatomy_list": [ "盆腹腔内" ] } ] }, { "id": 1071, "text": "4月前，患者因“左臀部臀部包块”于某医院就诊，行左臀部包块切除+病检术，术后病检提示：（左臀部）恶性肿瘤，结合临床病史考虑恶性淋巴瘤转移可能。", "event": [ { "core_name": "包块", "tendency": "", "character": [], "anatomy_list": [ "左臀部" ] }, { "core_name": "肿瘤", "tendency": "", "character": [ "恶性" ], "anatomy_list": [ "左臀部" ] }, { "core_name": "瘤", "tendency": "不确定", "character": [ "恶性", "转移" ], "anatomy_list": [ "淋巴" ] } ] }, { "id": 1514, "text": "患者本次发病后外院住院期间发生肺部感染、Ⅰ型呼吸衰竭、肺气肿、菌血症，予以抗感染，止咳化痰等对症治疗后病情逐渐平稳。", "event": [ { "core_name": "感染", "tendency": "", "character": [], "anatomy_list": [ "肺部" ] }, { "core_name": "呼吸衰竭", "tendency": "", "character": [ "Ⅰ型" ], "anatomy_list": [ "肺" ] }, { "core_name": "肺气肿", "tendency": "", "character": [], "anatomy_list": [ "肺" ] }, { "core_name": "菌血症", "tendency": "", "character": [], "anatomy_list": [] } ] }, { "id": 891, "text": "不咯黄脓痰及铁锈色痰，不伴畏寒、寒战、高热，不伴潮热、盗汗及午后低热，无明显喘累。", "event": [ { "core_name": "咳痰", "tendency": "否定", "character": [ "黄", "脓痰" ], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "否定", "character": [ "铁锈色" ], "anatomy_list": [] }, { "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": [ "高" ], "anatomy_list": [] }, { "core_name": "潮热", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "盗汗", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "发热", "tendency": "否定", "character": [ "午后", "低" ], "anatomy_list": [] }, { "core_name": "喘累", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [] } ] }, { "id": 1750, "text": "神经见癌侵犯。", "event": [ { "core_name": "癌", "tendency": "", "character": [ "侵犯" ], "anatomy_list": [ "神经" ] } ] }, { "id": 488, "text": "入院前6+月，患者发现左乳包块来我院就诊，完善相关检查后，于2016-06-03全麻下行左乳包块切除术+术中冰冻+左乳癌改良根治术。", "event": [ { "core_name": "包块", "tendency": "", "character": [], "anatomy_list": [ "左乳" ] } ] }, { "id": 1074, "text": "院外口服药物治疗（具体不详），患者 但仍感咳嗽明显，为进一步治疗入我院门诊， 胸部ct 提示：1、双肺内多发团片状、结节状状高密度高密度影，考虑结核可能。", "event": [ { "core_name": "咳嗽", "tendency": "", "character": [ "明显" ], "anatomy_list": [] }, { "core_name": "密度影", "tendency": "", "character": [ "多发", "团片状", "结节状", "高" ], "anatomy_list": [ "双肺" ] }, { "core_name": "结核", "tendency": "不确定", "character": [], "anatomy_list": [ "肺" ] } ] }, { "id": 220, "text": "患者 10+天 前无明显诱因下开始出现 中上腹 疼痛 ， 疼痛呈胀痛伴阵发性加重 ， 无放射痛 。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [ "呈胀痛", "阵发性加重", "无放射痛" ], "anatomy_list": [ "中上腹" ] } ] }, { "id": 898, "text": "反复前因上述症状加重再次于我院住院，检查后提示多浆膜腔积液，予以血液透析、改善心功能，穿刺抽胸腔积液后症状缓解；因肺癌转入呼吸肿瘤科，予以ct引导下行肺穿刺活检术，术后病检提示（右肺）恶性肿瘤，完善头颅mri未见转移征象，与患者及家属沟通后表示不愿行介入治疗等，予以经皮动脉栓塞术（肿瘤）；院外长期在我院规律血液透析。", "event": [ { "core_name": "积液", "tendency": "", "character": [ "多" ], "anatomy_list": [ "浆膜腔" ] }, { "core_name": "积液", "tendency": "", "character": [], "anatomy_list": [ "胸腔" ] }, { "core_name": "癌", "tendency": "", "character": [], "anatomy_list": [ "肺" ] }, { "core_name": "肿瘤", "tendency": "", "character": [ "恶性" ], "anatomy_list": [ "右肺" ] }, { "core_name": "转移", "tendency": "否定", "character": [], "anatomy_list": [ "头颅" ] }, { "core_name": "肿瘤", "tendency": "", "character": [], "anatomy_list": [ "右肺" ] } ] }, { "id": 714, "text": "患者近1月以来，食欲不振，神志清醒，精神尚可，睡眠欠佳，体重减少2kg。", "event": [ { "core_name": "食欲", "tendency": "", "character": [ "不振" ], "anatomy_list": [] }, { "core_name": "神志", "tendency": "", "character": [ "清醒" ], "anatomy_list": [] }, { "core_name": "精神", "tendency": "", "character": [ "尚可" ], "anatomy_list": [] }, { "core_name": "睡眠质量", "tendency": "", "character": [ "欠佳" ], "anatomy_list": [] }, { "core_name": "体重减轻", "tendency": "", "character": [], "anatomy_list": [] } ] }, { "id": 195, "text": "病程中患者有头晕，无头痛、视物旋转、晕厥。", "event": [ { "core_name": "头晕", "tendency": "", "character": [], "anatomy_list": [ "头" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "头" ] }, { "core_name": "视物旋转", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "晕厥", "tendency": "否定", "character": [], "anatomy_list": [] } ] }, { "id": 153, "text": "2.左肺上叶尖后段结节影，性质？转移可能。", "event": [ { "core_name": "结节影", "tendency": "", "character": [], "anatomy_list": [ "左肺上叶尖后段" ] }, { "core_name": "转移", "tendency": "不确定", "character": [], "anatomy_list": [] } ] }, { "id": 644, "text": "之后规律随访发现血hcg升高就诊于我院，诊断滋养细胞肿瘤：侵袭性葡萄胎（ic：3），分别于2015年9月10日，2015年10月8，2015年11月4号，2015年12月2日，2015-12-30我院规律行ema-co化疗，出院时血hcg-i分别为：31080.00m/ml↑，773.80m/ml↑，26.59m/ml，4.89m/m，2.66m/m。", "event": [ { "core_name": "血hcg", "tendency": "", "character": [ "升高" ], "anatomy_list": [] }, { "core_name": "肿瘤", "tendency": "", "character": [], "anatomy_list": [ "滋养细胞" ] }, { "core_name": "葡萄胎", "tendency": "", "character": [ "侵袭性", "ic：3" ], "anatomy_list": [] } ] }, { "id": 1657, "text": "化疗期间患者出现白细胞进行性下降，停用米托蒽醌化疗；诱导化疗期间因患者出现头痛等不适，氢化泼尼松预防维甲酸综合征。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [], "anatomy_list": [ "头" ] }, { "core_name": "白细胞", "tendency": "", "character": [ "进行性下降" ], "anatomy_list": [] }, { "core_name": "维甲酸综合征", "tendency": "", "character": [], "anatomy_list": [] } ] }, { "id": 1546, "text": "后于2017年9月13日、2017年10月11日行第二、三周期雷替曲塞+奥沙利铂方案化疗，化疗过程顺利，患者未诉特殊不适，院外休息期间，偶感肛门坠胀，无明显腹痛腹胀、畏寒发热、潮热盗汗、尿频、尿急、尿痛、黑便等特殊不适，今患者为行下一周期化疗入院，门诊以“直肠癌”收入我科。", "event": [ { "core_name": "坠胀", "tendency": "", "character": [], "anatomy_list": [ "肛门" ] }, { "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": "畏寒", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [] }, { "core_name": "发热", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [] }, { "core_name": "潮热", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [] }, { "core_name": "盗汗", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [] }, { "core_name": "尿频", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [] }, { "core_name": "尿急", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [] }, { "core_name": "尿痛", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [] }, { "core_name": "黑便", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [] }, { "core_name": "癌", "tendency": "", "character": [], "anatomy_list": [ "直肠" ] } ] }, { "id": 379, "text": "5、胰、肾未见明显异常 ，门诊以\"乙肝肝硬化，肝癌？\"收入我科。", "event": [ { "core_name": "硬化", "tendency": "", "character": [ "乙肝" ], "anatomy_list": [ "肝" ] }, { "core_name": "癌", "tendency": "不确定", "character": [], "anatomy_list": [ "肝" ] } ] }, { "id": 918, "text": "予以“瘿瘤丸”及中药行药物治疗，治疗后一月，患者复查甲状腺彩超示：甲状腺右叶囊性结节（3.2*1.2cm）。", "event": [ { "core_name": "结节", "tendency": "", "character": [ "囊性" ], "anatomy_list": [ "甲状腺右叶" ] } ] }, { "id": 730, "text": "入院前2+年，患者无明显诱因出现头昏、乏力，无心悸、黑朦，无皮下瘀斑、瘀点，无牙龈和口腔黏膜出血，无肉眼血尿，无呕血、黑便、便血，无视力障碍，无耳鸣，无头疼、恶心、呕吐，意识障碍，无畏寒、发热，无鼻塞、流涕，无咽痛、咳嗽、咳痰，无腹痛、腹泻，无肛周疼痛，无尿频、尿急、尿痛，无骨关节关节疼痛；患者在某医院行骨髓穿刺活检诊断为骨髓增生异常综合征（未见报告），未治疗。", "event": [ { "core_name": "头昏", "tendency": "", "character": [], "anatomy_list": [ "头" ] }, { "core_name": "乏力", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "心悸", "tendency": "否定", "character": [], "anatomy_list": [ "心" ] }, { "core_name": "黑朦", "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": "出血", "tendency": "否定", "character": [], "anatomy_list": [ "口腔粘膜" ] }, { "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": "便血", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "视力障碍", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "耳鸣", "tendency": "否定", "character": [], "anatomy_list": [ "耳" ] }, { "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": "意识障碍", "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": "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": [ "咽" ] }, { "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": [ "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": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "骨关节" ] }, { "core_name": "骨髓增生异常综合征", "tendency": "", "character": [ "异常" ], "anatomy_list": [ "骨髓" ] } ] }, { "id": 196, "text": "无恶心、呕吐、腹痛、腹胀，自述夜间有出汗及发热（未测体温），今日患者为进一步诊治来我院，门诊以“右肺门占位：肿瘤？”收入我科。", "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": "出汗", "tendency": "", "character": [ "夜间" ], "anatomy_list": [] }, { "core_name": "发热", "tendency": "", "character": [ "夜间" ], "anatomy_list": [] }, { "core_name": "占位", "tendency": "", "character": [], "anatomy_list": [ "右肺门" ] }, { "core_name": "肿瘤", "tendency": "不确定", "character": [], "anatomy_list": [ "右肺门" ] } ] }, { "id": 274, "text": "入院前5+月，患者无明显诱因出现咳嗽、咳痰，为阵发性干咳，痰中带血，为鲜红色，量少，偶有少许黄色粘痰，无胸闷、胸痛及呼吸困难，患者于某医院就诊，完善胸部增强ct示：左肺上叶软组织影伴双肺结节影，考虑肺癌伴转移。", "event": [ { "core_name": "咳嗽", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "咳嗽", "tendency": "", "character": [ "阵发性", "干" ], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "带血", "鲜红色", "量少" ], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "偶有少许", "黄色", "粘" ], "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": "呼吸困难", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "软组织影", "tendency": "", "character": [], "anatomy_list": [ "左肺上叶" ] }, { "core_name": "结节影", "tendency": "", "character": [], "anatomy_list": [ "双肺" ] }, { "core_name": "癌", "tendency": "不确定", "character": [], "anatomy_list": [ "肺" ] }, { "core_name": "转移", "tendency": "不确定", "character": [], "anatomy_list": [] } ] }, { "id": 1243, "text": "基底净，乳头未受累，前哨淋巴结未见癌转移（0/7），前稍0/3、前哨2 0/0、前哨3:0/4，免疫组化：er(++)80%，pr(+)30%，her(-)，p53(+)10%，ki-67（+）60%，术后1周于行化疗1周期（具体方案不详），病情好转出院；于2018-8-22于我院予以tac方案（多西他赛 120mg，环磷酰胺 0.6g，吡柔比星 60mg）化疗，化疗及化疗后无明显恶心、呕吐，无骨髓抑制及神经毒性反应，现为继续化疗，于我院就诊，门诊以“乳腺癌”收住我科。", "event": [ { "core_name": "累及", "tendency": "否定", "character": [], "anatomy_list": [ "乳头" ] }, { "core_name": "癌", "tendency": "否定", "character": [ "转移" ], "anatomy_list": [ "前哨淋巴结" ] }, { "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": "骨髓抑制", "tendency": "否定", "character": [], "anatomy_list": [ "骨髓" ] }, { "core_name": "毒性反应", "tendency": "否定", "character": [], "anatomy_list": [ "神经" ] }, { "core_name": "癌", "tendency": "", "character": [], "anatomy_list": [ "乳腺" ] } ] }, { "id": 1726, "text": "现患儿无咳嗽，无进行性面色苍白，无皮肤瘀斑瘀点及鼻衄、牙龈出血等出血表现，无腹痛、腹泻，无关节疼痛，无头痛、呕吐。", "event": [ { "core_name": "咳嗽", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "苍白", "tendency": "否定", "character": [ "进行性", "面色" ], "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": "鼻衄", "tendency": "否定", "character": [], "anatomy_list": [ "鼻" ] }, { "core_name": "出血", "tendency": "否定", "character": [], "anatomy_list": [ "牙龈" ] }, { "core_name": "出血", "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": [ "关节" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "头" ] }, { "core_name": "呕吐", "tendency": "否定", "character": [], "anatomy_list": [] } ] }, { "id": 1174, "text": "今门诊以“右甲状腺甲状腺包块待查”收入我科住院治疗。", "event": [ { "core_name": "包块", "tendency": "不确定", "character": [], "anatomy_list": [ "右甲状腺" ] } ] }, { "id": 729, "text": "患者本次起病以来，精神、睡眠一般，食纳下降，大便如上诉，小便无明显改变，体重无明显变化。", "event": [ { "core_name": "精神", "tendency": "", "character": [ "一般" ], "anatomy_list": [] }, { "core_name": "睡眠", "tendency": "", "character": [ "一般" ], "anatomy_list": [] }, { "core_name": "食纳", "tendency": "", "character": [ "下降" ], "anatomy_list": [] }, { "core_name": "小便", "tendency": "否定", "character": [ "明显", "改变" ], "anatomy_list": [] }, { "core_name": "体重改变", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [] } ] }, { "id": 1443, "text": "患者于一年前无明显诱因出现大便带血，为暗红色不与大便混合，伴粘液便3月余，大便次数增多，变细，为2-3次/天。", "event": [ { "core_name": "大便", "tendency": "", "character": [ "带血", "暗红色", "不与大便混合" ], "anatomy_list": [] }, { "core_name": "大便", "tendency": "", "character": [ "粘液", "3月余" ], "anatomy_list": [] }, { "core_name": "大便", "tendency": "", "character": [ "次数增多", "变细", "2-3次/天" ], "anatomy_list": [] } ] }, { "id": 299, "text": "入院前2天，患者无明显诱因出现右侧胸背部疼痛，与呼吸活动无关，偶有干咳，无发热，无咯血，无胸闷，无气促、呼吸困难,无潮热、盗汗，无乏力、消瘦，无声嘶，无呛咳等不适，病后患者于当地医院行心电图检查结果“未见明显异常”，建议完善肝胆检查寻找胸背痛病因，于我院行腹部彩超未见明显异常，肝功提示转氨酶稍升高；病程中行胸片检查结果提示“右下肺阴影”，进一步完善胸部ct检查提示：右肺下叶后基底段段团片影，考虑感染性病变可能，肿瘤不除外；为进一步治疗，门诊以“肺部阴影”收入我科。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [ "与呼吸活动无关" ], "anatomy_list": [ "右侧胸背部" ] }, { "core_name": "咳嗽", "tendency": "", "character": [ "偶有", "干" ], "anatomy_list": [] }, { "core_name": "发热", "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": "气促", "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": "乏力", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "消瘦", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "声嘶", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "呛咳", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "不确定", "character": [], "anatomy_list": [ "胸背" ] }, { "core_name": "转氨酶", "tendency": "", "character": [ "稍升高" ], "anatomy_list": [] }, { "core_name": "阴影", "tendency": "", "character": [], "anatomy_list": [ "右下肺" ] }, { "core_name": "团片影", "tendency": "", "character": [], "anatomy_list": [ "右肺下叶后基底段" ] }, { "core_name": "病变", "tendency": "不确定", "character": [ "感染性" ], "anatomy_list": [] }, { "core_name": "肿瘤", "tendency": "不确定", "character": [], "anatomy_list": [ "右肺下叶后基底段" ] }, { "core_name": "阴影", "tendency": "", "character": [], "anatomy_list": [ "肺部" ] } ] }, { "id": 1241, "text": "2+天前，患者无明显诱因出现左下腹持续性腹痛，伴呕吐、腹泻，呕吐物为胃内容物，腹泻7次，为黑稀便，无畏寒、发热，无活动后心悸、气促，无咳嗽、咳痰，小便正常，遂就诊于某医院，完善相关辅助检查，腹部超声提示：右肾结石肾结石伴轻度积水，予以相关对症支持治疗（具体治疗不详），无明显缓解，患者自觉症状加重，今日遂于某医院就诊，完善相关辅助检查，彩超提示：1.胆囊结石伴炎变 2.右肾结石 3.子宫实性伴占位性病变（肌瘤）3.左侧附件囊性占位占位性病变（囊肿）4.右下腹低回声低回声区（炎性阑尾？），未行相关治疗，遂于我院就诊，门诊以“腹痛待查”收入我科治疗。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [ "持续性" ], "anatomy_list": [ "左下腹" ] }, { "core_name": "呕吐", "tendency": "", "character": [ "呕吐物为胃内容物" ], "anatomy_list": [] }, { "core_name": "腹泻", "tendency": "", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "腹泻", "tendency": "", "character": [ "7次" ], "anatomy_list": [ "腹" ] }, { "core_name": "黑便", "tendency": "", "character": [ "稀" ], "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": [ "活动后" ], "anatomy_list": [ "心" ] }, { "core_name": "气促", "tendency": "否定", "character": [ "活动后" ], "anatomy_list": [] }, { "core_name": "咳嗽", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "小便", "tendency": "", "character": [ "正常" ], "anatomy_list": [] }, { "core_name": "结石", "tendency": "", "character": [], "anatomy_list": [ "右肾" ] }, { "core_name": "积水", "tendency": "", "character": [ "轻度" ], "anatomy_list": [ "右肾" ] }, { "core_name": "结石", "tendency": "", "character": [], "anatomy_list": [ "胆囊" ] }, { "core_name": "胆囊炎", "tendency": "", "character": [], "anatomy_list": [ "胆囊" ] }, { "core_name": "结石", "tendency": "", "character": [], "anatomy_list": [ "右肾" ] }, { "core_name": "病变", "tendency": "", "character": [ "实性", "占位性" ], "anatomy_list": [ "子宫" ] }, { "core_name": "肌瘤", "tendency": "", "character": [], "anatomy_list": [ "子宫" ] }, { "core_name": "病变", "tendency": "", "character": [ "囊性", "占位性" ], "anatomy_list": [ "左侧附件" ] }, { "core_name": "囊肿", "tendency": "", "character": [], "anatomy_list": [ "左侧附件" ] }, { "core_name": "回声异常", "tendency": "", "character": [ "低" ], "anatomy_list": [ "右下腹" ] }, { "core_name": "阑尾炎", "tendency": "不确定", "character": [], "anatomy_list": [ "阑尾" ] }, { "core_name": "疼痛", "tendency": "", "character": [], "anatomy_list": [ "腹" ] } ] }, { "id": 1692, "text": "患者于2016年3月8日行腹腔镜下行全子宫、双侧附件切除术+大网膜、阑尾切除术+盆腔淋巴结清扫术+盆腔转移灶切除术+直肠转移灶切除术，手术经过顺利，术后给予预防感染、止血等治疗，术后一般情况好，标本常规病检，病检（123456）提示：双侧卵巢低分化腺癌、盆腔及直肠见转移灶、右侧盆腔淋巴结见癌转移（1/7）；子宫肌壁间平滑肌瘤。", "event": [ { "core_name": "腺癌", "tendency": "", "character": [ "低分化" ], "anatomy_list": [ "双侧卵巢" ] }, { "core_name": "转移灶", "tendency": "", "character": [], "anatomy_list": [ "盆腔", "直肠" ] }, { "core_name": "癌", "tendency": "", "character": [ "转移" ], "anatomy_list": [ "右侧盆腔淋巴结" ] }, { "core_name": "瘤", "tendency": "", "character": [ "平滑肌" ], "anatomy_list": [ "子宫肌壁间" ] } ] }, { "id": 321, "text": "出院后愿定于每3月返院行“亮丙瑞林”抗雄激素激素治疗，1月前前患者无明显诱因出现血尿，为全程淡红色血尿，无血凝块，无尿频、尿急、尿痛，无排尿困难，排尿滴沥、踟蹰，无尿线变细，无发热、寒战、咳嗽、咳痰，无腹痛、腰痛，无恶心、呕吐等不适，我科抗雄激素激素治疗后缓解出院，后每月规律至我院抗雄激素激素治疗。", "event": [ { "core_name": "血尿", "tendency": "", "character": [ "全程淡红色", "无血凝块" ], "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": "排尿困难", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "排尿滴沥", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "排尿踟蹰", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "尿线变细", "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": "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": [ "腹" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "腰" ] }, { "core_name": "恶心", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "呕吐", "tendency": "否定", "character": [], "anatomy_list": [] } ] }, { "id": 929, "text": "21天前，患儿行术后第8次化疗结束出院后，不伴发热、不伴腹痛；复查血常规基本正常，今日按疗程入院继续治疗。", "event": [ { "core_name": "发热", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "腹部" ] } ] }, { "id": 164, "text": "2018-03-19全身pet-ct示：子宫切除术后，术区未见明显异常。", "event": [ { "core_name": "异常", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [ "术区" ] } ] }, { "id": 1475, "text": "5天前因下地干活后出现持续性腹痛，包块增大，平卧休息后缓解，包块消失，患者未予重视及相关诊治，今为求治疗至我院，以“右侧腹股沟疝”收入我科。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [ "持续性" ], "anatomy_list": [ "腹" ] }, { "core_name": "包块", "tendency": "", "character": [ "增大", "平卧休息后缓解", "消失" ], "anatomy_list": [] }, { "core_name": "疝", "tendency": "", "character": [], "anatomy_list": [ "右侧腹股沟" ] } ] }, { "id": 571, "text": "<右支气管>恶性肿瘤，结合形态及免疫组化符合肺小细胞癌。", "event": [ { "core_name": "肿瘤", "tendency": "", "character": [ "恶性" ], "anatomy_list": [ "右支气管" ] }, { "core_name": "癌", "tendency": "", "character": [], "anatomy_list": [ "肺", "小细胞" ] } ] }, { "id": 591, "text": "无咽喉部刺痛、饮水呛咳，未到医院进行相关检查，3+年前，患者自觉上述症状加重，并出现右上腹隐痛，呈间断性，进食后明显，不影响日常活动及睡眠，无反酸、烧心，无胸闷、心慌，遂于某医院就诊，行内镜镜检示：贲门ca，慢性萎缩性胃炎，胃镜病检示：贲门口腺癌，倾向于中分化型，于2017-5-4就诊于某医院行腹部ct提示：食管末端及胃底贲门贲门部胃壁明显不规则增厚，局部可见深大溃疡，局部增厚呈肿块状突向腔内生长，肝胃间隙多发肿大淋巴结，考虑转移，肝内散在斑片及结节状低低密度肿块，考虑转移，暂无手术指征，建议患者化疗，患者拒绝。", "event": [ { "core_name": "疼痛", "tendency": "否定", "character": [ "刺痛" ], "anatomy_list": [ "咽喉部" ] }, { "core_name": "呛咳", "tendency": "否定", "character": [ "饮水" ], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "", "character": [ "隐痛", "间断性", "进食后明显", "不影响日常活动及睡眠" ], "anatomy_list": [ "右上腹" ] }, { "core_name": "反酸", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "烧心", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "胸闷", "tendency": "否定", "character": [], "anatomy_list": [ "胸" ] }, { "core_name": "心慌", "tendency": "否定", "character": [], "anatomy_list": [ "心" ] }, { "core_name": "癌", "tendency": "", "character": [], "anatomy_list": [ "贲门" ] }, { "core_name": "胃炎", "tendency": "", "character": [ "慢性", "萎缩性" ], "anatomy_list": [ "胃" ] }, { "core_name": "腺癌", "tendency": "不确定", "character": [ "中分化型" ], "anatomy_list": [ "贲门口" ] }, { "core_name": "增厚", "tendency": "", "character": [ "明显", "不规则" ], "anatomy_list": [ "食管末端", "胃底", "贲门胃壁" ] }, { "core_name": "溃疡", "tendency": "", "character": [ "深", "大", "局部" ], "anatomy_list": [ "食管末端", "胃底", "贲门胃壁" ] }, { "core_name": "增厚", "tendency": "", "character": [ "肿块状", "突向腔内生长", "局部" ], "anatomy_list": [ "食管末端", "胃底", "贲门胃壁" ] }, { "core_name": "肿大", "tendency": "", "character": [ "多发" ], "anatomy_list": [ "肝胃间隙淋巴结" ] }, { "core_name": "转移", "tendency": "不确定", "character": [], "anatomy_list": [ "肝胃间隙" ] }, { "core_name": "斑片", "tendency": "", "character": [ "散在" ], "anatomy_list": [ "肝内" ] }, { "core_name": "肿块", "tendency": "", "character": [ "结节状", "低密度", "散在" ], "anatomy_list": [ "肝内" ] }, { "core_name": "转移", "tendency": "不确定", "character": [], "anatomy_list": [ "肝内" ] } ] }, { "id": 1760, "text": "标本送常规病检(123456):（左乳）浸润性癌，非特殊类型，ii级6分，局部见导管内癌成分。", "event": [ { "core_name": "癌", "tendency": "", "character": [ "非特殊类型", "浸润性", "ii级6分" ], "anatomy_list": [ "左乳" ] }, { "core_name": "癌", "tendency": "", "character": [ "导管内", "局部" ], "anatomy_list": [ "左乳" ] } ] }, { "id": 1941, "text": "化疗期间复查胸部ct提示病灶维持稳定无明显进展。", "event": [ { "core_name": "病灶", "tendency": "否定", "character": [ "明显进展" ], "anatomy_list": [] }, { "core_name": "病灶", "tendency": "", "character": [ "维持稳定" ], "anatomy_list": [] } ] }, { "id": 1284, "text": "右输卵管系膜囊肿。双侧卵巢组织。", "event": [ { "core_name": "囊肿", "tendency": "", "character": [], "anatomy_list": [ "右输卵管", "系膜" ] } ] }, { "id": 1194, "text": "于2016-07-20开始静脉化疗，化疗方案为多西他赛140mg+表柔比星110mg，分两次给药，化疗期间有脱发，无明显骨髓抑制现象，无恶心、呕吐等胃肠道反应。", "event": [ { "core_name": "脱发", "tendency": "", "character": [ "化疗期间" ], "anatomy_list": [] }, { "core_name": "骨髓抑制", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [ "骨髓" ] }, { "core_name": "恶心", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "呕吐", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "胃肠道反应", "tendency": "否定", "character": [], "anatomy_list": [ "胃肠道" ] } ] }, { "id": 971, "text": "化疗过程顺利，未见明显不良反应，现患者为求第5次化疗入我院，门诊以“乳腺癌术后”收入我科。", "event": [ { "core_name": "癌", "tendency": "", "character": [ "术后" ], "anatomy_list": [ "乳腺" ] } ] }, { "id": 222, "text": "患者 伴纳差、乏力 ， 不伴大汗淋漓 ， 不伴畏寒、发热 ， 不伴反酸、嗳气 ， 无咳嗽、咳痰 ， 无胸闷、心悸 ， 无尿频、尿急、尿痛等症状 。", "event": [ { "core_name": "纳差", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "乏力", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "出汗", "tendency": "否定", "character": [ "大汗" ], "anatomy_list": [] }, { "core_name": "畏寒", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "发热", "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": "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": "心悸", "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": "尿痛", "tendency": "否定", "character": [], "anatomy_list": [] } ] }, { "id": 131, "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": 1707, "text": "患者遂转诊某医院，行骨髓穿刺涂片（170696Mm1）示浆细胞异常增生，原始及幼稚为主，考虑多发性骨髓瘤。", "event": [ { "core_name": "增生", "tendency": "", "character": [ "异常", "原始及幼稚为主" ], "anatomy_list": [ "浆细胞" ] }, { "core_name": "瘤", "tendency": "不确定", "character": [ "多发性" ], "anatomy_list": [ "骨髓" ] } ] }, { "id": 1223, "text": "泌尿系彩超: 膀胱壁局限性增厚，请结合临床。", "event": [ { "core_name": "增厚", "tendency": "", "character": [ "局限性" ], "anatomy_list": [ "膀胱壁" ] } ] }, { "id": 1457, "text": "自诉病程中有咯鲜血，无血凝块、食物残渣。", "event": [ { "core_name": "咯血", "tendency": "", "character": [ "鲜", "无血凝块、食物残渣。" ], "anatomy_list": [] } ] }, { "id": 1385, "text": "病程中，患者无头晕、头痛、骨痛，无饮水呛咳、吞咽困难，无胸闷。", "event": [ { "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": [ "骨头" ] }, { "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": "胸闷", "tendency": "否定", "character": [], "anatomy_list": [ "胸" ] } ] }, { "id": 1646, "text": "10天前，患者在负重时突然出现上腹剧烈胀痛，向腰背部放射，伴气促、胸闷，无恶心、呕吐、反酸、嗳气，平卧时胀痛好转，站立、坐位、改变体位时腹痛加重，患者遂到当地医院门诊治疗，行钡餐检查提示胃下垂、胃炎，行腹部彩超提示胆总管扩张，予以“泮托拉唑”等药物治疗后患者腹痛无明显好转，遂到我院就诊，以“胆总管扩张”收入我科。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [ "负重时", "胀痛", "剧烈", "突然出现" ], "anatomy_list": [ "上腹" ] }, { "core_name": "疼痛", "tendency": "", "character": [ "放射性" ], "anatomy_list": [ "腰背部" ] }, { "core_name": "气促", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "胸闷", "tendency": "", "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": "返酸", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "嗳气", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "", "character": [ "胀痛", "平卧时好转" ], "anatomy_list": [ "上腹" ] }, { "core_name": "疼痛", "tendency": "", "character": [ "站立、坐位、改变体位时加重" ], "anatomy_list": [ "腹" ] }, { "core_name": "下垂", "tendency": "", "character": [], "anatomy_list": [ "胃" ] }, { "core_name": "胃炎", "tendency": "", "character": [], "anatomy_list": [ "胃" ] }, { "core_name": "扩张", "tendency": "", "character": [], "anatomy_list": [ "胆总管" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [ "明显好转" ], "anatomy_list": [ "上腹" ] }, { "core_name": "扩张", "tendency": "", "character": [], "anatomy_list": [ "胆总管" ] } ] }, { "id": 1012, "text": "3、盆腔中等量积液（不除外少许积血）。", "event": [ { "core_name": "积液", "tendency": "", "character": [ "中等量" ], "anatomy_list": [ "盆腔" ] }, { "core_name": "积血", "tendency": "不确定", "character": [ "少许" ], "anatomy_list": [ "盆腔" ] } ] }, { "id": 868, "text": "今为求进一步诊治，遂入我院，门诊以“便血待查”收入我科。", "event": [ { "core_name": "便血", "tendency": "", "character": [], "anatomy_list": [] } ] }, { "id": 1039, "text": "现患者为求复发后第三次化疗，遂以“卵巢中低分化浆液性腺癌iii期术后第八次化疗后复发伴直肠转移第二次化疗后”收入我科住院治疗。", "event": [ { "core_name": "腺癌", "tendency": "", "character": [ "中低分化", "浆液性", "术后", "iii期", "第八次化疗后复发" ], "anatomy_list": [ "卵巢" ] }, { "core_name": "转移", "tendency": "", "character": [ "第二次化疗后" ], "anatomy_list": [ "直肠" ] } ] }, { "id": 1711, "text": "住院期间血常规提示重度贫血，予以红细胞悬液400ml后好转；期间口服氨酚羟考酮止痛治疗，未规律服药，疼痛控制差；期间出现背部、颈部多发水泡，请皮肤科会诊后考虑免疫性大疱性皮病可能，疱疹病毒感染待排，建议行皮肤活检，患者及家属拒绝。", "event": [ { "core_name": "贫血", "tendency": "", "character": [ "重度" ], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "", "character": [ "控制差" ], "anatomy_list": [] }, { "core_name": "水泡", "tendency": "", "character": [ "多发" ], "anatomy_list": [ "背部", "颈部" ] }, { "core_name": "皮病", "tendency": "不确定", "character": [ "免疫性", "大疱性" ], "anatomy_list": [] }, { "core_name": "感染", "tendency": "不确定", "character": [ "疱疹病毒" ], "anatomy_list": [] } ] }, { "id": 977, "text": "8月前，患者无明显诱因出现咳嗽、咳痰加重，为黄白色粘液痰，量多，偶有低热、盗汗，无咯血、胸痛等不适，自服“感冒药”后无好转。", "event": [ { "core_name": "咳嗽", "tendency": "", "character": [ "加重" ], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "加重" ], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "黄白色", "粘液", "量多" ], "anatomy_list": [] }, { "core_name": "发热", "tendency": "", "character": [ "偶有", "低" ], "anatomy_list": [] }, { "core_name": "盗汗", "tendency": "", "character": [ "偶有" ], "anatomy_list": [] }, { "core_name": "咯血", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "胸" ] } ] }, { "id": 1962, "text": "高血压病史7年，血压最高180/？