text
stringlengths 5
708
| id
int64 1
2.07k
| event
list |
|---|---|---|
门诊以“宫颈包块，粘膜下肌瘤”收入我科住院治疗。 | 98 | [
{
"anatomy_list": [
"宫颈"
],
"character": [],
"core_name": "包块",
"tendency": ""
},
{
"anatomy_list": [
"粘膜下"
],
"character": [],
"core_name": "肌瘤",
"tendency": ""
}
] |
患者2年前常规体检行乳腺彩超提示左乳一纤维腺瘤（未见报告），患者未予处理。 | 323 | [
{
"anatomy_list": [
"左乳"
],
"character": [],
"core_name": "纤维腺瘤",
"tendency": ""
}
] |
分别于10月11日、11月11日、12月05日给予dp方案化疗3周期（药物总量：多西他赛290mg，顺铂240mg）化疗过程顺利，化疗期间患者无明显消化道反应及神经毒性反应，患者未规范监测血常规。 | 1,303 | [
{
"anatomy_list": [
"消化道"
],
"character": [
"明显"
],
"core_name": "消化道反应",
"tendency": "否定"
},
{
"anatomy_list": [
"神经"
],
"character": [],
"core_name": "毒性反应",
"tendency": "否定"
}
] |
患者本次发病以来，食欲正常， 神志清醒，精神尚可，睡眠尚可，大便正常，小便正常，体重增加。 | 1,589 | [
{
"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": [
"增加"
],
"core_name": "体重",
"tendency": ""
}
] |
病程中患者多次因贫血、感染入院，予以输血、抗感染等治疗后好转出院，院外长期予以沙利度按治疗。 | 1,501 | [
{
"anatomy_list": [],
"character": [],
"core_name": "贫血",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "感染",
"tendency": ""
}
] |
完善纤支镜提示黏膜上皮细胞，无手术禁忌症，于2016年12月06日在全麻下行右肺下叶肿物切除术，术后病检示：中分化鳞状细胞癌，（叶间裂）淋巴结2/2枚有低分化鳞状转移。 | 1,103 | [
{
"anatomy_list": [],
"character": [
"中分化"
],
"core_name": "鳞癌",
"tendency": ""
},
{
"anatomy_list": [
"（叶间裂）淋巴结"
],
"character": [
"低分化",
"鳞状"
],
"core_name": "转移",
"tendency": ""
}
] |
患者于 1周 前无意中发现 左侧乳腺外上象限 肿块， 大小约2*3cm，质韧，无压痛 ，无局部红肿热痛，无发热寒战，无乳头溢液，无橘皮症，无酒窝征。 | 496 | [
{
"anatomy_list": [
"左侧乳腺外上象限"
],
"character": [
"质韧"
],
"core_name": "肿块",
"tendency": ""
},
{
"anatomy_list": [
"左侧乳腺外上象限"
],
"character": [],
"core_name": "压痛",
"tendency": "否定"
},
{
"anatomy_list": [
"左侧乳腺外上象限"
],
"character": [
"局部"
],
"core_name": "红肿",
"tendency": "否定"
},
{
"anatomy_list": [
"左侧乳腺外上象限"
],
"character": [
"热痛",
"局部"
],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "发热",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "寒颤",
"tendency": "否定"
},
{
"anatomy_list": [
"乳头"
],
"character": [],
"core_name": "溢液",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "橘皮症",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "酒窝征",
"tendency": "否定"
}
] |
入院前1月，患者 无明显诱因 出现咳嗽，干咳为主，偶有少许白色泡沫痰，无 呼吸困难、气促 ，无 胸痛 ，无 咯血 ，无畏寒、发热，无盗汗， 不伴腹痛、腹泻 ； 不伴双下肢肿 。 | 1,073 | [
{
"anatomy_list": [],
"character": [],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"干性"
],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"白色",
"泡沫",
"偶有",
"少许"
],
"core_name": "咳痰",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "呼吸困难",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "气促",
"tendency": "否定"
},
{
"anatomy_list": [
"胸"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "咯血",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "畏寒",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "发热",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "盗汗",
"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": [
"双下肢"
],
"character": [],
"core_name": "肿",
"tendency": "否定"
}
] |
1+月前,患者因“腹胀、乏力、恶心、纳差10天”入院,查肝功:丙氨酸氨基转移酶:456U/L、门冬氨酸氨基转移酶:241U/L、γ谷氨酰基转移酶:86U/L、球蛋白:18.0g/L；血常规:淋巴细胞#:10.45*10^9/L、淋巴细胞百分比:72.7%、提示淋巴细胞升高,可见异常淋巴细胞；骨髓涂片：成熟淋巴细胞占74.5%；外周疑血疑难细胞学分析：1.有核细胞稍增多；2.粒细胞占26%,形态无明显异常；3.成熟红细胞无明显形态异常,计数一百个有核红细胞未见有核红细胞；4.淋巴细胞占72%,均为成熟淋巴细胞,单核细胞占2%,均为成熟单核细胞；5.血小板散在、少见。 | 47 | [
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "腹胀",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "乏力",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "恶心",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "纳差",
"tendency": ""
},
{
"anatomy_list": [
"淋巴细胞"
],
"character": [],
"core_name": "淋巴细胞异常",
"tendency": ""
}
] |
患者2015-10-22于我院在全麻下腹腔腹腔镜下行卵巢恶性肿瘤细胞减灭术（全子宫、双侧附件、大网膜、阑尾、盆腹膜腹膜转移灶切除术+盆腔淋巴结清扫术），术后病检（123456）示：（左、右卵巢）浆液性乳头状腺癌，中-低分化；（幽门下方大网膜，有髂外，左盆腔，右盆腔）淋巴结见癌转移（2/5、1/1、3/11、16/23），（直肠系膜，左侧盆腔盆腔腹膜腹膜后）见癌累及；（大网膜）未见癌累及；左输卵管系膜囊肿；慢性宫颈炎；增生期子宫内膜；双侧输卵管；（腹水）涂片见癌细胞；阑尾组织。 | 1,029 | [
{
"anatomy_list": [
"左右卵巢"
],
"character": [
"浆液性",
"乳头状",
"中-低分化"
],
"core_name": "腺癌",
"tendency": ""
},
{
"anatomy_list": [
"右盆腔淋巴结"
],
"character": [
"转移"
],
"core_name": "癌",
"tendency": ""
},
{
"anatomy_list": [
"幽门下方大网膜淋巴结"
],
"character": [
"转移"
],
"core_name": "癌",
"tendency": ""
},
{
"anatomy_list": [
"左盆腔淋巴结"
],
"character": [
"转移"
],
"core_name": "癌",
"tendency": ""
},
{
"anatomy_list": [
"髂外淋巴结"
],
"character": [
"转移"
],
"core_name": "癌",
"tendency": ""
},
{
"anatomy_list": [
"右盆腔淋巴结"
],
"character": [
"转移"
],
"core_name": "癌",
"tendency": ""
},
{
"anatomy_list": [
"直肠系膜"
],
"character": [
"累及"
],
"core_name": "癌",
"tendency": ""
},
{
"anatomy_list": [
"左侧盆腔腹膜后"
],
"character": [
"累及"
],
"core_name": "癌",
"tendency": ""
},
{
"anatomy_list": [
"大网膜"
],
"character": [
"累及"
],
"core_name": "癌",
"tendency": "否定"
},
{
"anatomy_list": [
"左输卵管系膜"
],
"character": [],
"core_name": "囊肿",
"tendency": ""
},
{
"anatomy_list": [
"宫颈"
],
"character": [
"慢性"
],
"core_name": "宫颈炎",
"tendency": ""
},
{
"anatomy_list": [
"子宫内膜"
],
"character": [],
"core_name": "增生",
"tendency": ""
},
{
"anatomy_list": [
"细胞"
],
"character": [
"腹水见"
],
"core_name": "癌",
"tendency": ""
}
] |
半年前患者再次双下肢凹陷性水肿，伴气促，无咳嗽、咳痰，无胸闷、胸痛，无心悸，入我院肾内科诊治，血红蛋白 93g/L ↓，肌酐 476.6umol/L，内生肌酐清除率 11.1ml/min，b型尿钠肽前体 10944.00pg/ml，予以降血压、控制血糖、改善循环、营养神经、延缓肾衰、纠正贫血及补钙、利尿等对症支持治疗，患者好转出院。 | 1,373 | [
{
"anatomy_list": [
"双下肢"
],
"character": [
"凹陷性"
],
"core_name": "水肿",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "气促",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "咳嗽",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "咳痰",
"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": [
"心"
],
"character": [],
"core_name": "心悸",
"tendency": "否定"
}
] |
2011-09-01患者门诊胃镜示：浅表性胃窦炎；十二指肠球部隆起（息肉？）；胃体息肉；食管胃吻合口炎。 | 2,048 | [
{
"anatomy_list": [
"胃窦"
],
"character": [
"浅表性"
],
"core_name": "胃窦炎",
