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stringlengths 5
708
| id
int64 1
2.07k
| event
list |
|---|---|---|
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。 | 268 | [
{
"anatomy_list": [],
"character": [
"正常"
],
"core_name": "食欲",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"清醒"
],
"core_name": "神志",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"尚可"
],
"core_name": "精神",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"欠佳"
],
"core_name": "睡眠",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"正常"
],
"core_name": "大便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"正常"
],
"core_name": "小便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"明显"
],
"core_name": "体重变化",
"tendency": "否定"
}
] |
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。 | 1,425 | [
{
"anatomy_list": [],
"character": [],
"core_name": "张口困难",
"tendency": ""
},
{
"anatomy_list": [
"左侧面",
"左侧颈部"
],
"character": [
"轻微"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "发热",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "咳嗽",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "咳痰",
"tendency": "否定"
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "腹泻",
"tendency": "否定"
},
{
"anatomy_list": [
"面部"
],
"character": [
"化疗后",
"缩小"
],
"core_name": "包块",
"tendency": ""
},
{
"anatomy_list": [
"口腔粘膜"
],
"character": [
"恶性"
],
"core_name": "肿瘤",
"tendency": ""
},
{
"anatomy_list": [
"口腔"
],
"character": [],
"core_name": "鳞癌",
"tendency": ""
}
] |
肝功仍轻度异常，乙肝标志物示hbsag、hbeab、hbcab阳性。 | 149 | [
{
"anatomy_list": [
"肝"
],
"character": [
"轻度"
],
"core_name": "肝功能异常",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"阳性"
],
"core_name": "hbsag",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"阳性"
],
"core_name": "hbeab",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"阳性"
],
"core_name": "hbcab",
"tendency": ""
}
] |
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。 | 1,636 | [
{
"anatomy_list": [
"结肠"
],
"character": [
"术后改变"
],
"core_name": "癌",
"tendency": ""
},
{
"anatomy_list": [
"肝右叶后段"
],
"character": [],
"core_name": "结节",
"tendency": ""
},
{
"anatomy_list": [
"肝右叶后段"
],
"character": [
"转移"
],
"core_name": "瘤",
"tendency": "不确定"
},
{
"anatomy_list": [
"右肺下叶胸膜下"
],
"character": [
"浅淡"
],
"core_name": "结节",
"tendency": ""
}
] |
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）。 | 1,539 | [
{
"anatomy_list": [
"双肾"
],
"character": [],
"core_name": "囊肿",
"tendency": ""
},
{
"anatomy_list": [
"脾"
],
"character": [],
"core_name": "脾增大",
"tendency": ""
},
{
"anatomy_list": [
"直肠下段"
],
"character": [],
"core_name": "改变",
"tendency": ""
},
{
"anatomy_list": [
"腹膜后淋巴结",
"直肠周围淋巴结"
],
"character": [
"肿瘤性",
"累及浆膜层"
],
"core_name": "病变",
"tendency": "不确定"
},
{
"anatomy_list": [
"直肠"
],
"character": [],
"core_name": "腺癌",
"tendency": "不确定"
},
{
"anatomy_list": [
"直肠"
],
"character": [
"中分化",
"侵及全层",
"近远端未见癌累及"
],
"core_name": "腺癌",
"tendency": ""
},
{
"anatomy_list": [
"肠周脂肪组织",
"淋巴结"
],
"character": [
"转移"
],
"core_name": "癌",
"tendency": ""
}
] |
无尿频、尿急、尿痛。 | 561 | [
{
"anatomy_list": [],
"character": [],
"core_name": "尿频",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "尿急",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "尿痛",
"tendency": "否定"
}
] |
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。 | 1,876 | [
{
"anatomy_list": [
"腹"
],
"character": [
"较前加重"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"中上腹"
],
"character": [
"蹿气样"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"后背部"
],
"character": [
"放射性"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"进食量减少1/3"
],
"core_name": "纳差",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"量不多"
],
"core_name": "黑便",
"tendency": ""
},
{
"anatomy_list": [
"头"
],
"character": [],
"core_name": "头昏",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "厌油",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "乏力",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "黒朦",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "晕厥",
"tendency": "否定"
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "腹胀",
"tendency": "否定"
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "腹泻",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "便秘",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "血便",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "粘液便",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "里急后重",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "排便不尽",
"tendency": "否定"
}
] |
门诊以“腰椎椎管内占位椎管内占位性病”变收入我科。 | 245 | [
{
"anatomy_list": [
"腰椎椎管内"
],
"character": [
"占位性"
],
"core_name": "病变",
"tendency": ""
}
] |
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。 | 1,089 | [
{
"anatomy_list": [],
"character": [
"次数增多",
"约5-6次/天",
"量少",
"呈糊状"
],
"core_name": "大便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "黑便",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"脓血"
],
"core_name": "大便",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"偶有",
"粘液"
],
"core_name": "大便",
"tendency": ""
},
{
"anatomy_list": [
"肛门"
],
"character": [],
"core_name": "坠胀",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "里急后重感",
"tendency": ""
},
{
"anatomy_list": [
"直肠"
],
"character": [],
"core_name": "癌",
"tendency": ""
},
{
"anatomy_list": [
"直肠"
],
"character": [
"改变"
],
"core_name": "炎症",
"tendency": ""
},
{
"anatomy_list": [
"直肠"
],
"character": [],
"core_name": "癌",
"tendency": "否定"
}
] |
鼻窦ct提示左侧上颌窦占位。 | 2,068 | [
{
"anatomy_list": [
"左侧上颌窦"
],
"character": [],
"core_name": "占位",
"tendency": ""
}
] |
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）。 | 1,571 | [
{
"anatomy_list": [
"直乙交界"
],
"character": [],
"core_name": "腺癌",
"tendency": ""
},
{
"anatomy_list": [
"结肠"
],
"character": [
"多发"
],
"core_name": "息肉",
"tendency": ""
},
{
"anatomy_list": [
"直肠"
],
"character": [
"中分化"
],
"core_name": "腺癌",