mmhg，目前规律口服降压药（具体不详），血压未监测。", "event": [ { "core_name": "高血压", "tendency": "", "character": [ "7年" ], "anatomy_list": [] } ] }, { "id": 520, "text": "彩超（腹部+泌尿系）：胆囊壁增厚，左侧腹腔季肋部混合型包块。", "event": [ { "core_name": "增厚", "tendency": "", "character": [], "anatomy_list": [ "胆囊壁" ] }, { "core_name": "包块", "tendency": "", "character": [ "混合型" ], "anatomy_list": [ "左侧腹腔季肋部" ] } ] }, { "id": 666, "text": "患者于1月前，因受凉出现咳嗽、咳痰，咯白色粘液痰，夜间较多，伴轻度乏力、纳差，步行平路感劳累，无畏寒、发热，无胸痛、胸闷，无头昏、头痛，无恶心、呕吐，无身黄、眼黄，无皮疹等不适，患者就诊于当地诊所，予以抗炎药物治疗3天（具体不详），患者症状未有缓解，故就诊于某医院，查胸部ct示“双肺感染”（未见报告），予以抗炎、止咳等对症治疗20天后复查胸部ct示病情好转（未见报告）出院，但患者自诉症状缓解不明显。", "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", "粘液", "夜间增多" ], "anatomy_list": [] }, { "core_name": "乏力", "tendency": "", "character": [ "轻度" ], "anatomy_list": [] }, { "core_name": "纳差", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "劳累", "tendency": "", "character": [ "步行平路" ], "anatomy_list": [] }, { "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": [ "胸" ] }, { "core_name": "胸闷", "tendency": "否定", "character": [], "anatomy_list": [ "胸" ] }, { "core_name": "头昏", "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": "黄染", "tendency": "否定", "character": [], "anatomy_list": [ "身" ] }, { "core_name": "黄染", "tendency": "否定", "character": [], "anatomy_list": [ "眼" ] }, { "core_name": "皮疹", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "感染", "tendency": "", "character": [], "anatomy_list": [ "双肺" ] } ] }, { "id": 1297, "text": "尿正常，无血尿。", "event": [ { "core_name": "小便", "tendency": "", "character": [ "正常" ], "anatomy_list": [] }, { "core_name": "血尿", "tendency": "否定", "character": [], "anatomy_list": [] } ] }, { "id": 363, "text": "患者自患病以来，精神、食欲、睡眠可，大小便正常，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": "大小便", "tendency": "", "character": [ "正常" ], "anatomy_list": [] }, { "core_name": "体重变化", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [] } ] }, { "id": 1409, "text": "1周前无明显诱因出现进行性纳差，每日少量流质，全身乏力，进食后腹胀、一般营养状态差，偶感上腹部隐痛；否认咳嗽、咳痰；无发热；肛门有排气，t管每日引流600ml左右褐色液体，门诊以“胰腺癌术后”收入我科。", "event": [ { "core_name": "纳差", "tendency": "", "character": [ "进行性" ], "anatomy_list": [] }, { "core_name": "乏力", "tendency": "", "character": [], "anatomy_list": [ "全身" ] }, { "core_name": "腹胀", "tendency": "", "character": [ "进食后" ], "anatomy_list": [ "腹" ] }, { "core_name": "营养状态", "tendency": "", "character": [ "差" ], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "", "character": [ "隐痛" ], "anatomy_list": [ "上腹部" ] }, { "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": "排气", "tendency": "", "character": [], "anatomy_list": [ "肛门" ] }, { "core_name": "癌", "tendency": "", "character": [ "术后" ], "anatomy_list": [ "胰腺" ] } ] }, { "id": 429, "text": "考虑肺癌可能，予 对症支持 等治疗。", "event": [ { "core_name": "癌", "tendency": "不确定", "character": [], "anatomy_list": [ "肺" ] } ] }, { "id": 2030, "text": "近来发现右肩背部肿物 逐渐增大致4*5cm 。", "event": [ { "core_name": "肿物", "tendency": "", "character": [ "逐渐增大" ], "anatomy_list": [ "右肩背部" ] } ] }, { "id": 1910, "text": "2月前改用奥西替尼治疗，住院期间予以唑来磷酸抗溶骨治疗，同时口服羟考酮缓释片 10mg q12h，疼痛控制可。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [ "控制可" ], "anatomy_list": [] } ] }, { "id": 543, "text": "患者本次发病以来，食欲下降， 神志清醒，精神欠佳，睡眠尚可，大便正常，小便正常，体重减少。", "event": [ { "core_name": "食欲", "tendency": "", "character": [ "下降" ], "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": [ "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": 2039, "text": "7月前患者给予亚砷酸氯化钠(伊泰达)注射液 10mg 静滴14天，6月前予以口服维甲酸 20mg bid*14天维持治疗，5月前行亚砷酸氯化钠(伊泰达)注射液 10mg 静滴14天维持化疗，3月余前复查骨髓检查示增生性骨髓象；fish：pml/rara（双色双融合）(15/17)：未见异常；腰穿脑脊液未见异常细胞。现为维持化疗入院。", "event": [ { "core_name": "fish：pml/rara（双色双融合）(15/17)异常", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "骨髓象", "tendency": "", "character": [ "增生性" ], "anatomy_list": [ "骨髓" ] } ] }, { "id": 964, "text": "2015-12-08于某医院复查，肿瘤标记物示：cea9.91ng/ml、ca125 45.8U/ml，故继续予以培美曲塞900mg（具体治疗不详）维持治疗，过程顺利，无骨髓抑制后好转出院。", "event": [ { "core_name": "骨髓抑制", "tendency": "否定", "character": [], "anatomy_list": [ "骨髓" ] } ] }, { "id": 1663, "text": "1月余前患者无明显诱因出现咳嗽咳痰，咳白色泡沫样痰，伴左侧胸部隐痛，胸痛与呼吸无关，逐渐出现气喘，伴乏力纳差，伴盗汗，无发热寒战，无午后低热，无咳血，无咳大量脓痰，无声音嘶哑，无呼吸困难，夜间可平卧，无吞咽困难，无头晕头痛，无恶心呕吐，无关节疼痛，无乏力浮肿，患者遂于某医院就诊，完善相关检查示血象升高，胸部ct示“1.左下肺空洞病灶，脓肿？癌性空洞？2.左侧肺门肺门淋巴结增大，3.左侧胸腔少量积液”，给予“帕拉西林他唑巴坦+莫西沙星+奥硝唑”抗感染治疗，患者上述症状未见明显好转，并于2016-5-4夜间出现发热，最高高体温为38.6℃，现患者为求进一步诊治来我院，门诊以“肺空洞待查”收治入院。", "event": [ { "core_name": "咳嗽", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "白色", "泡沫样" ], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "", "character": [ "隐痛" ], "anatomy_list": [ "左侧胸部" ] }, { "core_name": "疼痛", "tendency": "", "character": [ "与呼吸无关" ], "anatomy_list": [ "胸部" ] }, { "core_name": "气喘", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "乏力", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "纳差", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "盗汗", "tendency": "", "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": "发热", "tendency": "否定", "character": [ "午后", "低" ], "anatomy_list": [] }, { "core_name": "咳血", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "否定", "character": [ "大量", "脓痰" ], "anatomy_list": [] }, { "core_name": "声音嘶哑", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "呼吸困难", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "吞咽困难", "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": "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": [ "关节" ] }, { "core_name": "乏力", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "浮肿", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "血象", "tendency": "", "character": [ "升高" ], "anatomy_list": [] }, { "core_name": "病灶", "tendency": "", "character": [ "空洞" ], "anatomy_list": [ "左下肺" ] }, { "core_name": "脓肿", "tendency": "不确定", "character": [], "anatomy_list": [ "左下肺" ] }, { "core_name": "空洞", "tendency": "不确定", "character": [ "癌性" ], "anatomy_list": [] }, { "core_name": "增大", "tendency": "", "character": [], "anatomy_list": [ "左侧肺门淋巴结" ] }, { "core_name": "积液", "tendency": "", "character": [ "少量" ], "anatomy_list": [ "左侧胸腔" ] }, { "core_name": "发热", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "体温", "tendency": "", "character": [ "升高" ], "anatomy_list": [] }, { "core_name": "空洞", "tendency": "不确定", "character": [], "anatomy_list": [ "肺" ] } ] }, { "id": 761, "text": "3.右侧胸膜增厚、粘连。", "event": [ { "core_name": "增厚", "tendency": "", "character": [], "anatomy_list": [ "右侧胸膜" ] }, { "core_name": "粘连", "tendency": "", "character": [], "anatomy_list": [ "右侧胸膜" ] } ] }, { "id": 708, "text": "2017-2无明显诱因出现腰部胀痛，休息后自行缓解，2017-3-27复查ca-12578.1u/ml，2017-04-24ca-125152.3u/ml，he444.43pmol/l，妇科彩超提示双侧髂血管血管旁低回声，考虑：淋巴结？盆腔积液，考虑“卵巢癌术后化疗后复发”，于2017-4-27在我科行腹腔镜探查术+盆腔肿瘤切除术+肠粘连松解术+盆腔粘连松解术+输尿管镜检查+右侧输尿管双j管置入术，术后病检结果：<左侧阴道前壁、右侧阴道前壁>血管扩张充血，血管管壁增厚，未见肿瘤组织。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [ "胀痛", "休息后自行缓解" ], "anatomy_list": [ "腰部" ] }, { "core_name": "回声", "tendency": "", "character": [ "低" ], "anatomy_list": [ "双侧髂血管旁" ] }, { "core_name": "积液", "tendency": "", "character": [], "anatomy_list": [ "盆腔" ] }, { "core_name": "癌", "tendency": "不确定", "character": [ "术后化疗后", "复发" ], "anatomy_list": [ "卵巢" ] }, { "core_name": "扩张", "tendency": "", "character": [], "anatomy_list": [ "右侧左侧阴道前壁前壁血管" ] }, { "core_name": "血管充血", "tendency": "", "character": [], "anatomy_list": [ "右侧左侧阴道前壁前壁血管" ] }, { "core_name": "增厚", "tendency": "", "character": [], "anatomy_list": [ "血管管壁" ] }, { "core_name": "肿瘤组织", "tendency": "否定", "character": [], "anatomy_list": [] } ] }, { "id": 1112, "text": "患者2天前无明显诱因出现头昏、心悸，头昏程度中等，伴四肢麻木、乏力，伴轻度步态不稳，心悸间断发作，休息后可缓解。", "event": [ { "core_name": "头昏", "tendency": "", "character": [], "anatomy_list": [ "头" ] }, { "core_name": "心悸", "tendency": "", "character": [], "anatomy_list": [ "心" ] }, { "core_name": "头昏", "tendency": "", "character": [ "程度中等" ], "anatomy_list": [ "头" ] }, { "core_name": "麻木", "tendency": "", "character": [], "anatomy_list": [ "四肢" ] }, { "core_name": "乏力", "tendency": "", "character": [], "anatomy_list": [ "四肢" ] }, { "core_name": "步态不稳", "tendency": "", "character": [ "轻度" ], "anatomy_list": [] }, { "core_name": "心悸", "tendency": "", "character": [ "间断发作", "休息后可缓解" ], "anatomy_list": [ "心" ] } ] }, { "id": 847, "text": "入院后腹部ct检查提示：乙状结肠降结肠交界处局部肠壁增厚，管腔狭窄，浆膜面毛糙，遂行左半结肠根治性切除术，术后恢复好，病理提示t4n0M0。", "event": [ { "core_name": "增厚", "tendency": "", "character": [ "局部", "肠壁" ], "anatomy_list": [ "乙状结肠降结肠交界处" ] }, { "core_name": "狭窄", "tendency": "", "character": [], "anatomy_list": [ "乙状结肠降结肠交界处管腔" ] }, { "core_name": "毛糙", "tendency": "", "character": [], "anatomy_list": [ "乙状结肠降结肠交界处浆膜面" ] } ] }, { "id": 910, "text": "患者诉此后多次体检复查腹部彩超，均提示胆囊结石，患病以来，患者诉气候变化时右上腹有轻微疼痛，服用消炎利胆片稍有缓解，故患者未予进一步治疗。", "event": [ { "core_name": "结石", "tendency": "", "character": [], "anatomy_list": [ "胆囊" ] }, { "core_name": "疼痛", "tendency": "", "character": [ "轻微" ], "anatomy_list": [ "右上腹" ] }, { "core_name": "疼痛", "tendency": "", "character": [ "服用消炎利胆片稍有缓解" ], "anatomy_list": [ "右上腹" ] } ] }, { "id": 1536, "text": "1天前，患者再次出现胸痛明显家属见状遂来我院，以“肺癌”收入我科。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [ "明显" ], "anatomy_list": [ "胸" ] }, { "core_name": "癌", "tendency": "", "character": [], "anatomy_list": [ "肺" ] } ] }, { "id": 1840, "text": "患者于半月前受凉后出现阵发性咳嗽、咳黄色粘稠痰，右侧胸部阵发性隐痛，以剧烈咳嗽时为重，痛时尚能忍受，无转移性疼痛，无放射样疼痛，无畏寒、发热，无潮热、盗汗，无恶心、呕吐，无胸闷及呼吸困难，求诊于当地某社区卫生服务站予“抗感染”等治疗后（具体不详）症状无缓解。", "event": [ { "core_name": "咳嗽", "tendency": "", "character": [ "阵发性", "受凉后" ], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "黄色", "粘稠痰" ], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "", "character": [ "阵发性", "隐痛", "剧烈咳嗽时为重", "尚能忍受" ], "anatomy_list": [ "右侧胸部" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [ "转移性" ], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "否定", "character": [ "放射样" ], "anatomy_list": [] }, { "core_name": "畏寒", "tendency": "否定", "character": [], "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": "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": "呼吸困难", "tendency": "否定", "character": [], "anatomy_list": [] } ] }, { "id": 719, "text": "术后恢复可，规律行化疗及口服抗肿瘤药物，定期复查，入院前2年余因肝癌复发于我院行介入手术，现因患者门诊复查afp升高，为进一步诊断及治疗，遂来我院就诊，患者患病以来精神尚可，饮食差，二便正常。", "event": [ { "core_name": "癌", "tendency": "", "character": [ "复发" ], "anatomy_list": [ "肝" ] }, { "core_name": "afp", "tendency": "", "character": [ "升高" ], "anatomy_list": [] }, { "core_name": "精神", "tendency": "", "character": [ "尚可" ], "anatomy_list": [] }, { "core_name": "饮食", "tendency": "", "character": [ "差" ], "anatomy_list": [] }, { "core_name": "大小便", "tendency": "", "character": [ "正常" ], "anatomy_list": [] } ] }, { "id": 664, "text": "5天前患者再次咳嗽、咳痰加重，为白色泡沫痰，伴活动后传来不适，患者今日为求进一步诊治就诊于我院，胸片提示：1、右肺下叶病灶，多考虑炎症；2、右侧胸腔积液。", "event": [ { "core_name": "咳嗽", "tendency": "", "character": [ "加重" ], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "加重" ], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "白色", "泡沫痰" ], "anatomy_list": [] }, { "core_name": "病灶", "tendency": "", "character": [], "anatomy_list": [ "右肺下叶" ] }, { "core_name": "炎症", "tendency": "不确定", "character": [], "anatomy_list": [ "右肺下叶" ] }, { "core_name": "积液", "tendency": "", "character": [], "anatomy_list": [ "右侧胸腔" ] } ] }, { "id": 1207, "text": "4.“宫颈ca复查”：现子宫颈部增大，宫颈右前缘结节，累及邻近膀胱壁及右侧输尿管，伴近端输尿管及肾盂肾盏扩张。", "event": [ { "core_name": "癌", "tendency": "", "character": [], "anatomy_list": [ "宫颈" ] }, { "core_name": "增大", "tendency": "", "character": [], "anatomy_list": [ "子宫颈部" ] }, { "core_name": "结节", "tendency": "", "character": [], "anatomy_list": [ "宫颈右前缘" ] }, { "core_name": "累及", "tendency": "", "character": [], "anatomy_list": [ "膀胱壁", "右侧输尿管" ] }, { "core_name": "扩张", "tendency": "", "character": [], "anatomy_list": [ "近端输尿管", "肾盏", "肾盂" ] } ] }, { "id": 181, "text": "左侧输尿管及膀胱腔腔内双j管影，上端位置偏低。", "event": [ { "core_name": "双j管影", "tendency": "", "character": [], "anatomy_list": [ "左侧输尿管", "膀胱腔内" ] }, { "core_name": "位置偏低", "tendency": "", "character": [], "anatomy_list": [ "左侧输尿管上端" ] } ] }, { "id": 1013, "text": "综合考虑：不除外黄体破裂。", "event": [ { "core_name": "破裂", "tendency": "不确定", "character": [], "anatomy_list": [ "黄体" ] } ] }, { "id": 3, "text": "入院前3+年,患者患“肺结核”,服药8月,后出现快步活动后气促,休息后缓解,平时轻量活动可耐受,偶咳,不剧,痰少,未正规检查治疗。", "event": [ { "core_name": "结核", "tendency": "", "character": [], "anatomy_list": [ "肺" ] }, { "core_name": "气促", "tendency": "", "character": [ "快步活动后", "休息后", "缓解" ], "anatomy_list": [] }, { "core_name": "气促", "tendency": "", "character": [ "休息后缓解" ], "anatomy_list": [] }, { "core_name": "活动可耐受", "tendency": "", "character": [ "轻量" ], "anatomy_list": [] }, { "core_name": "咳嗽", "tendency": "", "character": [ "偶", "不剧" ], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "少" ], "anatomy_list": [] } ] }, { "id": 862, "text": "此次病程中精神较差，饮食稍差，大便如上述，小便正常，体重无明显改变。", "event": [ { "core_name": "精神", "tendency": "", "character": [ "较差" ], "anatomy_list": [] }, { "core_name": "进食", "tendency": "", "character": [ "稍差" ], "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": 755, "text": "3.右侧胸膜增厚。", "event": [ { "core_name": "增厚", "tendency": "", "character": [], "anatomy_list": [ "右侧胸膜" ] } ] }, { "id": 1332, "text": "入院前 10天 ，患者再次因受凉后咳嗽，喘息加重，咯少许 黄色粘痰 ，伴双下肢轻度水肿。", "event": [ { "core_name": "咳嗽", "tendency": "", "character": [ "加重", "受凉后" ], "anatomy_list": [] }, { "core_name": "气喘", "tendency": "", "character": [ "加重", "受凉后" ], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "黄色", "粘痰", "少许" ], "anatomy_list": [] }, { "core_name": "水肿", "tendency": "", "character": [ "轻度" ], "anatomy_list": [ "双下肢" ] } ] }, { "id": 854, "text": "于为进一步治疗，患者于今日就诊于我科，门诊以“霍奇金淋巴瘤”收住入院。", "event": [ { "core_name": "瘤", "tendency": "", "character": [ "霍奇金" ], "anatomy_list": [ "淋巴" ] } ] }, { "id": 651, "text": "1天前因“血尿”来我院门诊就诊，查“血常规：白细胞计数：3.3*10^9/L ，红细胞计数：4.16*10^12/L ，血红蛋白浓度：127g/L ，血小板计数：58*10^9/L ，淋巴细胞百分比：20.5%，中性粒细胞百分比：69.5%；尿常规：胆红素++，红细胞8214个/UL，白细胞++，蛋白质+++，隐血+++。", "event": [ { "core_name": "血尿", "tendency": "", "character": [], "anatomy_list": [] } ] }, { "id": 134, "text": "查无明显手术禁忌后于2017-9-28在局麻超声引导下行右乳包块麦默通旋切术+肿物切除+快速冰冻活检术。", "event": [ { "core_name": "包块", "tendency": "", "character": [], "anatomy_list": [ "右乳" ] } ] }, { "id": 2019, "text": "4+年前，患者因排尿不畅就诊，查前列腺psa升高，行穿刺活检诊断“前列腺癌”，给予内分泌治疗后，排尿不畅症状好转。", "event": [ { "core_name": "排尿不畅", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "前列腺psa", "tendency": "", "character": [ "升高" ], "anatomy_list": [] }, { "core_name": "癌", "tendency": "", "character": [], "anatomy_list": [ "前列腺" ] }, { "core_name": "排尿不畅", "tendency": "", "character": [ "好转" ], "anatomy_list": [] } ] }, { "id": 1132, "text": "2020/5/95/9Mmr检查报告：上腹部平扫磁共振胰胆管成像(mrcp); 1、肝左叶、肝门部及胆总管上段区域异常信号，考虑：肿瘤性病变继发高位胆道梗阻可能性大，建议ct增强扫描。", "event": [ { "core_name": "信号", "tendency": "", "character": [ "异常" ], "anatomy_list": [ "肝左叶", "肝门部", "胆总管上段" ] }, { "core_name": "病变", "tendency": "不确定", "character": [ "肿瘤性" ], "anatomy_list": [] }, { "core_name": "梗阻", "tendency": "不确定", "character": [ "高位", "继发" ], "anatomy_list": [ "胆道" ] } ] }, { "id": 1845, "text": "ctu(256层)(2015-03-09):膀胱占位性病变，考虑膀胱癌可能性大，右侧输尿管受侵。", "event": [ { "core_name": "病变", "tendency": "", "character": [ "占位性" ], "anatomy_list": [ "膀胱" ] }, { "core_name": "癌", "tendency": "不确定", "character": [], "anatomy_list": [ "膀胱" ] }, { "core_name": "癌", "tendency": "", "character": [ "受侵" ], "anatomy_list": [ "右侧输尿管" ] } ] }, { "id": 1289, "text": "诉化疗期间2+周前患者无明显诱因出现双臀部、腰背部及双下肢大腿前侧疼痛以左侧为着，自感站立、行走后缓解，休息后加重，夜间疼痛加重较明显，患者无双下肢麻木、乏力，无恶心、呕吐、畏寒、发热、头痛、胸闷、胸痛、咳嗽、咯血、腹痛、腹胀、尿频、尿急、尿痛，无大小便失禁等不适，在我院行ect：左侧髂骨异常放射性浓聚，转移性骨肿瘤可能性大，骨科行腰椎及骨盆mri检查提示：左侧髂骨异常信号，多系肿瘤性病变。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [ "站立、行走后缓解", "休息后加重", "夜间疼痛加重较明显" ], "anatomy_list": [ "双臀部", "腰背部", "双下肢大腿前侧" ] }, { "core_name": "麻木", "tendency": "否定", "character": [], "anatomy_list": [ "双下肢" ] }, { "core_name": "乏力", "tendency": "否定", "character": [], "anatomy_list": [ "双下肢" ] }, { "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": "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": "咳嗽", "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": [ "腹" ] }, { "core_name": "腹胀", "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": "大便", "tendency": "否定", "character": [ "失禁" ], "anatomy_list": [] }, { "core_name": "小便", "tendency": "否定", "character": [ "失禁" ], "anatomy_list": [] }, { "core_name": "浓聚", "tendency": "", "character": [ "异常", "放射性" ], "anatomy_list": [ "左侧髂骨" ] }, { "core_name": "肿瘤", "tendency": "不确定", "character": [ "转移性" ], "anatomy_list": [ "骨" ] }, { "core_name": "信号", "tendency": "", "character": [ "异常" ], "anatomy_list": [ "左侧髂骨" ] }, { "core_name": "病变", "tendency": "", "character": [ "肿瘤性" ], "anatomy_list": [ "左侧髂骨" ] } ] }, { "id": 2, "text": "患者自意识障碍以来, 精神差 ,未进食, 大、小便未排 , 体重无明显变化 。", "event": [ { "core_name": "意识障碍", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "精神", "tendency": "", "character": [ "差" ], "anatomy_list": [] }, { "core_name": "进食", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "大小便", "tendency": "", "character": [ "未排" ], "anatomy_list": [] }, { "core_name": "体重变化", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [] } ] }, { "id": 300, "text": "5年余前，患者无明显诱因出现咳嗽，咳白色粘痰，不带血丝，无咯血，无潮热、盗汗，无心慌、胸闷，无声音嘶哑等不适，在某医院行胸片检查提示左肺占位，考虑肺癌，于2009-11-24在我院心胸外科行左上肺叶切除+淋巴结清扫术，术后病检提示：左上肺肺腺癌。", "event": [ { "core_name": "咳嗽", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "白色", "粘", "不带血丝" ], "anatomy_list": [] }, { "core_name": "咯血", "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": "心慌", "tendency": "否定", "character": [], "anatomy_list": [ "心" ] }, { "core_name": "胸闷", "tendency": "否定", "character": [], "anatomy_list": [ "胸" ] }, { "core_name": "声音嘶哑", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "占位", "tendency": "", "character": [], "anatomy_list": [ "左肺" ] }, { "core_name": "癌", "tendency": "不确定", "character": [], "anatomy_list": [ "肺" ] }, { "core_name": "腺癌", "tendency": "", "character": [], "anatomy_list": [ "左上肺" ] } ] }, { "id": 208, "text": "现患者无恶心、呕吐等不适，今日为行第二次化疗来我院，门诊以“右肺小细胞肺癌”收治入院。", "event": [ { "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": [], "anatomy_list": [ "右肺", "小细胞" ] } ] }, { "id": 1640, "text": "入院前4小时，患者感中上腹疼痛较前加重，阵发性加重，尚能忍受，无放射痛，无大汗、心悸，无恶心、呕吐，无畏寒、发热等不适，遂到我院就诊，门诊以“腹痛待查”收入我科住院治疗。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [ "较前加重", "阵发性加重", "尚能忍受" ], "anatomy_list": [ "中上腹" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [ "放射性" ], "anatomy_list": [] }, { "core_name": "大汗", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "心悸", "tendency": "否定", "character": [], "anatomy_list": [ "心" ] }, { "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": "疼痛", "tendency": "不确定", "character": [], "anatomy_list": [ "腹" ] } ] }, { "id": 261, "text": "c14呼气试验阳性。", "event": [ { "core_name": "c14呼气试验", "tendency": "", "character": [ "阳性" ], "anatomy_list": [] } ] }, { "id": 1143, "text": "故昨日于我院门诊复查病理切片，结果示：子宫腔低分化腺癌，倾向于子宫内膜桨液性乳头状腺癌。", "event": [ { "core_name": "腺癌", "tendency": "", "character": [ "低分化" ], "anatomy_list": [ "子宫腔" ] }, { "core_name": "腺癌", "tendency": "不确定", "character": [ "乳头状", "桨液性" ], "anatomy_list": [ "子宫内膜" ] } ] }, { "id": 551, "text": "入院前1+月，患者自觉关节肿痛较前加重，四肢水肿，双手指指关节活动较前僵硬，有晨僵现象，偶有咳嗽，咳少量白色粘痰，无咽痛、流涕，无畏寒、发热，无颜面浮肿，无明显活动后心累、气促，无胸闷、胸痛等不适，患者遂于我院中医科就诊，予以止痛、中药调理等对症治疗，经治疗后未见明显好转，遂于某医院就诊，完善类风湿因子：306.0IU/ml；抗环瓜氨酸肽抗体抗体：120.71U/ml；抗角蛋白抗体阴性；血沉93mm/h；抗ra33抗体、抗o未见明显异常。", "event": [ { "core_name": "肿痛", "tendency": "", "character": [ "较前加重" ], "anatomy_list": [ "关节" ] }, { "core_name": "水肿", "tendency": "", "character": [], "anatomy_list": [ "四肢" ] }, { "core_name": "僵硬", "tendency": "", "character": [ "较前" ], "anatomy_list": [ "双手指", "指关节" ] }, { "core_name": "晨僵", "tendency": "", "character": [], "anatomy_list": [ "双手指", "指关节" ] }, { "core_name": "咳嗽", "tendency": "", "character": [ "偶有" ], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "少量", "白色", "粘性" ], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "咽" ] }, { "core_name": "流涕", "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": "浮肿", "tendency": "否定", "character": [], "anatomy_list": [ "颜面" ] }, { "core_name": "气促", "tendency": "否定", "character": [ "明显", "活动后" ], "anatomy_list": [] }, { "core_name": "心累", "tendency": "否定", "character": [ "明显", "活动后" ], "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": "抗o", "tendency": "否定", "character": [ "明显异常" ], "anatomy_list": [] }, { "core_name": "抗ra33抗体", "tendency": "否定", "character": [ "明显异常" ], "anatomy_list": [] } ] }, { "id": 1329, "text": "10年 来病情进行性加重，咳嗽，喘息发作渐趋频繁。", "event": [ { "core_name": "咳嗽", "tendency": "", "character": [ "发作渐趋频繁" ], "anatomy_list": [] }, { "core_name": "喘息", "tendency": "", "character": [ "发作渐趋频繁" ], "anatomy_list": [] } ] }, { "id": 105, "text": "到在当地检查彩超提示：甲状腺肿瘤。", "event": [ { "core_name": "肿瘤", "tendency": "", "character": [], "anatomy_list": [ "甲状腺" ] } ] }, { "id": 99, "text": "入院前3+月，患者因“黑便3+天，呕血10+小时”入我院消化内科，行胃镜提示残胃胃巨大溃疡；病理（123456）检查提示：胃体腺癌。", "event": [ { "core_name": "黑便", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "呕血", "tendency": "", "character": [ "10+小时" ], "anatomy_list": [] }, { "core_name": "残胃", "tendency": "", "character": [], "anatomy_list": [ "胃" ] }, { "core_name": "溃疡", "tendency": "", "character": [ "巨大" ], "anatomy_list": [ "胃" ] }, { "core_name": "腺癌", "tendency": "", "character": [], "anatomy_list": [ "胃体" ] } ] }, { "id": 1722, "text": "1月余前，患者自觉尿色逐渐加深，呈浓茶色尿，不伴腹痛、恶心、呕吐，无乏力、纳差等不适，无皮肤巩膜黄染，无全身皮肤巩膜黄染，无白陶土样大便，无黑朦、晕厥等不适。", "event": [ { "core_name": "小便", "tendency": "", "character": [ "浓茶色", "色逐渐加深" ], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "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": "乏力", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "纳差", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "黄染", "tendency": "否定", "character": [], "anatomy_list": [ "皮肤", "巩膜" ] }, { "core_name": "黄染", "tendency": "否定", "character": [], "anatomy_list": [ "全身皮肤", "巩膜" ] }, { "core_name": "大便", "tendency": "否定", "character": [ "白陶土样" ], "anatomy_list": [] }, { "core_name": "黑朦", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "晕厥", "tendency": "否定", "character": [], "anatomy_list": [] } ] }, { "id": 1949, "text": "1月前患者因反复夜尿增多3月入院，伴有排尿困难加重，表现为排尿踌躇、尿线变细、射程变短，伴有尿频、尿急，无明显尿痛，无血尿，无腰痛、腹痛、无腹痛、腹泻，不伴发热、寒战，无潮热、盗汗、乏力，无头晕、头痛，无心慌、胸闷、胸痛，无呕血、便血，无双下肢水肿、无骨痛等异常，行psa提示为：总前列腺特异性抗原(t-psa)185.00ng/ml↑mr检查报告：1.前列腺增大，中央带及外周带散在异常信号影，考虑前列腺癌，累及膀胱及精囊腺，伴淋巴结转移；2.