"tendency": ""
},
{
"anatomy_list": [
"十二指肠球"
],
"character": [],
"core_name": "十二指肠球隆起",
"tendency": ""
},
{
"anatomy_list": [
"十二指肠球"
],
"character": [],
"core_name": "息肉",
"tendency": "不确定"
},
{
"anatomy_list": [
"胃体"
],
"character": [],
"core_name": "息肉",
"tendency": ""
},
{
"anatomy_list": [
"食管胃吻合口"
],
"character": [],
"core_name": "食管胃吻合口炎",
"tendency": ""
}
] |
入院前5+月，患者无明显诱因出现咳嗽，偶伴咯痰，不伴胸痛，不伴咯血，不伴活动后心累、气促，不咯黄脓痰及铁锈色痰，不伴畏寒、寒战、高热，不伴潮热、盗汗及午后低热。 | 1,954 | [
{
"anatomy_list": [],
"character": [],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"偶"
],
"core_name": "咯痰",
"tendency": ""
},
{
"anatomy_list": [
"胸"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "咯血",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"活动后"
],
"core_name": "气促",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"铁锈色",
"黄脓"
],
"core_name": "咳痰",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "畏寒",
"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": [],
"character": [],
"core_name": "潮热",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "盗汗",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"午后",
"低"
],
"core_name": "发热",
"tendency": "否定"
}
] |
疑诊直肠癌。 | 406 | [
{
"anatomy_list": [
"直肠"
],
"character": [],
"core_name": "癌",
"tendency": ""
}
] |
未到医院诊治，未服药，咽喉疼痛及痰中带血症状逐渐消失。 | 1,717 | [
{
"anatomy_list": [
"咽",
"喉"
],
"character": [
"逐渐消失"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"带血",
"逐渐消失"
],
"core_name": "咳痰",
"tendency": ""
}
] |
入院前1月，患者感上腹胀感，进食后加重，肛门排气及解便后可缓解，伴有烧心、纳差等症状，无恶心、呕吐、畏寒、发热、腹泻、黑便等不适，遂来我院门诊就诊，遂收住入院。 | 822 | [
{
"anatomy_list": [
"上腹"
],
"character": [
"进食后加重",
"肛门排气后缓解",
"解便后可缓解"
],
"core_name": "腹胀",
"tendency": ""
},
{
"anatomy_list": [
"胃"
],
"character": [],
"core_name": "烧心",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "纳差",
"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": "畏寒",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "发热",
"tendency": "否定"
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "腹泻",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "黑便",
"tendency": "否定"
}
] |
患病以来，精神、食欲尚可，大便正常，小便如上述，体重无明显变化。 | 1,156 | [
{
"anatomy_list": [],
"character": [
"尚可"
],
"core_name": "精神",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"尚可"
],
"core_name": "食欲",
"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.慢性非萎缩性胃炎。 | 1,254 | [
{
"anatomy_list": [
"胃"
],
"character": [
"慢性",
"非萎缩性"
],
"core_name": "胃炎",
"tendency": ""
}
] |
入院前2月，患者无明显诱因出现厌油、纳差，饭量为既往的1/2，无反酸、嗳气，无腹痛、腹胀，无头昏、头痛，无发热、寒战，无心悸、气促，无身黄、尿黄等不适，患者未予以重视及治疗。 | 1,237 | [
{
"anatomy_list": [],
"character": [],
"core_name": "厌油",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"饭量为既往的1/2"
],
"core_name": "纳差",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "反酸",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "嗳气",
"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"
},
{
"anatomy_list": [
"头"
],
"character": [],
"core_name": "头昏",
"tendency": "否定"
},
{
"anatomy_list": [
"头"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "发热",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "寒颤",
"tendency": "否定"
},
{
"anatomy_list": [
"心"
],
"character": [],
"core_name": "心悸",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "气促",
"tendency": "否定"
},
{
"anatomy_list": [
"身"
],
"character": [],
"core_name": "黄染",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "尿黄",
"tendency": "否定"
}
] |
门诊以“1.宫颈鳞状细胞癌；2.肝细胞癌切除术后；”收入我科。 | 1,358 | [
{
"anatomy_list": [
"宫颈"
],
"character": [],
"core_name": "鳞癌",
"tendency": ""
},
{
"anatomy_list": [
"肝细胞"
],
"character": [
"切除",
"术后"
],
"core_name": "癌",
"tendency": ""
}
] |
今为求进一步诊治来我院，门诊以“慢性阻塞性肺病伴急性加重”收入我科。 | 2,015 | [
{
"anatomy_list": [
"肺"
],
"character": [
"慢性",
"阻塞性",
"急性加重"
],
"core_name": "肺病",
"tendency": ""
}
] |
行骨髓细胞形态学检查：骨髓增生极度活跃，早幼粒细胞85%；进一步流式细胞检测；cd117+细胞占83.1%，其免疫表型为cd34-，cd117+，cd33+，cd13+，hladr-，cd64+部分，cd14-，cd56-，cd19-，cd7-，cd5-，cd20-。 | 1,655 | [
{
"anatomy_list": [
"骨髓"
],
"character": [
"极度活跃"
],
"core_name": "增生",
"tendency": ""
}
] |
院外患者继续予以中成药抗肿瘤，患者仍述右侧胸痛明显，呈刀割样，伴有右侧后背部牵扯痛，咳嗽及深呼吸加重，持续10秒左右自行缓，予以曲马多缓释片 0.1g q12h 口服可缓解，无咳嗽咳痰，无咯血，无畏寒、发热，无心慌、胸闷，无腹胀、腹泻、腹痛等不适。现拟行维持性化疗入院。 | 967 | [
{
"anatomy_list": [
"右侧胸"
],
"character": [
"明显",
"呈刀割样"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"右侧后背部"
],
"character": [
"牵扯",
"咳嗽及深呼吸加重",
"持续10秒左右自行缓解"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "咳嗽",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "咳痰",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "咯血",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "畏寒",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"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": [
"腹"
],
"character": [],
"core_name": "腹胀",
"tendency": "否定"
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "腹泻",
"tendency": "否定"
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
}
] |
入院前3天，患者因呕吐就诊于某医院，行胸部x线检查提示：双肺中上野见小片、结节状影，感染？其他？建议行ct检查。 | 145 | [
{
"anatomy_list": [],
"character": [],
"core_name": "呕吐",
"tendency": ""
},
{
"anatomy_list": [
"双肺中上野"
],
"character": [
"小片",
"结节状"
],
"core_name": "结节状影",
"tendency": ""
},
{
"anatomy_list": [
"双肺中上野"
],
"character": [],
"core_name": "感染",
"tendency": "不确定"
}
] |
现患者疼痛较前减轻，但右肩活动、深呼吸时仍疼痛明显，右上肢活动、呼吸运动受限，为进一步康复治疗就诊于我科。 | 1,513 | [
{
"anatomy_list": [],
"character": [
"较前减轻"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"右肩"
],
"character": [
"活动、深呼吸时",
"明显"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"右上肢"
],
"character": [],
"core_name": "活动受限",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "呼吸运动受限",
"tendency": ""
}
] |
入院前2月患者疼痛加重，并出现右腰骶部胀痛，口服药物后疼痛缓解，停药后再次加重，患者为明确病情，遂就诊于某医院门诊，行腰椎mri（2019.10.15）检查示“腰5-骶1椎间盘突出；腰5椎体血管瘤”。 | 1,687 | [
{
"anatomy_list": [],