"tendency": ""
},
{
"anatomy_list": [
"肠壁深肌层"
],
"character": [
"浸润"
],
"core_name": "癌",
"tendency": ""
},
{
"anatomy_list": [
"双侧切缘",
"吻合环"
],
"character": [],
"core_name": "癌",
"tendency": "否定"
},
{
"anatomy_list": [
"肠周淋巴结"
],
"character": [],
"core_name": "癌",
"tendency": "否定"
}
] |
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。 | 673 | [
{
"anatomy_list": [],
"character": [],
"core_name": "恶心",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "寒颤",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"高"
],
"core_name": "发热",
"tendency": "否定"
},
{
"anatomy_list": [
"心"
],
"character": [],
"core_name": "心慌",
"tendency": "否定"
},
{
"anatomy_list": [
"胸"
],
"character": [],
"core_name": "胸闷",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "呼吸困难",
"tendency": "否定"
},
{
"anatomy_list": [
"四肢"
],
"character": [],
"core_name": "乏力",
"tendency": "否定"
}
] |
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。 | 2,014 | [
{
"anatomy_list": [],
"character": [
"下午明显"
],
"core_name": "发热",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "体温",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "畏寒",
"tendency": "否定"
},
{
"anatomy_list": [
"胸"
],
"character": [],
"core_name": "胸闷",
"tendency": "否定"
},
{
"anatomy_list": [
"胸"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "体温下降",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"反复"
],
"core_name": "发热",
"tendency": ""
}
] |
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。 | 1,659 | [
{
"anatomy_list": [],
"character": [],
"core_name": "恶心",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "呕吐",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"减少"
],
"core_name": "白细胞",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"减少"
],
"core_name": "血小板",
"tendency": ""
}
] |
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。 | 1,440 | [
{
"anatomy_list": [
"右肺"
],
"character": [
"低分化"
],
"core_name": "癌",
"tendency": ""
},
{
"anatomy_list": [
"右肺"
],
"character": [
"低分化"
],
"core_name": "腺癌",
"tendency": ""
}
] |
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。 | 894 | [
{
"anatomy_list": [],
"character": [
"阵时"
],
"core_name": "喘累",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"加重"
],
"core_name": "喘累",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "院内感染",
"tendency": "不确定"
}
] |
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。 | 233 | [
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "腹胀",
"tendency": ""
},
{
"anatomy_list": [
"右肾"
],
"character": [],
"core_name": "囊肿",
"tendency": ""
},
{
"anatomy_list": [
"双侧髂总动脉管壁"
],
"character": [],
"core_name": "钙化",
"tendency": ""
},
{
"anatomy_list": [
"胃"
],
"character": [
"慢性"
],
"core_name": "胃炎",
"tendency": ""
},
{
"anatomy_list": [
"腹"
],
"character": [
"功能性"
],
"core_name": "腹胀",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"2型"
],
"core_name": "糖尿病",
"tendency": ""
},
{
"anatomy_list": [
"心"
],
"character": [],
"core_name": "冠心病",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"3级",
"很高危"
],
"core_name": "高血压",
"tendency": ""
}
] |
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。 | 647 | [
{
"anatomy_list": [],
"character": [
"突发"
],
"core_name": "晕厥",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"不清"
],
"core_name": "意识",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"不稳"
],
"core_name": "站立",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"不能"
],
"core_name": "语言表达",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "大汗",
"tendency": "否定"
},
{
"anatomy_list": [
"头"
],
"character": [],
"core_name": "头晕",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "目眩",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "恶心",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "呕吐",
"tendency": "否定"
},
{
"anatomy_list": [
"四肢"
],
"character": [],
"core_name": "发麻",
"tendency": "否定"
}
] |
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。 | 607 | [
{
"anatomy_list": [],
"character": [
"清晰"
],
"core_name": "意识",
"tendency": ""
},
{
"anatomy_list": [
"肢体"
],
"character": [
"良好"
],
"core_name": "活动",
"tendency": ""
}
] |
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。 | 1,117 | [
{
"anatomy_list": [],
"character": [
"夜间",
"阵发性",
"明显"
],
"core_name": "呼吸困难",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "泡沫尿",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "黄疸",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"改变"
],
"core_name": "性格",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"改变"
],
"core_name": "食欲",
"tendency": "否定"
}
] |
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。 | 1,771 | [
{
"anatomy_list": [
"双肺"
],
"character": [
"多发"
],
"core_name": "结节",
"tendency": ""
},
{
"anatomy_list": [
"纵隔淋巴结"
],
"character": [],
"core_name": "肿大",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "转移",
"tendency": ""
}
] |
近两年来患者头晕症状发作较既往频繁。 | 1,310 | [
{
"anatomy_list": [
"头"
],
"character": [
"发作较既往频繁"
],
"core_name": "头晕",
"tendency": ""
}
] |
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。 | 1,506 | [
{
"anatomy_list": [],
"character": [],
"core_name": "发热",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "咳嗽",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "恶心",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "呕吐",
"tendency": "否定"
},
{
"anatomy_list": [
"皮肤"
],
"character": [],
"core_name": "瘀斑",
"tendency": "否定"
},
{
"anatomy_list": [
"皮肤"
],
"character": [],
"core_name": "瘀点",
"tendency": "否定"
},
{
"anatomy_list": [
"牙龈"
],
"character": [],
"core_name": "出血",
"tendency": "否定"
},
{
"anatomy_list": [
"鼻"
],
"character": [],
"core_name": "鼻衄",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "出血倾向",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "黄疸",
"tendency": "否定"
},
{
"anatomy_list": [
"骨关节"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [
"面"
],
"character": [