慢性膀胱炎。", "event": [ { "core_name": "夜尿增多", "tendency": "", "character": [ "反复" ], "anatomy_list": [] }, { "core_name": "排尿困难", "tendency": "", "character": [ "加重" ], "anatomy_list": [] }, { "core_name": "排尿踌躇", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "变细", "tendency": "", "character": [ "尿线" ], "anatomy_list": [] }, { "core_name": "射程变短", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "尿频", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "尿急", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "尿痛", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [] }, { "core_name": "血尿", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "腰" ] }, { "core_name": "疼痛", "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": "发热", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "寒颤", "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": "乏力", "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": "心慌", "tendency": "否定", "character": [], "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": "呕血", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "便血", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "水肿", "tendency": "否定", "character": [], "anatomy_list": [ "双下肢" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "骨" ] }, { "core_name": "增大", "tendency": "", "character": [], "anatomy_list": [ "前列腺" ] }, { "core_name": "异常信号影", "tendency": "", "character": [ "散在" ], "anatomy_list": [ "前列腺中央带及外周" ] }, { "core_name": "癌", "tendency": "", "character": [], "anatomy_list": [ "前列腺" ] }, { "core_name": "癌", "tendency": "", "character": [ "累及" ], "anatomy_list": [ "膀胱", "精囊腺" ] }, { "core_name": "癌", "tendency": "", "character": [ "转移" ], "anatomy_list": [ "淋巴结" ] }, { "core_name": "膀胱炎", "tendency": "", "character": [ "慢性" ], "anatomy_list": [ "膀胱" ] } ] }, { "id": 362, "text": "患者为求进一步诊治到我院就诊，门诊以“右股骨髁病变待查”收入我科住院治疗。", "event": [ { "core_name": "病变", "tendency": "不确定", "character": [], "anatomy_list": [ "右股骨髁" ] } ] }, { "id": 1093, "text": "2+月前患者无明显诱因出现全身乏力，后逐渐出现黑便，量多，呈糊状，偶有粘液，无脓血，伴有心慌、头晕、乏力，无恶心、呕吐，无畏寒发热等不适，来我院就诊，诊断“直肠癌术后伴肝转移，小肠转移转移性肿瘤可疑”，予行tace术后，术后在我科予（奥沙利铂 200mg d1+替吉奥 60mg bid d1-d14）方案化疗2周期，化疗后无不适，今为行化疗，遂来我院就诊，门诊以“直肠癌”收入我科住院治疗。", "event": [ { "core_name": "乏力", "tendency": "", "character": [], "anatomy_list": [ "全身" ] }, { "core_name": "黑便", "tendency": "", "character": [ "量多", "糊状" ], "anatomy_list": [] }, { "core_name": "大便", "tendency": "", "character": [ "偶有粘液" ], "anatomy_list": [] }, { "core_name": "大便", "tendency": "否定", "character": [ "脓血" ], "anatomy_list": [] }, { "core_name": "心慌", "tendency": "", "character": [], "anatomy_list": [ "心" ] }, { "core_name": "头晕", "tendency": "", "character": [], "anatomy_list": [ "头" ] }, { "core_name": "乏力", "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": "畏寒", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "发热", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "癌", "tendency": "", "character": [ "术后" ], "anatomy_list": [ "直肠" ] }, { "core_name": "转移", "tendency": "", "character": [ "直肠癌术后" ], "anatomy_list": [ "肝" ] }, { "core_name": "肿瘤", "tendency": "不确定", "character": [ "转移性" ], "anatomy_list": [ "小肠" ] }, { "core_name": "癌", "tendency": "", "character": [], "anatomy_list": [ "直肠" ] } ] }, { "id": 225, "text": "现患者腹痛腹部明显缓解，肛门排气排便 ，为进一步诊疗，门诊以“降结肠癌伴不全性肠梗阻？”收入我科。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [ "明显缓解" ], "anatomy_list": [ "腹" ] }, { "core_name": "癌", "tendency": "不确定", "character": [], "anatomy_list": [ "降结肠" ] }, { "core_name": "梗阻", "tendency": "不确定", "character": [ "不全性" ], "anatomy_list": [ "肠" ] } ] }, { "id": 679, "text": "患者自起病情加重以来，精神可，胃纳可，大便如常，尿急、小便如常，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": "尿急", "tendency": "", "character": [], "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": 618, "text": "10+天前患者因左侧腰痛，于某医院就诊，提示左肾积水，予以输液、止痛等对症治疗，为进一步诊疗来我科，以“神经纤维瘤”收治我科。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [], "anatomy_list": [ "左侧腰" ] }, { "core_name": "积水", "tendency": "", "character": [], "anatomy_list": [ "左肾" ] }, { "core_name": "瘤", "tendency": "", "character": [ "神经纤维" ], "anatomy_list": [] } ] }, { "id": 2033, "text": "入院前11月余，患者无明显诱因出现口腔双侧颊粘膜及舌头表面血泡、胸壁及左侧大腿内侧等处皮肤散在瘀斑，伴有阵发性头痛，不伴视物旋转，不伴头昏，不伴恶心、呕吐，不伴关节肌肉肌肉疼痛，不伴发热，于某医院查凝血象提示：PT 17.9s,APTT23.1s, pta55%, fbg 0.31g/L. 血常规示wbc：2.24×10^9/L，hb：113g/L，plt：30 ×109/l，n：36.0%，考虑诊断不详，予以输液治疗（具体不详）未见明显好转，遂来我院行骨髓检查示：急性早幼粒细胞白血病可能。", "event": [ { "core_name": "血泡", "tendency": "", "character": [ "表面" ], "anatomy_list": [ "口腔双侧颊粘膜" ] }, { "core_name": "血泡", "tendency": "", "character": [ "表面" ], "anatomy_list": [ "舌头" ] }, { "core_name": "瘀斑", "tendency": "", "character": [ "散在" ], "anatomy_list": [ "胸壁皮肤" ] }, { "core_name": "瘀斑", "tendency": "", "character": [ "散在" ], "anatomy_list": [ "左侧大腿内侧" ] }, { "core_name": "疼痛", "tendency": "", "character": [ "阵发性" ], "anatomy_list": [ "头" ] }, { "core_name": "视物旋转", "tendency": "否定", "character": [], "anatomy_list": [] }, { "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": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "关节", "肌肉" ] }, { "core_name": "发热", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "白血病", "tendency": "不确定", "character": [ "急性" ], "anatomy_list": [ "早幼粒细胞" ] } ] }, { "id": 535, "text": "逐渐出现反复乏力、腹胀、恶心、反酸、餐后呕吐、胸闷、气促等，无头晕、头痛、眩晕，无心悸、黑蒙、心前区疼痛，无发热、腹痛、黑便，无肢端麻木及针刺痛等。", "event": [ { "core_name": "乏力", "tendency": "", "character": [ "反复" ], "anatomy_list": [] }, { "core_name": "腹胀", "tendency": "", "character": [ "反复" ], "anatomy_list": [ "腹" ] }, { "core_name": "恶心", "tendency": "", "character": [ "反复" ], "anatomy_list": [] }, { "core_name": "反酸", "tendency": "", "character": [ "反复" ], "anatomy_list": [] }, { "core_name": "呕吐", "tendency": "", "character": [ "餐后", "反复" ], "anatomy_list": [] }, { "core_name": "胸闷", "tendency": "", "character": [ "反复" ], "anatomy_list": [ "胸" ] }, { "core_name": "气促", "tendency": "", "character": [ "反复" ], "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": "眩晕", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "心悸", "tendency": "否定", "character": [], "anatomy_list": [ "心" ] }, { "core_name": "黑朦", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "心前区" ] }, { "core_name": "发热", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "黑便", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "麻木", "tendency": "否定", "character": [], "anatomy_list": [ "肢端" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [ "针刺痛" ], "anatomy_list": [ "肢端" ] } ] }, { "id": 1507, "text": "今为行第2次hd-mtx化疗入院，门诊以“急性白血病”收入院。", "event": [ { "core_name": "白血病", "tendency": "", "character": [ "急性" ], "anatomy_list": [] } ] }, { "id": 1527, "text": "住院期间完善相关检查，胸部ct增强检查（2020-10-10）：右肺上叶前段结节并空洞形成，考虑：1.肿瘤2.结核及其他感染待排。", "event": [ { "core_name": "结节", "tendency": "", "character": [], "anatomy_list": [ "右肺上叶前段" ] }, { "core_name": "空洞形成", "tendency": "", "character": [], "anatomy_list": [ "右肺上叶前段" ] }, { "core_name": "结核", "tendency": "不确定", "character": [], "anatomy_list": [ "右肺上叶前段" ] }, { "core_name": "感染", "tendency": "不确定", "character": [ "其他" ], "anatomy_list": [ "右肺上叶前段" ] }, { "core_name": "肿瘤", "tendency": "不确定", "character": [], "anatomy_list": [ "肺" ] } ] }, { "id": 871, "text": "此后患者上述关节疼痛反复发作，性质同前，并累及出现左侧膝关节、双侧掌指关节，每次发作自行予以秋水仙碱、止痛药（泰国产、具体成分不详）或别嘌呤醇、非布司他口服，疼痛缓解后停药，未监测尿酸变化。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [ "反复" ], "anatomy_list": [ "关节" ] }, { "core_name": "疼痛", "tendency": "", "character": [ "累及" ], "anatomy_list": [ "左侧膝关节" ] }, { "core_name": "疼痛", "tendency": "", "character": [ "累及" ], "anatomy_list": [ "双侧掌指关节" ] }, { "core_name": "疼痛", "tendency": "", "character": [ "缓解" ], "anatomy_list": [ "关节" ] } ] }, { "id": 41, "text": "但今日无明显诱因感胸痛加重,性质同前,持续时间约1小时才缓解,今为求进一步诊治入院,门诊查“肝肾功、心酶、电解质、血常规及肌钙蛋白正常；胸部ct双肺气肿；双肺多发感染性病变,继发性肺结核可能（增殖、纤维化、空洞）；左肺下叶背段段结节影,肿瘤不能除外,建议进一步检查,左肺上叶尖后段真菌感染可能；双肺肺中叶炎性病变,纤维灶肌肺大疱形成,左肺下叶叶间质性纤维化,纵膈多发淋巴结显示伴钙化,双侧胸膜增厚；心电图正常”,为进一步诊治入院,门诊以“肺部感染”收入院。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [ "加重", "持续时间约1小时才缓解缓解", "性质同前" ], "anatomy_list": [ "胸" ] }, { "core_name": "肺气肿", "tendency": "", "character": [], "anatomy_list": [ "双肺" ] }, { "core_name": "病变", "tendency": "", "character": [ "多发", "感染性" ], "anatomy_list": [ "双肺" ] }, { "core_name": "结核", "tendency": "不确定", "character": [ "继发性", "增殖", "纤维化", "空洞" ], "anatomy_list": [ "肺" ] }, { "core_name": "结节影", "tendency": "", "character": [], "anatomy_list": [ "左肺下叶背段" ] }, { "core_name": "肿瘤", "tendency": "不确定", "character": [], "anatomy_list": [] }, { "core_name": "真菌感染", "tendency": "不确定", "character": [], "anatomy_list": [ "左肺上叶尖后段" ] }, { "core_name": "病变", "tendency": "", "character": [ "炎性" ], "anatomy_list": [ "双肺肺中叶" ] }, { "core_name": "肺大疱", "tendency": "", "character": [ "纤维灶肌", "形成" ], "anatomy_list": [ "肺" ] }, { "core_name": "纤维化", "tendency": "", "character": [ "间质性" ], "anatomy_list": [ "左肺下叶" ] }, { "core_name": "显示", "tendency": "", "character": [ "钙化", "多发" ], "anatomy_list": [ "纵膈淋巴结" ] }, { "core_name": "增厚", "tendency": "", "character": [ "增厚" ], "anatomy_list": [ "双侧胸膜" ] }, { "core_name": "感染", "tendency": "", "character": [], "anatomy_list": [ "肺部" ] } ] }, { "id": 1119, "text": "3年余前患者无明显诱因出现反复右下腹隐痛，无进行性加重，排气后可暂时缓解，无阴道阴道流血流液，无肛门坠胀，无畏寒发热，无恶心、呕吐，无尿频、尿急及尿痛，院外口服消炎药（具体不详）无明显缓解。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [ "隐痛", "反复", "排气后可暂时缓解" ], "anatomy_list": [ "右下腹" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [ "隐痛", "进行性加重" ], "anatomy_list": [ "右下腹" ] }, { "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": "坠胀", "tendency": "否定", "character": [], "anatomy_list": [ "肛门" ] }, { "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": "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": [] } ] }, { "id": 1339, "text": "<胆管下端切缘，切缘胆管壁>为见癌组织。", "event": [ { "core_name": "癌组织", "tendency": "否定", "character": [], "anatomy_list": [ "胆管下端切缘", "切缘胆管壁" ] } ] }, { "id": 234, "text": "入院前1+年，患者无明显诱因出现全身乏力，夜尿增多，约4-5次/晚，伴胸闷、怕冷、烦渴、多饮，伴四肢麻木，无视物模糊，无腹痛、腹泻，无恶心、呕吐，无心前区疼痛，患者未重视，未诊治。", "event": [ { "core_name": "乏力", "tendency": "", "character": [], "anatomy_list": [ "全身" ] }, { "core_name": "夜尿增多", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "胸闷", "tendency": "", "character": [], "anatomy_list": [ "胸" ] }, { "core_name": "怕冷", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "烦渴", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "多饮", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "麻木", "tendency": "", "character": [], "anatomy_list": [ "四肢" ] }, { "core_name": "视物模糊", "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": "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": [ "心前区" ] } ] }, { "id": 1032, "text": "患者因“便血”于2018-1-18于胃肠外科住院治疗，行妇科彩超示: 子宫术后：子宫、双侧卵巢未见显示；盆腔内探及两个大小分别约5.6x4.1cm、2.3x1.6cm偏低回声团块，形态不规则，边界不清晰，内回声不均质，较大者与直肠相连，cdfi:内探及较丰富血流信号；提示：盆腔内偏低回声团块，考虑转移性ca。", "event": [ { "core_name": "便血", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "显示", "tendency": "否定", "character": [ "子宫术后" ], "anatomy_list": [ "子宫" ] }, { "core_name": "显示", "tendency": "否定", "character": [ "子宫术后" ], "anatomy_list": [ "双侧卵巢" ] }, { "core_name": "术后", "tendency": "", "character": [ "术后" ], "anatomy_list": [ "子宫" ] }, { "core_name": "团块", "tendency": "", "character": [ "偏低回声", "边界不清晰", "内回声不均质", "较大者与直肠相连" ], "anatomy_list": [ "盆腔" ] }, { "core_name": "信号", "tendency": "", "character": [ "丰富", "血流" ], "anatomy_list": [] }, { "core_name": "团块", "tendency": "", "character": [ "偏低回声" ], "anatomy_list": [ "盆腔内" ] }, { "core_name": "癌", "tendency": "不确定", "character": [ "转移" ], "anatomy_list": [] } ] }, { "id": 604, "text": "左室顺应性降低。", "event": [ { "core_name": "顺应性降低", "tendency": "", "character": [], "anatomy_list": [ "左室" ] } ] }, { "id": 1512, "text": "紧急就诊于某急救中心完善相关检查示右肩胛骨骨折、肋骨多处骨折（1-6肋，3、4肋断端错位）、肺挫伤。", "event": [ { "core_name": "骨折", "tendency": "", "character": [], "anatomy_list": [ "右肩胛骨" ] }, { "core_name": "错位", "tendency": "", "character": [ "断端" ], "anatomy_list": [ "3、4肋" ] }, { "core_name": "骨折", "tendency": "", "character": [ "多处" ], "anatomy_list": [ "1-6肋骨" ] }, { "core_name": "挫伤", "tendency": "", "character": [], "anatomy_list": [ "肺" ] } ] }, { "id": 934, "text": "今患者为进一步就诊遂入我院，门诊以“干燥综合征”收入我科。", "event": [ { "core_name": "干燥综合征", "tendency": "", "character": [], "anatomy_list": [] } ] }, { "id": 479, "text": "无畏寒、发热、盗汗，无体重下降。", "event": [ { "core_name": "畏寒", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "发热", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "盗汗", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "体重下降", "tendency": "否定", "character": [], "anatomy_list": [] } ] }, { "id": 1849, "text": "于2015年3月11日行“膀胱镜检+新生物活检，同时行经尿道或经肛门前列腺活检”手术，活检结果提示：前列腺癌（gleason评+分4+5分），侵及膀胱；分别于3-26我科行前列腺、膀胱占位、盆腔淋巴引流区精确放疗，累计放疗：dt：pgtv：64.4G/28f，ptv1：56G/28f，ptv2：50.4G/28f，放疗后患者尿频、尿痛症状较前稍有缓解，复查ct提示前列腺及膀胱病灶缩小，评价为pr。", "event": [ { "core_name": "癌", "tendency": "", "character": [ "gleason评+分4+5分" ], "anatomy_list": [ "前列腺" ] }, { "core_name": "癌", "tendency": "", "character": [ "侵及" ], "anatomy_list": [ "膀胱" ] }, { "core_name": "占位", "tendency": "", "character": [], "anatomy_list": [ "前列腺", "膀胱" ] }, { "core_name": "尿频", "tendency": "", "character": [ "稍有缓解" ], "anatomy_list": [] }, { "core_name": "尿痛", "tendency": "", "character": [ "稍有缓解" ], "anatomy_list": [] }, { "core_name": "病灶", "tendency": "", "character": [ "缩小" ], "anatomy_list": [ "前列腺", "膀胱" ] } ] }, { "id": 1561, "text": "患者自发病以来，精神可，食欲较差，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": [ "可" ], "anatomy_list": [] }, { "core_name": "食欲", "tendency": "", "character": [ "较差" ], "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": 2038, "text": "并分别于2016.12.26、2017.2.2、2017.03.13予以da（柔红霉素70mg*3天+阿糖胞苷200mg*7天)巩固化疗3次，并于2017.1.5、2017.2.10、2017.03.20、2017.03.31行腰椎穿刺术，给予鞘内注射甲氨蝶呤15mg、地塞米松5mg预防中枢神经系统白血病，之后复查pml/rara（双色双融合）(15/17)：信号表达正常。", "event": [ { "core_name": "白血病", "tendency": "", "character": [], "anatomy_list": [ "中枢神经系统" ] } ] }, { "id": 1836, "text": "患者4月前出现右乳隐痛不适，无乳头溢液，无乳头凹陷等，遂就诊于某医院，行乳腺彩超示：双乳异常回声（纤维腺瘤可能），予以口服药物治疗（具体不详）后无明显好转，患者为进一步治疗，今来我院，门诊以“双乳包块待查”收治入科。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [ "隐痛" ], "anatomy_list": [ "右乳" ] }, { "core_name": "右乳不适", "tendency": "", "character": [], "anatomy_list": [ "右乳" ] }, { "core_name": "溢液", "tendency": "否定", "character": [], "anatomy_list": [ "乳头" ] }, { "core_name": "凹陷", "tendency": "否定", "character": [], "anatomy_list": [ "乳头" ] }, { "core_name": "异常回声", "tendency": "", "character": [], "anatomy_list": [ "双乳" ] }, { "core_name": "瘤", "tendency": "不确定", "character": [ "纤维腺" ], "anatomy_list": [ "双乳" ] }, { "core_name": "包块", "tendency": "不确定", "character": [], "anatomy_list": [ "双乳" ] } ] }, { "id": 1998, "text": "后患者定期复查，17个月前复查腹部ct提示：肝左叶内段结节结节灶，性质待定，不典型血管瘤？并于2011-6-7局麻下行肝癌介入术，术后予以保肝、阿德福韦酯抗病毒等对症治疗后好转出院。", "event": [ { "core_name": "结节灶", "tendency": "", "character": [ "性质待定" ], "anatomy_list": [ "肝左叶内段" ] }, { "core_name": "瘤", "tendency": "不确定", "character": [ "非典型", "血管" ], "anatomy_list": [ "肝左叶内段" ] } ] }, { "id": 1342, "text": "<门静脉旁，腹主动脉旁，腹腔干旁>淋巴结未见癌转移（分别0/3.0/1.0/5）。", "event": [ { "core_name": "癌", "tendency": "否定", "character": [ "转移" ], "anatomy_list": [ "腹腔干旁淋巴结", "门静脉旁淋巴结", "腹主动脉旁淋巴结" ] } ] }, { "id": 1092, "text": "诊断为:直肠腺癌 （t2n0M0）。", "event": [ { "core_name": "腺癌", "tendency": "", "character": [ "t2n0M0" ], "anatomy_list": [ "直肠" ] } ] }, { "id": 1532, "text": "患者现为求术后第4次化疗再次就诊于我院，门诊拟“右肺上叶腺癌术后化疗”收住院治疗。", "event": [ { "core_name": "腺癌", "tendency": "", "character": [ "术后化疗" ], "anatomy_list": [ "右肺上叶" ] } ] }, { "id": 792, "text": "入院前7年，患者渐感劳力性呼吸困难，以上楼、上坡或剧烈活动后明显，间断出现双下肢水肿，不伴夜间阵发性呼吸困难或端坐呼吸，多次在外院就医诊治，诊断为“慢性阻塞性肺疾病、慢性肺源性心脏病”，长期服用平喘等药物控制症状。", "event": [ { "core_name": "呼吸困难", "tendency": "", "character": [ "劳力性", "以上楼、上坡或剧烈活动后明显" ], "anatomy_list": [] }, { "core_name": "水肿", "tendency": "", "character": [ "间断" ], "anatomy_list": [ "双下肢" ] }, { "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": "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" ] } ] }, { "id": 988, "text": "6月前至我院行第一次化疗，并于2017-4-18、2017-05-09于我科行dp(多西他赛100mg+奈达铂120mg)化疗治疗，无明显化疗副反应，2017-6-7行第三次化疗（多西他赛100mg+奈达铂100mg),出院后患者自觉偶有干咳，伴恶心、嗳气、食欲下降，伴活动后喘息、气促。", "event": [ { "core_name": "咳嗽", "tendency": "", "character": [ "干性", "偶有" ], "anatomy_list": [] }, { "core_name": "恶心", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "嗳气", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "食欲下降", "tendency": "", "character": [ "下降" ], "anatomy_list": [] }, { "core_name": "喘息", "tendency": "", "character": [ "活动后" ], "anatomy_list": [] }, { "core_name": "气促", "tendency": "", "character": [ "活动后" ], "anatomy_list": [] } ] }, { "id": 1124, "text": "2014年2月患者再发右下腹痛，无恶心、呕吐，无腹胀、阴道流血，自行口服药物后无缓解，于我院复查示ca-125大于1000U/ml，全腹部ct未见转移病灶,腹腔内网膜增厚及部分小肠小肠粘连聚集。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [], "anatomy_list": [ "右下腹" ] }, { "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": "增厚", "tendency": "", "character": [], "anatomy_list": [ "腹腔内网膜" ] }, { "core_name": "粘连聚集", "tendency": "", "character": [], "anatomy_list": [ "小肠" ] } ] }, { "id": 914, "text": "2年前于某医院行右侧腕部瘢痕修复术，术中病理检查结果提示鳞状细胞癌，术后腕部有一处经久不愈，于我科室行瘢痕修复术及植皮术，创面愈合良好。", "event": [ { "core_name": "鳞癌", "tendency": "", "character": [], "anatomy_list": [ "右腕部" ] }, { "core_name": "经久不愈", "tendency": "", "character": [ "术后" ], "anatomy_list": [ "腕部" ] } ] }, { "id": 1933, "text": "腹部ct示：1、结肠癌术后表现，腹膜后多发淋巴结多发淋巴结转移癌，吻合口上方淋巴结增大；2、轻度脂肪肝，脾大；3、双肾小囊肿；4、下腹、盆腔ct未见明显异常。", "event": [ { "core_name": "癌", "tendency": "", "character": [ "术后" ], "anatomy_list": [ "结肠" ] }, { "core_name": "癌", "tendency": "", "character": [ "多发", "转移" ], "anatomy_list": [ "腹膜后淋巴结" ] }, { "core_name": "增大", "tendency": "", "character": [], "anatomy_list": [ "吻合口上方淋巴结" ] }, { "core_name": "脂肪肝", "tendency": "", "character": [ "轻度" ], "anatomy_list": [ "肝" ] }, { "core_name": "脾大", "tendency": "", "character": [], "anatomy_list": [ "脾" ] }, { "core_name": "囊肿", "tendency": "", "character": [ "小" ], "anatomy_list": [ "双肾" ] } ] }, { "id": 1597, "text": "院外间断服用“地高辛、美托洛尔、单硝酸异山梨酯”，心累、气促、胸闷、心悸等症状仍旧反复发作，多次于我院住院治疗，治疗好转后出院。", "event": [ { "core_name": "心累", "tendency": "", "character": [ "反复发作" ], "anatomy_list": [ "心" ] }, { "core_name": "气促", "tendency": "", "character": [ "反复发作" ], "anatomy_list": [] }, { "core_name": "胸闷", "tendency": "", "character": [ "反复发作" ], "anatomy_list": [ "胸" ] }, { "core_name": "心悸", "tendency": "", "character": [ "反复发作" ], "anatomy_list": [ "心" ] } ] }, { "id": 1641, "text": "发病以来，精神、睡眠可，清淡饮食，大小便正常，近期体重无明显改变。", "event": [ { "core_name": "精神", "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": "体重改变", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [] } ] }, { "id": 187, "text": "入院前4余年，患者开始出现咳嗽、咳痰症状，主要为咳白色泡沫痰，好发于冬春季或受凉后，每年发病时间累计大于3个月。", "event": [ { "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", "好发于冬春季或受凉后" ], "anatomy_list": [] } ] }, { "id": 1435, "text": "术后病检结果提示为：尿路上皮癌，术后继续规律膀胱灌注治疗，3月前患者复查b超未见明显异常，患者未诉解血尿、腰痛等不适，患者为求复查今日于我科门诊再次就诊，门诊以“膀胱癌”收住入院。", "event": [ { "core_name": "癌", "tendency": "", "character": [], "anatomy_list": [ "尿路上皮" ] }, { "core_name": "血尿", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "腰" ] }, { "core_name": "癌", "tendency": "", "character": [], "anatomy_list": [ "膀胱" ] } ] }, { "id": 25, "text": "后转入我科,行纤支镜示：血中见较多支气管粘膜上皮上皮细胞和少许散落异型细胞,倾向腺癌细胞,后分别于2014-10-24、2014-10-30在ct引导下行经皮肺穿刺右肺肺癌穿刺活检+放射性粒子植入术2次（共注入放射性粒子200粒）,术后病检提示：血块中散落极个别异型性细胞,免疫组化提示肺腺癌,复查胸部ct增强(2014-11-13)示：右肺下叶肿块明显缩小,根据基因检测,于2014-11-17行“吉西他滨 2000mg d1,d8+奈达铂150mg d1”方案化疗,化疗后出现骨髓抑制,予特尔津升白细胞治疗后好转出院。", "event": [ { "core_name": "异型细胞", "tendency": "", "character": [ "少许", "散落", "异型", "血中见较多" ], "anatomy_list": [ "支气管粘膜上皮", "上皮细胞" ] }, { "core_name": "腺癌细胞", "tendency": "不确定", "character": [], "anatomy_list": [ "支气管粘膜上皮" ] }, { "core_name": "异形性细胞", "tendency": "", "character": [ "血块中散落", "极个别异型性" ], "anatomy_list": [] }, { "core_name": "腺癌", "tendency": "", "character": [], "anatomy_list": [ "肺" ] }, { "core_name": "肿块", "tendency": "", "character": [ "明显", "缩小" ], "anatomy_list": [ "右肺下叶" ] }, { "core_name": "骨髓抑制", "tendency": "", "character": [ "化疗后" ], "anatomy_list": [ "骨髓" ] } ] }, { "id": 210, "text": "建议住院治疗，患者因经济原因，未住院治疗，到诊所输液及中药治疗（具体治疗不详），患者1月前出现上腹部隐痛，间断性，夜间明显，疼痛与体位变化无明显关系，每次疼痛10余分钟按压上腹部逐渐缓解，伴反酸，嗳气及烧心，无明显胸骨后疼痛，无肩部放射痛，无腰部疼痛，大便仍不成形，偶伴粘液脓血及里急后重，到诊所就诊，考虑胃肠炎，给予相关治疗（具体不详），患者经过上述治疗，尿黄眼黄及皮肤瘙痒逐渐加重，2天前遂再次到某医院就诊，考虑“肝门部占位并胆管梗阻”，告知相关情况，建议住院治疗，患者为进一步治疗，遂急来我院，门诊以“1.原发性肝癌？2.梗阻性黄疸原因待查”收入病房。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [ "隐痛", "间断性", "夜间明显", "与体位变化无明显关系", "每次疼痛10余分钟按压上腹部逐渐缓解" ], "anatomy_list": [ "上腹部" ] }, { "core_name": "反酸", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "嗳气", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "烧心", "tendency": "", "character": [], "anatomy_list": [ "心" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [ "胸骨后" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [ "发射性" ], "anatomy_list": [ "肩部" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "腰部" ] }, { "core_name": "大便", "tendency": "", "character": [ "不成形" ], "anatomy_list": [] }, { "core_name": "大便", "tendency": "", "character": [ "粘液脓血" ], "anatomy_list": [] }, { "core_name": "里急后重", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "胃肠炎", "tendency": "不确定", "character": [], "anatomy_list": [ "胃", "肠" ] }, { "core_name": "尿黄", "tendency": "", "character": [ "逐渐加重" ], "anatomy_list": [] }, { "core_name": "黄染", "tendency": "", "character": [ "逐渐加重" ], "anatomy_list": [ "眼" ] }, { "core_name": "皮肤瘙痒", "tendency": "", "character": [ "逐渐加重" ], "anatomy_list": [ "皮肤" ] }, { "core_name": "占位", "tendency": "不确定", "character": [], "anatomy_list": [ "肝门" ] }, { "core_name": "梗阻", "tendency": "不确定", "character": [], "anatomy_list": [ "胆管" ] }, { "core_name": "癌", "tendency": "不确定", "character": [ "原发性" ], "anatomy_list": [ "肝" ] }, { "core_name": "黄疸", "tendency": "", "character": [ "梗阻性" ], "anatomy_list": [] } ] }, { "id": 275, "text": "纤支镜活检提示（2018年7月27日）：（左肺支气管支气管粘膜）送检物见少许异性腺体，肺腺癌待排。", "event": [ { "core_name": "异性腺体", "tendency": "", "character": [ "少许" ], "anatomy_list": [ "左肺", "支气管粘膜" ] }, { "core_name": "腺癌", "tendency": "不确定", "character": [], "anatomy_list": [ "肺" ] } ] }, { "id": 1885, "text": "7天前，患者无明显诱因出现夜间胸闷，伴呼吸困难，无前期压榨感，无左肩、及手指放射痛，持续几个小时可自行缓解，伴腹胀，伴反酸、嗳气，伴出汗、心悸、头昏、视物模糊，伴四肢麻木疼痛，为针刺样疼痛，无易饥多食，无便秘、腹泻，无畏寒、发热、咳嗽、咳痰等不适，遂于我院消化内科门诊就诊，行腹部彩超示：脂肪肝，于心血管内科门诊行心电图示：正常心电图，心肌损伤检查：tnt：29.9pg/ml，myo：60.7ng/ml，ck-mb:1.4ng/ml。", "event": [ { "core_name": "胸闷", "tendency": "", "character": [ "夜间" ], "anatomy_list": [ "胸" ] }, { "core_name": "呼吸困难", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "压榨感", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "否定", "character": [ "放射性" ], "anatomy_list": [ "左肩", "手指" ] }, { "core_name": "疼痛", "tendency": "", "character": [ "持续几个小时可自行缓解" ], "anatomy_list": [ "左肩", "手指" ] }, { "core_name": "腹胀", "tendency": "", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "返酸", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "嗳气", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "出汗", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "心悸", "tendency": "", "character": [], "anatomy_list": [ "心" ] }, { "core_name": "头昏", "tendency": "", "character": [], "anatomy_list": [ "头" ] }, { "core_name": "视物模糊", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "麻木", "tendency": "", "character": [], "anatomy_list": [ "四肢" ] }, { "core_name": "疼痛", "tendency": "", "character": [], "anatomy_list": [ "四肢" ] }, { "core_name": "疼痛", "tendency": "", "character": [ "针刺样" ], "anatomy_list": [] }, { "core_name": "易饥多食", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "便秘", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "腹泻", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "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": "脂肪肝", "tendency": "", "character": [], "anatomy_list": [ "肝" ] } ] }, { "id": 784, "text": "自发病以来，精神稍差，未进食，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": [ "稍差" ], "anatomy_list": [] }, { "core_name": "进食", "tendency": "", "character": [ "未" ], "anatomy_list": [] }, { "core_name": "睡眠", "tendency": "否定", "character": [ "可" ], "anatomy_list": [] }, { "core_name": "大便", "tendency": "否定", "character": [ "如常" ], "anatomy_list": [] }, { "core_name": "小便", "tendency": "否定", "character": [ "如常" ], "anatomy_list": [] }, { "core_name": "体重改变", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [] } ] }, { "id": 2065, "text": "入院前1+年无明显诱因出现鼻阻，双侧交替性，鼻根胀痛不适，伴嗅觉稍下降，受凉后咳嗽、咳痰，无鼻痒、打喷嚏，无记忆力下降，无发热、听力下降、眩晕、耳鸣、潮热、乏力等症状。", "event": [ { "core_name": "鼻阻", "tendency": "", "character": [ "双侧交替性" ], "anatomy_list": [ "鼻" ] }, { "core_name": "疼痛", "tendency": "", "character": [ "胀痛" ], "anatomy_list": [ "鼻根" ] }, { "core_name": "鼻根不适", "tendency": "", "character": [], "anatomy_list": [ "鼻根" ] }, { "core_name": "嗅觉下降", "tendency": "", "character": [ "稍" ], "anatomy_list": [] }, { "core_name": "咳嗽", "tendency": "", "character": [ "受凉后" ], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "受凉后" ], "anatomy_list": [] }, { "core_name": "鼻痒", "tendency": "否定", "character": [], "anatomy_list": [ "鼻" ] }, { "core_name": "打喷嚏", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "记忆力下降", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "发热", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "听觉下降", "tendency": "否定", "character": [], "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": "潮热", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "乏力", "tendency": "否定", "character": [], "anatomy_list": [] } ] }, { "id": 1734, "text": "11月5日查血常规示“白细胞数目1.98*10^9/L↓，血红蛋白43g/l↓，血小板数目41*10^9/L↓，中性粒细胞数目0.65*10^9/L↓”，11月7日复查骨髓穿刺示“1.