"character": [
"加重"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"右腰骶部"
],
"character": [
"胀痛"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"右腰骶部"
],
"character": [
"口服药物后缓解"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"右腰骶部"
],
"character": [
"停药后再次加重"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"腰5-骶1椎间盘"
],
"character": [],
"core_name": "突出",
"tendency": ""
},
{
"anatomy_list": [
"腰5椎体"
],
"character": [
"血管"
],
"core_name": "瘤",
"tendency": ""
}
] |
无明显食欲下降及体重减轻。 | 426 | [
{
"anatomy_list": [],
"character": [
"明显",
"下降"
],
"core_name": "食欲",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"明显"
],
"core_name": "体重减轻",
"tendency": "否定"
}
] |
4.纵隔及双肺门多发淋巴结肿大伴钙化。 | 682 | [
{
"anatomy_list": [
"纵隔淋巴结",
"双肺门淋巴结"
],
"character": [
"多发"
],
"core_name": "肿大",
"tendency": ""
},
{
"anatomy_list": [
"纵隔淋巴结",
"双肺门淋巴结"
],
"character": [
"多发"
],
"core_name": "钙化",
"tendency": ""
}
] |
bcr/abl基因检测：p210阳性；骨髓流式：异常髓系表达，异常细胞r4占88.60%，表达cd33,cd15,cd38,cd11b部分细胞表达cd16,cd64但cd19,cd7,cd10,cd117,cd34,cd123,hladr,cd13均为阴性。 | 1,178 | [
{
"anatomy_list": [],
"character": [
"阳性"
],
"core_name": "p210",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"髓系表达"
],
"core_name": "异常",
"tendency": ""
}
] |
4+月前患者无明显诱因出现阴道不规则点滴流血，无畏寒、发热，无腹痛、腹胀及阴道流液，无咳嗽、咳痰等不适，当时未引起重视，为求进一步治疗，遂到某医院就诊，行宫腔镜及诊断性刮宫提示子宫内膜癌，经金域检验中心会诊后，病检结果（123456）提示：子宫腔腺癌，结合免疫表型及he形态符合低分化子宫内膜样腺癌，免疫组化结果：ck(2+)、vim(2+)、er(小灶+)、pr（-)、p16(2+)、p53(2+)、a-inhibin（-)、ki-67(2+,约80%)。 | 1,279 | [
{
"anatomy_list": [
"阴道"
],
"character": [
"不规则",
"点滴"
],
"core_name": "出血",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "畏寒",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "发热",
"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"
},
{
"anatomy_list": [
"阴道"
],
"character": [],
"core_name": "流液",
"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": [
"子宫内膜"
],
"character": [],
"core_name": "癌",
"tendency": ""
},
{
"anatomy_list": [
"子宫腔"
],
"character": [],
"core_name": "腺癌",
"tendency": ""
},
{
"anatomy_list": [
"子宫腔"
],
"character": [
"低分化",
"子宫内膜样"
],
"core_name": "腺癌",
"tendency": ""
}
] |
现患者一般情况可，为求进一步诊疗而来，门诊以“卵巢癌术后腹膜后转移”收入院。 | 186 | [
{
"anatomy_list": [],
"character": [
"可"
],
"core_name": "一般情况",
"tendency": ""
},
{
"anatomy_list": [
"卵巢"
],
"character": [],
"core_name": "癌",
"tendency": ""
},
{
"anatomy_list": [
"腹膜后"
],
"character": [
"术后"
],
"core_name": "转移",
"tendency": ""
}
] |
入院前5+月，患者受凉后出现发热，体温不详，伴畏寒，无寒战，稍咳嗽、咳痰，咳少量白色粘痰，伴乏力、活动后心累、气促不适，自行予以口服药物退热治疗后体温降至正常（具体不详），无恶心、呕吐，无腹痛、腹胀，无牙龈出血、鼻出血、呕血，无晕厥、黑曚。 | 1,652 | [
{
"anatomy_list": [],
"character": [
"受凉后",
"体温不详"
],
"core_name": "发热",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "畏寒",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "寒颤",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"稍"
],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"稍"
],
"core_name": "咳痰",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"少量",
"白色",
"粘"
],
"core_name": "咳痰",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "乏力",
"tendency": ""
},
{
"anatomy_list": [
"心"
],
"character": [
"活动后"
],
"core_name": "心累",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "气促",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"口服药物退热治疗后降至正常"
],
"core_name": "体温",
"tendency": ""
},
{
"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": "腹胀",
"tendency": "否定"
},
{
"anatomy_list": [
"牙龈"
],
"character": [],
"core_name": "出血",
"tendency": "否定"
},
{
"anatomy_list": [
"鼻"
],
"character": [],
"core_name": "出血",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "呕血",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "晕厥",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "黒朦",
"tendency": "否定"
}
] |
（乳头）未见癌累及。 | 490 | [
{
"anatomy_list": [
"乳头"
],
"character": [
"累及"
],
"core_name": "癌",
"tendency": "否定"
}
] |
患者1月前因乙状结肠癌，于我院行腹腔镜下乙状结肠癌根治术，术中见盆腔内少许淡黄色腹水。 | 1,780 | [
{
"anatomy_list": [
"乙状结肠"
],
"character": [],
"core_name": "癌",
"tendency": ""
},
{
"anatomy_list": [
"盆腔内"
],
"character": [
"少许",
"淡黄色"
],
"core_name": "腹水",
"tendency": ""
}
] |
1年前，患者出现活动后气促，行走不到100米便可诱发，无胸闷、胸痛、心悸、黑朦、晕厥，无咳嗽、咳痰、畏寒、发热，夜间半卧位休息，偶有双下肢水肿，伴有夜间阵发性呼吸困难，先后于A医院、B医院、C医院及我院治疗，考虑“心衰、冠心病？”，建议完善冠脉造影进一步明确，患者及家属拒绝完善冠脉造影，药物治疗后症状好转，未规律服药。上述症状反复发作。 | 878 | [
{
"anatomy_list": [],
"character": [
"活动后",
"行走不到100米便可诱发"
],
"core_name": "气促",
"tendency": ""
},
{
"anatomy_list": [
"胸"
],
"character": [],
"core_name": "胸闷",
"tendency": "否定"
},
{
"anatomy_list": [
"胸部"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [
"心"
],
"character": [],
"core_name": "心悸",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "黑朦",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "晕厥",
"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": [],
"character": [],
"core_name": "畏寒",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "发热",
"tendency": "否定"
},
{
"anatomy_list": [
"双下肢"
],
"character": [
"偶有"
],
"core_name": "水肿",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"夜间",
"阵发性"
],
"core_name": "呼吸困难",
"tendency": ""
},
{
"anatomy_list": [
"心"
],
"character": [],
"core_name": "心力衰竭",
"tendency": "不确定"
},
{
"anatomy_list": [
"心"
],
"character": [],
"core_name": "冠心病",
"tendency": "不确定"
}
] |
患者自发病以来，精神、食欲可，睡眠可，大便通畅，小便如常，体重无明显变化。 | 1,675 | [
{
"anatomy_list": [],
"character": [
"可"
],
"core_name": "精神",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"可"
],
"core_name": "食欲",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"可"
],
"core_name": "睡眠",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"通畅"
],
"core_name": "大便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"如常"
],
"core_name": "小便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"明显"
],
"core_name": "体重改变",
"tendency": "否定"
}
] |