"进行性"
],
"core_name": "面色苍白",
"tendency": "否定"
}
] |
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%）。 | 1,598 | [
{
"anatomy_list": [
"心"
],
"character": [
"活动后"
],
"core_name": "心累",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"活动后"
],
"core_name": "气促",
"tendency": ""
},
{
"anatomy_list": [
"胸"
],
"character": [],
"core_name": "胸闷",
"tendency": ""
},
{
"anatomy_list": [
"心"
],
"character": [],
"core_name": "心悸",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"夜间",
"阵发性"
],
"core_name": "呼吸困难",
"tendency": ""
},
{
"anatomy_list": [
"双下肢"
],
"character": [],
"core_name": "水肿",
"tendency": ""
},
{
"anatomy_list": [
"右房"
],
"character": [],
"core_name": "增大",
"tendency": ""
},
{
"anatomy_list": [
"左室下壁"
],
"character": [
"节段性",
"减低"
],
"core_name": "运动幅度",
"tendency": ""
},
{
"anatomy_list": [
"二尖瓣"
],
"character": [
"轻度"
],
"core_name": "反流",
"tendency": ""
},
{
"anatomy_list": [
"主动脉瓣"
],
"character": [
"轻度"
],
"core_name": "反流",
"tendency": ""
},
{
"anatomy_list": [
"左室"
],
"character": [
"EF38%"
],
"core_name": "左室功能减低",
"tendency": ""
}
] |
术后患者恢复可，伤口无感染渗液，愈合情况良好。 | 389 | [
{
"anatomy_list": [],
"character": [],
"core_name": "感染",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "渗液",
"tendency": "否定"
}
] |
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。 | 642 | [
{
"anatomy_list": [
"升结肠"
],
"character": [
"术后",
"pT4n0M0",
"第6次化疗"
],
"core_name": "癌",
"tendency": ""
}
] |
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。 | 1,047 | [
{
"anatomy_list": [],
"character": [],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"阵发性",
"干性"
],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "咳痰",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "咯血",
"tendency": "否定"
},
{
"anatomy_list": [
"胸"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "气促",
"tendency": "否定"
},
{
"anatomy_list": [
"肝"
],
"character": [],
"core_name": "硬化",
"tendency": ""
},
{
"anatomy_list": [
"肝"
],
"character": [],
"core_name": "囊肿",
"tendency": ""
},
{
"anatomy_list": [
"右肾"
],
"character": [],
"core_name": "囊肿",
"tendency": ""
},
{
"anatomy_list": [
"腹腔",
"盆腔"
],
"character": [],
"core_name": "积液",
"tendency": ""
},
{
"anatomy_list": [
"腹膜后腹主动脉左侧"
],
"character": [],
"core_name": "结节",
"tendency": ""
},
{
"anatomy_list": [
"淋巴结"
],
"character": [],
"core_name": "肿大",
"tendency": "不确定"
},
{
"anatomy_list": [
"双侧胸膜"
],
"character": [],
"core_name": "增厚",
"tendency": ""
}
] |
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。 | 1,216 | [
{
"anatomy_list": [
"阴道"
],
"character": [
"呈咖啡色",
"偶有异味",
"同房后症状加重",
"增多"
],
"core_name": "分泌物",
"tendency": ""
},
{
"anatomy_list": [
"阴道"
],
"character": [
"少量",
"鲜红色"
],
"core_name": "出血",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "发热",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "寒颤",
"tendency": "否定"
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "腹胀",
"tendency": "否定"
}
] |
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。 | 2,057 | [
{
"anatomy_list": [
"右半结肠",
"回盲部"
],
"character": [],
"core_name": "肿瘤",
"tendency": ""
},
{
"anatomy_list": [
"右半结肠",
"回盲部"
],
"character": [
"管状",
"隆起型",
"ii级"
],
"core_name": "管状腺癌",
"tendency": ""
},
{
"anatomy_list": [
"右半结肠",
"回盲部"
],
"character": [],
"core_name": "坏死",
"tendency": ""
},
{
"anatomy_list": [
"右半结肠",
"回盲部"
],
"character": [
"部分",
"粘液"
],
"core_name": "腺癌",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"侵出浆膜达脂肪组织"
],
"core_name": "癌组织",
"tendency": ""
},
{
"anatomy_list": [
"回盲部"
],
"character": [],
"core_name": "肿瘤",
"tendency": ""
},
{
"anatomy_list": [
"腹壁肌肉"
],
"character": [
"累及"
],
"core_name": "肿瘤",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"未见确切"
],
"core_name": "癌栓",
"tendency": ""
},
{
"anatomy_list": [
"神经"
],
"character": [
"侵犯"
],
"core_name": "肿瘤",
"tendency": ""
},
{
"anatomy_list": [
"结肠环周切缘"
],
"character": [
"累及",
"粘液"
],
"core_name": "腺癌",
"tendency": ""
},
{
"anatomy_list": [
"阑尾区"
],
"character": [
"累及"
],
"core_name": "癌",
"tendency": "否定"
},
{
"anatomy_list": [
"盆侧壁"
],
"character": [
"累及"
],
"core_name": "癌",
"tendency": ""
},
{
"anatomy_list": [
"结肠"
],
"character": [],
"core_name": "息肉",
"tendency": ""
},
{
"anatomy_list": [
"结肠"
],
"character": [
"绒毛状"
],
"core_name": "腺瘤",
"tendency": ""
},
{
"anatomy_list": [
"区域淋巴结",
"肠周脂肪淋巴结",
"肠系膜上淋巴结"
],
"character": [
"转移"
],
"core_name": "癌",
"tendency": ""
}
] |
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。 | 1,455 | [
{
"anatomy_list": [
"左肩部"
],
"character": [
"隐痛",
"持续性"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"左肩部"
],
"character": [
"活动时疼痛加重",
"呈刺痛",
"停止活动可缓解"
],
"core_name": "疼痛",
"tendency": ""
}
] |
腋窝淋巴结未见癌转移（0/11），免疫组化：er（-），pr（-），ccrbb-2（3+），ki676730%（+）。 | 1,643 | [
{
"anatomy_list": [
"腋窝淋巴结"
],
"character": [
"转移"
],
"core_name": "癌",
"tendency": "否定"
}
] |
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。 | 337 | [
{
"anatomy_list": [
"右侧乳腺"
],
"character": [
"浸润性"
],
"core_name": "癌",
"tendency": ""
},
{
"anatomy_list": [
"右侧乳腺"
],
"character": [
"浸润性"
],
"core_name": "癌",
"tendency": ""
},
{
"anatomy_list": [
"腋窝淋巴结"
],
"character": [],
"core_name": "转移",
"tendency": ""
}
] |
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。 | 814 | [
{
"anatomy_list": [],
"character": [],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"白色",
"粘性",
"易咳出"
],
"core_name": "咳痰",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "呼吸困难",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "端坐呼吸",
"tendency": ""
},
{
"anatomy_list": [
"双下肢"
],
"character": [],
"core_name": "水肿",
"tendency": ""
},
{
"anatomy_list": [
"双下肢"
],
"character": [],
"core_name": "乏力",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "潮热",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "盗汗",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "咯血",
"tendency": "否定"
},
{