红系增生旺盛，粒、红、巨三系可见病态造血2.细胞外铁：+++，细胞内铁：72%，环铁占26%”，予以口服环孢素治疗。", "event": [ { "core_name": "红系增生", "tendency": "", "character": [ "旺盛" ], "anatomy_list": [ "红系" ] }, { "core_name": "病态造血", "tendency": "", "character": [], "anatomy_list": [ "粒、红、巨三系" ] } ] }, { "id": 843, "text": "3+年前因“体重下降”就诊我科完善相关检查后考虑“2型糖尿病”，2月前体检时查糖化血红蛋白11.5%，葡萄糖13.55mmol/L。", "event": [ { "core_name": "体重下降", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "糖尿病", "tendency": "不确定", "character": [ "2型" ], "anatomy_list": [] } ] }, { "id": 1187, "text": "于2015-2-28日在局麻下行右乳肿物麦默通旋切活检，冰冻活检示：（右乳）浸润性癌。", "event": [ { "core_name": "癌", "tendency": "", "character": [ "浸润性" ], "anatomy_list": [ "右乳" ] } ] }, { "id": 569, "text": "2月余前，患者因“咳嗽、咳痰2月，痰中带血1月，院外发现右肺包块”至我科就诊，入院查胸部ct提示：右肺门占位伴周围阻塞性炎症、右肺上叶支气管闭塞，肺ca？右肺多发结节影，转移？纵隔、右肺门及锁骨下多发淋巴结肿大。", "event": [ { "core_name": "咳嗽", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "带血" ], "anatomy_list": [] }, { "core_name": "包块", "tendency": "", "character": [], "anatomy_list": [ "右肺" ] }, { "core_name": "占位", "tendency": "", "character": [], "anatomy_list": [ "右肺门" ] }, { "core_name": "炎症", "tendency": "", "character": [ "阻塞性" ], "anatomy_list": [ "右肺门周围" ] }, { "core_name": "闭塞", "tendency": "", "character": [], "anatomy_list": [ "右肺上叶支气管" ] }, { "core_name": "癌", "tendency": "不确定", "character": [], "anatomy_list": [ "肺" ] }, { "core_name": "结节影", "tendency": "", "character": [ "多发" ], "anatomy_list": [ "右肺" ] }, { "core_name": "转移", "tendency": "不确定", "character": [], "anatomy_list": [ "右肺" ] }, { "core_name": "肿大", "tendency": "", "character": [ "多发" ], "anatomy_list": [ "纵隔淋巴结", "右肺门淋巴结", "锁骨下淋巴结" ] } ] }, { "id": 1819, "text": "患者平素月经规则，有痛经，lmp：2017.2.3；10+小时前患者于走路时无明显诱因突然出现右下腹阵发性剧烈疼痛，位置相对固定，无转移性放射至后背部，改变体位缓解不明显，伴恶心呕吐，冷汗，无发热、寒颤。", "event": [ { "core_name": "月经", "tendency": "", "character": [ "规则" ], "anatomy_list": [] }, { "core_name": "痛经", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "", "character": [ "走路时", "阵发性", "剧烈", "位置相对固定", "改变体位缓解不明显" ], "anatomy_list": [ "右下腹" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [ "转移性放射" ], "anatomy_list": [ "后背部" ] }, { "core_name": "恶心", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "呕吐", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "冷汗", "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": 1524, "text": "上腹部饱胀，饮食差，夜间反酸、烧心，阵发性心悸不适，夜间明显，自诉端坐位后可缓解，无夜间阵发性呼吸困难、咯粉红色泡沫痰，无呕吐、黑便，自服奥美拉唑胶囊无缓解，今日自觉腹胀明显，为进一步诊治，以“慢性阻塞性肺疾病急性发作 、心房纤颤 ，胃炎？”收入我科。", "event": [ { "core_name": "饱胀感", "tendency": "", "character": [], "anatomy_list": [ "上腹部" ] }, { "core_name": "饮食", "tendency": "", "character": [], "anatomy_list": [ "差" ] }, { "core_name": "反酸", "tendency": "", "character": [ "夜间" ], "anatomy_list": [] }, { "core_name": "烧心", "tendency": "", "character": [ "夜间" ], "anatomy_list": [] }, { "core_name": "心悸", "tendency": "", "character": [ "阵发性", "夜间明显", "端坐位后可缓解" ], "anatomy_list": [ "心" ] }, { "core_name": "呼吸困难", "tendency": "否定", "character": [ "阵发性", "夜间" ], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "否定", "character": [ "粉红色", "泡沫" ], "anatomy_list": [] }, { "core_name": "呕吐", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "黑便", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "腹胀", "tendency": "", "character": [ "明显" ], "anatomy_list": [ "腹" ] }, { "core_name": "肺疾病", "tendency": "", "character": [ "急性发作", "慢性", "阻塞性" ], "anatomy_list": [ "肺" ] }, { "core_name": "心房纤颤", "tendency": "", "character": [], "anatomy_list": [ "心房" ] }, { "core_name": "胃炎", "tendency": "不确定", "character": [], "anatomy_list": [ "胃" ] } ] }, { "id": 1583, "text": "2、子宫腺肌症。", "event": [ { "core_name": "腺肌症", "tendency": "", "character": [], "anatomy_list": [ "子宫" ] } ] }, { "id": 1712, "text": "入院前1+月，患者于我科住院治疗，诊断为“1、多发性骨髓瘤iga к型 ds iiia期；2、肺部感染 双侧胸腔积液；3、心包积液；4、天疱疮；5、肝损害；6、低蛋白血症；7、电解质紊乱；8、慢性胃炎”，予以抗肿瘤、增强免疫力、补钙、促进造血、ctp方案化疗、护胃、抗感染、补充白蛋白、活血、通便、利尿、抗病毒、保肝、雾化、补钙、碱化尿液、促进胃肠动力、止汗等治疗后症状好转出院，现患者诉目前右褪疼痛较前稍加重，行走时右脚不实，如踏棉花，右腿麻木，今为行巩固化疗于我科住院治疗。", "event": [ { "core_name": "瘤", "tendency": "", "character": [ "多发性", "iga к型 ds iiia期" ], "anatomy_list": [ "骨髓" ] }, { "core_name": "感染", "tendency": "", "character": [], "anatomy_list": [ "肺部" ] }, { "core_name": "积液", "tendency": "", "character": [], "anatomy_list": [ "双侧胸腔" ] }, { "core_name": "积液", "tendency": "", "character": [], "anatomy_list": [ "心包" ] }, { "core_name": "天疱疮", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "损害", "tendency": "", "character": [], "anatomy_list": [ "肝" ] }, { "core_name": "低蛋白血症", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "胃炎", "tendency": "", "character": [ "慢性" ], "anatomy_list": [ "胃" ] }, { "core_name": "电解质紊乱", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "", "character": [ "较前稍加重" ], "anatomy_list": [ "右腿" ] }, { "core_name": "右脚不实", "tendency": "", "character": [ "行走时", "如踏棉花" ], "anatomy_list": [ "右脚" ] }, { "core_name": "麻木", "tendency": "", "character": [], "anatomy_list": [ "右腿" ] } ] }, { "id": 853, "text": "诊断“霍奇金淋巴瘤（混合细胞型，Ⅱ期a组”，同年5月起至2019年4月给予abvd方案化疗8周期，化疗后腹股沟包块缩小至黄豆大小。10月29日在某医院复查胸部+全腹部ct示“1、右肺上叶尖段及水平裂陈旧性病灶2、双肺多发结节，考虑转移性肿瘤3、双肺多发病变，考虑炎性病变，部分小空洞形成”，考虑淋巴瘤细胞侵犯双肺，建议至血液科就诊。于11月4日就诊于我科，行全身pet/ct示“腹主动脉左旁（双侧髂总血管分叉处上方）、左侧髂外血管旁及左侧腹股沟腹股沟区淋巴结显示，未见异常fdg摄取，提示肿瘤活性受抑；右肺上叶尖段陈旧结核，两肺多发病变，考虑炎性病变，两肺上叶上叶胸膜胸膜增厚，左侧胸膜多发钙化，两肺门及纵膈淋巴结炎性增生可能”。", "event": [ { "core_name": "霍奇金淋巴瘤", "tendency": "", "character": [ "混合细胞型", "Ⅱ期a组" ], "anatomy_list": [] }, { "core_name": "包块", "tendency": "", "character": [ "化疗后", "缩小至黄豆大小" ], "anatomy_list": [ "腹股沟" ] }, { "core_name": "病灶", "tendency": "", "character": [ "陈旧性" ], "anatomy_list": [ "右肺上叶尖段及水平裂" ] }, { "core_name": "结节", "tendency": "", "character": [ "多发" ], "anatomy_list": [ "双肺" ] }, { "core_name": "肿瘤", "tendency": "不确定", "character": [ "转移性" ], "anatomy_list": [ "双肺" ] }, { "core_name": "病变", "tendency": "不确定", "character": [ "炎性" ], "anatomy_list": [ "双肺" ] }, { "core_name": "空洞形成", "tendency": "", "character": [ "部分", "小" ], "anatomy_list": [ "双肺" ] }, { "core_name": "瘤", "tendency": "不确定", "character": [ "侵犯双肺" ], "anatomy_list": [ "淋巴", "细胞" ] }, { "core_name": "fdg摄取", "tendency": "否定", "character": [ "异常" ], "anatomy_list": [] }, { "core_name": "肿瘤", "tendency": "", "character": [ "活性受抑" ], "anatomy_list": [] }, { "core_name": "结核", "tendency": "", "character": [ "陈旧" ], "anatomy_list": [ "右肺上叶尖段" ] }, { "core_name": "病变", "tendency": "", "character": [ "多发性" ], "anatomy_list": [ "两肺" ] }, { "core_name": "病变", "tendency": "不确定", "character": [ "炎性" ], "anatomy_list": [ "两肺" ] }, { "core_name": "增厚", "tendency": "", "character": [], "anatomy_list": [ "两肺上叶胸膜" ] }, { "core_name": "钙化", "tendency": "", "character": [ "多发", "钙化" ], "anatomy_list": [ "左侧胸膜" ] }, { "core_name": "增生", "tendency": "不确定", "character": [ "炎性" ], "anatomy_list": [ "两肺门淋巴结" ] }, { "core_name": "增生", "tendency": "不确定", "character": [ "炎性" ], "anatomy_list": [ "纵膈淋巴结" ] } ] }, { "id": 407, "text": "取病检示（1813818）：小细胞恶性肿瘤，建议免疫组化协助诊断。", "event": [ { "core_name": "肿瘤", "tendency": "", "character": [ "恶性" ], "anatomy_list": [ "小细胞" ] } ] }, { "id": 1617, "text": "10-19再入我科，完善相关检查：全腹部增强ct提示：1.子宫颈形态不规则，增强扫描可见强化，宫颈癌待排，建议mr增强扫描检查。", "event": [ { "core_name": "形态不规则", "tendency": "", "character": [ "增强扫描可强化" ], "anatomy_list": [ "子宫颈" ] }, { "core_name": "癌", "tendency": "不确定", "character": [], "anatomy_list": [ "子宫颈" ] } ] }, { "id": 1642, "text": "入院前11+月，患者因“发现左乳包块2天”入院，于2016年10月21日行左乳癌改良根治术，术后病检（病检号123456）：左乳浸润性癌，非特殊类型，ii级7分。", "event": [ { "core_name": "包块", "tendency": "", "character": [], "anatomy_list": [ "左乳" ] }, { "core_name": "癌", "tendency": "", "character": [ "浸润性", "非特殊类型", "ii级7分" ], "anatomy_list": [ "左乳" ] } ] }, { "id": 893, "text": "入院前2+月，患者因气促加重于我院住院，胸水找脱落细胞中查见肿瘤细胞，院外行基因检测后，目前口服吉非替尼治疗，1+月前，患者再次感气促加重，不能活动，伴咳嗽，较多黄色粘液痰，遂再次来院，胸部ct示与2017-10-28同部位片相比双侧胸腔积液较前增多，左肺上叶结节影较前稍增大，双肺内肺内斑片影较前明显增多并部分为新出现病灶，诊断“1.肺癌伴胸膜转移；2.间质性肺炎；3.低蛋白血症，4.肝功异常”。", "event": [ { "core_name": "气促", "tendency": "", "character": [ "加重" ], "anatomy_list": [] }, { "core_name": "气促", "tendency": "", "character": [ "加重", "不能活动" ], "anatomy_list": [] }, { "core_name": "咳嗽", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "较多", "黄色", "粘液" ], "anatomy_list": [] }, { "core_name": "积液", "tendency": "", "character": [ "增多" ], "anatomy_list": [ "双侧胸腔" ] }, { "core_name": "结节影", "tendency": "", "character": [ "稍增大" ], "anatomy_list": [ "左肺上叶" ] }, { "core_name": "斑片影", "tendency": "", "character": [ "明显增多" ], "anatomy_list": [ "双肺内" ] }, { "core_name": "病灶", "tendency": "", "character": [ "新出现", "部分" ], "anatomy_list": [ "双肺内" ] }, { "core_name": "癌", "tendency": "", "character": [ "胸膜转移" ], "anatomy_list": [ "肺" ] }, { "core_name": "肺炎", "tendency": "", "character": [ "间质性" ], "anatomy_list": [ "肺" ] }, { "core_name": "低蛋白血症", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "肝功能异常", "tendency": "", "character": [], "anatomy_list": [ "肝" ] } ] }, { "id": 1623, "text": "鳞癌癌细胞抗原0.75ng/mL。", "event": [ { "core_name": "鳞癌", "tendency": "", "character": [], "anatomy_list": [] } ] }, { "id": 1410, "text": "患者此次患病以来，精神状态欠佳，小便正常，大便黄色软便。", "event": [ { "core_name": "精神", "tendency": "", "character": [ "欠佳" ], "anatomy_list": [] }, { "core_name": "小便", "tendency": "", "character": [ "正常" ], "anatomy_list": [] }, { "core_name": "大便", "tendency": "", "character": [ "黄色", "软" ], "anatomy_list": [] } ] }, { "id": 138, "text": "患者既往有“高血压病”病史20+年，最高血压180/？mmhg，长期口服硝苯地平控释片控制血压，血压控制情况不详。", "event": [ { "core_name": "高血压", "tendency": "", "character": [ "病史20+年" ], "anatomy_list": [] } ] }, { "id": 35, "text": "4+年患者受凉后开始出现咳嗽、咳痰,无明显昼夜差异,闻及刺激性气味咳嗽无诱发或加重,痰为白色泡沫痰,量不多,无喘息,伴活动后气促、心悸,休息后缓解,无胸痛,无双下肢水肿等不适。", "event": [ { "core_name": "咳嗽", "tendency": "", "character": [ "明显昼夜差异", "受凉" ], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "明显昼夜差异", "受凉" ], "anatomy_list": [] }, { "core_name": "咳嗽", "tendency": "", "character": [ "闻及刺激性气味无诱发或加重" ], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "白色", "泡沫痰", "量不多" ], "anatomy_list": [] }, { "core_name": "喘息", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "气促", "tendency": "", "character": [ "活动后", "休息后缓解" ], "anatomy_list": [] }, { "core_name": "心悸", "tendency": "", "character": [ "活动后", "休息后缓解" ], "anatomy_list": [ "心" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "胸" ] }, { "core_name": "水肿", "tendency": "否定", "character": [], "anatomy_list": [ "双下肢" ] } ] }, { "id": 199, "text": "2、（食管旁）淋巴结未见癌转移（0/7）。", "event": [ { "core_name": "癌", "tendency": "否定", "character": [ "转移" ], "anatomy_list": [ "食管旁淋巴结" ] } ] }, { "id": 1510, "text": "门诊以“腰椎滑脱”收入院。", "event": [ { "core_name": "滑脱", "tendency": "", "character": [], "anatomy_list": [ "腰椎" ] } ] }, { "id": 1180, "text": "2017年患者自觉脾脏逐渐开始增大，但仍未调整治疗。", "event": [ { "core_name": "增大", "tendency": "", "character": [ "逐渐" ], "anatomy_list": [ "脾脏" ] } ] }, { "id": 355, "text": "术前术后共行5疗程辅助化疗，方案为吡柔比星+多西他赛，化疗期产生药物毒性副反应，重度骨髓抑制，无明显胃肠道反应。现为进一步治疗入院。", "event": [ { "core_name": "副反应", "tendency": "", "character": [ "药物毒性" ], "anatomy_list": [] }, { "core_name": "骨髓抑制", "tendency": "", "character": [ "重度" ], "anatomy_list": [ "骨髓" ] }, { "core_name": "胃肠道反应", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [ "胃肠道" ] } ] }, { "id": 1269, "text": "入院6月余前患者无明显诱因出现反酸、烧心，常于进食后及平卧位、身体前驱时出现，影响夜间休息，持续时间数小时不等，伴有上腹胀、嗳气，无腹痛、恶心、呕吐，无胸闷、胸痛、心悸、呼吸困难，无食欲减退、体重减轻、厌油、纳差，患者2017-02-07我院行胃镜检查提示反流性食管炎（la d级）、食管裂孔疝、浅表性胃窦炎，患者服用“莫沙比利、耐信、铝碳酸镁片”后，症状缓解；近期患者停用口服药物后，上述症状再次出现，且程度较前加重，现患者为进一步治疗于我院就诊，门诊拟“反流性食管炎”收住我科。", "event": [ { "core_name": "反酸", "tendency": "", "character": [ "进食后、平卧位、身体前驱时出现", "影响夜间休息", "持续时间数小时不等" ], "anatomy_list": [] }, { "core_name": "烧心", "tendency": "", "character": [ "进食后、平卧位、身体前驱时出现", "影响夜间休息", "持续时间数小时不等" ], "anatomy_list": [] }, { "core_name": "腹胀", "tendency": "", "character": [], "anatomy_list": [ "上腹" ] }, { "core_name": "嗳气", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "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": "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": "呼吸困难", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "食欲", "tendency": "否定", "character": [ "减退" ], "anatomy_list": [] }, { "core_name": "体重减轻", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "厌油", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "纳差", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "食管炎", "tendency": "", "character": [ "反流性" ], "anatomy_list": [ "食管" ] }, { "core_name": "疝", "tendency": "", "character": [], "anatomy_list": [ "食管裂孔" ] }, { "core_name": "胃窦炎", "tendency": "", "character": [ "浅表性" ], "anatomy_list": [ "胃窦" ] }, { "core_name": "食管炎", "tendency": "", "character": [ "反流性" ], "anatomy_list": [ "食管" ] } ] }, { "id": 1616, "text": "放疗后程出现白细胞、血小板下降，予以“粒细胞刺激因子、咖啡酸片”升白细胞及升血小板治疗后恢复正常。", "event": [ { "core_name": "白细胞", "tendency": "", "character": [ "下降" ], "anatomy_list": [] }, { "core_name": "血小板", "tendency": "", "character": [ "下降" ], "anatomy_list": [] } ] }, { "id": 900, "text": "患病来精神、饮食一般，大便正常，尿量约700ml/天。", "event": [ { "core_name": "精神", "tendency": "", "character": [ "一般" ], "anatomy_list": [] }, { "core_name": "进食", "tendency": "", "character": [ "一般" ], "anatomy_list": [] }, { "core_name": "大便", "tendency": "", "character": [ "正常" ], "anatomy_list": [] } ] }, { "id": 830, "text": "<13组组淋巴结>见癌组织。", "event": [ { "core_name": "癌组织", "tendency": "", "character": [], "anatomy_list": [ "13组淋巴结" ] } ] }, { "id": 5, "text": "患者多次因“气促伴喘累、咳嗽、进食哽咽感”在我科住院治疗,经抗感染、止咳化痰、平喘等对症治疗后好转出院,病程中反复出现双下肢浮肿及胸腔积液。", "event": [ { "core_name": "气促", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "喘累", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "咳嗽", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "哽噎感", "tendency": "", "character": [ "进食" ], "anatomy_list": [] }, { "core_name": "浮肿", "tendency": "", "character": [ "反复出现" ], "anatomy_list": [ "双下肢" ] }, { "core_name": "积液", "tendency": "", "character": [ "反复出现" ], "anatomy_list": [ "胸腔" ] } ] }, { "id": 483, "text": "10月11日至某医院就诊，行右侧颈部包块穿刺活检报告：（右侧面部）送检少许组织示淋巴组织增生性病变，结合病史及免疫组化考虑结外黏膜相关淋巴结组织边缘区淋巴瘤，免疫组化：cd20（+），cd21散在（+），cd3灶（+），bcl-2（+），cd79a（+），pax-5（+），ki67约10%（+）。建议至上级医院就诊。", "event": [ { "core_name": "包块", "tendency": "", "character": [], "anatomy_list": [ "右侧颈部" ] }, { "core_name": "病变", "tendency": "", "character": [ "增生性" ], "anatomy_list": [ "右侧面部淋巴组织" ] }, { "core_name": "瘤", "tendency": "不确定", "character": [ "结外黏膜相关" ], "anatomy_list": [ "淋巴结组织边缘区", "淋巴" ] } ] }, { "id": 1741, "text": "现为输血治疗，患者今日就诊于我科，门诊以“骨髓增生异常综合征”收住院。", "event": [ { "core_name": "骨髓增生异常综合征", "tendency": "", "character": [], "anatomy_list": [ "骨髓" ] } ] }, { "id": 1345, "text": "术后患者规律化疗9次，分别于2019年4月24日、2019年5月6日、2019年5月13日，2019年6月13日，2019年6月21日,2019年6月29日，2019年7月23日，2019年7月30日，2019年8月7日行吉西他滨1000mg+白蛋白紫杉醇100mg静脉化疗，化疗后患者无明显腹胀、腹痛，无恶心、呕吐，无反酸、嗳气。", "event": [ { "core_name": "腹胀", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [ "腹" ] }, { "core_name": "疼痛", "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": [] } ] }, { "id": 1565, "text": "门诊以“左乳包块待查”收入我科住院治疗。", "event": [ { "core_name": "包块", "tendency": "不确定", "character": [], "anatomy_list": [ "左乳" ] } ] }, { "id": 601, "text": "二尖瓣关闭不全（轻度）。", "event": [ { "core_name": "关闭不全", "tendency": "", "character": [ "轻度" ], "anatomy_list": [ "二尖瓣" ] } ] }, { "id": 514, "text": "10+天前无明显诱因患者出现咳嗽、咳痰，伴喘累，痰为白色黏痰，不易咳出。", "event": [ { "core_name": "咳嗽", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "喘累", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "白色", "黏痰", "不易咳出" ], "anatomy_list": [] } ] }, { "id": 1895, "text": "入院前10余年，患者无明显诱因出现排尿困难症状，主要表现为尿线变细、排尿滴沥、尿不尽感，伴有夜尿次数增多，4-5次/晚，患者未重视，未行特殊诊治。", "event": [ { "core_name": "排尿", "tendency": "", "character": [ "困难" ], "anatomy_list": [] }, { "core_name": "尿线变细", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "排尿", "tendency": "", "character": [ "滴沥" ], "anatomy_list": [] }, { "core_name": "尿不尽感", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "夜尿", "tendency": "", "character": [ "次数增多" ], "anatomy_list": [] } ] }, { "id": 546, "text": "后于我院门诊行胸片（2014-10-03）示：右下肺门区及右上肺团片影，双下肺肺炎症改变，双肺间质改变，双上胸膜增厚，遂收住我院呼吸科继续治疗，入院后积极予以抗感染、解痉祛痰、活血化瘀等治疗，行胸部ct增强（2014-10-04）提示：右肺门、右肺上叶及右肺下叶肿块肿块影，考虑中央型肺癌可能大，淋巴瘤待除外，行纤支镜（2014-10-08）见：右上叶后段内见肉芽肿新生物，组织病理检查回示：（右上叶后段）鳞癌，行全腹部mri增强（2014-10-14）提示：脾脏内多发异常信号异常信号灶，结合病史，考虑转移可能，双侧腹股沟腹股沟淋巴结显示。", "event": [ { "core_name": "团片影", "tendency": "", "character": [], "anatomy_list": [ "右下肺门区", "右上肺" ] }, { "core_name": "炎症改变", "tendency": "", "character": [], "anatomy_list": [ "双下肺" ] }, { "core_name": "改变", "tendency": "", "character": [], "anatomy_list": [ "双肺间质" ] }, { "core_name": "增厚", "tendency": "", "character": [], "anatomy_list": [ "双上胸膜" ] }, { "core_name": "肿块", "tendency": "", "character": [], "anatomy_list": [ "右肺门", "右肺上叶", "右肺下叶" ] }, { "core_name": "肿块影", "tendency": "", "character": [], "anatomy_list": [ "右肺门", "右肺上叶", "右肺下叶" ] }, { "core_name": "癌", "tendency": "不确定", "character": [ "中央型" ], "anatomy_list": [ "肺" ] }, { "core_name": "瘤", "tendency": "不确定", "character": [], "anatomy_list": [ "淋巴" ] }, { "core_name": "肉芽肿新生物", "tendency": "", "character": [], "anatomy_list": [ "肺右上叶后段" ] }, { "core_name": "鳞癌", "tendency": "", "character": [], "anatomy_list": [ "肺右上叶后段" ] }, { "core_name": "信号灶", "tendency": "", "character": [ "多发", "异常" ], "anatomy_list": [ "脾脏内" ] }, { "core_name": "转移", "tendency": "不确定", "character": [ "肺鳞癌" ], "anatomy_list": [ "脾脏内" ] }, { "core_name": "显示", "tendency": "", "character": [], "anatomy_list": [ "双侧腹股沟淋巴结" ] } ] }, { "id": 152, "text": "2.动脉期多发富血供小结节，灌注异常？胸部平扫+增强：1.双肺间质性改变。", "event": [ { "core_name": "结节", "tendency": "", "character": [ "动脉期", "多发", "富血供", "小" ], "anatomy_list": [] }, { "core_name": "灌注异常", "tendency": "不确定", "character": [], "anatomy_list": [] }, { "core_name": "间质改变", "tendency": "", "character": [], "anatomy_list": [ "双肺" ] } ] }, { "id": 1790, "text": "1天前，患者发热至38.4℃且红肿呈线形蔓延至右大腿根部，右小腿红肿、胀痛明显，故于我院门诊就诊，拟诊“蜂窝组织炎”，予以青霉素抗感染等治疗。", "event": [ { "core_name": "发热", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "红肿", "tendency": "", "character": [ "线形" ], "anatomy_list": [ "右大腿根部" ] }, { "core_name": "红肿", "tendency": "", "character": [ "明显" ], "anatomy_list": [ "右小腿" ] }, { "core_name": "疼痛", "tendency": "", "character": [ "明显", "胀痛" ], "anatomy_list": [ "右小腿" ] }, { "core_name": "蜂窝组织炎", "tendency": "", "character": [], "anatomy_list": [ "右小腿" ] } ] }, { "id": 1417, "text": "自患病以来，患者精神、食欲、睡眠一般，二便正常，体重未见明显变化。", "event": [ { "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": [ "一般" ], "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": "", "character": [ "明显" ], "anatomy_list": [] } ] }, { "id": 171, "text": "后2018-04-28于某医院行腹部mri示：腹膜后约平腰2-腰44椎体前缘可见团块状异常信号影，呈等t1等t2信号改变，大小约3.7×3.0×6.9cm，增强扫描呈不均匀环形强化。", "event": [ { "core_name": "异常信号影", "tendency": "", "character": [ "团块状", "等t1等t2信号改变" ], "anatomy_list": [ "腹膜后平腰椎L2L4椎体前缘" ] }, { "core_name": "强化", "tendency": "", "character": [ "不均匀", "环形" ], "anatomy_list": [] } ] }, { "id": 1987, "text": "解暗红色血便1次，呈稀糊状，约150g。", "event": [ { "core_name": "血便", "tendency": "", "character": [ "暗红色", "稀糊状" ], "anatomy_list": [] } ] }, { "id": 1882, "text": "5月前，患者因视力下降于我院眼科就诊，完善相关辅助检查，诊断为：1.双眼糖尿病性视网膜病变；2.双眼青光眼；3.左眼球占位后待查；3.双眼白内障术后人工晶体眼；5.2型糖尿病；6.原发性高血压病；7.脑梗死。", "event": [ { "core_name": "视力下降", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "病变", "tendency": "", "character": [ "糖尿病性" ], "anatomy_list": [ "双眼", "视网膜" ] }, { "core_name": "青光眼", "tendency": "", "character": [], "anatomy_list": [ "双眼" ] }, { "core_name": "占位", "tendency": "", "character": [], "anatomy_list": [ "左眼球" ] }, { "core_name": "白内障", "tendency": "", "character": [ "术后", "人工晶体眼" ], "anatomy_list": [ "双眼" ] }, { "core_name": "糖尿病", "tendency": "", "character": [ "2型" ], "anatomy_list": [] }, { "core_name": "高血压", "tendency": "", "character": [ "原发性" ], "anatomy_list": [] }, { "core_name": "梗死", "tendency": "", "character": [], "anatomy_list": [ "脑" ] } ] }, { "id": 1777, "text": "入院前1天，患者再次出现畏寒、发热、寒战，体温约38.5℃。", "event": [ { "core_name": "畏寒", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "发热", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "寒颤", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "体温", "tendency": "", "character": [ "升高" ], "anatomy_list": [] } ] }, { "id": 1296, "text": "病后无腹泻，无恶心，无呕吐，无抽搐，无意识障碍，无出血倾向，无心悸,无颈部包块。", "event": [ { "core_name": "腹泻", "tendency": "否定", "character": [ "病后" ], "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": "抽搐", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "意识障碍", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "出血倾向", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "心悸", "tendency": "否定", "character": [], "anatomy_list": [ "心" ] }, { "core_name": "包块", "tendency": "否定", "character": [], "anatomy_list": [ "颈部" ] } ] }, { "id": 1860, "text": "故以\"直肠癌术后第一次化疗\"收入我科住院治疗。", "event": [ { "core_name": "癌", "tendency": "", "character": [ "术后", "第一次化疗" ], "anatomy_list": [ "直肠" ] } ] }, { "id": 831, "text": "<7、8、9、10、11、12组>淋巴结未见癌转移。", "event": [ { "core_name": "癌", "tendency": "否定", "character": [ "转移" ], "anatomy_list": [ "7、8、9、10、11、12组淋巴结" ] } ] }, { "id": 1393, "text": "患者自发病以来， 精神可 ， 食欲可 ， 睡眠可 ， 大便如常 ， 小便尿频 ， 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": "睡眠质量", "tendency": "", "character": [ "可" ], "anatomy_list": [] }, { "core_name": "大便", "tendency": "", "character": [ "如常" ], "anatomy_list": [] }, { "core_name": "尿频", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "体重改变", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [] } ] }, { "id": 1335, "text": "入院前20+年，患者偶然发现左上眼睑长新生物，并渐渐增大，伴轻微异物感，无其他特殊不适，患者未引起重视未做治疗；入院前4+年曾就诊于某医院就诊，因血糖控制不佳，故没有进行后续手术治疗，入院1+年患者发现肿物生长迅速，偶有有眼痛、眼胀，眼痒，流泪无畏光、虹视，复视等不适，为求进一步诊治，遂于今日我院门诊就诊，门诊完善相关检查后以\"左眼上睑新生物 \"收入。", "event": [ { "core_name": "新生物", "tendency": "", "character": [ "渐渐增大" ], "anatomy_list": [ "左上眼睑" ] }, { "core_name": "异物感", "tendency": "", "character": [ "轻微" ], "anatomy_list": [ "左上眼睑" ] }, { "core_name": "血糖", "tendency": "", "character": [ "控制不佳" ], "anatomy_list": [] }, { "core_name": "肿物", "tendency": "", "character": [ "生长迅速" ], "anatomy_list": [ "左上眼睑" ] }, { "core_name": "疼痛", "tendency": "", "character": [], "anatomy_list": [ "眼" ] }, { "core_name": "眼胀", "tendency": "", "character": [], "anatomy_list": [ "眼" ] }, { "core_name": "瘙痒", "tendency": "", "character": [], "anatomy_list": [ "眼" ] }, { "core_name": "流泪", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "畏光", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "虹视", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "复视", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "新生物", "tendency": "", "character": [], "anatomy_list": [ "左眼上睑" ] } ] }, { "id": 2006, "text": "3.