我院门诊b超提示：盆腔内混合性包块。 | 1,120 | [
{
"anatomy_list": [
"盆腔内"
],
"character": [
"混合性"
],
"core_name": "包块",
"tendency": ""
}
] |
后为求进一步治疗于某医院就诊，完善全腹部ct示：左肾门下方腹主动脉旁占位主动脉旁占位性病变，并侵及相邻上段输尿管伴上方输尿管及左肾积水，腰44椎体结节状状高密度高密度影。 | 163 | [
{
"anatomy_list": [
"左肾门下方腹主动脉旁"
],
"character": [
"占位性"
],
"core_name": "病变",
"tendency": ""
},
{
"anatomy_list": [
"上段输尿管"
],
"character": [],
"core_name": "病变",
"tendency": ""
},
{
"anatomy_list": [
"上方输尿管",
"左肾"
],
"character": [],
"core_name": "积水",
"tendency": ""
},
{
"anatomy_list": [
"腰L4椎体"
],
"character": [
"高",
"高密度",
"结节状"
],
"core_name": "密度影",
"tendency": ""
}
] |
无畏寒、发热，无午后潮热、盗汗，无腹痛、腹胀，双下肢无明显麻木、乏力等不适。 | 242 | [
{
"anatomy_list": [],
"character": [],
"core_name": "畏寒",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "发热",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"午后"
],
"core_name": "潮热",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "盗汗",
"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"
},
{
"anatomy_list": [
"双下肢"
],
"character": [
"明显"
],
"core_name": "麻木",
"tendency": "否定"
},
{
"anatomy_list": [
"双下肢"
],
"character": [
"明显"
],
"core_name": "乏力",
"tendency": "否定"
}
] |
2019年7月4日拟行第二次后装治疗，但镜下发现患者气道内情况相对稳定，故未行第二次后装治疗。 | 833 | [
{
"anatomy_list": [
"气道内"
],
"character": [
"相对"
],
"core_name": "情况稳定",
"tendency": ""
}
] |
现患者无发热、腹痛、腹胀、腹泻等不适，为进一步治疗，患者今来我院，要求住院治疗。 | 634 | [
{
"anatomy_list": [],
"character": [],
"core_name": "发热",
"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"
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "腹泻",
"tendency": "否定"
}
] |
入院前1+年（2016年1月），患者于无明显诱因出现大便带血，为进一步治疗就诊于我院胃肠外科，行ct检查提示(2016-01-18 某医院):肺气肿征，左肺上叶尖后段肺大泡；右肺下叶外侧基底段小结节，性质待定；肝脏内多发小圆形低密度影，转移性肿瘤？双肾囊肿；直肠肠壁明显增厚，考虑肿瘤性病变，直肠癌可能性大；盆腔内内淋巴结淋巴结肿大；电子肠镜示：直肠距肛7~12cm见一个环状新生物，表面溃疡，肠腔狭窄；病理活检：（直肠）腺上皮中-重度异型增生，局部癌变。 | 1,537 | [
{
"anatomy_list": [],
"character": [
"带血"
],
"core_name": "大便",
"tendency": ""
},
{
"anatomy_list": [
"肺"
],
"character": [],
"core_name": "肺气肿",
"tendency": ""
},
{
"anatomy_list": [
"左肺上叶尖后段"
],
"character": [],
"core_name": "肺大疱",
"tendency": ""
},
{
"anatomy_list": [
"右肺下叶外侧基底段"
],
"character": [
"小"
],
"core_name": "结节",
"tendency": ""
},
{
"anatomy_list": [
"肝脏内"
],
"character": [
"多发",
"小",
"圆形",
"低"
],
"core_name": "密度影",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"转移性"
],
"core_name": "肿瘤",
"tendency": "不确定"
},
{
"anatomy_list": [
"双肾"
],
"character": [],
"core_name": "囊肿",
"tendency": ""
},
{
"anatomy_list": [
"直肠肠壁"
],
"character": [
"明显"
],
"core_name": "增厚",
"tendency": ""
},
{
"anatomy_list": [
"直肠"
],
"character": [
"肿瘤性"
],
"core_name": "病变",
"tendency": "不确定"
},
{
"anatomy_list": [
"直肠"
],
"character": [],
"core_name": "癌",
"tendency": "不确定"
},
{
"anatomy_list": [
"盆腔内淋巴结"
],
"character": [],
"core_name": "肿大",
"tendency": ""
},
{
"anatomy_list": [
"直肠距肛7~12CM"
],
"character": [
"环状",
"表面溃疡"
],
"core_name": "新生物",
"tendency": ""
},
{
"anatomy_list": [
"直"
],
"character": [
"肠腔"
],
"core_name": "狭窄",
"tendency": ""
},
{
"anatomy_list": [
"直肠上皮"
],
"character": [
"异型",
"中-重度",
"腺上皮"
],
"core_name": "增生",
"tendency": ""
},
{
"anatomy_list": [
"直肠上皮"
],
"character": [
"局部"
],
"core_name": "癌变",
"tendency": ""
}
] |
入院前8年，患者健康体检时发现乙肝标志物：hbsag阳性，肝功正常，病毒载量不详，当时无任何不适症状，患者未予以重视，未进一步随诊。 | 1,236 | [
{
"anatomy_list": [],
"character": [
"阳性"
],
"core_name": "hbsag",
"tendency": ""
}
] |
骨髓病理检查（123456）提示多发性骨髓瘤。 | 1,708 | [
{
"anatomy_list": [
"骨髓"
],
"character": [
"多发性"
],
"core_name": "瘤",
"tendency": ""
}
] |
5.胆囊结石。 | 1,263 | [
{
"anatomy_list": [
"胆囊"
],
"character": [],
"core_name": "结石",
"tendency": ""
}
] |
患者遂来我院消化科门诊就诊，行胃镜检查提示慢性胃炎，予以抑酸护胃治疗（具体药物不详），效果欠佳。 | 1,239 | [
{
"anatomy_list": [
"胃"
],
"character": [
"慢性"
],
"core_name": "胃炎",
"tendency": ""
}
] |
现患儿精神食欲较好，无发热、咳嗽、吐泻，无进行性面色苍白，无皮肤瘀斑瘀点及鼻衄、牙龈出血等；3+天前患儿诉双侧踝关节疼痛，不剧，可忍受，阵发性发作，无活动受限。 | 1,470 | [
{
"anatomy_list": [],
"character": [
"较好"
],
"core_name": "精神",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"较好"
],
"core_name": "食欲",
"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": "呕吐",
"tendency": ""
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "腹泻",
"tendency": ""
},
{
"anatomy_list": [
"面"
],
"character": [
"进行性"
],
"core_name": "面色苍白",
"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": [
"鼻"
],
"character": [],
"core_name": "鼻衄",
"tendency": "否定"
},
{
"anatomy_list": [
"牙龈"
],
"character": [],
"core_name": "出血",
"tendency": "否定"
},
{
"anatomy_list": [
"双侧踝关节"
],
"character": [
"不剧",
"可忍受",
"阵发性发作",
"无活动受限"
],
"core_name": "疼痛",
"tendency": ""
}
] |
3、慢性宫颈炎伴潴留囊肿形成。 | 1,584 | [
{
"anatomy_list": [
"宫颈"
],
"character": [
"慢性"
],
"core_name": "宫颈炎",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"潴留"
],
"core_name": "囊肿",
"tendency": ""
}
] |
3月前排便困难加重，偶有尿踌躇，因排便困难反复就诊于我院肛肠门诊和胃肠外科，行盆腔ct（我院2016-04-09）提示：盆腔少量积液。 | 239 | [
{
"anatomy_list": [],
"character": [
"加重"
],
"core_name": "排便困难",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"反复"
],
"core_name": "排便困难",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"偶有"
],
"core_name": "尿踌躇",
"tendency": ""
},
{
"anatomy_list": [
"盆腔"
],
"character": [
"少量"
],
"core_name": "积液",
"tendency": ""
}
] |
左侧腹膜后肿物病理示：（左侧）腹膜后低分化腺癌。结合免疫组化，以卵巢源性可能性大。 | 174 | [
{
"anatomy_list": [
"左侧腹膜后"
],
"character": [],
"core_name": "肿物",
"tendency": ""
},
{
"anatomy_list": [
"左侧腹膜后"
],
"character": [
"低分化"
],
"core_name": "腺癌",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"卵巢源性"
],
"core_name": "癌",
"tendency": "不确定"
}
] |
4+月前，患者受凉后出现咳嗽、咳痰，为白色泡沫痰，伴发热，自测体温38.5℃，伴气促、乏力，无畏寒、盗汗，无恶心、呕吐，无胸痛、咯血，患者遂至某医院输液治疗（具体不详）后未见明显好转，仍咳嗽、咳痰，伴发热、乏力，体温仍波动于38℃左右，患者活动耐力下降，走平路即感气喘。 | 545 | [
{
"anatomy_list": [],
"character": [
"受凉后"
],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"白色",
"泡沫痰",
"受凉后"
],