"anatomy_list": [
"头"
],
"character": [],
"core_name": "头昏",
"tendency": "否定"
},
{
"anatomy_list": [
"头"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [
"心"
],
"character": [],
"core_name": "心悸",
"tendency": "否定"
},
{
"anatomy_list": [
"胸"
],
"character": [],
"core_name": "胸闷",
"tendency": "否定"
},
{
"anatomy_list": [
"胸"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "反酸",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "嗳气",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "恶心",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "呕吐",
"tendency": "否定"
},
{
"anatomy_list": [
"肩背部"
],
"character": [
"放射性"
],
"core_name": "疼痛",
"tendency": "否定"
}
] |
4、脾大，脾内增强回声结节。 | 378 | [
{
"anatomy_list": [
"脾"
],
"character": [
"大"
],
"core_name": "脾大",
"tendency": ""
},
{
"anatomy_list": [
"脾内"
],
"character": [
"增强回声"
],
"core_name": "结节",
"tendency": ""
}
] |
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。 | 317 | [
{
"anatomy_list": [
"宫腔内"
],
"character": [],
"core_name": "异常回声",
"tendency": "不确定"
},
{
"anatomy_list": [
"子宫内膜"
],
"character": [],
"core_name": "癌",
"tendency": "不确定"
},
{
"anatomy_list": [
"子宫内膜"
],
"character": [],
"core_name": "子宫内膜炎",
"tendency": "不确定"
},
{
"anatomy_list": [
"宫内"
],
"character": [],
"core_name": "节育器嵌顿",
"tendency": "不确定"
}
] |
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。 | 1,758 | [
{
"anatomy_list": [
"左乳"
],
"character": [],
"core_name": "包块",
"tendency": ""
},
{
"anatomy_list": [
"左乳内上象限"
],
"character": [
"性质待定"
],
"core_name": "肿块",
"tendency": ""
}
] |
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。 | 1,458 | [
{
"anatomy_list": [],
"character": [
"缓解"
],
"core_name": "咯血",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "咯血",
"tendency": ""
}
] |
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。 | 1,755 | [
{
"anatomy_list": [
"肝左内叶"
],
"character": [
"缺失"
],
"core_name": "缺失",
"tendency": ""
},
{
"anatomy_list": [
"邻近肝实质"
],
"character": [
"多发"
],
"core_name": "密度影",
"tendency": ""
},
{
"anatomy_list": [
"肝"
],
"character": [],
"core_name": "硬化",
"tendency": ""
},
{
"anatomy_list": [
"脾"
],
"character": [],
"core_name": "脾大",
"tendency": ""
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "腹水",
"tendency": ""
},
{
"anatomy_list": [
"肝内胆管"
],
"character": [
"扩张"
],
"core_name": "扩张",
"tendency": ""
},
{
"anatomy_list": [
"右侧胸腔"
],
"character": [
"中量"
],
"core_name": "积液",
"tendency": ""
},
{
"anatomy_list": [
"右肺下叶"
],
"character": [],
"core_name": "肺不张",
"tendency": ""
},
{
"anatomy_list": [
"右肺下叶"
],
"character": [],
"core_name": "实变",
"tendency": ""
}
] |
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。 | 995 | [
{
"anatomy_list": [],
"character": [],
"core_name": "喘累",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "呼吸困难",
"tendency": ""
},
{
"anatomy_list": [
"气管"
],
"character": [],
"core_name": "气管新生物",
"tendency": ""
},
{
"anatomy_list": [
"支气管"
],
"character": [
"新生物致"
],
"core_name": "狭窄",
"tendency": ""
},
{
"anatomy_list": [
"气管"
],
"character": [
"腺样囊性"
],
"core_name": "癌",
"tendency": ""
}
] |
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。 | 501 | [
{
"anatomy_list": [],
"character": [
"进食后",
"胃液"
],
"core_name": "反流",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"偶有"
],
"core_name": "呕吐",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"进食"
],
"core_name": "梗阻感",
"tendency": "否定"
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [
"左侧手术伤口处"
],
"character": [],
"core_name": "疼痛",
"tendency": ""
}
] |
患儿患病以来精神好，食欲好，大小便正常。 | 77 | [
{
"anatomy_list": [],
"character": [
"好"
],
"core_name": "精神",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"好"
],
"core_name": "食欲",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"正常"
],
"core_name": "大小便",
"tendency": ""
}
] |
（2018-1-15 我院）病检结果（123456）提示直肠腺癌。 | 1,031 | [
{
"anatomy_list": [
"直肠"
],
"character": [],
"core_name": "腺癌",
"tendency": ""
}
] |
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。 | 184 | [
{
"anatomy_list": [
"胃"
],
"character": [],
"core_name": "胃潴留",
"tendency": ""
}
] |
肝中静脉显示欠佳，请结合临床随诊。 | 455 | [
{
"anatomy_list": [
"肝中静脉"
],
"character": [
"欠佳"
],
"core_name": "显示",
"tendency": ""
}
] |
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。 | 34 | [
{
"anatomy_list": [],
"character": [
"减退"
],
"core_name": "食欲",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"清醒"
],
"core_name": "神志",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"尚可"
],
"core_name": "精神",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"尚可"
],
"core_name": "睡眠",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"正常"
],
"core_name": "大便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"量少"
],
"core_name": "小便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"明显"
],
"core_name": "体重变化",
"tendency": "否定"
}
] |
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。 | 1,714 | [
{
"anatomy_list": [],
"character": [
"较前下降"
],
"core_name": "精神",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"较前下降"
],
"core_name": "食欲",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"正常"
],
"core_name": "大小便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "体重下降",
"tendency": ""
}
] |
患者未重视未就诊，期间胸痛程度逐渐加重。 | 288 | [
{
"anatomy_list": [
"胸"
],
"character": [
"程度逐渐加重"
],
"core_name": "疼痛",
"tendency": ""
}
] |
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。 | 949 | [
{
"anatomy_list": [
"上腹"
],
"character": [
"饮酒后",
"隐痛",
"持续数秒后可自行好转"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"上腹"
],
"character": [],
"core_name": "饱胀感",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "嗳气",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "反酸",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "烧心",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "恶心",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "呕吐",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "便血",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"粘液",