乳头未见癌组织累及。", "event": [ { "core_name": "癌组织", "tendency": "否定", "character": [ "累及" ], "anatomy_list": [ "乳头" ] } ] }, { "id": 477, "text": "患者自患病以来，精神食欲可，大小便正常，体重无明显改变。", "event": [ { "core_name": "精神", "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": "体重改变", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [] } ] }, { "id": 125, "text": "患者一般情况良好，无畏寒、发热，无咯血、胸痛、呼吸困难，无胸闷、气促、心悸，无潮热、盗汗，无咳嗽、咳痰，无头晕、头痛，无恶心、呕吐，无腹痛、腹泻等不适。", "event": [ { "core_name": "畏寒", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "发热", "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": "呼吸困难", "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": "心悸", "tendency": "否定", "character": [], "anatomy_list": [ "心" ] }, { "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": "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": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "腹泻", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] } ] }, { "id": 1613, "text": "2.左侧筛窦筛窦炎。", "event": [ { "core_name": "筛窦炎", "tendency": "", "character": [], "anatomy_list": [ "左侧筛窦" ] } ] }, { "id": 465, "text": "患者平素月经欠规律，初潮年龄14岁，4-6/3030-35天，lmp：2019-01-10。", "event": [ { "core_name": "月经", "tendency": "", "character": [ "欠规律" ], "anatomy_list": [] } ] }, { "id": 133, "text": "我院门诊彩超提示：右乳低回声结节，性质待定，建议穿刺活检。右乳bi-rads 4c。", "event": [ { "core_name": "结节", "tendency": "", "character": [ "低回声" ], "anatomy_list": [ "右乳" ] } ] }, { "id": 732, "text": "患者于2016年9月至2017年9月在某医院先后化疗5次（具体不详），化疗后出现恶心、呕吐及iii度骨髓抑制，予以升白细胞、输血纠正贫血及对症等治疗后好转。", "event": [ { "core_name": "恶心", "tendency": "", "character": [ "化疗后" ], "anatomy_list": [] }, { "core_name": "呕吐", "tendency": "", "character": [ "化疗后" ], "anatomy_list": [] }, { "core_name": "骨髓抑制", "tendency": "", "character": [ "化疗后", "iii度" ], "anatomy_list": [ "骨髓" ] }, { "core_name": "贫血", "tendency": "", "character": [], "anatomy_list": [] } ] }, { "id": 745, "text": "患者入院前4天无明显诱因出现头昏，稍有头痛，伴眩晕、恶心、呕吐，耳鸣，呕吐非喷射状，同时有上腹部腹胀、腹部隐痛、反酸、嗳气，进食后明显，无放射痛，无腹泻、黑便，有肛门坠胀感，大便呈细条状，偶有咳嗽、咳痰，无胸闷、心悸，在某镇医输液3天后头昏有好转，今日出现大便带鲜血，曾滴沥状，无黑便，现为就诊来我院，门诊以“腹痛便血待查”收入我科。", "event": [ { "core_name": "头昏", "tendency": "", "character": [], "anatomy_list": [ "头" ] }, { "core_name": "疼痛", "tendency": "", "character": [ "稍有" ], "anatomy_list": [ "头" ] }, { "core_name": "眩晕", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "恶心", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "呕吐", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "耳鸣", "tendency": "", "character": [], "anatomy_list": [ "耳" ] }, { "core_name": "呕吐", "tendency": "", "character": [ "非喷射状" ], "anatomy_list": [] }, { "core_name": "腹胀", "tendency": "", "character": [], "anatomy_list": [ "上腹" ] }, { "core_name": "疼痛", "tendency": "", "character": [ "隐痛" ], "anatomy_list": [ "腹" ] }, { "core_name": "反酸", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "嗳气", "tendency": "", "character": [ "进食后明显" ], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "否定", "character": [ "放射性" ], "anatomy_list": [] }, { "core_name": "腹泻", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "黑便", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "坠胀感", "tendency": "", "character": [], "anatomy_list": [ "肛门" ] }, { "core_name": "大便", "tendency": "", "character": [ "细条状" ], "anatomy_list": [] }, { "core_name": "咳嗽", "tendency": "", "character": [ "偶有" ], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "偶有" ], "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": "头昏", "tendency": "", "character": [ "输液3天后", "好转" ], "anatomy_list": [ "头" ] }, { "core_name": "大便", "tendency": "", "character": [ "带血", "滴沥状" ], "anatomy_list": [] }, { "core_name": "黑便", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "便血", "tendency": "", "character": [], "anatomy_list": [] } ] }, { "id": 528, "text": "三尖瓣重度反流，肺动脉增宽，肺动脉高压；二尖瓣中度反流；主动脉瓣钙化伴中度狭窄。", "event": [ { "core_name": "反流", "tendency": "", "character": [ "重度" ], "anatomy_list": [ "三尖瓣" ] }, { "core_name": "增宽", "tendency": "", "character": [], "anatomy_list": [ "肺动脉" ] }, { "core_name": "高压", "tendency": "", "character": [], "anatomy_list": [ "肺动脉" ] }, { "core_name": "反流", "tendency": "", "character": [ "中度" ], "anatomy_list": [ "二尖瓣" ] }, { "core_name": "钙化", "tendency": "", "character": [], "anatomy_list": [ "主动脉瓣" ] }, { "core_name": "狭窄", "tendency": "", "character": [ "中度" ], "anatomy_list": [ "主动脉瓣" ] } ] }, { "id": 1189, "text": "化疗过程顺利，患者未诉特殊不适，右乳包块变软、缩小。", "event": [ { "core_name": "包块", "tendency": "", "character": [ "变软", "缩小" ], "anatomy_list": [ "右乳" ] } ] }, { "id": 579, "text": "伴有疼痛，月经前明显，月经后缓解，局部皮肤无红肿、瘙痒，无发热、恶心、潮热、盗汗、腹痛、腹胀等不适，患者规律服用乳增宁片治疗，乳腺疼痛较前明显缓解。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [ "月经前明显", "月经后缓解" ], "anatomy_list": [] }, { "core_name": "红肿", "tendency": "否定", "character": [ "局部" ], "anatomy_list": [ "皮肤" ] }, { "core_name": "瘙痒", "tendency": "否定", "character": [ "局部" ], "anatomy_list": [ "皮肤" ] }, { "core_name": "发热", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "恶心", "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": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "腹胀", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "疼痛", "tendency": "", "character": [ "较前明显缓解" ], "anatomy_list": [ "乳腺" ] } ] }, { "id": 464, "text": "现患者无发热、恶心、呕吐等，无腹痛、腹胀、腹泻等，今为进一步治疗入院。", "event": [ { "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": [ "腹" ] }, { "core_name": "腹胀", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "腹泻", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] } ] }, { "id": 1459, "text": "5月前，患者于我院住院时后查体发现双侧下颌下下颌下淋巴结淋巴结肿大，具体检查诊断不详，诊断“颈动脉狭窄、胸椎椎管内髓外病变:肿瘤性病变?、亚临床甲状腺功能减退症?”，患者椎管内髓外病变未进一步处理。", "event": [ { "core_name": "肿大", "tendency": "", "character": [], "anatomy_list": [ "双侧下颌下淋巴结" ] }, { "core_name": "狭窄", "tendency": "", "character": [], "anatomy_list": [ "颈动脉" ] }, { "core_name": "病变", "tendency": "", "character": [], "anatomy_list": [ "胸椎椎管内", "髓外" ] }, { "core_name": "病变", "tendency": "不确定", "character": [ "肿瘤性" ], "anatomy_list": [] }, { "core_name": "亚临床甲状腺功能减退症", "tendency": "不确定", "character": [], "anatomy_list": [ "甲状腺" ] }, { "core_name": "病变", "tendency": "", "character": [], "anatomy_list": [ "椎管内", "髓外" ] } ] }, { "id": 1727, "text": "2016-08-01 血液分析(门诊)wbc 3.52*10^9/L，plt 274*10^9/L，hb 92g/L，anc 2.22*10^9/L；今为行间期治疗1-8周第2次静脉化疗入院，门诊以“急性前b淋巴细胞淋巴细胞白血病”收入我科。", "event": [ { "core_name": "白血病", "tendency": "", "character": [ "急性", "前B淋巴细胞" ], "anatomy_list": [] } ] }, { "id": 500, "text": "术后诊断：1.食管贲门腺癌；2.慢性浅表性胃窦炎胃窦炎伴糜烂。", "event": [ { "core_name": "腺癌", "tendency": "", "character": [], "anatomy_list": [ "食管", "贲门" ] }, { "core_name": "胃窦炎", "tendency": "", "character": [ "慢性", "浅表性" ], "anatomy_list": [ "胃窦" ] }, { "core_name": "糜烂", "tendency": "", "character": [], "anatomy_list": [ "胃窦" ] } ] }, { "id": 1245, "text": "胸部增强ct+肺动脉cta+头颅mri、纤维支气管镜等，诊断为：右肺腺癌伴纵膈、锁骨上淋巴结转移、胸膜、心包、颅内转移，t3n3Mm1b，诊断明确后给予培美曲赛及铂类化疗3次。", "event": [ { "core_name": "腺癌", "tendency": "", "character": [], "anatomy_list": [ "右肺" ] }, { "core_name": "转移", "tendency": "", "character": [], "anatomy_list": [ "纵膈淋巴结", "锁骨上淋巴结", "胸膜", "心包", "颅内" ] } ] }, { "id": 589, "text": "不伴胸骨后灼烧感，不伴厌油、乏力、黄疸。", "event": [ { "core_name": "灼烧感", "tendency": "否定", "character": [], "anatomy_list": [ "胸骨后" ] }, { "core_name": "厌油", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "乏力", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "黄疸", "tendency": "否定", "character": [], "anatomy_list": [] } ] }, { "id": 1233, "text": "2、肠系膜扭转，肠系膜密度增高、模糊，小肠管较多积液。请结合临床。", "event": [ { "core_name": "扭转", "tendency": "", "character": [], "anatomy_list": [ "肠系膜" ] }, { "core_name": "密度", "tendency": "", "character": [ "增高", "模糊" ], "anatomy_list": [ "肠系膜" ] }, { "core_name": "积液", "tendency": "", "character": [ "较多" ], "anatomy_list": [ "小肠管" ] } ] }, { "id": 787, "text": "不伴畏寒，寒战，高热；不伴潮热、盗汗及午后低热；不咯鲜血及痰中带血；不伴胸痛，气促及呼吸困难；不伴体重减轻及食欲下降。", "event": [ { "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": [ "高" ], "anatomy_list": [] }, { "core_name": "潮热", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "盗汗", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "发热", "tendency": "否定", "character": [ "午后", "低" ], "anatomy_list": [] }, { "core_name": "咯血", "tendency": "否定", "character": [ "鲜红色" ], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "否定", "character": [ "带血" ], "anatomy_list": [] }, { "core_name": "疼痛", "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": "体重减轻", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "食欲下降", "tendency": "否定", "character": [], "anatomy_list": [] } ] }, { "id": 1881, "text": "自述反复冷汗、头昏、饥饿感明显，自测指血糖2.5mmol/L左右。", "event": [ { "core_name": "冷汗", "tendency": "", "character": [ "反复" ], "anatomy_list": [] }, { "core_name": "头昏", "tendency": "", "character": [ "反复" ], "anatomy_list": [ "头" ] }, { "core_name": "饥饿感", "tendency": "", "character": [ "明显" ], "anatomy_list": [] } ] }, { "id": 754, "text": "2.双肺多发结节影，转移可能，请随访复查。", "event": [ { "core_name": "结节影", "tendency": "", "character": [ "多发" ], "anatomy_list": [ "双肺" ] }, { "core_name": "转移", "tendency": "不确定", "character": [], "anatomy_list": [ "双肺" ] } ] }, { "id": 877, "text": "门诊遂以“慢性肾脏病”收入我科。", "event": [ { "core_name": "肾病", "tendency": "", "character": [ "慢性" ], "anatomy_list": [ "肾" ] } ] }, { "id": 1805, "text": "今日为进一步检查治疗转入我院，门诊以“头部外伤、左颞骨骨折”收住入院。", "event": [ { "core_name": "外伤", "tendency": "", "character": [], "anatomy_list": [ "头部" ] }, { "core_name": "骨折", "tendency": "", "character": [], "anatomy_list": [ "左颞骨" ] } ] }, { "id": 857, "text": "不伴发热、畏寒、寒战、反酸、烧心、嗳气、呃逆、头痛、胸闷、胸痛、气促，到重医附一院就诊行腹部ct检查提示“1、肝硬化，脾大，食道胃底静脉曲张，2、肝癌待排，查乙肝标志物示hbsag阳性。", "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": "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": "呃逆", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "头" ] }, { "core_name": "胸闷", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "胸" ] }, { "core_name": "气促", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "硬化", "tendency": "", "character": [], "anatomy_list": [ "肝" ] }, { "core_name": "脾大", "tendency": "", "character": [], "anatomy_list": [ "脾" ] }, { "core_name": "曲张", "tendency": "", "character": [], "anatomy_list": [ "食管静脉", "胃底静脉" ] }, { "core_name": "癌", "tendency": "不确定", "character": [], "anatomy_list": [ "肝" ] }, { "core_name": "hbsag", "tendency": "", "character": [ "阳性" ], "anatomy_list": [] } ] }, { "id": 1411, "text": "体重减轻5斤。", "event": [ { "core_name": "体重减轻", "tendency": "", "character": [], "anatomy_list": [] } ] }, { "id": 114, "text": "病程中，患者神志清，精神可，饮食睡眠正常，大小便正常，体重无异常变化。", "event": [ { "core_name": "神志", "tendency": "", "character": [ "清" ], "anatomy_list": [] }, { "core_name": "精神", "tendency": "", "character": [ "可" ], "anatomy_list": [] }, { "core_name": "饮食", "tendency": "", "character": [ "正常" ], "anatomy_list": [] }, { "core_name": "睡眠", "tendency": "", "character": [ "正常" ], "anatomy_list": [] }, { "core_name": "大小便", "tendency": "", "character": [ "正常" ], "anatomy_list": [] }, { "core_name": "体重变化", "tendency": "否定", "character": [ "异常" ], "anatomy_list": [] } ] }, { "id": 419, "text": "于2015年8月11日行神经导航下开路探查+左侧前颅底路况沟通肿瘤纤维切除术，术中可见肿瘤位于左侧前颅底，已经将蝶骨脊及眼眶外侧板侵蚀破坏，起源于硬脑膜，硬膜外及硬膜下均可见肿瘤，硬膜下肿瘤呈肉红色，血供丰富，与周围脑组织边界尚清，粘连明显，完整切除肿瘤致肿瘤镜下全切，之后切除眼眶内肿瘤，探查肿瘤位于框内，与周围骨质两联紧密，深部侵及眶外脂肪层，小心游离眼眶内肿瘤后完整切除肿瘤。", "event": [ { "core_name": "肿瘤", "tendency": "", "character": [], "anatomy_list": [ "左侧前颅底" ] }, { "core_name": "侵蚀破坏", "tendency": "", "character": [], "anatomy_list": [ "眼眶外侧板", "蝶骨脊" ] }, { "core_name": "肿瘤", "tendency": "", "character": [], "anatomy_list": [ "硬脑膜", "硬膜外", "硬膜下" ] }, { "core_name": "肿瘤", "tendency": "", "character": [ "呈肉红色", "血供丰富", "与周围脑组织边界尚清", "粘连明显" ], "anatomy_list": [ "硬膜下" ] }, { "core_name": "肿瘤", "tendency": "", "character": [ "与周围骨质两联紧密", "深部侵及眶外脂肪层" ], "anatomy_list": [ "眼眶内" ] } ] }, { "id": 544, "text": "2+年前，患者无明显诱因反复出现咳嗽，多为干咳，偶咳白色泡沫痰，偶有发热，体温多为38℃左右，无畏寒、盗汗，无胸闷、胸痛，无咯血，于某医院输液治疗（具体不详）后可好转，未予以进一步检查。", "event": [ { "core_name": "咳嗽", "tendency": "", "character": [ "反复出现" ], "anatomy_list": [] }, { "core_name": "咳嗽", "tendency": "", "character": [ "干性", "反复出现" ], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "偶尔", "白色", "泡沫痰" ], "anatomy_list": [] }, { "core_name": "发热", "tendency": "", "character": [ "偶有" ], "anatomy_list": [] }, { "core_name": "体温", "tendency": "", "character": [ "升高", "偶有" ], "anatomy_list": [] }, { "core_name": "畏寒", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "盗汗", "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": "咯血", "tendency": "否定", "character": [], "anatomy_list": [] } ] }, { "id": 825, "text": "7+月前至某医院医院复查妇科彩超：左附件区可见64mm×35mm的无回声区，查ca125、he4均正常，hpv-dna均阴性，建议手术，患者仍未做。", "event": [ { "core_name": "无回声", "tendency": "", "character": [], "anatomy_list": [ "左附件" ] } ] }, { "id": 740, "text": "入院3天前再次出现意识丧失（家属未看到），发病形式、过程不详。", "event": [ { "core_name": "意识丧失", "tendency": "", "character": [ "家属未看到", "发病形式", "过程不详" ], "anatomy_list": [] } ] }, { "id": 1072, "text": "于2019-3-27给予e-chop方案（依托泊苷100mg d1-2、吡柔比星20mg d1-3、环磷酰胺400mg d1-3、地塞米松20mg d1-5、长春新碱1.5mg d1、d8）方案化疗1周期，于2019-4-23、2019-5-17给予re-chop方案（美罗华600mg d1、依托泊苷100mg d1-2、吡柔比星60mg d1、环磷酰胺400mg d1-3、地塞米松20mg d1-5、长春新碱3mg d1）化疗第2周期，化疗后患者出现ii°骨髓抑制，给予升白治疗后骨髓抑制纠正，今日为行下一周期化疗来我科，以“弥漫大b细胞淋巴瘤（iv期 b组）化疗后复发”收入住院治疗。", "event": [ { "core_name": "骨髓抑制", "tendency": "", "character": [ "化疗后", "ii°" ], "anatomy_list": [ "骨髓" ] }, { "core_name": "骨髓抑制", "tendency": "", "character": [ "矫正" ], "anatomy_list": [ "骨髓" ] }, { "core_name": "瘤", "tendency": "", "character": [ "弥漫性", "iv期 b组", "化疗后", "复发" ], "anatomy_list": [ "淋巴", "大B细胞" ] } ] }, { "id": 1291, "text": "院外于某医院行内分泌治疗及抗溶骨治疗，患者近期左侧腰部及下肢疼痛明显，为求进一步治疗，以“乳腺癌 骨转移”收入我科住院治疗。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [ "近期", "明显" ], "anatomy_list": [ "左侧腰部", "下肢" ] }, { "core_name": "癌", "tendency": "", "character": [ "骨转移" ], "anatomy_list": [ "乳腺", "骨" ] } ] }, { "id": 1006, "text": "后一直我院随访，肿瘤病灶稳定，1年前前，患者在我科复查腹部mri提示肝右后叶小富血供结节，不排除原发性肝癌hifu术后复发可能，于2013年12月30日行tae治疗，于2014年1月4日在全身麻醉下行原发性肝癌姑息性hifu术，术后患者恢复可，多次复查腹部mri提示肿瘤控制可，现为求再次复查入住我科。", "event": [ { "core_name": "病灶", "tendency": "", "character": [ "肿瘤", "稳定" ], "anatomy_list": [] }, { "core_name": "结节", "tendency": "", "character": [ "小", "富血供" ], "anatomy_list": [ "肝右后叶" ] }, { "core_name": "癌", "tendency": "不确定", "character": [ "原发性", "hifu术后", "复发" ], "anatomy_list": [ "肝" ] }, { "core_name": "肿瘤", "tendency": "", "character": [ "控制可" ], "anatomy_list": [] } ] }, { "id": 724, "text": "院外一直口服中成药治疗（具体用药）治疗，并于2011年5月和2011年9月、2012年3月22日和2012年7月到我科复查，行相关检查，提示肿瘤尚无进展。", "event": [ { "core_name": "肿瘤", "tendency": "否定", "character": [ "进展" ], "anatomy_list": [] } ] }, { "id": 748, "text": "肠壁上淋巴结见癌转移（1/15）。", "event": [ { "core_name": "癌", "tendency": "", "character": [ "转移" ], "anatomy_list": [ "肠壁上淋巴结" ] } ] }, { "id": 2025, "text": "到某医院就诊，行胸片示肺上局部钙化钙化灶（未见报告），未予特殊治疗。", "event": [ { "core_name": "钙化灶", "tendency": "", "character": [ "局部" ], "anatomy_list": [ "肺上局部" ] } ] }, { "id": 368, "text": "患者1+月前出现咳嗽咳痰，咳嗽声音正常，不伴有鸡鸣样咳嗽，不伴有刺激性干咳，咳嗽时有胸痛症状。", "event": [ { "core_name": "咳嗽", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "咳嗽", "tendency": "", "character": [ "声音正常" ], "anatomy_list": [] }, { "core_name": "咳嗽", "tendency": "否定", "character": [ "鸡鸣样" ], "anatomy_list": [] }, { "core_name": "咳嗽", "tendency": "否定", "character": [ "刺激性", "干" ], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "", "character": [ "咳嗽时" ], "anatomy_list": [ "胸" ] } ] }, { "id": 20, "text": "后续于2016年12月25日、2017年1月18日、2017年2月15日行3周期原方案原剂量化疗,未见明显骨髓抑制；后于2017年3月14日、2017年4月8日予以吡柔比星50mg d1+紫杉醇240mg d2+环磷酰胺800mg d3化疗；化疗期间患者均无明显恶心、呕吐、骨髓抑制等副反应。", "event": [ { "core_name": "骨髓抑制", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [ "骨髓" ] }, { "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": "骨髓抑制", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [ "骨髓" ] } ] }, { "id": 162, "text": "2+年前（2018年3月）患者于某医院因体检腹部彩超发现左侧肾脏下级占位，左肾积水，无腰痛、无腹胀腹痛，无恶心呕吐，无尿频尿急尿痛，无肉眼血尿等不适。", "event": [ { "core_name": "占位", "tendency": "", "character": [], "anatomy_list": [ "左侧肾脏下级" ] }, { "core_name": "积水", "tendency": "", "character": [], "anatomy_list": [ "左肾" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "腰" ] }, { "core_name": "腹胀", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "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": "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": [] } ] }, { "id": 7, "text": "右上肺肺陈旧性病灶,以纤维化为主；右上肺结节影,考虑为纤维结节可能,不除外肿瘤性病变。食道中下段壁可疑稍增厚。", "event": [ { "core_name": "病灶", "tendency": "", "character": [ "陈旧性" ], "anatomy_list": [ "右上肺" ] }, { "core_name": "纤维化", "tendency": "", "character": [], "anatomy_list": [ "右上肺" ] }, { "core_name": "结节影", "tendency": "", "character": [], "anatomy_list": [ "右上肺" ] }, { "core_name": "纤维结节", "tendency": "不确定", "character": [], "anatomy_list": [ "右上肺" ] }, { "core_name": "病变", "tendency": "不确定", "character": [ "肿瘤性" ], "anatomy_list": [ "右上肺" ] }, { "core_name": "增厚", "tendency": "不确定", "character": [ "稍" ], "anatomy_list": [ "食道中下段壁" ] } ] }, { "id": 1990, "text": "现为求进一步诊疗到我院，急诊以“消化道出血原因待查”收入院。", "event": [ { "core_name": "出血", "tendency": "不确定", "character": [], "anatomy_list": [ "消化道" ] } ] }, { "id": 852, "text": "2018年4月患者发现左侧腹股沟腹股沟包块较前明显增大、增多，左侧腹股沟穿刺病理提示“<左腹股沟淋巴结穿刺活检标本>淋巴组织结构破坏，于组织细胞及淋巴细胞背景中查见散在r-s样细胞，结合免疫组化及t细胞基因重排满负荷经典型霍奇金淋巴瘤（混合细胞亚型）”，全身pet/ct示“腹膜后、盆腔、左侧腹股沟可见多发淋巴结肿大，fdg代谢异常增高”，未行骨髓穿刺检查。", "event": [ { "core_name": "包块", "tendency": "", "character": [ "明显增大、增多" ], "anatomy_list": [ "左侧腹股沟淋巴结" ] }, { "core_name": "破坏", "tendency": "", "character": [], "anatomy_list": [ "左侧腹股沟淋巴结组织结构" ] }, { "core_name": "r-s样细胞", "tendency": "", "character": [ "组织细胞及淋巴细胞背景中查见", "散在" ], "anatomy_list": [ "r-s样细胞" ] }, { "core_name": "瘤", "tendency": "", "character": [ "混合细胞亚型" ], "anatomy_list": [ "淋巴" ] }, { "core_name": "瘤", "tendency": "", "character": [ "经典型", "霍奇金" ], "anatomy_list": [ "淋巴" ] }, { "core_name": "肿大", "tendency": "", "character": [ "多发" ], "anatomy_list": [ "腹膜后淋巴结" ] }, { "core_name": "肿大", "tendency": "", "character": [ "多发" ], "anatomy_list": [ "盆腔淋巴结" ] }, { "core_name": "肿大", "tendency": "", "character": [ "多发" ], "anatomy_list": [ "左侧腹股沟淋巴结" ] }, { "core_name": "fdg代谢", "tendency": "", "character": [ "异常增高" ], "anatomy_list": [] } ] }, { "id": 815, "text": "现患者为求进一步诊疗，门诊以“冠心病、慢性阻塞性肺疾病、心力衰竭”收入我科住院治疗。", "event": [ { "core_name": "冠心病", "tendency": "", "character": [], "anatomy_list": [ "心" ] }, { "core_name": "肺疾病", "tendency": "", "character": [ "慢性", "阻塞性" ], "anatomy_list": [ "肺" ] }, { "core_name": "心力衰竭", "tendency": "", "character": [], "anatomy_list": [ "心" ] } ] }, { "id": 1831, "text": "今患者为求进一步治疗，至我院门诊就诊，门诊以“膀胱占位”收入我科住院治疗。", "event": [ { "core_name": "占位", "tendency": "", "character": [], "anatomy_list": [ "膀胱" ] } ] }, { "id": 1171, "text": "患者自起病以来，精神可，胃纳略差，大便如常，尿急，体重未见明显下降。", "event": [ { "core_name": "精神", "tendency": "", "character": [ "可" ], "anatomy_list": [] }, { "core_name": "胃纳", "tendency": "", "character": [ "略差" ], "anatomy_list": [ "胃" ] }, { "core_name": "大便", "tendency": "", "character": [ "如常" ], "anatomy_list": [] }, { "core_name": "尿急", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "体重下降", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [] } ] }, { "id": 1479, "text": "3月余前，患者出现胸前区疼痛，为阵发性胀痛，于夜间采取侧卧位时疼痛明显，休息后自行缓解，无压榨感，无胸闷、心悸、气促，无头痛、头晕，无咳嗽、咯血、呼吸困难，无畏寒、寒战，无潮热、盗汗，无吞咽困难，出现喉部异物感，遂于某中医院就诊，行胸部ct提示：左中上纵膈混杂密度占位影，考虑肿瘤性病变，胸腺瘤（侵袭性）可能；左侧后肋肋胸膜胸膜局限性增厚，不除外胸膜转移可能。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [ "阵发性", "胀痛", "夜间采取侧卧位时疼痛明显", "休息后自行缓解" ], "anatomy_list": [ "胸前区" ] }, { "core_name": "压榨感", "tendency": "否定", "character": [], "anatomy_list": [ "胸前区" ] }, { "core_name": "胸闷", "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": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "头" ] }, { "core_name": "头晕", "tendency": "否定", "character": [], "anatomy_list": [ "头" ] }, { "core_name": "咳嗽", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "咯血", "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": "寒颤", "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": "吞咽困难", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "异物感", "tendency": "", "character": [], "anatomy_list": [ "喉部" ] }, { "core_name": "占位影", "tendency": "", "character": [ "混杂密度" ], "anatomy_list": [ "左中上纵膈" ] }, { "core_name": "病变", "tendency": "不确定", "character": [ "肿瘤性" ], "anatomy_list": [ "左中上纵膈" ] }, { "core_name": "瘤", "tendency": "不确定", "character": [ "侵袭性" ], "anatomy_list": [ "胸腺" ] }, { "core_name": "增厚", "tendency": "", "character": [ "局限性" ], "anatomy_list": [ "左侧后肋", "肋胸膜" ] }, { "core_name": "转移", "tendency": "不确定", "character": [], "anatomy_list": [ "胸膜" ] } ] }, { "id": 1693, "text": "患者自患病以来精神、食欲、睡眠可，大小便正常，近期体重无明显变化。", "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": "大小便", "tendency": "", "character": [ "正常" ], "anatomy_list": [] }, { "core_name": "体重改变", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [] } ] }, { "id": 538, "text": "半月前患者无明显诱因再次血糖控制不佳，监测血糖空腹波动在15-16mm16mmol/L，餐后血糖在21-22mm22mmol/L，患者近期均进食稀饭，现患者有耳鸣，偶有恶心、反酸，无畏寒、发热，无头痛、头晕，无呕吐，有胸闷、心悸，偶有胸痛，伴上腹部不适，伴腹胀、腹泻，无双下肢凹陷性水肿，患者现使用胰岛素剂量为“门冬胰岛素早餐前14u，午餐前14u，晚餐前14u，甘精胰岛素睡前34u”，为进一步治疗就诊，门诊以“糖尿病、糖尿病肾病”收住院治疗。", "event": [ { "core_name": "血糖", "tendency": "", "character": [ "控制不佳" ], "anatomy_list": [] }, { "core_name": "血糖", "tendency": "", "character": [ "空腹", "波动", "升高" ], "anatomy_list": [] }, { "core_name": "血糖", "tendency": "", "character": [ "餐后", "波动", "升高" ], "anatomy_list": [] }, { "core_name": "进食", "tendency": "", "character": [ "稀饭" ], "anatomy_list": [] }, { "core_name": "耳鸣", "tendency": "", "character": [], "anatomy_list": [ "耳" ] }, { "core_name": "恶心", "tendency": "", "character": [ "偶有" ], "anatomy_list": [] }, { "core_name": "反酸", "tendency": "", "character": [ "偶有" ], "anatomy_list": [] }, { "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": "呕吐", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "胸闷", "tendency": "", "character": [], "anatomy_list": [ "胸" ] }, { "core_name": "心悸", "tendency": "", "character": [], "anatomy_list": [ "心" ] }, { "core_name": "疼痛", "tendency": "", "character": [ "偶有" ], "anatomy_list": [ "胸" ] }, { "core_name": "不适", "tendency": "", "character": [], "anatomy_list": [ "上腹部" ] }, { "core_name": "腹胀", "tendency": "", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "腹泻", "tendency": "", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "水肿", "tendency": "否定", "character": [ "凹陷性" ], "anatomy_list": [ "双下肢" ] }, { "core_name": "糖尿病", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "肾病", "tendency": "", "character": [ "糖尿病" ], "anatomy_list": [ "肾" ] } ] }, { "id": 1402, "text": "患者 今为进一步诊治，来我院就诊，门诊以\"lsil\"收入我科。", "event": [ { "core_name": "低度鳞状上皮内病变", "tendency": "", "character": [], "anatomy_list": [] } ] }, { "id": 1247, "text": "1周前出现喘累不适，无明显缓解，胸水b超定位提示：右侧胸腔积液，最大前后径约148mm。", "event": [ { "core_name": "喘累", "tendency": "", "character": [ "无明显缓解" ], "anatomy_list": [] }, { "core_name": "胸水", "tendency": "", "character": [], "anatomy_list": [ "胸" ] }, { "core_name": "积液", "tendency": "", "character": [], "anatomy_list": [ "右侧胸腔" ] } ] }, { "id": 1110, "text": "无禁忌症，于10.19开始给予颈部转移病灶调强放射治疗，dt:66G/33f，放疗过程中出现放射性皮炎，给予局部外敷康复新促进皮肤修护治疗，建议患者行化疗，患者拒绝。", "event": [ { "core_name": "病灶", "tendency": "", "character": [ "转移" ], "anatomy_list": [ "颈部" ] }, { "core_name": "皮炎", "tendency": "", "character": [ "放射性" ], "anatomy_list": [ "颈部", "皮" ] } ] }, { "id": 650, "text": "3月前患者无明显诱因出现腰痛，伴尿黄，无腹胀、腹痛，无胸闷、胸痛，无尿频、尿急、尿痛，院外就诊诊断为“肾结石、肝功异常”，当时未予重视，自行院外输液治疗（具体用药及诊断不详）后腰痛缓解，未复查及随访。