"core_name": "咳痰",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"升高",
"受凉后"
],
"core_name": "体温",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"受凉后"
],
"core_name": "发热",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"受凉后"
],
"core_name": "气促",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"受凉后"
],
"core_name": "乏力",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "畏寒",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "盗汗",
"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": [
"胸"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "咯血",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "咳痰",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "发热",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "乏力",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"波动",
"升高"
],
"core_name": "体温",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"下降"
],
"core_name": "活动耐量",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"走平路"
],
"core_name": "气喘",
"tendency": ""
}
] |
2018-4-19于我院复查宫颈hpv仍提示16型阳性，宫颈tct未见上皮内病变及恶性病变。 | 631 | [
{
"anatomy_list": [],
"character": [
"阳性"
],
"core_name": "宫颈hpv16型",
"tendency": ""
},
{
"anatomy_list": [
"宫颈"
],
"character": [
"上皮内"
],
"core_name": "病变",
"tendency": "否定"
},
{
"anatomy_list": [
"宫颈"
],
"character": [
"恶性"
],
"core_name": "病变",
"tendency": "否定"
}
] |
入院前1+年，患者因"反复腹痛2余年，加重2余月"于我科住院治疗,诊断为原发性肝癌,完善相关辅助检查后入介入科行了肝动脉化疗栓塞（tace）手术治疗,术后给予保肝、制酸及对症支持治疗,病情好转后出院,院外遵医嘱按时服用保肝类药物(具体药物不详)。 | 1,490 | [
{
"anatomy_list": [
"腹"
],
"character": [
"反复",
"加重"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"肝"
],
"character": [
"原发性"
],
"core_name": "癌",
"tendency": ""
}
] |
门诊以“消化道出血”收入住院。 | 1,971 | [
{
"anatomy_list": [
"消化道"
],
"character": [],
"core_name": "出血",
"tendency": ""
}
] |
入院前1年，患者于某卫生院常规体检发现双侧尿路结石，为进一步检查，未诊治。 | 920 | [
{
"anatomy_list": [
"双侧尿路"
],
"character": [],
"core_name": "结石",
"tendency": ""
}
] |
1月余前，患者使用“诺和锐3030R 早晚各18u，阿卡波糖50mg tid”情况下，患者无明显诱因出现血糖控制不佳，空腹血糖波动于4-8mm/ l,餐后2小时血糖波动于11-16mm/ l，遂改为“诺和锐3030R 早晚各18u，伏格列波糖0.2mg tid”控制血糖，患者血糖波动情况仍同前。 | 1,276 | [
{
"anatomy_list": [],
"character": [
"控制不佳"
],
"core_name": "血糖",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"空腹",
"波动于4-8mm/ l"
],
"core_name": "血糖",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"餐后2小时",
"波动于11-16mm/ l"
],
"core_name": "血糖",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"波动"
],
"core_name": "血糖",
"tendency": ""
}
] |
患病以来患者食欲差，大、小便正常。 | 1,984 | [
{
"anatomy_list": [],
"character": [
"差"
],
"core_name": "食欲",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"正常"
],
"core_name": "大小便",
"tendency": ""
}
] |
起病以来，患者精神尚可，睡眠欠佳，大小便正常，体重无明显变化。 | 937 | [
{
"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": "大小便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"明显"
],
"core_name": "体重改变",
"tendency": "否定"
}
] |
无恶心呕吐，无畏寒发热、无胸闷气促、无尿频尿急尿痛等不适。 | 1,669 | [
{
"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": "畏寒",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "发热",
"tendency": "否定"
},
{
"anatomy_list": [
"胸"
],
"character": [],
"core_name": "胸闷",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "气促",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "尿急",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "尿频",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "尿痛",
"tendency": "否定"
}
] |
后就诊我科，完善相关检查明确无明显放化疗禁忌症后，分别于10-10、11.2、11.22、12-23行tac方案化疗，过程中患者出现四肢麻木，予以“甲钴胺”对症后好转，并于10-16行同步放疗50G/25f/5w，患者无特殊不适，现为行下一周期治疗，就诊我院，门诊以“乳腺癌”收住我科。 | 1,352 | [
{
"anatomy_list": [
"四肢"
],
"character": [],
"core_name": "麻木",
"tendency": ""
},
{
"anatomy_list": [
"乳腺"
],
"character": [],
"core_name": "癌",
"tendency": ""
}
] |
右侧肾肾周间隙改变，考虑感染。 | 1,848 | [
{
"anatomy_list": [],
"character": [],
"core_name": "感染",
"tendency": "不确定"
},
{
"anatomy_list": [
"右侧肾周"
],
"character": [],
"core_name": "间隙改变",
"tendency": ""
}
] |
患者诉20+年前开始发作头晕，伴视物旋转，明显恶心呕吐，大汗淋漓，体位改变时症状明显加重，发生过2-3次耳鸣，每次均不能自行缓解，需到医院用药治疗（具体诊断及用药不详）。 | 1,308 | [
{
"anatomy_list": [
"头"
],
"character": [
"体位改变时明显加重"
],
"core_name": "头晕",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"体位改变时明显加重"
],
"core_name": "视物旋转",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"明显"
],
"core_name": "恶心",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"明显"
],
"core_name": "呕吐",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"大汗",
"体位改变时明显加重"
],
"core_name": "出汗",
"tendency": ""
},
{
"anatomy_list": [
"耳"
],
"character": [
"2-3次",
"不能自行缓解"
],
"core_name": "耳鸣",
"tendency": ""
}
] |
现患者拟行第四次化疗来我院，门诊以“子宫内膜癌术后，第3次化疗后”收入我科。 | 1,588 | [
{
"anatomy_list": [
"子宫内膜"
],
"character": [
"术后",
"第3次化疗后"
],
"core_name": "癌",
"tendency": ""
}
] |
提示肿瘤复发；2019-05-14故给予dp方案化疗3周期:多西他赛100mg ivd1，顺铂 40mg ivd1-3 ；化疗过程顺利，无骨髓抑制及胃肠反应；今日为行下一周期化疗，门诊以"宫颈癌"收入院。 | 1,027 | [
{
"anatomy_list": [],
"character": [
"复发"
],
"core_name": "肿瘤",
"tendency": ""
},
{
"anatomy_list": [
"骨髓"
],
"character": [],
"core_name": "骨髓抑制",
"tendency": "否定"
},
{
"anatomy_list": [
"胃",
"肠"
],
"character": [],
"core_name": "胃肠反应",
"tendency": "否定"
},
{
"anatomy_list": [
"宫颈"
],
"character": [],
"core_name": "癌",
"tendency": ""
}
] |
入院前4月，患者无明显诱因开始出现咳嗽、咳痰，为阵发性咳嗽，咯白色痰液，痰中带少量血丝，伴潮热、多汗，活动后偶有气促，偶有胸部发紧，与活动无明显关系，无恶心、呕吐、头晕、头痛，无乏力、浮肿、体重减轻。 | 2,024 | [
{
"anatomy_list": [],
"character": [],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "咳痰",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"阵发性"
],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"白色"
],
"core_name": "咳痰",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"少量血丝"
],
"core_name": "咳痰",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "潮热",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "多汗",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"活动后",
"偶有"
],