"脓血"
],
"core_name": "大便",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "厌油",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "乏力",
"tendency": "否定"
},
{
"anatomy_list": [
"皮肤"
],
"character": [],
"core_name": "黄染",
"tendency": "否定"
},
{
"anatomy_list": [
"巩膜"
],
"character": [],
"core_name": "黄染",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "尿黄",
"tendency": "否定"
}
] |
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。 | 1,099 | [
{
"anatomy_list": [],
"character": [],
"core_name": "尿频",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "尿急",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"严重影响"
],
"core_name": "睡眠",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "尿痛",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "血尿",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "畏寒",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "发热",
"tendency": "否定"
}
] |
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。 | 297 | [
{
"anatomy_list": [
"膀胱右前壁"
],
"character": [
"菜花样",
"有蒂"
],
"core_name": "新生物",
"tendency": ""
}
] |
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。 | 973 | [
{
"anatomy_list": [
"胸腔"
],
"character": [],
"core_name": "积液",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"胸水量"
],
"core_name": "减少",
"tendency": ""
}
] |
2、门静脉增宽，门静脉内低回声（栓子？）3、胆囊结石。 | 377 | [
{
"anatomy_list": [
"门静脉"
],
"character": [],
"core_name": "增宽",
"tendency": ""
},
{
"anatomy_list": [
"门静脉内"
],
"character": [
"低"
],
"core_name": "回声",
"tendency": ""
},
{
"anatomy_list": [
"门静脉内"
],
"character": [],
"core_name": "栓子",
"tendency": "不确定"
},
{
"anatomy_list": [
"胆囊"
],
"character": [],
"core_name": "结石",
"tendency": ""
}
] |
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。 | 1,993 | [
{
"anatomy_list": [
"结肠"
],
"character": [],
"core_name": "腺癌",
"tendency": ""
},
{
"anatomy_list": [
"升结肠"
],
"character": [
"中分化",
"侵及全层"
],
"core_name": "腺癌",
"tendency": ""
},
{
"anatomy_list": [
"升结肠"
],
"character": [
"粘液性",
"部分"
],
"core_name": "腺癌",
"tendency": ""
},
{
"anatomy_list": [
"双侧切缘及系膜切缘"
],
"character": [
"累及"
],
"core_name": "癌",
"tendency": "否定"
},
{
"anatomy_list": [
"肠周脂肪组织"
],
"character": [
"转移",
"淋巴结"
],
"core_name": "癌",
"tendency": "否定"
}
] |
主动脉瓣狭窄（中度）伴关闭不全（轻度）。 | 472 | [
{
"anatomy_list": [
"主动脉瓣"
],
"character": [
"中度"
],
"core_name": "狭窄",
"tendency": ""
},
{
"anatomy_list": [
"主动脉瓣"
],
"character": [
"轻度"
],
"core_name": "关闭不全",
"tendency": ""
}
] |
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。 | 1,558 | [
{
"anatomy_list": [],
"character": [
"进食",
"进食粗糙食物明显"
],
"core_name": "梗阻",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "恶心",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "呕吐",
"tendency": "否定"
},
{
"anatomy_list": [
"胸骨后"
],
"character": [],
"core_name": "灼烧感",
"tendency": "否定"
},
{
"anatomy_list": [
"腹部"
],
"character": [
"胀痛"
],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "反酸",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "嗳气",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "畏寒",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "声嘶",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"饮水"
],
"core_name": "呛咳",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "发热",
"tendency": "否定"
}
] |
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。 | 736 | [
{
"anatomy_list": [],
"character": [
"突发"
],
"core_name": "意识丧失",
"tendency": ""
},
{
"anatomy_list": [],
"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"
],
"core_name": "意识恢复",
"tendency": ""
}
] |
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。 | 1,314 | [
{
"anatomy_list": [],
"character": [
"清醒"
],
"core_name": "神志",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"欠佳"
],
"core_name": "精神",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"尚可"
],
"core_name": "睡眠",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"正常"
],
"core_name": "大便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"正常"
],
"core_name": "小便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"明显"
],
"core_name": "体重改变",
"tendency": "否定"
}
] |
2、上腹部平扫未见明显异常。 | 942 | [
{
"anatomy_list": [
"上腹部"
],
"character": [],
"core_name": "异常",
"tendency": "否定"
}
] |
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。 | 1,604 | [
{
"anatomy_list": [
"下腹"
],
"character": [],
"core_name": "坠胀",
"tendency": ""
},
{
"anatomy_list": [
"阴道"
],
"character": [],
"core_name": "出血",
"tendency": ""
},
{
"anatomy_list": [
"鳞状上皮"
],
"character": [
"高度"
],
"core_name": "病变",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"阳性"
],
"core_name": "hpv16型",
"tendency": ""
}
] |
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。 | 502 | [
{
"anatomy_list": [
"肛门"
],
"character": [],
"core_name": "排气",
"tendency": "否定"
},
{
"anatomy_list": [
"肛门"
],
"character": [],
"core_name": "排便",
"tendency": "否定"
},
{
"anatomy_list": [
"食管"
],
"character": [
"术后"
],
"core_name": "癌",
"tendency": ""
}
] |
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,。 | 1,351 | [
{
"anatomy_list": [
"左侧乳房"
],
"character": [
"逐渐增大"
],
"core_name": "包块",
"tendency": ""
},
{
"anatomy_list": [
"乳腺"
],
"character": [],
"core_name": "癌",
"tendency": ""
},
{
"anatomy_list": [
"左侧乳腺"
],
"character": [
"浸润性",
"术后恢复可"
],
"core_name": "癌",
"tendency": ""
}
] |
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。 | 597 | [
{
"anatomy_list": [
"胆囊壁"
],
"character": [
"与邻近肝脏病灶分界欠清"
],
"core_name": "增厚",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"慢性"
],
"core_name": "炎症",
"tendency": "不确定"
},
{
"anatomy_list": [],
"character": [
"累及"
],
"core_name": "肿瘤",
"tendency": "不确定"
}
] |
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。 | 100 | [
{
"anatomy_list": [
"残胃吻合口"
],
"character": [
"低分化"
],