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [], "anatomy_list": [ "腰" ] }, { "core_name": "尿黄", "tendency": "", "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": "胸闷", "tendency": "否定", "character": [], "anatomy_list": [ "胸" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "胸" ] }, { "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": "结石", "tendency": "", "character": [], "anatomy_list": [ "肾" ] }, { "core_name": "肝功能异常", "tendency": "", "character": [], "anatomy_list": [ "肝" ] }, { "core_name": "疼痛", "tendency": "", "character": [ "输液治疗缓解" ], "anatomy_list": [ "腰" ] } ] }, { "id": 1444, "text": "无腹胀、腹痛，恶心、呕吐，无里急后重。患者未予以重视。", "event": [ { "core_name": "腹胀", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "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": "里急后重", "tendency": "否定", "character": [], "anatomy_list": [] } ] }, { "id": 1445, "text": "患者今为求进一步治疗，门诊以“消化道出血”收治我科。", "event": [ { "core_name": "出血", "tendency": "", "character": [], "anatomy_list": [ "消化道" ] } ] }, { "id": 703, "text": "之后上述症状反复发作，每次发作均无明显诱因，均突然发作，持续数分钟至10+分钟后自行缓解，性质同前，未治疗；近1月来，患者发作频率较前增加，间隔时间减短，约每小时1-2次，持续10+分钟，无胸闷、气促、胸痛，无黑蒙、晕厥、意识障碍，无咯血、呼吸困难等不适。", "event": [ { "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": [ "胸" ] }, { "core_name": "黑朦", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "晕厥", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "意识", "tendency": "否定", "character": [ "障碍" ], "anatomy_list": [] }, { "core_name": "咯血", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "呼吸困难", "tendency": "否定", "character": [], "anatomy_list": [] } ] }, { "id": 401, "text": "原始肿物位于左侧乳房与乳头内侧，大小约为2*2cm。", "event": [ { "core_name": "肿物", "tendency": "", "character": [ "原始" ], "anatomy_list": [ "左侧乳房与乳头内侧" ] } ] }, { "id": 267, "text": "发现血压增高5年，血压最高达170/105mmHg，长期口服“苯磺酸氨氯地平”降压，血压控制情况不详。", "event": [ { "core_name": "血压", "tendency": "", "character": [ "增高" ], "anatomy_list": [] } ] }, { "id": 313, "text": "患者既往月经规律，自然绝经20+年，绝经后无阴道阴道流血流液。", "event": [ { "core_name": "月经", "tendency": "", "character": [ "规律" ], "anatomy_list": [] }, { "core_name": "出血", "tendency": "否定", "character": [ "绝经后" ], "anatomy_list": [ "阴道" ] }, { "core_name": "流液", "tendency": "否定", "character": [ "绝经后" ], "anatomy_list": [ "阴道" ] } ] }, { "id": 183, "text": "左颈部软组织影，考虑淋巴结转移可能。", "event": [ { "core_name": "组织影", "tendency": "", "character": [ "软组织" ], "anatomy_list": [ "左颈部" ] }, { "core_name": "转移", "tendency": "不确定", "character": [], "anatomy_list": [ "淋巴结" ] } ] }, { "id": 1399, "text": "平时白带较不多，无异味。", "event": [ { "core_name": "白带", "tendency": "", "character": [ "较不多" ], "anatomy_list": [] }, { "core_name": "白带", "tendency": "否定", "character": [ "异味" ], "anatomy_list": [] } ] }, { "id": 451, "text": "22月前患者为进一步治疗来我科，完善术前检查，于2015-10-12行原发性肝癌介入术，2015-10-19复查ct提示碘油沉积可，2015-10-23行原发性肝癌姑息性hifu术，术后给予保肝、消炎、增强免疫、抗肿瘤等治疗，患者术后多次复查腹部mr提示肿瘤无复发。", "event": [ { "core_name": "碘油沉积", "tendency": "", "character": [ "可" ], "anatomy_list": [] }, { "core_name": "肿瘤", "tendency": "否定", "character": [ "复发" ], "anatomy_list": [] } ] }, { "id": 1327, "text": "入院前10年，患者受凉后咳嗽， 咯白色泡沫痰 ，以晨起明显。", "event": [ { "core_name": "咳嗽", "tendency": "", "character": [ "受凉后" ], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "白色", "泡沫痰", "晨起明显" ], "anatomy_list": [] } ] }, { "id": 1567, "text": "21年来患者反复心悸、胸痛、胸闷，偶伴心前区疼痛及压榨感，每次持续20秒，呈锐痛，含服硝酸甘油后症状可立即缓解，偶伴头晕、头痛，无视物旋转、一过性黑朦，11年前在我科住院治疗，经冠状动脉造影示lad开口狭窄、并行支架成型术。", "event": [ { "core_name": "心悸", "tendency": "", "character": [ "反复" ], "anatomy_list": [ "心" ] }, { "core_name": "疼痛", "tendency": "", "character": [ "反复" ], "anatomy_list": [ "胸" ] }, { "core_name": "胸闷", "tendency": "", "character": [ "反复" ], "anatomy_list": [ "胸" ] }, { "core_name": "疼痛", "tendency": "", "character": [ "偶" ], "anatomy_list": [ "心前区" ] }, { "core_name": "压榨感", "tendency": "", "character": [ "偶" ], "anatomy_list": [ "心前区" ] }, { "core_name": "疼痛", "tendency": "", "character": [ "锐痛" ], "anatomy_list": [ "心前区" ] }, { "core_name": "头晕", "tendency": "", "character": [ "偶" ], "anatomy_list": [ "头" ] }, { "core_name": "疼痛", "tendency": "", "character": [ "偶" ], "anatomy_list": [ "头" ] }, { "core_name": "黑朦", "tendency": "否定", "character": [ "一过性" ], "anatomy_list": [] }, { "core_name": "视物旋转", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "狭窄", "tendency": "", "character": [], "anatomy_list": [ "冠状动脉lad开口" ] } ] }, { "id": 482, "text": "后患者颈部包块逐渐增大，2020年10月开始出现咳嗽、咳痰，咳白色粘痰，咳嗽剧烈时伴有呼吸困难。", "event": [ { "core_name": "包块增大", "tendency": "", "character": [ "逐渐", "增大" ], "anatomy_list": [ "颈部" ] }, { "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": "呼吸困难", "tendency": "", "character": [ "咳嗽剧烈时" ], "anatomy_list": [] } ] }, { "id": 1313, "text": "患者本次发病以来，食欲下降，感进食后饱胀不适。", "event": [ { "core_name": "食欲", "tendency": "", "character": [ "下降" ], "anatomy_list": [] }, { "core_name": "饱胀", "tendency": "", "character": [ "进食后" ], "anatomy_list": [] } ] }, { "id": 1473, "text": "入院前半年，患者站立时扪及右侧腹股沟区一大拇指大小包块，质地较软，移动可，可回纳，活动后伴右侧腹股沟区胀痛，取平卧位可明显减轻，不伴腹痛、腹胀、恶心、呕吐、肛门停止排便排气等，患者未予重视及相关诊治。", "event": [ { "core_name": "包块", "tendency": "", "character": [ "一大拇指大小", "质地较软", "移动可", "可回纳" ], "anatomy_list": [ "右侧腹股沟区" ] }, { "core_name": "疼痛", "tendency": "", "character": [ "活动后胀痛", "平卧位可明显减轻" ], "anatomy_list": [ "右侧腹股沟区" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "腹胀", "tendency": "否定", "character": [], "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": "排便", "tendency": "否定", "character": [], "anatomy_list": [ "肛门" ] }, { "core_name": "排气", "tendency": "否定", "character": [], "anatomy_list": [ "肛门" ] } ] }, { "id": 1932, "text": "2017-3-9某医院复查肠镜示：结肠癌术后表现。", "event": [ { "core_name": "癌", "tendency": "", "character": [ "术后" ], "anatomy_list": [ "结肠" ] } ] }, { "id": 1262, "text": "4.肝囊肿。", "event": [ { "core_name": "囊肿", "tendency": "", "character": [], "anatomy_list": [ "肝" ] } ] }, { "id": 459, "text": "2017-8-16 ect检查报告：全身骨显像 与2017-5-5全身骨显像比较：1.出现新增病灶：左侧第5前肋肋缘，考虑肋骨损伤可能大。", "event": [ { "core_name": "病灶", "tendency": "", "character": [ "新增" ], "anatomy_list": [ "左侧第5前肋肋缘" ] }, { "core_name": "损伤", "tendency": "不确定", "character": [ "可能大" ], "anatomy_list": [ "肋骨" ] } ] }, { "id": 1544, "text": "治疗上予以禁食水、补液、胃肠减压、灌肠等治疗后腹痛、腹胀症状明显缓解，后请我科会诊后转入我科治疗，请肛肠科会诊行直肠病灶活检提示腺癌。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [ "明显缓解" ], "anatomy_list": [ "腹" ] }, { "core_name": "腹胀", "tendency": "", "character": [ "明显缓解" ], "anatomy_list": [ "腹" ] }, { "core_name": "腺癌", "tendency": "", "character": [], "anatomy_list": [ "直肠" ] } ] }, { "id": 381, "text": "遂于我院行胸部ct提示肺内占位（具体报告未见）；后患者于某医院行ct引导下经皮肺穿刺活检术，术后病理示：非小细胞肺癌；行基因检测未见阳性突变。", "event": [ { "core_name": "占位", "tendency": "", "character": [], "anatomy_list": [ "肺内" ] }, { "core_name": "非小细胞癌", "tendency": "", "character": [], "anatomy_list": [ "肺" ] }, { "core_name": "突变", "tendency": "否定", "character": [ "阳性" ], "anatomy_list": [] } ] }, { "id": 1704, "text": "入院前4月，患者无明显诱因出现右腿疼痛，为持续性，无阵发性加重，活动时明显，不伴下肢麻木等不适，患者就诊于我院，腰椎mri示腰椎间盘突出症、骨盆多发骨质破坏。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [ "持续性", "无阵发性加重", "活动时明显" ], "anatomy_list": [ "右腿" ] }, { "core_name": "麻木", "tendency": "否定", "character": [], "anatomy_list": [ "下肢" ] }, { "core_name": "突出症", "tendency": "", "character": [], "anatomy_list": [ "腰椎间盘" ] }, { "core_name": "骨质破坏", "tendency": "", "character": [ "多发" ], "anatomy_list": [ "骨盆" ] } ] }, { "id": 932, "text": "入院前1年，患者出现口干，进食干食需用水送服，伴反复腮腺炎，患者仍未重视，故未治疗。", "event": [ { "core_name": "口干", "tendency": "", "character": [ "进食干食需用水送服" ], "anatomy_list": [ "口" ] }, { "core_name": "腮腺炎", "tendency": "", "character": [ "反复" ], "anatomy_list": [ "腮腺" ] } ] }, { "id": 902, "text": "入院前2日发现患儿无明显诱因发热，以高热为主，最高高体温39.8℃，自行予退烧药口服后，体温能降至正常。", "event": [ { "core_name": "发热", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "发热", "tendency": "", "character": [ "高" ], "anatomy_list": [] }, { "core_name": "体温", "tendency": "", "character": [ "升高" ], "anatomy_list": [] }, { "core_name": "体温", "tendency": "", "character": [ "降至正常", "予退烧药口服后" ], "anatomy_list": [] } ] }, { "id": 1404, "text": "入院前4月，患者无明显诱因出现胸闷，诉活动后明显，偶有心前区压榨感，胸闷明显时伴有呼吸困难，休息后胸闷好转，患者无咳嗽、咳痰，无发热，无咯血，偶有胸部刺痛，偶有午后潮热及夜间盗汗，无明显乏力、消瘦，无声嘶，无呛咳，无心慌、心悸，无下肢水肿等不适，病后患者未重视，未行特殊治疗，患者胸闷仍反复发作，现患者胸闷仍明显，遂来我院，门诊胸部ct结果提示“左上肺结节：考虑纤维灶可能，肺部肿瘤不除外”，为进一步诊治，门诊以“左肺结节”收入我科。", "event": [ { "core_name": "胸闷", "tendency": "", "character": [ "活动后明显" ], "anatomy_list": [ "胸" ] }, { "core_name": "压榨感", "tendency": "", "character": [], "anatomy_list": [ "心前区" ] }, { "core_name": "呼吸困难", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "胸闷", "tendency": "", "character": [ "休息后好转" ], "anatomy_list": [ "胸" ] }, { "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": "咯血", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "", "character": [ "刺痛" ], "anatomy_list": [ "胸部" ] }, { "core_name": "潮热", "tendency": "", "character": [ "午后" ], "anatomy_list": [] }, { "core_name": "盗汗", "tendency": "", "character": [ "夜间" ], "anatomy_list": [] }, { "core_name": "乏力", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [] }, { "core_name": "消瘦", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "声嘶", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "呛咳", "tendency": "否定", "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" ] }, { "core_name": "水肿", "tendency": "否定", "character": [], "anatomy_list": [ "下肢" ] }, { "core_name": "胸闷", "tendency": "", "character": [ "反复发作" ], "anatomy_list": [ "胸" ] }, { "core_name": "胸闷", "tendency": "", "character": [ "明显" ], "anatomy_list": [ "胸" ] }, { "core_name": "结节", "tendency": "", "character": [], "anatomy_list": [ "左上肺" ] }, { "core_name": "纤维灶", "tendency": "不确定", "character": [], "anatomy_list": [ "左上肺" ] }, { "core_name": "肿瘤", "tendency": "不确定", "character": [], "anatomy_list": [ "肺部" ] }, { "core_name": "结节", "tendency": "", "character": [], "anatomy_list": [ "左肺" ] } ] }, { "id": 1624, "text": "患者既往于我院行同步放化疗及后装治疗后复查盆腔ct提示宫颈病灶明显减小，鳞癌癌细胞抗原已降至正常范围内，但盆腔ct提示宫颈形状不规则、仍有强化；妇科检查示：宫颈表现颗粒状增生、触血，前穹隆消失，右侧穹隆变浅。", "event": [ { "core_name": "病灶", "tendency": "", "character": [ "明显", "减小" ], "anatomy_list": [ "宫颈" ] }, { "core_name": "形态不规则", "tendency": "", "character": [ "仍有强化" ], "anatomy_list": [ "宫颈" ] }, { "core_name": "增生", "tendency": "", "character": [ "颗粒状" ], "anatomy_list": [ "宫颈" ] }, { "core_name": "出血", "tendency": "", "character": [], "anatomy_list": [ "宫颈" ] }, { "core_name": "消失", "tendency": "", "character": [], "anatomy_list": [ "宫颈前穹隆" ] }, { "core_name": "变浅", "tendency": "", "character": [], "anatomy_list": [ "宫颈右侧穹隆" ] } ] }, { "id": 686, "text": "患者lmp：2020-3-20，停经40+天自测尿hcg阳性，就诊于某卫生院，超声提示宫内未见孕囊，次日就诊于某医院，血hcg阳性（具体数值不详）、孕酮偏低。", "event": [ { "core_name": "停经", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "孕囊", "tendency": "", "character": [ "未见" ], "anatomy_list": [ "宫内" ] }, { "core_name": "血hcg", "tendency": "", "character": [ "阳性" ], "anatomy_list": [] }, { "core_name": "尿hcg", "tendency": "", "character": [ "阳性" ], "anatomy_list": [] }, { "core_name": "孕酮", "tendency": "", "character": [ "偏低" ], "anatomy_list": [] } ] }, { "id": 269, "text": "入院前4天，患者无明显诱因出现腰背部酸胀，弯腰、负重及久坐后加重，卧床休息后可缓解；双下肢无放射痛，无麻木、乏力。", "event": [ { "core_name": "酸胀", "tendency": "", "character": [ "弯腰、负重及久坐后加重", "卧床休息后可缓解" ], "anatomy_list": [ "腰背部" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [ "放射性" ], "anatomy_list": [ "双下肢" ] }, { "core_name": "麻木", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "乏力", "tendency": "否定", "character": [], "anatomy_list": [] } ] }, { "id": 305, "text": "13月前，患者在左锁骨上触一大小约2x3cm的包块，体表包块b超提示：临床扪及包块处探及低回声结节，性质待定，考虑肿大淋巴结可能。", "event": [ { "core_name": "包块", "tendency": "", "character": [], "anatomy_list": [ "左锁骨上" ] }, { "core_name": "包块", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "结节", "tendency": "", "character": [ "低回声" ], "anatomy_list": [] }, { "core_name": "肿大", "tendency": "不确定", "character": [], "anatomy_list": [ "淋巴结" ] } ] }, { "id": 185, "text": "2020/6/1ct：腹膜后偏左侧占位，结合病史考虑转移瘤伴周围结构多发侵犯，与2020-04-27片对比，肿块较前缩小，胃内较多积液、积气。", "event": [ { "core_name": "占位", "tendency": "", "character": [], "anatomy_list": [ "腹膜后偏左侧" ] }, { "core_name": "瘤", "tendency": "不确定", "character": [ "转移" ], "anatomy_list": [] }, { "core_name": "侵犯", "tendency": "", "character": [ "多发" ], "anatomy_list": [ "周围结构" ] }, { "core_name": "肿块", "tendency": "", "character": [ "较前缩小" ], "anatomy_list": [] }, { "core_name": "积液", "tendency": "", "character": [ "较多" ], "anatomy_list": [ "胃内" ] }, { "core_name": "积气", "tendency": "", "character": [ "较多" ], "anatomy_list": [ "胃内" ] } ] }, { "id": 46, "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": 1197, "text": "进一步完善肾脏ct示：左肾下极占位，大小约3cm，考虑肿瘤性病变，透明细胞癌可能。", "event": [ { "core_name": "占位", "tendency": "", "character": [], "anatomy_list": [ "左肾下极" ] }, { "core_name": "病变", "tendency": "不确定", "character": [ "肿瘤性" ], "anatomy_list": [] }, { "core_name": "癌", "tendency": "不确定", "character": [], "anatomy_list": [ "透明细胞" ] } ] }, { "id": 983, "text": "１周前，患者出现咳嗽、咳痰较前加重，伴活动后喘累气促，进食减少，食欲差，伴全身乏力，无恶心、呕吐，无心悸、胸闷，无胸痛，无咯血，无发热，未重视。", "event": [ { "core_name": "咳嗽", "tendency": "", "character": [ "加重" ], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "加重" ], "anatomy_list": [] }, { "core_name": "喘累", "tendency": "", "character": [ "活动后" ], "anatomy_list": [] }, { "core_name": "气促", "tendency": "", "character": [ "活动后" ], "anatomy_list": [] }, { "core_name": "进食减少", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "食欲", "tendency": "", "character": [ "差" ], "anatomy_list": [] }, { "core_name": "乏力", "tendency": "", "character": [], "anatomy_list": [ "全身" ] }, { "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": "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": "发热", "tendency": "否定", "character": [], "anatomy_list": [] } ] }, { "id": 1277, "text": "今患者为进一步明确诊治来我院，门诊以“糖尿病”收入我科。", "event": [ { "core_name": "糖尿病", "tendency": "", "character": [], "anatomy_list": [] } ] }, { "id": 1441, "text": "化疗过程顺利，后再入我院行第2次化疗，方案为dp方案（多西他赛120mg+顺铂130mg静脉化疗），化疗过程患者出现便秘不适，今患者诉右侧髋部疼痛较前明显，为复查就诊于我院门诊，门诊拟“右上肺肺腺癌”收住院治疗。", "event": [ { "core_name": "便秘", "tendency": "", "character": [ "化疗过程" ], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "", "character": [ "较前明显" ], "anatomy_list": [ "右侧髋部" ] }, { "core_name": "腺癌", "tendency": "", "character": [], "anatomy_list": [ "右上肺" ] } ] }, { "id": 944, "text": "骨扫描：左肩关节、胸骨、脊柱（约胸55椎体及上位颈椎明显）、右侧髋臼多发异常显像剂浓聚灶，考虑肿瘤骨转移，予以止痛对症后患者疼痛控制。", "event": [ { "core_name": "浓聚灶", "tendency": "", "character": [ "多发", "异常", "显像剂" ], "anatomy_list": [ "左肩关节" ] }, { "core_name": "浓聚灶", "tendency": "", "character": [ "多发", "异常", "显像剂" ], "anatomy_list": [ "胸骨" ] }, { "core_name": "浓聚灶", "tendency": "", "character": [ "多发", "异常", "显像剂", "约胸55椎体及上位颈椎明显" ], "anatomy_list": [ "脊柱" ] }, { "core_name": "浓聚灶", "tendency": "", "character": [ "多发", "异常", "显像剂" ], "anatomy_list": [ "右侧髋臼" ] }, { "core_name": "肿瘤", "tendency": "不确定", "character": [ "骨转移" ], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "", "character": [ "控制" ], "anatomy_list": [] } ] }, { "id": 1851, "text": "2+月前，患者出现双侧肩胛骨骨疼痛，疼痛剧烈，口服吗啡疼痛无明显缓解，于9月5日在我科行右侧肩胛骨放疗，累计放疗：dt：30G/10f，患者疼痛缓解出院。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [], "anatomy_list": [ "双侧肩胛骨" ] }, { "core_name": "疼痛", "tendency": "", "character": [ "剧烈" ], "anatomy_list": [ "双侧肩胛骨" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [ "缓解" ], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "", "character": [ "缓解" ], "anatomy_list": [] } ] }, { "id": 861, "text": "为进一步诊治，遂来我科住院，门诊以“上消化道出血，肝硬化失代偿”收入我科。", "event": [ { "core_name": "出血", "tendency": "", "character": [], "anatomy_list": [ "上消化道" ] }, { "core_name": "硬化", "tendency": "", "character": [ "失代偿" ], "anatomy_list": [ "肝" ] } ] }, { "id": 1761, "text": "（左乳左、右、上、下、后切缘）未见癌累及。", "event": [ { "core_name": "癌", "tendency": "否定", "character": [ "累及" ], "anatomy_list": [ "左乳左、右、上、下、后切缘" ] } ] }, { "id": 2021, "text": "1+月前患者排尿不畅症状明显，并伴排尿费力，尿频、尿急、尿痛，尿不尽，尿线变细，排尿滴沥，偶有全身疼痛感。", "event": [ { "core_name": "排尿不畅", "tendency": "", "character": [ "明显" ], "anatomy_list": [] }, { "core_name": "排尿费力", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "尿频", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "尿急", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "尿痛", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "尿不尽", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "尿线变细", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "排尿滴沥", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "", "character": [ "偶有" ], "anatomy_list": [ "全身" ] } ] }, { "id": 872, "text": "入院前7年，患者体检中发现发现血压升高，最高血压180+/？mmhg，长期予以苯磺酸氨氯地平5mg qd降压，自诉近期血压控制在150-160/？mmhg，有视物模糊不适；入院前6年，患者无意间发现左侧第一跖趾关节及左侧膝关节出现无痛性结节，未重视及处理。", "event": [ { "core_name": "血压", "tendency": "", "character": [ "升高" ], "anatomy_list": [] }, { "core_name": "视物模糊", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "结节", "tendency": "", "character": [ "无痛性" ], "anatomy_list": [ "左侧第1跖趾关节" ] }, { "core_name": "结节", "tendency": "", "character": [ "无痛性" ], "anatomy_list": [ "左侧膝关节" ] } ] }, { "id": 1518, "text": "入院5+年前患者无明显诱因出现咳嗽、咳痰、喘累，痰为白色泡沫痰，无潮热、盗汗，病程中冬春季易发，每年持续时间大于3月，患者未予重视。", "event": [ { "core_name": "咳嗽", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "白色", "泡沫痰" ], "anatomy_list": [] }, { "core_name": "喘累", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "潮热", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "盗汗", "tendency": "否定", "character": [], "anatomy_list": [] } ] }, { "id": 1288, "text": "5+年前，患者述腰背部伴双侧大腿前侧间断性痛，疼痛尚可忍受，无麻木、乏力不能行走，患者未予以重视，自服药物或膏药治疗（具体用药不详）后缓解，其后间断疼痛，为予以特别重视，自行好转，患者10+月前我院体检发现乳腺包块，其后于某医院行spect检查提示：左侧髂骨异常成骨增强灶，考虑肿瘤骨转移可能性大，于行新辅助化疗后于某医院行左侧乳腺癌保乳术，术后病检提示：（左侧乳腺）浸润性癌，非特殊类型。iii级。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [ "间断性", "尚可忍受" ], "anatomy_list": [ "双侧大腿前侧", "腰部", "背部" ] }, { "core_name": "麻木", "tendency": "否定", "character": [], "anatomy_list": [ "双侧大腿" ] }, { "core_name": "乏力", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "行走障碍", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "", "character": [ "间断" ], "anatomy_list": [] }, { "core_name": "包块", "tendency": "", "character": [], "anatomy_list": [ "乳腺" ] }, { "core_name": "增强灶", "tendency": "", "character": [ "异常成骨" ], "anatomy_list": [ "左侧髂骨" ] }, { "core_name": "肿瘤", "tendency": "不确定", "character": [ "转移" ], "anatomy_list": [ "骨" ] }, { "core_name": "癌", "tendency": "", "character": [ "浸润性", "非特殊类型", "iii级" ], "anatomy_list": [ "左侧乳腺" ] } ] }, { "id": 235, "text": "院外期间仍有烦渴、多饮，全身乏力，胸闷怕冷等症状。", "event": [ { "core_name": "烦渴", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "多饮", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "乏力", "tendency": "", "character": [], "anatomy_list": [ "全身" ] }, { "core_name": "胸闷", "tendency": "", "character": [], "anatomy_list": [ "胸" ] }, { "core_name": "怕冷", "tendency": "", "character": [], "anatomy_list": [] } ] }, { "id": 1701, "text": "诊断为“中央型肺癌肺癌伴淋巴结转移”，未行手术及放化疗，经抗感染、止咳、祛痰等对症支持治疗后，病情好转后出院。症状反复发生，未见明显加重。", "event": [ { "core_name": "癌", "tendency": "", "character": [ "中央型" ], "anatomy_list": [ "肺" ] }, { "core_name": "癌", "tendency": "", "character": [ "转移" ], "anatomy_list": [ "淋巴结" ] } ] }, { "id": 1286, "text": "无化疗禁忌症，分别于2016-3-11、2016-4-1、2016-4-22行tp方案（紫杉醇240mg+奈达铂140mg）化疗，化疗后出现明显骨髓抑制，予以生白细胞治疗后好转出院，院外未诉特殊不适。", "event": [ { "core_name": "骨髓抑制", "tendency": "", "character": [ "明显" ], "anatomy_list": [ "骨髓" ] } ] }, { "id": 963, "text": "患者期间仍感右上胸部针刺样疼痛，阵发性，呼吸咳嗽加重，可向肩背部放射，未予以特殊处理。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [ "针刺样", "阵发性" ], "anatomy_list": [ "右上胸部" ] }, { "core_name": "咳嗽", "tendency": "", "character": [ "加重" ], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "", "character": [ "放射性" ], "anatomy_list": [ "肩背部" ] } ] }, { "id": 497, "text": "遂于我院行乳腺b超检查提示：左侧乳腺2点钟方向距乳头约40mm处可见大小约24*22mm低回声包块，边界不清不规则 。", "event": [ { "core_name": "包块", "tendency": "", "character": [ "低回声", "边界不清不规则" ], "anatomy_list": [ "左侧乳腺2点钟方向距乳头约40mm处" ] } ] }, { "id": 91, "text": "2年前患者于外院行辅助检查，考虑诊断为“肝癌”，遂行肝癌切除术，住院期间因患者肾功能差，改用“替比夫定”抗病毒治疗。", "event": [ { "core_name": "癌", "tendency": "不确定", "character": [], "anatomy_list": [ "肝" ] }, { "core_name": "肾功能差", "tendency": "", "character": [], "anatomy_list": [ "肾" ] } ] }, { "id": 1026, "text": "与2018-8-29片比较：病灶较明显增大。", "event": [ { "core_name": "病灶", "tendency": "", "character": [ "明显", "增大" ], "anatomy_list": [] } ] }, { "id": 1792, "text": "入院前3+年，患者排尿时出现全程血尿，鲜红色，伴尿频、尿急及尿痛，行b超检查提示前列腺增生。", "event": [ { "core_name": "血尿", "tendency": "", "character": [ "鲜红色" ], "anatomy_list": [] }, { "core_name": "尿频", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "尿急", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "尿痛", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "增生", "tendency": "", "character": [], "anatomy_list": [ "前列腺" ] } ] }, { "id": 253, "text": "2.甲状腺左叶上份稍低密度影，结合图像融合考虑：结节性甲状腺中可能。", "event": [ { "core_name": "密度影", "tendency": "", "character": [ "稍低" ], "anatomy_list": [ "甲状腺左叶上" ] }, { "core_name": "肿", "tendency": "不确定", "character": [ "结节性" ], "anatomy_list": [ "甲状腺" ] } ] }, { "id": 851, "text": "就诊于某医院整形美容科，行浅表淋巴结超声提示：左侧腹股沟腹股沟区可见数个低回声结节结节影，较大者大小约5.7×2.7cm，并行左侧腹股沟腹股沟区淋巴结淋巴结活检，活检病理提示：（左侧腹股沟淋巴结）淋巴组织增生，建议免疫组化进一步诊断。患者随后未行任何检查及治疗。", "event": [ { "core_name": "结节影", "tendency": "", "character": [ "数个", "低回声" ], "anatomy_list": [ "左侧腹股沟" ] }, { "core_name": "增生", "tendency": "", "character": [], "anatomy_list": [ "左侧腹股沟淋巴结组织" ] } ] }, { "id": 367, "text": "现患儿精神食欲可，大便2次/天，稀水样，无血丝及粘液，小便黄清，尿量无减少。", "event": [ { "core_name": "精神", "tendency": "", "character": [ "可" ], "anatomy_list": [] }, { "core_name": "食欲", "tendency": "", "character": [ "可" ], "anatomy_list": [] }, { "core_name": "大便", "tendency": "", "character": [ "2次/天", "稀水样", "无血丝及粘液" ], "anatomy_list": [] }, { "core_name": "小便", "tendency": "", "character": [ "黄清" ], "anatomy_list": [] }, { "core_name": "尿量", "tendency": "", "character": [ "无减少" ], "anatomy_list": [] } ] }, { "id": 1088, "text": "病程中患者精神、饮食稍差，大小便正常，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": [ "正常" ], "anatomy_list": [] }, { "core_name": "小便", "tendency": "", "character": [ "正常" ], "anatomy_list": [] }, { "core_name": "体重下降", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [] } ] }, { "id": 636, "text": "入院前5-月，患者因\"升结肠癌\"于2019-03-19全麻下行腹腔镜下右半结肠癌根治术（扩大）、腹腔镜下肠粘连松解术，手术顺利，术后病检（右半结肠）粘液腺癌，侵及肠壁全层。", "event": [ { "core_name": "癌", "tendency": "", "character": [], "anatomy_list": [ "升结肠" ] }, { "core_name": "腺癌", "tendency": "", "character": [ "粘液", "侵及肠壁" ], "anatomy_list": [ "右半结肠" ] } ] }, { "id": 1670, "text": "现患者为求第五次新辅助化疗，就诊于我院，门诊以“胰腺癌伴肝转移”收住入院。", "event": [ { "core_name": "癌", "tendency": "", "character": [], "anatomy_list": [ "胰腺" ] }, { "core_name": "癌", "tendency": "", "character": [ "转移" ], "anatomy_list": [ "肝" ] } ] }, { "id": 519, "text": "胸片：双下肺少许感染，主动脉球少许钙化，胸椎退行性变。", "event": [ { "core_name": "感染", "tendency": "", "character": [ "少许" ], "anatomy_list": [ "双下肺" ] }, { "core_name": "钙化", "tendency": "", "character": [ "少许" ], "anatomy_list": [ "主动脉球" ] }, { "core_name": "病变", "tendency": "", "character": [ "退行性" ], "anatomy_list": [ "胸椎" ] } ] }, { "id": 1080, "text": "患者入院前10年无明显诱因出现排尿踌躇、费力、不尽感,夜尿4-5次，尿线无力、分叉、变细、终末滴沥，未予重视，未予特殊处理，7年前患者到某医院行前列腺电切术，术后排尿困难症状无明显改善，夜尿7-8次，6年前患者出现排尿困难加重，排尿费力，偶有尿线中断，排尿滴沥明显，患者遂到某医院就诊，予以扩尿道2次，患者排尿困难稍有改善。", "event": [ { "core_name": "排尿", "tendency": "", "character": [ "踌躇", "费力", "不尽感" ], "anatomy_list": [] }, { "core_name": "夜尿", "tendency": "", "character": [ "4-5次" ], "anatomy_list": [] }, { "core_name": "尿线无力", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "尿线分叉", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "尿线变细", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "排尿", "tendency": "", "character": [ "终末滴沥" ], "anatomy_list": [] }, { "core_name": "排尿困难", "tendency": "", "character": [ "术后", "无明显改善" ], "anatomy_list": [] }, { "core_name": "夜尿", "tendency": "", "character": [ "7-8次" ], "anatomy_list": [] }, { "core_name": "排尿困难", "tendency": "", "character": [ "加重" ], "anatomy_list": [] }, { "core_name": "排尿费力", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "尿线中断", "tendency": "", "character": [ "偶有" ], "anatomy_list": [] }, { "core_name": "排尿滴沥", "tendency": "", "character": [ "明显" ], "anatomy_list": [] }, { "core_name": "排尿困难", "tendency": "", "character": [ "稍有改善" ], "anatomy_list": [] } ] }, { "id": 217, "text": "与患者及家属沟通可选择的治疗方案，计划予以dp方案（多西他赛+顺铂）化疗，于2020-04-02、2020-04-24予以2周期dp方案化疗（多西他赛100mg1+顺铂50mg1-2，q3w），化疗期间出现恶心、食欲下降，予以奥美拉唑抑酸，昂丹司琼止吐等治疗后缓解。", "event": [ { "core_name": "恶心", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "食欲", "tendency": "", "character": [ "下降" ], "anatomy_list": [] } ] }, { "id": 1658, "text": "患者住院期间多次输注血小板、悬浮红细胞，输注过程中及输注后均无不良反应。", "event": [ { "core_name": "不良反应", "tendency": "否定", "character": [ "输注过程中" ], "anatomy_list": [] }, { "core_name": "不良反应", "tendency": "否定", "character": [ "输注后" ], "anatomy_list": [] } ] }, { "id": 1131, "text": "无畏寒发热，无胸闷气紧，无心慌心悸，无黑便便血血便，无肉眼血尿。", "event": [ { "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": "气紧", "tendency": "否定", "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" ] }, { "core_name": "黑便", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "血便", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "便血", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "血尿", "tendency": "否定", "character": [], "anatomy_list": [] } ] }, { "id": 1215, "text": "术后口服“替格瑞洛90mg bid”治疗，入院前12小时（2017-11-04 22:00），患者自觉剑突下绞痛，伴胸骨后哽咽感及喉部不适，持续约20分20分钟左右，无胸痛、胸部压榨感，无大汗、乏力，无头昏、头痛，无黑曚、意识障碍，含服“速效救心丸”可缓解，入院前8小时，患者再次感剑突下不适，稍疼痛，持续约10分10分钟，后自行缓解，入院前3小时，患者自行口服“阿司匹林300mg、替格瑞洛180mg”后入我院，以“冠心病”收入我科。