"core_name": "气促",
"tendency": ""
},
{
"anatomy_list": [
"胸部"
],
"character": [
"与活动无明显关系"
],
"core_name": "发紧",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "恶心",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "呕吐",
"tendency": "否定"
},
{
"anatomy_list": [
"头"
],
"character": [],
"core_name": "头晕",
"tendency": "否定"
},
{
"anatomy_list": [
"头"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "乏力",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "浮肿",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "体重减轻",
"tendency": "否定"
}
] |
病程中咳嗽偶有发生，偶有少量血丝，咳嗽无明显诱发与缓解因素。 | 2,026 | [
{
"anatomy_list": [],
"character": [
"偶有"
],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"少量",
"偶有"
],
"core_name": "血丝",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"无明显诱发与缓解因素"
],
"core_name": "咳嗽",
"tendency": ""
}
] |
胃镜提示：慢性食管炎；慢性非萎缩性胃炎伴胆汁反流。 | 1,913 | [
{
"anatomy_list": [
"食管"
],
"character": [
"慢性"
],
"core_name": "食管炎",
"tendency": ""
},
{
"anatomy_list": [
"胃"
],
"character": [
"慢性",
"非萎缩性"
],
"core_name": "胃炎",
"tendency": ""
},
{
"anatomy_list": [
"胆汁"
],
"character": [],
"core_name": "反流",
"tendency": ""
}
] |
入院前7小时，患者无明显诱因出现中上腹疼痛，为串气样隐痛，无放射痛，与进食无明显相关，伴嗳气，无反酸、烧心、恶心、呕吐、腹泻，无畏寒、发热、黄疸、潮热、盗汗，无尿频、尿急、尿痛，无肛门停止排便、排气。未引起患者重视，未行诊治。 | 1,639 | [
{
"anatomy_list": [
"中上腹"
],
"character": [],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"中上腹"
],
"character": [
"串气样隐痛"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"放射性"
],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"进食无明显相关"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "嗳气",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "反酸",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "烧心",
"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": "腹泻",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "畏寒",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "发热",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "黄疸",
"tendency": "否定"
},
{
"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": "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"
},
{
"anatomy_list": [
"肛门"
],
"character": [
"停止"
],
"core_name": "排便",
"tendency": "否定"
},
{
"anatomy_list": [
"肛门"
],
"character": [
"停止"
],
"core_name": "排气",
"tendency": "否定"
}
] |
13年前因患者偶测血糖控制不佳至某医院调整为胰岛素降糖至今，使用三短一长方案降糖，监测血糖波动8-20mm20mmol/L，最高38mmol/L，每月至某医院复诊调整血糖方案，多次在某医院住院调整治疗方案。 | 533 | [
{
"anatomy_list": [],
"character": [
"控制不佳"
],
"core_name": "血糖",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"波动"
],
"core_name": "血糖",
"tendency": ""
}
] |
患者于2020-01无明显诱因开始出现右上腹不适，活动时疼痛，伴有食欲下降，乏力、纳差，无恶心、呕吐、反酸、嗳气，无腹胀、腹泻，无发热、畏寒、寒颤，予以保胃等治疗，无明显好转。 | 882 | [
{
"anatomy_list": [
"右上腹"
],
"character": [],
"core_name": "不适",
"tendency": ""
},
{
"anatomy_list": [
"右上腹"
],
"character": [
"活动时"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"下降"
],
"core_name": "食欲",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "乏力",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "纳差",
"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": "反酸",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "嗳气",
"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": "发热",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "畏寒",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "寒颤",
"tendency": "否定"
}
] |
消化内科考虑慢性胃炎，给予予以六味能消胶囊1.8g tid、马来酸曲美布汀分散片 0.2g tid口服，但患者腹胀症状未见明显缓解；今日遂至我院门诊就诊，门诊查得血糖偏高（具体不详），门诊以“2型糖尿病”收入我科住院治疗。 | 1,886 | [
{
"anatomy_list": [
"胃"
],
"character": [
"慢性"
],
"core_name": "胃炎",
"tendency": ""
},
{
"anatomy_list": [
"腹"
],
"character": [
"未见明显缓解"
],
"core_name": "腹胀",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"偏高"
],
"core_name": "血糖",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"2型"
],
"core_name": "糖尿病",
"tendency": ""
}
] |
入院前2+年，患者无明显诱因出现一左侧腹股沟腹股沟包块，大小约1cm*1cm，质韧，与周围分界清楚，伴疼痛，表面光滑，无红肿及溃烂，无渗血、渗液。 | 1,066 | [
{
"anatomy_list": [
"左侧腹股沟"
],
"character": [
"质韧",
"与周围分界清楚",
"疼痛",
"表面光滑",
"无红肿及溃烂",
"无渗血、渗液"
],
"core_name": "包块",
"tendency": ""
}
] |
患者于2018-5-30复查胸部ct提示左肺占位，后在某医院行肺穿活检提示鳞状细胞癌，考虑肿瘤转移，于6月5日按tp方案化疗1周期（药物总量：紫杉醇210mg，奈达铂100mg），化疗后出现ii°白细胞下降，予以粒细胞刺激因子升白细胞治疗后好转出院。 | 1,301 | [
{
"anatomy_list": [
"左肺"
],
"character": [],
"core_name": "占位",
"tendency": ""
},
{
"anatomy_list": [
"肺"
],
"character": [],
"core_name": "鳞癌",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"转移"
],
"core_name": "肿瘤",
"tendency": "不确定"
}
] |
入院前 3天，患者胸痛加重，家人为进一步治疗送入我科，遂以“胸痛待诊”收入住院 患者自发病以来， 精神较差 ， 食欲较差 ， 睡眠可 ， 大便如常 ， 小便如常 ， 体重减轻约5kg 。 | 430 | [
{
"anatomy_list": [
"胸"
],
"character": [
"加重"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"胸"
],
"character": [],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"较差"
],
"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": [],
"core_name": "体重减轻",
"tendency": ""
}
] |
3年前，患者无明显诱因出现尿色加深，如茶水样，偶有痰中带血，为鲜红色，量不等，无全身皮肤瘙痒，无陶土样大便、无腹痛腹胀等不适，患者仍未引起重视。 | 60 | [
{
"anatomy_list": [],
"character": [
"加深",
"如茶水样"
],
"core_name": "尿色",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"偶有",
"鲜红色",
"量不等"
],
"core_name": "咳痰",
"tendency": ""
},
{
"anatomy_list": [
"全身皮肤"
],
"character": [],
"core_name": "瘙痒",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"陶土样"
],
"core_name": "大便",
"tendency": "否定"
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "腹胀",
"tendency": "否定"
}
] |
1+月前，患者无诱因出现恶心伴上腹部胀痛不适，为阵发性隐痛，疼痛可忍受，不影响睡眠，无反酸、嗳气，无呃逆，无腹泻等不适，无畏寒、发热，完善胃镜：慢性浅表性全胃炎 糜烂性胃窦炎 十二指肠炎 活检：胃窦粘膜中度慢性炎症伴活动（+）、糜烂，hp（+）。 | 1,573 | [
{
"anatomy_list": [],
"character": [],
"core_name": "恶心",
"tendency": ""
},
{
"anatomy_list": [
"上腹部"
],
"character": [
"胀痛"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"上腹部"
],
"character": [
"阵发性隐痛"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"可忍受",
"不影响睡眠"
],
"core_name": "疼痛",
"tendency": ""