"core_name": "腺癌",
"tendency": ""
},
{
"anatomy_list": [
"胃"
],
"character": [],
"core_name": "残胃",
"tendency": ""
}
] |
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。 | 1,166 | [
{
"anatomy_list": [
"胸"
],
"character": [],
"core_name": "胸闷",
"tendency": ""
},
{
"anatomy_list": [
"心"
],
"character": [],
"core_name": "心悸",
"tendency": ""
},
{
"anatomy_list": [
"头"
],
"character": [
"体位改变时"
],
"core_name": "头昏",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"阵阵",
"干咳为主"
],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "畏寒",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "发热",
"tendency": "否定"
},
{
"anatomy_list": [
"头"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "恶心",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "呕吐",
"tendency": "否定"
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "腹泻",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "咯血",
"tendency": "否定"
}
] |
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。 | 390 | [
{
"anatomy_list": [
"左乳腺"
],
"character": [
"根治术后"
],
"core_name": "腺癌",
"tendency": ""
}
] |
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。 | 1,703 | [
{
"anatomy_list": [],
"character": [
"清楚"
],
"core_name": "神志",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"尚可"
],
"core_name": "精神",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"一般"
],
"core_name": "饮食",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"可"
],
"core_name": "睡眠",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"明显"
],
"core_name": "大小便异常",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"明显"
],
"core_name": "体重减轻",
"tendency": "否定"
}
] |
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。 | 541 | [
{
"anatomy_list": [
"心"
],
"character": [
"活动后"
],
"core_name": "心悸",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"活动后"
],
"core_name": "气促",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"走平路即感"
],
"core_name": "气促",
"tendency": ""
},
{
"anatomy_list": [
"双下肢"
],
"character": [
"凹陷性"
],
"core_name": "水肿",
"tendency": ""
},
{
"anatomy_list": [
"肝"
],
"character": [],
"core_name": "癌",
"tendency": ""
}
] |
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。 | 172 | [
{
"anatomy_list": [
"左侧输尿管上段"
],
"character": [
"受累"
],
"core_name": "狭窄",
"tendency": ""
},
{
"anatomy_list": [
"左侧输尿管上段",
"肾盂"
],
"character": [],
"core_name": "扩张",
"tendency": ""
},
{
"anatomy_list": [
"左侧输尿管上段",
"肾盂"
],
"character": [],
"core_name": "积水",
"tendency": ""
}
] |
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。 | 1,985 | [
{
"anatomy_list": [
"切口"
],
"character": [],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"切口"
],
"character": [],
"core_name": "切口不适",
"tendency": ""
},
{
"anatomy_list": [
"腹部"
],
"character": [],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "恶心",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "呕吐",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "呕血",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "眩晕",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "黑朦",
"tendency": "否定"
},
{
"anatomy_list": [
"心"
],
"character": [],
"core_name": "心悸",
"tendency": "否定"
},
{
"anatomy_list": [
"胸"
],
"character": [],
"core_name": "胸闷",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "咳嗽",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "咳痰",
"tendency": "否定"
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "腹胀",
"tendency": "否定"
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "腹泻",
"tendency": "否定"
},
{
"anatomy_list": [
"结肠"
],
"character": [
"术后"
],
"core_name": "癌",
"tendency": ""
}
] |
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）。 | 232 | [
{
"anatomy_list": [],
"character": [
"每日饮水量2000ml"
],
"core_name": "多饮",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"饮水量与尿量相当"
],
"core_name": "多尿",
"tendency": ""
},
{
"anatomy_list": [
"全身"
],
"character": [],
"core_name": "乏力",
"tendency": ""
},
{
"anatomy_list": [
"双下肢"
],
"character": [],
"core_name": "麻木",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "易饥多食",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "视物模糊",
"tendency": "否定"
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "腹泻",
"tendency": "否定"
},
{
"anatomy_list": [
"心前区"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [
"心"
],
"character": [
"活动后"
],
"core_name": "心累",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"活动后"
],
"core_name": "气促",
"tendency": "否定"
},
{
"anatomy_list": [
"四肢肢端"
],
"character": [],
"core_name": "麻木",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"2型"
],
"core_name": "糖尿病",
"tendency": ""
}
] |
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。 | 1,713 | [
{
"anatomy_list": [],
"character": [
"突然出现"
],
"core_name": "食欲下降",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"量较前减少约1/2",
"以流质饮食为主"
],
"core_name": "进食",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "乏力",
"tendency": "否定"
},
{
"anatomy_list": [
"头"
],
"character": [],
"core_name": "头昏",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "咳嗽",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "咳痰",
"tendency": "否定"
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "腹泻",
"tendency": "否定"
},
{
"anatomy_list": [
"全身"
],
"character": [],
"core_name": "乏力",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "不能行走",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "嗜睡",
"tendency": ""
},
{
"anatomy_list": [
"头"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "呕吐",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "抽搐",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "大小便失禁",
"tendency": "否定"
},
{
"anatomy_list": [
"肺部"
],
"character": [],
"core_name": "感染",
"tendency": ""
}
] |
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。 | 1,082 | [
{
"anatomy_list": [
"前列腺"
],
"character": [],
"core_name": "增生",
"tendency": ""
},
{
"anatomy_list": [