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [ "绞痛" ], "anatomy_list": [ "剑突下" ] }, { "core_name": "哽咽感", "tendency": "", "character": [], "anatomy_list": [ "胸骨后" ] }, { "core_name": "喉部不适", "tendency": "", "character": [], "anatomy_list": [ "喉部" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "胸" ] }, { "core_name": "压榨感", "tendency": "否定", "character": [], "anatomy_list": [ "胸部" ] }, { "core_name": "出汗", "tendency": "否定", "character": [ "大汗" ], "anatomy_list": [] }, { "core_name": "乏力", "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": "意识障碍", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "剑突下不适", "tendency": "", "character": [], "anatomy_list": [ "剑突下" ] }, { "core_name": "疼痛", "tendency": "", "character": [ "稍" ], "anatomy_list": [ "剑突下" ] }, { "core_name": "心脏病", "tendency": "", "character": [ "硬化性", "粥样" ], "anatomy_list": [ "冠状动脉", "心脏" ] } ] }, { "id": 126, "text": "门诊以“肺占位性病变”收住院治疗。", "event": [ { "core_name": "病变", "tendency": "", "character": [ "占位性" ], "anatomy_list": [ "肺" ] } ] }, { "id": 444, "text": "伴心悸、胸闷，无发热、无潮热、盗汗，无咳血、咯血，无胸痛。", "event": [ { "core_name": "心悸", "tendency": "", "character": [], "anatomy_list": [ "心" ] }, { "core_name": "胸闷", "tendency": "", "character": [], "anatomy_list": [ "胸" ] }, { "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": "咳血", "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" ] } ] }, { "id": 1553, "text": "完善胸部ct提示左肺下野片团影，慢性炎症？肿瘤待排。", "event": [ { "core_name": "团影", "tendency": "", "character": [ "片" ], "anatomy_list": [ "左肺下野" ] }, { "core_name": "炎症", "tendency": "不确定", "character": [ "慢性" ], "anatomy_list": [ "左肺下野" ] }, { "core_name": "肿瘤", "tendency": "不确定", "character": [], "anatomy_list": [ "左肺下野" ] } ] }, { "id": 197, "text": "患者1年前因进行性吞咽困难在我院胸外科住院，2015年03月28日胸部ct：1.食管下段改变，考虑食管癌可能性大，考虑食管肿瘤，于2015年03月31日在全麻下行胸-腹腔镜食管癌根治术+食管-胃颈部吻合+空肠造瘘术，术后病检：（食管）高分化鳞状细胞癌。", "event": [ { "core_name": "吞咽困难", "tendency": "", "character": [ "进行性" ], "anatomy_list": [] }, { "core_name": "改变", "tendency": "", "character": [], "anatomy_list": [ "食管下段" ] }, { "core_name": "癌", "tendency": "不确定", "character": [], "anatomy_list": [ "食管" ] }, { "core_name": "肿瘤", "tendency": "不确定", "character": [], "anatomy_list": [ "食管" ] }, { "core_name": "鳞癌", "tendency": "", "character": [ "高分化" ], "anatomy_list": [ "食管" ] } ] }, { "id": 1837, "text": "患者4月多前无明显诱因出现双肩关节疼痛，伴双上臂上举困难，未予特殊治疗，2月余前受凉后出现流涕，伴咳嗽咳痰，偶有脓痰，于当地诊所服用中药后疼痛稍好转，继出现左踝关节关节肿痛，于某医院就诊，行踝关节平片、查肾功提示尿酸 178umol/L，未予进一步处理。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [], "anatomy_list": [ "双肩关节" ] }, { "core_name": "上举困难", "tendency": "", "character": [], "anatomy_list": [ "双上臂" ] }, { "core_name": "流涕", "tendency": "", "character": [ "受凉后" ], "anatomy_list": [] }, { "core_name": "咳嗽", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "偶有", "脓痰" ], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "", "character": [ "服用中药后稍好转" ], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "", "character": [ "肿痛" ], "anatomy_list": [ "左踝关节" ] } ] }, { "id": 1192, "text": "今患者为进一步治疗食道赘生物遂于我院门诊求诊，门诊以“食道肿瘤”收入我科住院治疗。", "event": [ { "core_name": "赘生物", "tendency": "", "character": [], "anatomy_list": [ "食道" ] }, { "core_name": "肿瘤", "tendency": "", "character": [], "anatomy_list": [ "食道" ] } ] }, { "id": 789, "text": "曾连续2年以上发作，每次发作均在3月以上，诊断为“慢性支气管炎、肺气肿”。", "event": [ { "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" ] } ] }, { "id": 806, "text": "门诊拟“腰椎压缩性骨折”收住我科。", "event": [ { "core_name": "骨折", "tendency": "", "character": [ "压缩性" ], "anatomy_list": [ "腰椎" ] } ] }, { "id": 1671, "text": "患者于1月前，因不慎受凉后出现咳嗽，咳痰，痰为白色粘液痰，无发热、胸痛、潮热、盗汗，无乏力等不适，曾在我院诊断为“肺炎”，予“头孢米诺抗感染，氨溴索止咳化痰”等治疗后好转，未坚持治疗，仍间断咳嗽、咳痰。", "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", "粘液" ], "anatomy_list": [] }, { "core_name": "发热", "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": [] }, { "core_name": "肺炎", "tendency": "", "character": [], "anatomy_list": [ "肺" ] }, { "core_name": "咳嗽", "tendency": "", "character": [ "间断" ], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "间断" ], "anatomy_list": [] } ] }, { "id": 1379, "text": "入院前1+天，患者因胸背部疼痛于我院门诊就诊，行胸部ct示：1.双肺下叶多发结节，性质待定，请结合其他进一步检查。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [], "anatomy_list": [ "胸部", "背部" ] }, { "core_name": "结节", "tendency": "", "character": [ "多发" ], "anatomy_list": [ "双肺下叶" ] } ] }, { "id": 470, "text": "多次于外院就诊，行心脏彩超检查示：左房、左室增大，伴左室壁肥厚，主动脉深部增宽。", "event": [ { "core_name": "增大", "tendency": "", "character": [], "anatomy_list": [ "左房", "左室" ] }, { "core_name": "肥厚", "tendency": "", "character": [], "anatomy_list": [ "左室壁" ] }, { "core_name": "增宽", "tendency": "", "character": [], "anatomy_list": [ "主动脉深部" ] } ] }, { "id": 567, "text": "骨髓检查：可见不典型淋巴细胞，请明确诊断为“非霍奇金淋巴瘤（弥漫大b细胞弥漫大b细胞淋巴瘤iii期）”，病程中患者无发热、盗汗、体重明显下降，无腹痛、腹胀、恶心、呕吐，无咳嗽、咳痰、黄疸等不适，于2016-11-21行r-chop（长春瑞滨40mg，吡柔比星30mg，环磷酰胺1g，泼尼松100mg，美罗华500mg）方案行化疗，化疗过程顺利。", "event": [ { "core_name": "不典型淋巴细胞", "tendency": "", "character": [ "骨髓检查可见" ], "anatomy_list": [] }, { "core_name": "瘤", "tendency": "", "character": [ "非霍奇金氏" ], "anatomy_list": [ "淋巴" ] }, { "core_name": "瘤", "tendency": "", "character": [], "anatomy_list": [ "弥漫大b细胞", "淋巴" ] }, { "core_name": "发热", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "盗汗", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "体重下降", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "腹部" ] }, { "core_name": "腹胀", "tendency": "否定", "character": [], "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": "咳嗽", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "黄疸", "tendency": "否定", "character": [], "anatomy_list": [] } ] }, { "id": 608, "text": "患者于入院前10年无明显诱因开始出现尿频、尿急，伴有排尿踌躇，无夜尿增多，无尿线变细、尿不尽、尿滴沥，无尿痛及肉眼血尿。患者未予重视，未予特殊处理。", "event": [ { "core_name": "尿频", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "尿急", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "排尿踌躇", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "夜尿增多", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "尿线变细", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "尿不尽", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "尿滴沥", "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": [] } ] }, { "id": 387, "text": "后包块逐渐增大，遂到某医院完善乳腺超声、ct、乳腺包块针刺活检等检查后诊断为“左乳腺浸润性癌”，并于2016-3-3日行左乳腺癌改良根治术，术后病理检查：左乳腺浸润性癌。", "event": [ { "core_name": "包块增大", "tendency": "", "character": [ "逐渐" ], "anatomy_list": [] }, { "core_name": "癌", "tendency": "", "character": [ "浸润性" ], "anatomy_list": [ "左乳腺" ] }, { "core_name": "癌", "tendency": "", "character": [ "浸润性" ], "anatomy_list": [ "左乳腺" ] } ] }, { "id": 2067, "text": "1周前患者出现咳血不适，主要表现为鼻式咳痰，痰中带血，无气促、发热，无胸痛，无明显嗅觉减退，无面部麻木，无头昏、头痛、视力下降、复视等，于某医院住院治疗，胸部ct提示慢性支气管炎肺气肿、肺大泡。", "event": [ { "core_name": "咳血", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "鼻式" ], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "带血" ], "anatomy_list": [] }, { "core_name": "气促", "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": [ "胸" ] }, { "core_name": "嗅觉减退", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [] }, { "core_name": "麻木", "tendency": "否定", "character": [], "anatomy_list": [ "面部" ] }, { "core_name": "头昏", "tendency": "否定", "character": [], "anatomy_list": [ "头" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "头" ] }, { "core_name": "视力下降", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "复视", "tendency": "否定", "character": [], "anatomy_list": [] }, { "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": "肺大疱", "tendency": "", "character": [], "anatomy_list": [ "肺" ] } ] }, { "id": 428, "text": "纤支镜取肺组织病理诊断：支气管粘膜慢性炎。", "event": [ { "core_name": "炎", "tendency": "", "character": [ "慢性" ], "anatomy_list": [ "支气管粘膜" ] } ] }, { "id": 2061, "text": "入院前3年，患者活动后出现心累、气促，伴头晕，休息时可缓解，无视物模糊、视物旋转、黑朦、晕厥等，无咳嗽、咳痰，无胸闷、胸痛，无黑朦、恶心、呕吐，无大小便失禁，至当地医院输液（具体不详）后好转出院，入院前3天，患者上述症状加重，伴剑突下疼痛、纳差，不伴肩背部放射痛，进食后加重，伴反酸、嗳气，嗳气后症状稍缓解，不伴呕吐，呕血、黑便等，遂患者至当地医院治疗，无明显好转，为求进一步就诊，遂至我院，门诊以“冠心病”收入我院。", "event": [ { "core_name": "心累", "tendency": "", "character": [ "活动后" ], "anatomy_list": [] }, { "core_name": "气促", "tendency": "", "character": [ "活动后" ], "anatomy_list": [] }, { "core_name": "头晕", "tendency": "", "character": [ "休息时可缓解" ], "anatomy_list": [ "头" ] }, { "core_name": "视物模糊", "tendency": "否定", "character": [], "anatomy_list": [ "眼" ] }, { "core_name": "视物旋转", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "黑朦", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "晕厥", "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": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "胸" ] }, { "core_name": "黑朦", "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": "大小便失禁", "tendency": "否定", "character": [ "失禁" ], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "", "character": [], "anatomy_list": [ "剑突下" ] }, { "core_name": "纳差", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "否定", "character": [ "放射性" ], "anatomy_list": [ "肩背部" ] }, { "core_name": "反酸", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "嗳气", "tendency": "", "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": "冠心病", "tendency": "", "character": [], "anatomy_list": [ "心" ] } ] }, { "id": 1477, "text": "伴头部闷胀感，不伴视物旋转，不伴恶心、呕吐，能持物及行走，，无反应迟钝，无呼之不应，无精神异常，无胡言乱语，无吞咽困难，无饮水呛咳，无四肢抽搐，无大小便失禁，无跌倒外伤。", "event": [ { "core_name": "闷胀", "tendency": "", "character": [], "anatomy_list": [ "头部" ] }, { "core_name": "视物旋转", "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": "反应迟钝", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "呼之不应", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "精神", "tendency": "否定", "character": [ "异常" ], "anatomy_list": [] }, { "core_name": "胡言乱语", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "吞咽困难", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "呛咳", "tendency": "否定", "character": [ "饮水" ], "anatomy_list": [] }, { "core_name": "抽搐", "tendency": "否定", "character": [], "anatomy_list": [ "四肢" ] }, { "core_name": "大便", "tendency": "否定", "character": [ "失禁" ], "anatomy_list": [] }, { "core_name": "小便", "tendency": "否定", "character": [ "失禁" ], "anatomy_list": [] }, { "core_name": "跌倒", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "外伤", "tendency": "否定", "character": [], "anatomy_list": [] } ] }, { "id": 1946, "text": "后患者转入我院，骨髓检查提示有核细胞增生程度明显活跃，粒系增生减低，以中，后期细胞为主，可见中毒颗粒，红系增生尚可，以中，晚红为主，成熟红细胞呈缗钱状排列，巨核细胞尚可，以产板巨为主，散在血小板可见，浆细胞增生极度活跃，以骨髓瘤瘤细胞为主，可见2-4核浆。", "event": [ { "core_name": "增生", "tendency": "", "character": [ "明显", "活跃" ], "anatomy_list": [] }, { "core_name": "增生", "tendency": "", "character": [], "anatomy_list": [ "中，后期细胞为主", "粒系", "减低" ] }, { "core_name": "中毒颗粒", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "增生", "tendency": "", "character": [], "anatomy_list": [ "中，晚红为主", "红系" ] }, { "core_name": "增生", "tendency": "", "character": [ "可见2-4核浆", "极度活跃" ], "anatomy_list": [ "以骨髓瘤瘤细胞为主", "极度活跃" ] } ] }, { "id": 1005, "text": "无皮肤巩膜黄染，大小便无异常。", "event": [ { "core_name": "黄染", "tendency": "否定", "character": [], "anatomy_list": [ "皮肤", "巩膜" ] }, { "core_name": "大便", "tendency": "否定", "character": [ "异常" ], "anatomy_list": [] }, { "core_name": "小便", "tendency": "否定", "character": [ "异常" ], "anatomy_list": [] } ] }, { "id": 1272, "text": "患病以来，患者精神、食欲、睡眠可，大小便正常，近期体重无明显变化。", "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": [ "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": 991, "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，体重下降约5kg。", "event": [ { "core_name": "食欲减退", "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": "体重下降", "tendency": "", "character": [], "anatomy_list": [] } ] }, { "id": 1720, "text": "患者于2月前于某医院检查，行腹部mr提示“肝硬化、脾大；肝脏占位，考虑：小肝癌”，两对半提示“大三阳”。", "event": [ { "core_name": "硬化", "tendency": "", "character": [], "anatomy_list": [ "肝" ] }, { "core_name": "脾大", "tendency": "", "character": [], "anatomy_list": [ "脾" ] }, { "core_name": "占位", "tendency": "", "character": [], "anatomy_list": [ "肝脏" ] }, { "core_name": "癌", "tendency": "", "character": [ "小" ], "anatomy_list": [ "肝" ] }, { "core_name": "大三阳", "tendency": "", "character": [], "anatomy_list": [] } ] }, { "id": 1064, "text": "2012年于某医院检查诊断“前列腺癌”，行手术治疗后好转，未行放疗或化疗，具体诊治不详，现予“比卡鲁胺、果舍瑞林”控制。", "event": [ { "core_name": "癌", "tendency": "", "character": [ "行手术治疗后好转" ], "anatomy_list": [ "前列腺" ] } ] }, { "id": 1594, "text": "入院前10+年，三次非同日测得血压大于140/？mmhg，最高收缩压达210/?mmhg，平素口服“硝苯地平、氨氯地平”控制血压，血压控制一般（具体不详），入院前6+年，患者出现活动后心累、气促（上坡及上楼时明显），伴胸闷，偶有心悸，休息后可缓解，无头晕、头痛、黑曚，无胸痛、肩部、背部放射痛，无夜间阵发性呼吸困难，无腹痛、腹胀、反酸、恶心、呕吐，无双下肢水肿等症状。", "event": [ { "core_name": "血压", "tendency": "", "character": [ "升高" ], "anatomy_list": [] }, { "core_name": "血压", "tendency": "", "character": [ "控制一般" ], "anatomy_list": [] }, { "core_name": "心累", "tendency": "", "character": [ "上坡及上楼时明显", "活动后" ], "anatomy_list": [ "心" ] }, { "core_name": "气促", "tendency": "", "character": [ "上坡及上楼时明显", "活动后" ], "anatomy_list": [] }, { "core_name": "胸闷", "tendency": "", "character": [], "anatomy_list": [ "胸" ] }, { "core_name": "心悸", "tendency": "", "character": [ "休息后可缓解", "偶有" ], "anatomy_list": [ "心" ] }, { "core_name": "头晕", "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": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "胸" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [ "放射性" ], "anatomy_list": [ "肩部" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [ "放射性" ], "anatomy_list": [ "肩部", "背部" ] }, { "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": "腹胀", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "反酸", "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": "水肿", "tendency": "否定", "character": [], "anatomy_list": [ "双下肢" ] } ] }, { "id": 1995, "text": "（左）卵巢浆液性囊腺瘤。（左侧）输卵管组织。（右侧）附件组织。", "event": [ { "core_name": "囊腺瘤", "tendency": "", "character": [ "浆液性" ], "anatomy_list": [ "左卵巢" ] } ] }, { "id": 1244, "text": "入院前 1+年前无明显诱因出现咳嗽，无明显缓解。", "event": [ { "core_name": "咳嗽", "tendency": "否定", "character": [ "明显缓解" ], "anatomy_list": [] } ] }, { "id": 1874, "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，体重无明显变化。", "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": "体重改变", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [] } ] }, { "id": 1041, "text": "遂到我科住院治疗，诊断为“直肠癌”，完善术前准备，于2014-4-23在全麻下行腹腔镜下直肠癌根治术手术（dixon），手术顺利，病检报告（123456）回示：<直肠>中分化腺癌，侵及全层，双侧切缘未见癌累及，肠周脂肪组织中淋巴结见癌转移<3/11>,<肠系膜根部>淋巴结未见癌转移（0/1），术后予以补液、抗感染、抑酸护胃、营养支持、卡络磺止血、雾化祛痰等治疗后好转出院，出院后规律服用“复方斑螯胶囊 bid 3sx0.25g”抗肿瘤。", "event": [ { "core_name": "癌", "tendency": "", "character": [], "anatomy_list": [ "直肠" ] }, { "core_name": "腺癌", "tendency": "", "character": [ "中分化", "侵及全层" ], "anatomy_list": [ "直肠" ] }, { "core_name": "癌", "tendency": "否定", "character": [ "累及" ], "anatomy_list": [ "直肠双侧切缘" ] }, { "core_name": "癌", "tendency": "", "character": [ "转移", "脂肪组织" ], "anatomy_list": [ "肠周淋巴结" ] }, { "core_name": "癌", "tendency": "否定", "character": [ "转移" ], "anatomy_list": [ "肠系膜根部淋巴结" ] } ] }, { "id": 283, "text": "入院 前4天 ，患者无明显诱因出现头昏伴阵发视物旋转，眩晕与体位变化有关，于起床时较为明显，每次眩晕症状持续约10秒钟左右，经休息可好转，缓解期自诉走路时仍头昏；患者伴恶心、呕吐胃内容物，发病以来共呕吐9次，无咖啡色样物质，无喷射性呕吐；无耳鸣、耳胀、听力下降；无意识丧失、鼻唇沟变浅，无饮水呛咳、吞咽困难、肢体麻木、肢体无力；发病前无感冒受凉，余无特殊不适，曾于当地医院就诊，予以止吐、抗眩晕等对症治疗，具体用药不详，患者症状稍好转；为求进一步诊治，遂入我院门诊就诊；完善头ct平扫：1.右侧额叶片状低密度影，2.双侧上颌窦炎。", "event": [ { "core_name": "头昏", "tendency": "", "character": [], "anatomy_list": [ "头" ] }, { "core_name": "视物旋转", "tendency": "", "character": [ "阵发" ], "anatomy_list": [] }, { "core_name": "眩晕", "tendency": "", "character": [ "与体位变化有关", "于起床时较为明显", "持续约10秒钟左右", "经休息可好转" ], "anatomy_list": [] }, { "core_name": "头昏", "tendency": "", "character": [ "缓解期", "走路时" ], "anatomy_list": [ "头" ] }, { "core_name": "恶心", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "呕吐", "tendency": "", "character": [ "胃内容物" ], "anatomy_list": [] }, { "core_name": "呕吐", "tendency": "", "character": [ "9次", "无咖啡色样物质", "无喷射性呕吐" ], "anatomy_list": [] }, { "core_name": "耳鸣", "tendency": "否定", "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": "意识丧失", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "变浅", "tendency": "否定", "character": [], "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": "感冒", "tendency": "否定", "character": [ "发病前" ], "anatomy_list": [] }, { "core_name": "密度影", "tendency": "", "character": [ "片状", "低" ], "anatomy_list": [ "右侧额叶" ] }, { "core_name": "颌窦炎", "tendency": "", "character": [], "anatomy_list": [ "双侧上颌窦" ] } ] }, { "id": 1460, "text": "近段时间，患者感双侧下颌下下颌下淋巴结进行性增大，但无红肿、疼痛。", "event": [ { "core_name": "增大", "tendency": "", "character": [ "进行性" ], "anatomy_list": [ "双侧下颌下淋巴结" ] }, { "core_name": "红肿", "tendency": "否定", "character": [], "anatomy_list": [ "双侧下颌下淋巴结" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "双侧下颌下淋巴结" ] } ] }, { "id": 1921, "text": "吻合口未见癌累及，其中见一枚淋巴结，未见癌转移。贲门旁淋巴结送检为血管脂肪组织。", "event": [ { "core_name": "癌", "tendency": "否定", "character": [ "累及" ], "anatomy_list": [ "吻合口" ] }, { "core_name": "癌", "tendency": "否定", "character": [ "转移" ], "anatomy_list": [ "吻合口淋巴结" ] } ] }, { "id": 1996, "text": "（右）卵巢囊性滤泡，术后好转出院。", "event": [ { "core_name": "滤泡", "tendency": "", "character": [ "囊状" ], "anatomy_list": [ "右卵巢" ] } ] }, { "id": 1786, "text": "肠周脂肪中淋巴结未见癌转移（0/13）。", "event": [ { "core_name": "癌", "tendency": "否定", "character": [ "转移" ], "anatomy_list": [ "肠周脂肪淋巴结" ] } ] }, { "id": 276, "text": "（建议做相关免疫组化明确）会诊：（左肺上叶舌段）肺腺癌。", "event": [ { "core_name": "腺癌", "tendency": "", "character": [], "anatomy_list": [ "左肺上叶舌段", "肺" ] } ] }, { "id": 771, "text": "双肾结石，左肾囊肿。", "event": [ { "core_name": "结石", "tendency": "", "character": [], "anatomy_list": [ "双肾" ] }, { "core_name": "囊肿", "tendency": "", "character": [], "anatomy_list": [ "左肾" ] } ] }, { "id": 101, "text": "于2015-06-24行奥沙利铂+雷替曲塞方案化疗一次，化疗反应轻。", "event": [ { "core_name": "化疗反应", "tendency": "", "character": [ "轻" ], "anatomy_list": [] } ] }, { "id": 596, "text": "肝内少许小囊肿可能。", "event": [ { "core_name": "囊肿", "tendency": "不确定", "character": [ "小", "少许" ], "anatomy_list": [ "肝内" ] } ] }, { "id": 804, "text": "胸12椎体上缘许莫氏结节。", "event": [ { "core_name": "许莫氏结节", "tendency": "", "character": [], "anatomy_list": [ "胸12椎体上缘" ] } ] }, { "id": 473, "text": "4年前我院行“肾动脉交感神经射频消融术”，术后半年，患者血压逐步降低，但患者仍口服“坎地沙坦、呋塞米、螺内酯”等降压、改善心室重构药物，自测血压约116/66mmHg左右。", "event": [ { "core_name": "血压", "tendency": "", "character": [ "逐步降低" ], "anatomy_list": [] } ] }, { "id": 1438, "text": "某医院骨扫描结果回示：胸中段、左侧肩关节、右侧第7后肋近腋后线处、t3、右侧骶髂关节处、左侧坐骨支呈散在分布的多发的形态各异的放射性浓聚，考虑转移性骨肿瘤。", "event": [ { "core_name": "浓聚", "tendency": "", "character": [ "散在", "多发", "放射性" ], "anatomy_list": [ "胸中段", "左侧坐骨支", "左侧肩关节", "骶髂关节", "右侧第7后肋近腋后线处", "t3" ] }, { "core_name": "肿瘤", "tendency": "不确定", "character": [ "转移性" ], "anatomy_list": [ "骨" ] } ] }, { "id": 1673, "text": "患者本次发病以来，食欲下降， 神志清醒，精神欠佳，睡眠欠佳，大便正常，小便正常，体重减少。", "event": [ { "core_name": "食欲下降", "tendency": "", "character": [], "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", "tendency": "", "character": [ "减少" ], "anatomy_list": [] } ] }, { "id": 10, "text": "入院前2天,患者受凉后再次出现气促,并咳嗽,痰液粘稠,不易咳出,遂就诊于我院,为进一步治疗,门诊以“慢阻肺急性期”收入我科。", "event": [ { "core_name": "气促", "tendency": "", "character": [ "受凉" ], "anatomy_list": [] }, { "core_name": "咳嗽", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "痰液粘稠", "不易咳出" ], "anatomy_list": [] }, { "core_name": "肺疾病", "tendency": "", "character": [ "急性期", "慢性", "阻塞性" ], "anatomy_list": [ "肺" ] } ] }, { "id": 1530, "text": "出院后患者时有咳嗽、痰少，偶有右侧胸部切口轻微疼痛，无畏寒、发热，无咯血、呼吸困难等不适。", "event": [ { "core_name": "咳嗽", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "少" ], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "", "character": [ "轻微" ], "anatomy_list": [ "右侧胸部切口" ] }, { "core_name": "畏寒", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "发热", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "咯血", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "呼吸困难", "tendency": "否定", "character": [], "anatomy_list": [] } ] }, { "id": 1877, "text": "2天前，患者于我院就诊，门诊完善胃镜检查提示：贲门溃疡性病变，病理报告提示：贲门粘膜慢性溃疡性炎，肝功提示：alt 58U/L，ggt 93U/L，肾功、血常规未见异常，予以抑酸护胃等治疗后症状无缓解，今为进一步诊治，再次就诊于我院，门诊以“巨大溃疡”收入我科。", "event": [ { "core_name": "病变", "tendency": "", "character": [ "溃疡型" ], "anatomy_list": [ "贲门" ] }, { "core_name": "贲门粘膜炎", "tendency": "", "character": [ "慢性", "溃疡型" ], "anatomy_list": [ "贲门粘膜" ] }, { "core_name": "溃疡", "tendency": "", "character": [ "巨大" ], "anatomy_list": [] }, { "core_name": "肾功能异常", "tendency": "否定", "character": [], "anatomy_list": [ "肾" ] }, { "core_name": "血常规", "tendency": "否定", "character": [ "异常" ], "anatomy_list": [] } ] }, { "id": 768, "text": "现患者偶有咳嗽、咳痰，无畏寒、发热，无腹痛、腹胀等不适，患者为求进一步诊治遂至我院，门诊以“肺癌”收入我科。", "event": [ { "core_name": "咳嗽", "tendency": "", "character": [ "偶有" ], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "偶有" ], "anatomy_list": [] }, { "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": [ "腹" ] }, { "core_name": "腹胀", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "癌", "tendency": "", "character": [], "anatomy_list": [ "肺" ] } ] }, { "id": 1775, "text": "患者1月前出现尿黄（呈深黄色），家人发现其眼黄、身黄，伴乏力、纳差（食量约为原来1/3），无厌油、恶心、呕吐，无腹痛、腹胀，无大便颜色变浅，无皮肤瘙痒，患者未予以重视，未做任何处理。", "event": [ { "core_name": "尿黄", "tendency": "", "character": [ "深黄色" ], "anatomy_list": [] }, { "core_name": "黄染", "tendency": "", "character": [], "anatomy_list": [ "身" ] }, { "core_name": "黄染", "tendency": "", "character": [], "anatomy_list": [ "眼" ] }, { "core_name": "乏力", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "纳差", "tendency": "", "character": [ "食量约为原来1/3" ], "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": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "腹胀", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "大便", "tendency": "否定", "character": [ "颜色变浅" ], "anatomy_list": [] }, { "core_name": "瘙痒", "tendency": "否定", "character": [], "anatomy_list": [ "皮肤" ] } ] }, { "id": 76, "text": "今为继续治疗来我院，未行第3次类克输注，门诊以“幼年特发性关节炎”收入院。", "event": [ { "core_name": "关节炎", "tendency": "", "character": [ "幼年", "特发性" ], "anatomy_list": [ "关节" ] } ] }, { "id": 1897, "text": "入院前1天，患者再次出现小便不能自解情况，伴有下腹部持续性胀痛，患者感症状不能忍受，今日于我科门诊就诊，门诊以“尿潴留”收入我科住院治疗。", "event": [ { "core_name": "小便", "tendency": "", "character": [ "不能自解" ], "anatomy_list": [] }, { "core_name": "疼痛", "tendency": "", "character": [ "持续性", "胀痛", "不能忍受" ], "anatomy_list": [ "下腹部" ] }, { "core_name": "尿潴留", "tendency": "", "character": [], "anatomy_list": [] } ] }, { "id": 989, "text": "20天前患者因喘累不适就诊于我院，完善胸部彩超示：大量胸腔积液；遂行胸腔穿刺抽液并胸腔内局部注射“顺铂、艾迪”化疗药物治疗，后喘累不适好转出院。", "event": [ { "core_name": "喘累", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "积液", "tendency": "", "character": [ "大量" ], "anatomy_list": [ "胸腔" ] }, { "core_name": "喘累", "tendency": "", "character": [ "好转" ], "anatomy_list": [] } ] }, { "id": 1633, "text": "17月余前，患者因“左下腹痛1月余，加重半月。