},
{
"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": "呃逆",
"tendency": "否定"
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "腹泻",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "畏寒",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "发热",
"tendency": "否定"
},
{
"anatomy_list": [
"全胃"
],
"character": [
"慢性",
"浅表性"
],
"core_name": "全胃炎",
"tendency": ""
},
{
"anatomy_list": [
"胃窦"
],
"character": [
"糜烂性"
],
"core_name": "胃窦炎",
"tendency": ""
},
{
"anatomy_list": [
"十二指肠"
],
"character": [],
"core_name": "十二指肠炎",
"tendency": ""
},
{
"anatomy_list": [
"胃窦粘膜"
],
"character": [
"中度",
"慢性"
],
"core_name": "炎症",
"tendency": ""
},
{
"anatomy_list": [
"胃窦粘膜"
],
"character": [],
"core_name": "糜烂",
"tendency": ""
}
] |
患者自发病以来，精神较差，食欲较差，睡眠可，大便如常，小便如常，体重无明显变化。 | 895 | [
{
"anatomy_list": [],
"character": [
"较差"
],
"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": [
"正常"
],
"core_name": "小便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"明显"
],
"core_name": "体重改变",
"tendency": "否定"
}
] |
患者自起病以来，精神可，胃纳可，大便如常，小便如常 。 | 1,421 | [
{
"anatomy_list": [],
"character": [
"可"
],
"core_name": "精神",
"tendency": ""
},
{
"anatomy_list": [
"胃"
],
"character": [
"可"
],
"core_name": "胃纳",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"如常"
],
"core_name": "大便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"如常"
],
"core_name": "小便",
"tendency": ""
}
] |
完善颈部淋巴结彩超示：右侧颌下淋巴结肿大，皮髓质分界不清，约1.3cm*0.4cm大小。 | 1,054 | [
{
"anatomy_list": [
"右侧颌下淋巴结",
"皮髓质"
],
"character": [
"分界不清"
],
"core_name": "肿大",
"tendency": ""
}
] |
自患病以来，患者精神、食欲、睡眠可，二便正常，体征未见明显变化。 | 1,403 | [
{
"anatomy_list": [],
"character": [
"可"
],
"core_name": "精神",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"可"
],
"core_name": "食欲",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"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": ""
}
] |
近20多年来上述症状约1-2年发作一次，听力无明显下降，每次治疗后可缓解。 | 1,309 | [
{
"anatomy_list": [],
"character": [
"明显下降"
],
"core_name": "听力下降",
"tendency": "否定"
}
] |
入院前1月余(2015.2.27)，患者因“发现右乳房无痛性肿块4月”入院。 | 1,183 | [
{
"anatomy_list": [
"右乳房"
],
"character": [
"无痛性"
],
"core_name": "肿块",
"tendency": ""
}
] |
6周期化疗结束后完善颈部及胸部增强ct后诊断为：左下肺鳞癌伴肺门、纵膈、锁骨上淋巴结转移、胸膜转移（ct3n3Mm1a iva期）。 | 1,557 | [
{
"anatomy_list": [
"左下肺"
],
"character": [
"转移",
"ct3n3Mm1a iva期"
],
"core_name": "鳞癌",
"tendency": ""
},
{
"anatomy_list": [
"肺门淋巴结 "
],
"character": [
"转移",
"ct3n3Mm1a iva期"
],
"core_name": "癌",
"tendency": ""
},
{
"anatomy_list": [
"纵隔淋巴结"
],
"character": [
"转移",
"ct3n3Mm1a iva期"
],
"core_name": "癌",
"tendency": ""
},
{
"anatomy_list": [
"锁骨上淋巴结"
],
"character": [
"转移",
"ct3n3Mm1a iva期"
],
"core_name": "癌",
"tendency": ""
},
{
"anatomy_list": [
"胸膜"
],
"character": [
"转移",
"ct3n3Mm1a iva期"
],
"core_name": "癌",
"tendency": ""
}
] |
患者约1月前（2020-6-22）于我院普外科行腹腔镜探查术+大网膜结节活检术+盆腔肿物切除术+腹腔热灌注套管置管术，术后病检：大网膜网膜结节及右侧盆腔盆腔病变组织恶性肿瘤伴大片出血、坏死，免疫组化支持低分化腺癌，考虑为卵巢高级别浆液性癌转移。 | 1,861 | [
{
"anatomy_list": [
"大网膜"
],
"character": [],
"core_name": "结节",
"tendency": ""
},
{
"anatomy_list": [
"右侧盆腔病变组织"
],
"character": [
"恶性"
],
"core_name": "肿瘤",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"大片"
],
"core_name": "出血",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"大片"
],
"core_name": "坏死",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"低分化"
],
"core_name": "腺癌",
"tendency": ""
},
{
"anatomy_list": [
"卵巢"
],
"character": [
"高级别",
"浆液性",
"转移"
],
"core_name": "癌",
"tendency": ""
}
] |
1+年来间断性出现咳嗽不适。 | 1,246 | [
{
"anatomy_list": [],
"character": [
"间断性"
],
"core_name": "咳嗽",
"tendency": ""
}
] |
既往有“冠状动脉粥样硬化性心脏病”病史6+年，正规口服冠心病二级预防药物治疗。 | 140 | [
{
"anatomy_list": [
"冠状动脉",
"心脏"
],
"character": [
"粥样",
"硬化性",
"病史6+年"
],
"core_name": "冠状动脉粥样硬化性心脏病",
"tendency": ""
}
] |
遂急诊入我院，患者呼吸困难进行性加重，氧饱和度下降至40%，于急诊科行气管插管后急转我科。 | 1,378 | [
{
"anatomy_list": [],
"character": [
"进行性加重"
],
"core_name": "呼吸困难",
"tendency": ""
}
] |
1月前开始，患者每次餐后开始出现中上腹疼痛，为绞痛，无放射痛，程度剧烈，难以忍受，每次约持续5秒后自行缓解。 | 1,250 | [
{
"anatomy_list": [
"中上腹"
],
"character": [
"绞痛",
"餐后开始出现",
"无放射痛",
"程度剧烈",
"难以忍受",
"每次约持续5秒后自行缓解"
],
"core_name": "疼痛",
"tendency": ""
}
] |
某医院考虑诊断：前列腺癌？给予积极止血、抗感染等治疗，患者血尿缓解出院。 | 1,975 | [
{
"anatomy_list": [
"前列腺"
],
"character": [],
"core_name": "癌",
"tendency": "不确定"
},
{
"anatomy_list": [],
"character": [
"缓解"
],
"core_name": "血尿",
"tendency": ""
}
] |
6月余前患者因“间断便血5年余”入我院就诊，入院肠镜提示直肠肿瘤，无明显手术禁忌，于2016-1-27在全麻下行腹腔镜下直肠癌根治术（dixon)+放射性粒子置入术，手术顺利，术后安返病房，组织病理：（直肠）中-低分化管状腺癌，浸及肠壁深肌层，脉管内见癌栓。 | 747 | [
{
"anatomy_list": [],
"character": [
"间断"
],
"core_name": "便血",
"tendency": ""
},
{
"anatomy_list": [
"直肠"
],
"character": [],
"core_name": "肿瘤",
"tendency": ""
},
{
"anatomy_list": [
"直肠"
],
"character": [
"中-低分化",
"管状",
"浸及肠壁深肌层"
],
"core_name": "腺癌",
"tendency": ""
},
{
"anatomy_list": [
"脉管内"
],
"character": [],
"core_name": "癌栓",
"tendency": ""
}
] |
双肺多发结节，考虑转移可能大。 | 885 | [
{
"anatomy_list": [
"双肺"
],
"character": [
"多发"
],
"core_name": "结节",
"tendency": ""
},
{
"anatomy_list": [
"双肺"
],
"character": [],
"core_name": "转移",
"tendency": "不确定"
}
] |
自行口服药物治疗后无明显好转；今日4+天前于我科门诊就诊，诊断为：慢性咽炎/左侧声带新生物。 | 1,389 | [
{
"anatomy_list": [
"咽"
],
"character": [
"慢性"
],
"core_name": "咽炎",
"tendency": ""
},
{
"anatomy_list": [
"左侧声带"
],
"character": [],
"core_name": "新生物",
"tendency": ""
}
] |
<左上肺前段+舌段>浸润性腺癌，以贴壁样生长方式为主；支气管切缘及肺切缘未见癌累及。 | 1,811 | [
{
"anatomy_list": [
"左上肺前段舌段"
],
"character": [
"浸润性",
"贴壁样生长方式为主"
],
"core_name": "腺癌",
"tendency": ""
},
{
"anatomy_list": [
"支气管切缘",
"肺切缘"
],
"character": [
"累及"
],
"core_name": "癌",
"tendency": "否定"
}
] |
无畏寒、发热，无潮热、盗汗；伴体重下降；无头昏、眼花，无乏力、面色苍白，无心悸，无气促、心前区压榨感，无恶心、呕吐，无腹胀、腹痛、腹泻，无咳嗽、咳痰，无咯血，无进食梗阻感，无声嘶，无胸闷、气促，无耳鸣及听力下降，无回吸性涕血，无尿频、尿急、尿痛，无排尿困难及血尿，无头昏、头疼。 | 1,067 | [
{
"anatomy_list": [],
"character": [],