"膀胱"
],
"character": [
"术后"
],
"core_name": "造瘘",
"tendency": ""
}
] |
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。 | 347 | [
{
"anatomy_list": [],
"character": [
"滴沥感"
],
"core_name": "小便",
"tendency": ""
}
] |
腹胀伴肛门停止排气、排便。 | 556 | [
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "腹胀",
"tendency": ""
},
{
"anatomy_list": [
"肛门"
],
"character": [
"停止"
],
"core_name": "排气",
"tendency": ""
},
{
"anatomy_list": [
"肛门"
],
"character": [
"停止"
],
"core_name": "排便",
"tendency": ""
}
] |
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。 | 8 | [
{
"anatomy_list": [],
"character": [
"异常增高"
],
"core_name": "癌胚抗原",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"肿瘤性"
],
"core_name": "病变",
"tendency": "不确定"
},
{
"anatomy_list": [
"食管"
],
"character": [],
"core_name": "癌",
"tendency": "不确定"
}
] |
（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。 | 839 | [
{
"anatomy_list": [
"左前哨淋巴结"
],
"character": [
"转移"
],
"core_name": "癌",
"tendency": ""
}
] |
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。 | 278 | [
{
"anatomy_list": [],
"character": [],
"core_name": "基因突变",
"tendency": "否定"
}
] |
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。 | 1,596 | [
{
"anatomy_list": [
"心"
],
"character": [
"活动后反复发作"
],
"core_name": "心累",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"活动后反复发作"
],
"core_name": "气促",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"逐渐下降"
],
"core_name": "活动耐量",
"tendency": ""
},
{
"anatomy_list": [
"心"
],
"character": [
"平路行走后加重",
"活动后加重"
],
"core_name": "心累",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"平路行走后加重",
"活动后加重"
],
"core_name": "气促",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"夜间",
"阵发性"
],
"core_name": "呼吸困难",
"tendency": ""
},
{
"anatomy_list": [
"双下肢"
],
"character": [],
"core_name": "水肿",
"tendency": ""
},
{
"anatomy_list": [
"心前区"
],
"character": [
"偶有"
],
"core_name": "紧闷",
"tendency": ""
},
{
"anatomy_list": [
"右冠"
],
"character": [],
"core_name": "右冠优势型",
"tendency": ""
},
{
"anatomy_list": [
"左主干"
],
"character": [],
"core_name": "异常",
"tendency": "否定"
},
{
"anatomy_list": [
"前降支近中段"
],
"character": [],
"core_name": "斑块",
"tendency": ""
},
{
"anatomy_list": [
"回旋支"
],
"character": [
"管腔"
],
"core_name": "细小",
"tendency": ""
},
{
"anatomy_list": [
"回旋支中段"
],
"character": [
"局限性",
"浸润"
],
"core_name": "斑块",
"tendency": ""
},
{
"anatomy_list": [
"右冠近段"
],
"character": [
"向心性"
],
"core_name": "斑块",
"tendency": ""
},
{
"anatomy_list": [
"回旋支中段"
],
"character": [
"最严重处狭窄约80%"
],
"core_name": "狭窄",
"tendency": ""
},
{
"anatomy_list": [
"右冠状动脉近段"
],
"character": [
"最严重处狭窄约40%"
],
"core_name": "狭窄",
"tendency": ""
},
{
"anatomy_list": [
"左主干"
],
"character": [
"最严重处狭窄约50%"
],
"core_name": "狭窄",
"tendency": ""
}
] |
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。 | 1,852 | [
{
"anatomy_list": [
"头"
],
"character": [],
"core_name": "头昏",
"tendency": ""
},
{
"anatomy_list": [
"头"
],
"character": [],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "呕吐",
"tendency": ""
},
{
"anatomy_list": [
"脑"
],
"character": [],
"core_name": "转移",
"tendency": "否定"
}
] |
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。 | 613 | [
{
"anatomy_list": [],
"character": [
"稍好转"
],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"稍好转"
],
"core_name": "咳痰",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"带血"
],
"core_name": "咳痰",
"tendency": "否定"
},
{
"anatomy_list": [
"左上肺"
],
"character": [],
"core_name": "包块",
"tendency": ""
},
{
"anatomy_list": [
"左上肺"
],
"character": [
"纤维支气管镜检及病理"
],
"core_name": "鳞癌",
"tendency": ""
},
{
"anatomy_list": [
"骨组织"
],
"character": [],
"core_name": "转移",
"tendency": "否定"
},
{
"anatomy_list": [
"左上肺"
],
"character": [
"t2n0M0期"
],
"core_name": "鳞癌",
"tendency": ""
}
] |
3.主动脉壁钙化。 | 1,206 | [
{
"anatomy_list": [
"主动脉壁"
],
"character": [],
"core_name": "钙化",
"tendency": ""
}
] |
乙肝三对示“大三阳”。 | 1,003 | [
{
"anatomy_list": [
"肝"
],
"character": [],
"core_name": "肝炎",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "大三阳",
"tendency": ""
}
] |
今为行再诱导i化疗，门诊以“急性白血病”收住院。 | 1,471 | [
{
"anatomy_list": [],
"character": [
"急性"
],
"core_name": "白血病",
"tendency": ""
}
] |
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。 | 646 | [
{
"anatomy_list": [
"阴道"
],
"character": [],
"core_name": "出血",
"tendency": "否定"
},
{
"anatomy_list": [
"阴道"
],
"character": [],
"core_name": "流液",
"tendency": "否定"
},
{
"anatomy_list": [
"阴道"
],
"character": [
"葡萄胎样组织"
],
"core_name": "排出",
"tendency": "否定"
},
{
"anatomy_list": [
"肛门"
],
"character": [],
"core_name": "坠胀",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "咳嗽",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "咯血",
"tendency": "否定"
},
{
"anatomy_list": [
"心"
],
"character": [],
"core_name": "心慌",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "恶心",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "发热",
"tendency": "否定"
},
{
"anatomy_list": [
"滋养细胞"
],
"character": [],
"core_name": "肿瘤",
"tendency": ""
}
] |
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。 | 1,416 | [
{
"anatomy_list": [],
"character": [],
"core_name": "发热",
"tendency": "否定"
},
{
"anatomy_list": [
"腹"
],
"character": [
"胀痛"
],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [
"阴道"
],
"character": [
"异常"
],
"core_name": "出血",
"tendency": "否定"
},
{
"anatomy_list": [
"阴道"
],
"character": [
"异常"
],
"core_name": "流液",
"tendency": "否定"
},
{
"anatomy_list": [
"双下肢"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "恶心",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "呕吐",
"tendency": ""
},
{
"anatomy_list": [
"左侧卵巢"
],
"character": [
"iv期",
"术后"
],
"core_name": "腺癌",
"tendency": ""
}
] |
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。 | 855 | [
{
"anatomy_list": [],
"character": [
"正常"
],
"core_name": "食欲",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"清醒"
],