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [], "anatomy_list": [ "左下腹" ] }, { "core_name": "疼痛", "tendency": "", "character": [ "加重" ], "anatomy_list": [ "左下腹" ] } ] }, { "id": 58, "text": "患者自起病以来,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": "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": 2046, "text": "患者于4年前因“间断吞咽困难，进食梗阻感”于某医院行胃镜检查提示“食道中下段癌”，病理活检提示“鳞癌”，行胸部ct提示“食道中下段占位及纵膈多处淋巴结转移”，遂入住某医院行“电视胸腔镜探查，下段食管癌段食管癌切除，脾切除和胃食管左侧颈部侧-侧吻合术”，术后病检提示：食管下段髓质型低-中等分化鳞癌，予以抗感染、祛痰、营养支持等治疗后好转出院。", "event": [ { "core_name": "吞咽困难", "tendency": "", "character": [ "间断" ], "anatomy_list": [] }, { "core_name": "梗阻感", "tendency": "", "character": [ "进食" ], "anatomy_list": [] }, { "core_name": "癌", "tendency": "", "character": [], "anatomy_list": [ "食道中段下段" ] }, { "core_name": "鳞癌", "tendency": "", "character": [], "anatomy_list": [ "食道中段下段" ] }, { "core_name": "占位", "tendency": "", "character": [], "anatomy_list": [ "食道中段下段" ] }, { "core_name": "转移", "tendency": "", "character": [ "多处淋巴结" ], "anatomy_list": [ "纵膈淋巴结" ] }, { "core_name": "鳞癌", "tendency": "", "character": [ "髓质型", "低-中等分化" ], "anatomy_list": [ "食管下段" ] } ] }, { "id": 948, "text": "患者自发病以来，精神可，食欲欠佳，睡眠欠佳，大便如常，小便如常，体重下降明显。", "event": [ { "core_name": "精神", "tendency": "", "character": [ "可" ], "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": [ "明显" ], "anatomy_list": [] } ] }, { "id": 675, "text": "此后咳嗽、咳痰症状反复发作，每年发作时间大于3个月，两年前受凉后出现间断咳黄色粘稠脓痰,痰量较之前稍有增加，活动后加重，曾反复于我院住院治疗，诊断为“慢性阻塞性肺疾病、肺气肿”予以积极抗感染、解痉、化痰等化疗治疗后好转出院，病程中无劳力性心累呼吸困难，无夜间阵发性呼吸困难，无端坐呼吸，无咳粉红色泡沫痰，无双下肢水肿，无夜尿增多，无便秘、腹泻、腹胀，无黄疸、厌油、乏力、纳差。", "event": [ { "core_name": "咳嗽", "tendency": "", "character": [ "反复发作" ], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "反复发作" ], "anatomy_list": [] }, { "core_name": "咳嗽", "tendency": "", "character": [ "受凉后", "间断", "黄色", "粘稠", "脓痰", "痰量较之前稍有增加", "活动后加重" ], "anatomy_list": [] }, { "core_name": "肺疾病", "tendency": "", "character": [ "慢性", "阻塞性" ], "anatomy_list": [ "肺" ] }, { "core_name": "肺气肿", "tendency": "", "character": [], "anatomy_list": [ "肺" ] }, { "core_name": "心累", "tendency": "否定", "character": [ "劳累性" ], "anatomy_list": [] }, { "core_name": "呼吸困难", "tendency": "否定", "character": [ "劳累性" ], "anatomy_list": [] }, { "core_name": "呼吸困难", "tendency": "", "character": [ "夜间", "阵发性" ], "anatomy_list": [] }, { "core_name": "端坐呼吸", "tendency": "否定", "character": [], "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" ] }, { "core_name": "夜尿增多", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "便秘", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "腹泻", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "腹胀", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "黄疸", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "厌油", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "乏力", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "纳差", "tendency": "否定", "character": [], "anatomy_list": [] } ] }, { "id": 549, "text": "门诊遂以“右肺鳞癌，化疗后骨髓抑制”收治入院。", "event": [ { "core_name": "鳞癌", "tendency": "", "character": [], "anatomy_list": [ "右肺" ] }, { "core_name": "骨髓抑制", "tendency": "", "character": [ "化疗后" ], "anatomy_list": [ "骨髓" ] } ] }, { "id": 16, "text": "现患儿一般情况可,今再次入院,拟行储液囊拔除术。", "event": [ { "core_name": "一般情况", "tendency": "", "character": [ "可" ], "anatomy_list": [] } ] }, { "id": 1343, "text": "<胰头上方>淋巴结见癌转移（1/1）慢性胆囊炎。", "event": [ { "core_name": "癌", "tendency": "", "character": [ "转移" ], "anatomy_list": [ "胰头上方淋巴结" ] }, { "core_name": "胆囊炎", "tendency": "", "character": [ "慢性" ], "anatomy_list": [ "胆囊" ] } ] }, { "id": 2055, "text": "2019-5月无明显诱因扪及右下腹包块，质地硬，无明显疼痛感，无畏寒发热，无咳嗽咳痰，无头晕疼痛，无腹泻腹痛，于2019-6就诊于某肿瘤医院，行肠镜提示“结肠肝区和横结肠肿瘤，病检提示腺癌”，行右下腹肿块穿刺明确为腺癌。", "event": [ { "core_name": "包块", "tendency": "", "character": [ "质地硬", "无明显疼痛感" ], "anatomy_list": [ "右下腹" ] }, { "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": "头晕", "tendency": "否定", "character": [], "anatomy_list": [ "头" ] }, { "core_name": "疼痛", "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": "肿瘤", "tendency": "", "character": [], "anatomy_list": [ "结肠肝区", "横结肠" ] }, { "core_name": "腺癌", "tendency": "", "character": [], "anatomy_list": [ "结肠肝区", "横结肠" ] }, { "core_name": "腺癌", "tendency": "", "character": [], "anatomy_list": [] } ] }, { "id": 933, "text": "入院前1月，患者因下肢静脉曲张于我院行“双下肢大隐静脉高位结扎＋抽拨＋evlt术”，术前查肝功：谷丙转氨酶 107U/L ↑，谷草转氨酶 95U/L ↑，碱性磷酸酶 218U/L ↑，γ-谷胺酰转移酶 289U/L ↑，前白蛋白 192mg/L ↓，无皮肤瘙痒等不适，未做特殊处理。", "event": [ { "core_name": "曲张", "tendency": "", "character": [], "anatomy_list": [ "下肢静脉" ] }, { "core_name": "瘙痒", "tendency": "否定", "character": [], "anatomy_list": [ "皮肤" ] } ] }, { "id": 681, "text": "3.右肺上叶及左肺下叶下叶钙化灶。", "event": [ { "core_name": "钙化灶", "tendency": "", "character": [], "anatomy_list": [ "右肺上叶", "左肺下叶" ] } ] }, { "id": 658, "text": "2+月前，患者无明显诱因出现咳嗽、咳痰，咳嗽以阵发性咳嗽为主，无犬吠样咳嗽及鸡鸣样回声，咳痰呈白色泡沫痰，痰量多，痰中偶带鲜红色血丝，晨起时较重，日间减轻，夜间可平卧入睡，活动后略感气促。", "event": [ { "core_name": "咳嗽", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "咳嗽", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "咳嗽", "tendency": "", "character": [ "阵发性" ], "anatomy_list": [] }, { "core_name": "咳嗽", "tendency": "否定", "character": [ "犬吠样" ], "anatomy_list": [] }, { "core_name": "咳嗽", "tendency": "否定", "character": [ "鸡鸣样回声" ], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "白色", "泡沫痰", "痰量多" ], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "偶带鲜红色血丝" ], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "晨起时较重", "日间减轻" ], "anatomy_list": [] }, { "core_name": "气促", "tendency": "", "character": [ "活动后", "略感" ], "anatomy_list": [] } ] }, { "id": 979, "text": "腹部彩超：肝内实性结节，血管瘤可能，肝实质回声增粗、不均质。建议患者到上级医院就诊。", "event": [ { "core_name": "结节", "tendency": "", "character": [ "实性" ], "anatomy_list": [ "肝内" ] }, { "core_name": "瘤", "tendency": "不确定", "character": [ "血管" ], "anatomy_list": [ "肝内" ] }, { "core_name": "回声", "tendency": "", "character": [ "增粗", "不均质" ], "anatomy_list": [ "肝实质" ] } ] }, { "id": 425, "text": "入院前 5+月 ，患者无明显诱因感 右侧胸痛 ，偶有咳嗽，偶有少许白色粘痰，不伴咳血，感活动后心累、气促，不咯黄脓痰及铁锈色痰，不伴畏寒、寒战、高热，不伴潮热、盗汗及午后低热。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [], "anatomy_list": [ "右侧胸" ] }, { "core_name": "咳嗽", "tendency": "", "character": [ "偶有" ], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "偶有", "少许", "白色", "粘" ], "anatomy_list": [] }, { "core_name": "咳血", "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": "咳痰", "tendency": "否定", "character": [ "黄脓", "铁锈色" ], "anatomy_list": [] }, { "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": [ "高" ], "anatomy_list": [] }, { "core_name": "潮热", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "盗汗", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "发热", "tendency": "否定", "character": [ "午后", "低" ], "anatomy_list": [] } ] }, { "id": 752, "text": "至我院行纤支镜活检，病检结果（2015-01-21）示：<右下叶下叶支气管活检>腺癌。", "event": [ { "core_name": "腺癌", "tendency": "", "character": [], "anatomy_list": [ "右下叶支气管" ] } ] }, { "id": 335, "text": "20+天前患者无诱因出现阴道少量流血，色暗红，质中，偶有少量血凝块，无腹痛、腹胀、畏寒、发热、头昏、心慌等不适，患者未予重视未诊治；阴道流血持续至今，遂来我院就诊，门诊以\"阴道流血待查：功能失调性子宫出血？子宫内膜癌？\"收入我科。", "event": [ { "core_name": "出血", "tendency": "", "character": [ "少量", "色暗红", "质中", "偶有少量血凝块" ], "anatomy_list": [ "阴道" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "腹胀", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "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": "心慌", "tendency": "否定", "character": [], "anatomy_list": [ "心" ] }, { "core_name": "出血", "tendency": "", "character": [ "持续至今" ], "anatomy_list": [ "阴道" ] }, { "core_name": "出血", "tendency": "不确定", "character": [], "anatomy_list": [ "阴道" ] }, { "core_name": "出血", "tendency": "不确定", "character": [ "功能失调性" ], "anatomy_list": [ "子宫" ] }, { "core_name": "癌", "tendency": "不确定", "character": [], "anatomy_list": [ "子宫内膜" ] } ] }, { "id": 2058, "text": "2020-12-7患者感右下腹部下腹部疼痛，向右下腹放射。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [], "anatomy_list": [ "右下腹部", "下腹部" ] }, { "core_name": "疼痛", "tendency": "", "character": [ "放射性" ], "anatomy_list": [ "右下腹" ] } ] }, { "id": 167, "text": "鼻咽双侧壁稍厚，fdg代谢增高，建议鼻镜检查。", "event": [ { "core_name": "壁厚", "tendency": "", "character": [ "稍" ], "anatomy_list": [ "鼻咽双侧壁" ] }, { "core_name": "fdg", "tendency": "", "character": [ "代谢增高" ], "anatomy_list": [] } ] }, { "id": 1579, "text": "其后间断一段时间无明显诱因再次出现少量阴道流血，未就医。", "event": [ { "core_name": "出血", "tendency": "", "character": [ "少量" ], "anatomy_list": [ "阴道" ] } ] }, { "id": 415, "text": "患者目前无咳嗽，无肝区疼痛，无骨关节关节疼痛。", "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": "否定", "character": [], "anatomy_list": [ "骨关节" ] } ] }, { "id": 1282, "text": "术后剖视子宫：子宫腔后壁及底部一大小约为4*3*2cm菜花样包块，病灶浸及浅肌层，子宫内膜菲薄；术后继续予以抗感染、止血等处理，术后病检（123456）结果提示：子宫内膜样腺癌（3级），侵及深肌层（近浆膜层），宫颈内口及双侧宫旁未见癌累及，（左髂总、右髂总、左盆腔、右盆腔）淋巴结未见癌转移（0/3、0/2、0/9、0/13）。", "event": [ { "core_name": "包块", "tendency": "", "character": [ "菜花样" ], "anatomy_list": [ "子宫腔后壁", "子宫腔底部" ] }, { "core_name": "病灶", "tendency": "", "character": [ "浸及" ], "anatomy_list": [ "浅肌层" ] }, { "core_name": "子宫内膜菲薄", "tendency": "", "character": [], "anatomy_list": [ "子宫内膜" ] }, { "core_name": "腺癌", "tendency": "", "character": [ "子宫内膜样", "3级" ], "anatomy_list": [] }, { "core_name": "腺癌", "tendency": "", "character": [ "侵及" ], "anatomy_list": [ "深肌层", "近浆膜层" ] }, { "core_name": "癌", "tendency": "否定", "character": [ "累及" ], "anatomy_list": [ "宫颈内口", "双侧宫旁" ] }, { "core_name": "癌", "tendency": "否定", "character": [ "转移" ], "anatomy_list": [ "左盆腔淋巴结", "右盆腔淋巴结", "左髂总淋巴结", "右髂总淋巴结" ] } ] }, { "id": 383, "text": "1+周前，患者再次出现咳嗽、咯痰，伴活动后喘累，无胸闷、胸痛、咯血、呼吸困难，无畏寒、发热等。", "event": [ { "core_name": "咳嗽", "tendency": "", "character": [ "再次" ], "anatomy_list": [] }, { "core_name": "咯痰", "tendency": "", "character": [ "再次" ], "anatomy_list": [] }, { "core_name": "喘累", "tendency": "", "character": [ "活动后" ], "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": "咯血", "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": [] } ] }, { "id": 340, "text": "伴下腹部疼痛 ， 疼痛呈阵发性隐痛 ， 无放射痛 。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [], "anatomy_list": [ "下腹部" ] }, { "core_name": "疼痛", "tendency": "", "character": [ "阵发性", "隐痛" ], "anatomy_list": [ "下腹部" ] }, { "core_name": "疼痛", "tendency": "否定", "character": [ "放射性" ], "anatomy_list": [ "下腹部" ] } ] }, { "id": 1317, "text": "3天前复查ct提示：1.肝内多发稍低密度小结节并可疑强化；2.双肺多发结节，转移瘤可能。现患者为求进一步治疗入院。", "event": [ { "core_name": "结节", "tendency": "", "character": [ "多发", "小", "稍低密度" ], "anatomy_list": [ "肝内" ] }, { "core_name": "结节", "tendency": "不确定", "character": [ "强化" ], "anatomy_list": [ "肝内" ] }, { "core_name": "结节", "tendency": "", "character": [ "多发" ], "anatomy_list": [ "双肺" ] }, { "core_name": "瘤", "tendency": "不确定", "character": [ "转移" ], "anatomy_list": [] } ] }, { "id": 848, "text": "已于我科行规律化疗5次，未诉特殊不适，现患者一般情况可，无腹痛、腹胀、恶心、呕吐、畏寒、发热等症状，拟行第6次化疗入院。", "event": [ { "core_name": "疼痛", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "腹胀", "tendency": "否定", "character": [], "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": "畏寒", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "发热", "tendency": "否定", "character": [], "anatomy_list": [] } ] }, { "id": 726, "text": "院外每日解不成形软便２－３次，无血便，无腹泻、肛门坠胀等不适。", "event": [ { "core_name": "大便", "tendency": "", "character": [ "不成形", "软" ], "anatomy_list": [] }, { "core_name": "大便", "tendency": "否定", "character": [ "带血" ], "anatomy_list": [] }, { "core_name": "腹泻", "tendency": "否定", "character": [], "anatomy_list": [ "腹" ] }, { "core_name": "坠胀", "tendency": "否定", "character": [], "anatomy_list": [ "肛门" ] } ] }, { "id": 1647, "text": "入院前3-月，患者因诊断为“左侧乳腺癌”。", "event": [ { "core_name": "癌", "tendency": "", "character": [], "anatomy_list": [ "左侧乳腺" ] } ] }, { "id": 1318, "text": "门诊以“直肠癌术后”收入我科。", "event": [ { "core_name": "癌", "tendency": "", "character": [ "术后" ], "anatomy_list": [ "直肠" ] } ] }, { "id": 192, "text": "发现高血压3年，最高血压160/？mmhg，患者自行服用“硝苯地平”降压，未规律监测血压。", "event": [ { "core_name": "高血压", "tendency": "", "character": [ "3年" ], "anatomy_list": [] } ] }, { "id": 1511, "text": "1-月前（2020/5/24）患者上下楼梯时不慎滑倒，右侧胸背部着地致右肩、胸背部剧烈疼痛，右肩不能活动，呼吸胸闷、疼痛明显，右侧头部磕伤疼痛，无意识障碍，无恶心呕吐，无全身其它部位明显疼痛。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [ "剧烈" ], "anatomy_list": [ "右肩", "胸背部" ] }, { "core_name": "活动", "tendency": "否定", "character": [], "anatomy_list": [ "右肩" ] }, { "core_name": "胸闷", "tendency": "", "character": [ "呼吸" ], "anatomy_list": [ "胸" ] }, { "core_name": "疼痛", "tendency": "", "character": [ "明显" ], "anatomy_list": [ "胸" ] }, { "core_name": "疼痛", "tendency": "", "character": [ "磕伤" ], "anatomy_list": [ "右侧头部" ] }, { "core_name": "意识障碍", "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": [ "明显" ], "anatomy_list": [ "全身其它部位" ] } ] }, { "id": 521, "text": "门诊以“肺部感染”收入我科。", "event": [ { "core_name": "感染", "tendency": "", "character": [], "anatomy_list": [ "肺部" ] } ] }, { "id": 1372, "text": "1年前患者出现双下肢水肿，伴活动后气促，无胸闷、胸痛，伴夜间阵发性呼吸困难，入我院诊治，查肌酐 276.5umol/L，诊断为“1.2型糖尿病糖尿病糖尿病肾病 糖尿病周围神经病变 糖尿病视网膜病变；2.慢性肾功能不全（失代偿期） 肾性贫血；3.原发性高血压3级高血压3级极高危极高危组 高血压心脏病 左房左室大 心功能iii级”，给予控制血糖、降压、护肾等对症支持治疗，患者病情好转后出院。", "event": [ { "core_name": "水肿", "tendency": "", "character": [], "anatomy_list": [ "双下肢" ] }, { "core_name": "气促", "tendency": "", "character": [ "活动后" ], "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": "呼吸困难", "tendency": "", "character": [ "夜间", "阵发性" ], "anatomy_list": [] }, { "core_name": "糖尿病", "tendency": "", "character": [ "2型" ], "anatomy_list": [] }, { "core_name": "肾病", "tendency": "", "character": [ "糖尿病" ], "anatomy_list": [ "肾" ] }, { "core_name": "周围神经病变", "tendency": "", "character": [ "糖尿病" ], "anatomy_list": [ "周围神经" ] }, { "core_name": "病变", "tendency": "", "character": [ "糖尿病" ], "anatomy_list": [ "视网膜" ] }, { "core_name": "肾功能不全", "tendency": "", "character": [ "慢性", "失代偿期" ], "anatomy_list": [ "肾" ] }, { "core_name": "贫血", "tendency": "", "character": [ "肾性" ], "anatomy_list": [] }, { "core_name": "高血压", "tendency": "", "character": [ "原发性", "极高危", "3级" ], "anatomy_list": [] }, { "core_name": "心脏病", "tendency": "", "character": [ "高血压" ], "anatomy_list": [ "心脏" ] }, { "core_name": "左房左室大", "tendency": "", "character": [], "anatomy_list": [ "左房", "左室" ] }, { "core_name": "心功能", "tendency": "", "character": [ "iii级" ], "anatomy_list": [ "心" ] } ] }, { "id": 731, "text": "1+年前，患者诉头昏、乏力加重，伴活动后气促，遂入某医院就诊，再次行骨髓穿刺活检（未见报告）确诊为骨髓增生异常综合征-rcmd，予以改善病态造血、促进造血等对症治疗，患者症状缓解出院，院外口服维a酸1片tid、沙利度胺2片qn治疗，于2016年05月20日复查骨髓穿刺检查示骨髓病态造血无明显改善，遂于2016年06月07日予以小剂量地西他滨治疗（药物总量：96mg），又于2016年07月25日复查骨髓穿刺检查示原始及单核细胞比例增高，占4%（nec:21%），考虑aml-m6，再次予以小剂量地西他滨治疗（药物总量：160mg），于2016年08月12日复查骨髓穿刺检查示原始细胞比例有所下降，粒红巨三系病态造血现象仍可见，予以地西他滨+依托泊苷+阿糖胞苷+gcsf方案化疗（具体时间及药物剂量不详），同时予以输血小板、红细胞治疗，化疗后出现iii度骨髓抑制，予以升白细胞治疗后恢复正常，化疗期间及化疗后无明显恶心、呕吐等毒副反应。", "event": [ { "core_name": "头昏", "tendency": "", "character": [ "加重" ], "anatomy_list": [ "头" ] }, { "core_name": "乏力", "tendency": "", "character": [ "加重" ], "anatomy_list": [] }, { "core_name": "气促", "tendency": "", "character": [ "活动后" ], "anatomy_list": [] }, { "core_name": "骨髓增生异常综合征", "tendency": "", "character": [ "异常" ], "anatomy_list": [ "骨髓" ] }, { "core_name": "病态造血", "tendency": "否定", "character": [ "明显改善" ], "anatomy_list": [ "骨髓" ] }, { "core_name": "aml-m6", "tendency": "不确定", "character": [], "anatomy_list": [] }, { "core_name": "骨髓抑制", "tendency": "", "character": [ "化疗后", "iii度" ], "anatomy_list": [ "骨髓" ] }, { "core_name": "恶心", "tendency": "否定", "character": [ "明显", "化疗期间及化疗后" ], "anatomy_list": [] }, { "core_name": "呕吐", "tendency": "否定", "character": [ "明显", "化疗期间及化疗后" ], "anatomy_list": [] } ] }, { "id": 1857, "text": "肠周淋巴结未见癌转移（0/11）。", "event": [ { "core_name": "癌", "tendency": "否定", "character": [ "转移" ], "anatomy_list": [ "肠周淋巴结" ] } ] }, { "id": 1304, "text": "今患者为求下一周期化疗入我院，遂以“左肺鳞癌化疗后”收治入院。", "event": [ { "core_name": "鳞癌", "tendency": "", "character": [ "化疗后" ], "anatomy_list": [ "左肺" ] } ] }, { "id": 1295, "text": "患儿入院前5+月前因“步态异常8月”第一次入院，入院考虑诊断1.左侧肢体中枢性偏瘫 2.右侧基底基底节丘脑生殖细胞瘤？于1月7日行第一次诊断性化疗，于1月30日行第二次诊断性化疗，3月份在某医院行放疗治疗，今日到本院门诊就诊，为求第三次化疗，门诊以“肿瘤化疗”收入院。", "event": [ { "core_name": "步态异常", "tendency": "", "character": [ "8月" ], "anatomy_list": [] }, { "core_name": "偏瘫", "tendency": "", "character": [ "中枢性" ], "anatomy_list": [ "左侧肢体" ] }, { "core_name": "瘤", "tendency": "不确定", "character": [ "生殖细胞" ], "anatomy_list": [ "右侧基底", "基底节", "丘脑" ] }, { "core_name": "肿瘤", "tendency": "", "character": [], "anatomy_list": [] } ] }, { "id": 527, "text": "入院前数天，患者感呼吸困难较前加重，静息状态下仍有呼吸困难，伴双下肢水肿，四肢乏力，伴咳嗽、咳痰，痰为白色泡沫痰，感腹胀，进食后加重，饭量较前减少，尿量减少，无头晕头疼，无左肩部放射痛，无黑朦晕厥，自诉予以“消肿药”治疗后呼吸困难无明显缓解，为求进一步诊治，遂于我院急诊科就诊，完善心电图“心房纤颤”，心肌损伤标志物“ctni＜0.50ng/ml，ck-mb＜3.0ng/ml,myo＜50ng/ml”，急诊心脏彩超提示“全心增大。", "event": [ { "core_name": "呼吸困难", "tendency": "", "character": [ "较前加重" ], "anatomy_list": [] }, { "core_name": "呼吸困难", "tendency": "", "character": [ "静息状态下仍有" ], "anatomy_list": [] }, { "core_name": "水肿", "tendency": "", "character": [], "anatomy_list": [ "双下肢" ] }, { "core_name": "乏力", "tendency": "", "character": [], "anatomy_list": [ "四肢" ] }, { "core_name": "咳嗽", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "咳痰", "tendency": "", "character": [ "白色泡沫" ], "anatomy_list": [] }, { "core_name": "腹胀", "tendency": "", "character": [ "进食后加重" ], "anatomy_list": [ "腹" ] }, { "core_name": "饭量", "tendency": "", "character": [ "较前减少" ], "anatomy_list": [] }, { "core_name": "尿量", "tendency": "", "character": [ "减少" ], "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": [ "放射性" ], "anatomy_list": [ "左肩部" ] }, { "core_name": "黑朦", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "晕厥", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "呼吸困难", "tendency": "否定", "character": [ "明显缓解" ], "anatomy_list": [] }, { "core_name": "心房纤颤", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "全心增大", "tendency": "", "character": [], "anatomy_list": [ "全心" ] } ] }, { "id": 1043, "text": "入院前1月，患者腹胀明显，进食后腹痛明显，伴大便干结，纳差、厌油，无恶心、呕吐，无呕血、便血，遂于某医院住院治疗，予以抑酸护胃、抗感染等治疗，行“伽马刀治疗肝转移转移肿瘤”完成一个疗程后出院。", "event": [ { "core_name": "腹胀", "tendency": "", "character": [ "明显" ], "anatomy_list": [ "腹" ] }, { "core_name": "疼痛", "tendency": "", "character": [ "明显", "进食后" ], "anatomy_list": [ "腹" ] }, { "core_name": "大便性状", "tendency": "", "character": [ "干结" ], "anatomy_list": [] }, { "core_name": "纳差", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "厌油", "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": "呕血", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "便血", "tendency": "否定", "character": [], "anatomy_list": [] }, { "core_name": "肿瘤", "tendency": "", "character": [ "转移" ], "anatomy_list": [ "肝" ] } ] }, { "id": 632, "text": "行阴道镜示高级别病变，遂行行宫颈活检术，术后病检回示：<颈管>血凝块及炎性渗出物中见散碎颈管组织显示慢性炎症。", "event": [ { "core_name": "病变", "tendency": "", "character": [ "高级别" ], "anatomy_list": [ "宫颈" ] }, { "core_name": "散碎颈管组织", "tendency": "", "character": [ "血凝块及炎性渗出物中见" ], "anatomy_list": [] }, { "core_name": "炎症", "tendency": "", "character": [ "慢性" ], "anatomy_list": [ "宫颈管" ] } ] }, { "id": 1387, "text": "患病以来，患者精神、睡眠、饮食可，大、小便正常，体重无明显变化。", "event": [ { "core_name": "精神", "tendency": "", "character": [ "可" ], "anatomy_list": [] }, { "core_name": "睡眠", "tendency": "", "character": [ "可" ], "anatomy_list": [] }, { "core_name": "进食", "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": 345, "text": "患者3月前，因“反复便血2+月”到我院就诊，行肠镜检查提示直肠癌，积极术前准备，于2020年01月02日在手术室全麻下行了腹腔镜探查+腹腔镜辅助下经腹会阴联合直肠癌根治术。", "event": [ { "core_name": "便血", "tendency": "", "character": [ "反复" ], "anatomy_list": [] }, { "core_name": "癌", "tendency": "", "character": [], "anatomy_list": [ "直肠" ] } ] }, { "id": 19, "text": "诊断为右乳浸润性癌 pT2n3M0 iii期 luminal b型 her-2阴性型,于2016年11月28日行tac方案化疗（吡柔比星50mg d1+紫杉醇210mg d2+环磷酰胺800mg d3）,辅以止吐等处理,患者未诉明显恶心、呕吐等不适。", "event": [ { "core_name": "癌", "tendency": "", "character": [ "浸润性", "iii期", " luminal b型", " her-2阴性型" ], "anatomy_list": [ "右乳" ] }, { "core_name": "恶心", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [] }, { "core_name": "呕吐", "tendency": "否定", "character": [ "明显" ], "anatomy_list": [] } ] }, { "id": 1751, "text": "2、胆囊切端未见癌累及。", "event": [ { "core_name": "癌", "tendency": "否定", "character": [ "累及" ], "anatomy_list": [ "胆囊切端" ] } ] }, { "id": 1018, "text": "2个多月前患者再次出现右耳流脓，到当地医院就诊，予以口服药物及耳道冲洗（具体不详）治疗后，右耳溢液无明显好转且伴血性分泌物。", "event": [ { "core_name": "流脓", "tendency": "", "character": [], "anatomy_list": [ "右耳" ] }, { "core_name": "溢液", "tendency": "", "character": [ "无明显好转", "伴血性分泌物" ], "anatomy_list": [ "右耳" ] } ] }, { "id": 1731, "text": "4月29日以“骨髓增生异常综合征”收住院进一步检查，查血常规“白细胞2.36×10^9/L↓、血红蛋白88g↓、血小板计数112×10^9/”，骨髓“骨髓增生明显活跃，粒系占34%；骨髓铁染色细胞内铁88%，细胞外铁(++)；外周血片白细胞分类中性比例低，红细胞大小不均可见异形红细胞；结论：与2015.9.9比粒系减少，红系增多，巨核增多”。", "event": [ { "core_name": "骨髓增生异常综合征", "tendency": "", "character": [], "anatomy_list": [ "骨髓" ] }, { "core_name": "增生", "tendency": "", "character": [ "明显活跃" ], "anatomy_list": [ "骨髓" ] }, { "core_name": "红细胞大小不均", "tendency": "", "character": [ "大小不均" ], "anatomy_list": [ "红细胞" ] }, { "core_name": "异形红细胞", "tendency": "", "character": [], "anatomy_list": [ "红细胞" ] }, { "core_name": "粒系减少", "tendency": "", "character": [ "减少" ], "anatomy_list": [ "粒系" ] }, { "core_name": "红系增多", "tendency": "", "character": [ "增多" ], "anatomy_list": [ "红系" ] }, { "core_name": "巨核增多", "tendency": "", "character": [ "增多" ], "anatomy_list": [ "巨核" ] } ] }, { "id": 23, "text": "1月余前,患者因“反复痰中带血2月”入我院耳鼻喉科就诊,行胸部ct平扫（2014-10-14）示：右下肺块影,肿瘤性病变待除外,进一步行胸部ct增强（2014-10-19）示：右肺下叶片块影,考虑中央型肺ca可能大,伴右肺下叶阻塞性炎症,右肺门及纵隔淋巴结明显肿大。", "event": [ { "core_name": "咳痰", "tendency": "", "character": [ "反复", "带血" ], "anatomy_list": [] }, { "core_name": "块影", "tendency": "", "character": [], "anatomy_list": [ "右下肺" ] }, { "core_name": "病变", "tendency": "不确定", "character": [ "肿瘤性" ], "anatomy_list": [ "右下肺" ] }, { "core_name": "片块影", "tendency": "", "character": [], "anatomy_list": [ "右肺下叶" ] }, { "core_name": "癌", "tendency": "不确定", "character": [ "中央型" ], "anatomy_list": [ "肺" ] }, { "core_name": "炎症", "tendency": "", "character": [ "阻塞性" ], "anatomy_list": [ "右肺下叶" ] }, { "core_name": "肿大", "tendency": "", "character": [ "明显" ], "anatomy_list": [ "右肺门淋巴结", "纵隔淋巴结" ] } ] }, { "id": 48, "text": "骨髓活检结果报告单（123456）：结合免疫组化,符合小b细胞淋巴瘤。", "event": [ { "core_name": "瘤", "tendency": "", "character": [], "anatomy_list": [ "小b细胞", "淋巴" ] } ] }, { "id": 330, "text": "2天前患者腹痛加重，伴恶心、呕吐，呕吐物为淡黄色胃内容物，量不多，不伴喷射性呕吐，患者就诊于某医院，行全腹部ct示：1、小肠积气积液，稍显扩张 2、回盲部壁增厚，回盲部淋巴结淋巴结肿大。", "event": [ { "core_name": "疼痛", "tendency": "", "character": [ "加重" ], "anatomy_list": [ "腹" ] }, { "core_name": "恶心", "tendency": "", "character": [], "anatomy_list": [] }, { "core_name": "呕吐", "tendency": "", "character": [ "呕吐物为淡黄色胃内容物，量不多" ], "anatomy_list": [] }, { "core_name": "呕吐", "tendency": "否定", "character": [ "喷射性" ], "anatomy_list": [] }, { "core_name": "积气", "tendency": "", "character": [], "anatomy_list": [ "小肠" ] }, { "core_name": "积液", "tendency": "", "character": [], "anatomy_list": [ "小肠" ] }, { "core_name": "扩张", "tendency": "", "character": [ "稍显" ], "anatomy_list": [ "小肠" ] }, { "core_name": "增厚", "tendency": "", "character": [], "anatomy_list": [ "回盲部壁" ] }, { "core_name": "肿大", "tendency": "", "character": [], "anatomy_list": [ "回盲部淋巴结" ] } ] } ]