"core_name": "畏寒",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "发热",
"tendency": "否定"
},
{
"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": "体重下降",
"tendency": ""
},
{
"anatomy_list": [
"头"
],
"character": [],
"core_name": "头昏",
"tendency": "否定"
},
{
"anatomy_list": [
"眼"
],
"character": [],
"core_name": "眼花",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "乏力",
"tendency": "否定"
},
{
"anatomy_list": [
"面"
],
"character": [],
"core_name": "面色苍白",
"tendency": "否定"
},
{
"anatomy_list": [
"心"
],
"character": [],
"core_name": "心悸",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "气促",
"tendency": "否定"
},
{
"anatomy_list": [
"心前区"
],
"character": [],
"core_name": "压榨感",
"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": "腹胀",
"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": "咳嗽",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "咳痰",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "咯血",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"进食"
],
"core_name": "梗阻感",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "声嘶",
"tendency": "否定"
},
{
"anatomy_list": [
"胸"
],
"character": [],
"core_name": "胸闷",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "气促",
"tendency": "否定"
},
{
"anatomy_list": [
"耳"
],
"character": [],
"core_name": "耳鸣",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "听力下降",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"带血",
"回吸性"
],
"core_name": "鼻涕",
"tendency": "否定"
},
{
"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"
},
{
"anatomy_list": [],
"character": [],
"core_name": "排尿困难",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "血尿",
"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"
}
] |
1月前，患者自觉腹胀、腹痛，到我科就诊，诊断为造瘘口梗阻，经积极对症治疗后好转，此后反复发作，予以安置引流管后能排除粪便，本次患者为求巩固治疗及要求化疗再次到我科就诊，门诊以“直肠癌术后”收入住院。 | 348 | [
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "腹胀",
"tendency": ""
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"造瘘口"
],
"character": [],
"core_name": "梗阻",
"tendency": ""
},
{
"anatomy_list": [
"直肠"
],
"character": [
"术后"
],
"core_name": "癌",
"tendency": ""
}
] |
1天前，患者食欲明显降低，不思饮食，恶心，呕吐胃内容物一次，非喷射状，不含血液及胆汁，全身乏力。 | 1,893 | [
{
"anatomy_list": [],
"character": [
"明显",
"降低"
],
"core_name": "食欲",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "不思饮食",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "恶心",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"胃内容物",
"非喷射状",
"不含血液及胆汁"
],
"core_name": "呕吐",
"tendency": ""
},
{
"anatomy_list": [
"全身"
],
"character": [],
"core_name": "乏力",
"tendency": ""
}
] |
9天前（2016.09.04 22:00），患者睡前休息时突发胸骨中下段压榨性疼痛，伴大汗淋漓、双肩胀痛，双上肢乏力，持续约20分20分钟，无黑蒙、晕厥，无恶心、呕吐，无呼吸困难，疼痛持续无缓解，患者遂于某医院就诊，查心电图示：窦性心律，iii、avf 导联qs型，患者未予药物治疗后胸痛自行缓解，此次发病至今，患者反复出现胸骨中下段疼痛，伴呼吸困难，每次持续约2-3m，自行缓解，与活动及呼吸无明显关系，无夜间高枕卧位，无头昏、视物模糊，无四肢乏力，无咳嗽咳痰，无恶心呕吐症状，疼痛与呼吸活动无关，为进一步诊治，患者今日于我院心内科门诊就诊，门诊行心电图（2016-10-13 08:04）提示：窦性心律，ii 呈qr型，iii、avf 呈qs型，v2-v5 st段抬高0.1-0.2m，以“冠心病”收治入院。 | 957 | [
{
"anatomy_list": [
"胸骨中段下段"
],
"character": [
"睡前休息时",
"突发",
"压榨性"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "大汗淋漓",
"tendency": ""
},
{
"anatomy_list": [
"双肩"
],
"character": [
"胀痛"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"双上肢"
],
"character": [],
"core_name": "乏力",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "黑朦",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "晕厥",
"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": [],
"character": [],
"core_name": "呼吸困难",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"持续",
"缓解"
],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [
"心"
],
"character": [],
"core_name": "窦性心律",
"tendency": ""
},
{
"anatomy_list": [
"胸部"
],
"character": [
"缓解"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"胸骨中段下段"
],
"character": [],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"自行缓解",
"与活动及呼吸无明显关系"
],
"core_name": "呼吸困难",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"夜间",
"高枕"
],
"core_name": "卧位",
"tendency": "否定"
},
{
"anatomy_list": [
"头"
],
"character": [],
"core_name": "头昏",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "视物模糊",
"tendency": "否定"
},
{
"anatomy_list": [
"四肢"
],
"character": [],
"core_name": "乏力",
"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": [],
"character": [],
"core_name": "恶心",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "呕吐",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"与呼吸活动无关"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"心"
],
"character": [],
"core_name": "窦性心律",
"tendency": ""
},
{
"anatomy_list": [
"心"
],
"character": [],
"core_name": "冠心病",
"tendency": ""
}
] |
入院前 1周 ，患者再次因受凉后咳嗽，喘息加重，不能平卧，咯少许 黄色粘痰 （每日约 10 毫升）。 | 1,366 | [
{
"anatomy_list": [],
"character": [
"受凉后"
],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"加重",
"不能平卧"
],
"core_name": "喘息",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"黄色",
"粘",
"少许",
"每日约 10 毫升"
],
"core_name": "咳痰",
"tendency": ""
}
] |
于 我院门诊 查 腹部ct示肠梗阻 ，为进一步诊疗，门诊以“肠梗阻”收入我科。 | 398 | [
{
"anatomy_list": [
"肠"
],
"character": [],
"core_name": "梗阻",
"tendency": ""
},
{
"anatomy_list": [
"肠"
],
"character": [],
"core_name": "梗阻",
"tendency": ""
}
] |
诊疗期间患者仍反复出现便血，仍为少量鲜红色血液，伴少许粘液，大便渐行变细，排便困难渐行加重，仍无明显腹痛、腹泻，无发热、寒战等不适。 | 412 | [
{
"anatomy_list": [],
"character": [
"反复",
"仍为少量鲜红色血液",
"少许粘液"
],
"core_name": "便血",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"逐渐变细"
],
"core_name": "大便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"渐行加重"
],
"core_name": "排便困难",
"tendency": ""
},
{
"anatomy_list": [
"腹"
],
"character": [
"明显"
],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [
"腹"
],
"character": [
"明显"
],
"core_name": "腹泻",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "发热",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "寒颤",
"tendency": "否定"
}
] |