"core_name": "神志",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"尚可"
],
"core_name": "精神",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"尚可"
],
"core_name": "睡眠",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"正常"
],
"core_name": "大便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"正常"
],
"core_name": "小便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"明显"
],
"core_name": "体重改变",
"tendency": "否定"
}
] |
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。 | 1,789 | [
{
"anatomy_list": [
"右下肢"
],
"character": [],
"core_name": "行走困难",
"tendency": "否定"
},
{
"anatomy_list": [
"右踝关节"
],
"character": [],
"core_name": "活动受限",
"tendency": "否定"
},
{
"anatomy_list": [
"下肢"
],
"character": [],
"core_name": "感觉异常",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"可耐受",
"行走时加重"
],
"core_name": "疼痛",
"tendency": ""
}
] |
门诊遂以“后循环缺血”收治入院。 | 285 | [
{
"anatomy_list": [
"后循环"
],
"character": [],
"core_name": "缺血",
"tendency": ""
}
] |
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。 | 2,069 | [
{
"anatomy_list": [
"左侧上颌骨"
],
"character": [],
"core_name": "肿瘤",
"tendency": ""
}
] |
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）。 | 1,255 | [
{
"anatomy_list": [
"胃窦粘膜下"
],
"character": [],
"core_name": "肿瘤",
"tendency": ""
},
{
"anatomy_list": [
"胃窦平滑肌"
],
"character": [],
"core_name": "肿瘤",
"tendency": "不确定"
}
] |
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 。 | 385 | [
{
"anatomy_list": [],
"character": [
"可"
],
"core_name": "精神",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"较差"
],
"core_name": "食欲",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"可"
],
"core_name": "睡眠",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"如常"
],
"core_name": "大便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"如常"
],
"core_name": "小便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"明显"
],
"core_name": "体重变化",
"tendency": "否定"
}
] |
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）。 | 1,664 | [
{
"anatomy_list": [],
"character": [
"下降"
],
"core_name": "食欲",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"清醒"
],
"core_name": "神志",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"欠佳"
],
"core_name": "精神",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"尚可"
],
"core_name": "睡眠",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"正常"
],
"core_name": "大便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"量多"
],
"core_name": "小便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"下降"
],
"core_name": "体重",
"tendency": ""
}
] |
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。 | 1,592 | [
{
"anatomy_list": [
"左乳"
],
"character": [],
"core_name": "红肿",
"tendency": "否定"
},
{
"anatomy_list": [
"左乳"
],
"character": [],
"core_name": "破损",
"tendency": "否定"
},
{
"anatomy_list": [
"左乳"
],
"character": [],
"core_name": "溢液",
"tendency": "否定"
},
{
"anatomy_list": [
"乳头"
],
"character": [],
"core_name": "凹陷",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "发热",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "寒战",
"tendency": "否定"
}
] |
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。 | 1,556 | [
{
"anatomy_list": [
"左颈淋巴结"
],
"character": [
"转移性"
],
"core_name": "鳞癌",
"tendency": ""
}
] |
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。 | 691 | [
{
"anatomy_list": [
"阴道"
],
"character": [
"少量"
],
"core_name": "出血",
"tendency": ""
},
{
"anatomy_list": [
"宫内"
],
"character": [],
"core_name": "孕囊",
"tendency": ""
},
{
"anatomy_list": [
"宫内"
],
"character": [
"未见"
],
"core_name": "卵黄囊",
"tendency": ""
},
{
"anatomy_list": [
"宫内"
],
"character": [
"可见"
],
"core_name": "胎芽",
"tendency": ""
},
{
"anatomy_list": [
"心管"
],
"character": [
"原始",
"可见"
],
"core_name": "搏动",
"tendency": ""
}
] |
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。 | 376 | [
{
"anatomy_list": [
"剑突下"
],
"character": [
"隐痛"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "呕血",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "黑便",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "发热",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "畏寒",
"tendency": "否定"
},
{
"anatomy_list": [
"皮肤",
"巩膜"
],
"character": [],
"core_name": "黄染",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "意识改变",
"tendency": "否定"
},
{
"anatomy_list": [
"肝"
],
"character": [
"增粗",
"不均质"
],
"core_name": "回声",
"tendency": ""
},
{
"anatomy_list": [
"肝内"
],
"character": [],
"core_name": "异常回声",
"tendency": ""
},
{
"anatomy_list": [
"肝"
],
"character": [],
"core_name": "癌",
"tendency": "不确定"
}
] |
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。 | 62 | [
{
"anatomy_list": [
"肝左叶"
],
"character": [],
"core_name": "异常信号",
"tendency": ""
},
{
"anatomy_list": [
"肝左叶"
],
"character": [
"强化"
],
"core_name": "结节",
"tendency": ""
},
{
"anatomy_list": [
"肝"
],
"character": [],
"core_name": "癌",
"tendency": "不确定"
}
] |
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。 | 130 | [
{
"anatomy_list": [
"左乳"
],
"character": [
"术后",
"第3次化疗后"
],
"core_name": "癌",
"tendency": ""
}
] |
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。 | 1,889 | [
{
"anatomy_list": [
"鼻咽"
],
"character": [],
"core_name": "癌",
"tendency": "不确定"
},
{
"anatomy_list": [
"鼻咽"
],
"character": [],
"core_name": "癌",
"tendency": ""
},
{
"anatomy_list": [
"肺"
],
"character": [
"转移"
],
"core_name": "癌",
"tendency": ""
},
{
"anatomy_list": [
"鼻"
],
"character": [],
"core_name": "鼻衄",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "呼吸困难",
"tendency": "否定"
},
{
"anatomy_list": [
"胃肠道"
],
"character": [],
"core_name": "胃肠道反应",
"tendency": "否定"
},
{
"anatomy_list": [
"骨髓"
],
"character": [],
"core_name": "骨髓抑制",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "脱发",
"tendency": "否定"
}
] |
患者为行进一步治疗，门诊以“脾血管肉瘤术后”收入我科。 | 1,016 | [
{
"anatomy_list": [
"脾"
],
"character": [
"术后",
"血管"
],
"core_name": "肉瘤",
"tendency": ""
}
] |