text
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": "" } ]