text
stringlengths 5
708
| id
int64 1
2.07k
| event
list |
|---|---|---|
2.左肺上叶尖后段结节影，性质？转移可能。 | 153 | [
{
"anatomy_list": [
"左肺上叶尖后段"
],
"character": [],
"core_name": "结节影",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "转移",
"tendency": "不确定"
}
] |
之后规律随访发现血hcg升高就诊于我院，诊断滋养细胞肿瘤：侵袭性葡萄胎（ic：3），分别于2015年9月10日，2015年10月8，2015年11月4号，2015年12月2日，2015-12-30我院规律行ema-co化疗，出院时血hcg-i分别为：31080.00m/ml↑，773.80m/ml↑，26.59m/ml，4.89m/m，2.66m/m。 | 644 | [
{
"anatomy_list": [],
"character": [
"升高"
],
"core_name": "血hcg",
"tendency": ""
},
{
"anatomy_list": [
"滋养细胞"
],
"character": [],
"core_name": "肿瘤",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"侵袭性",
"ic：3"
],
"core_name": "葡萄胎",
"tendency": ""
}
] |
化疗期间患者出现白细胞进行性下降，停用米托蒽醌化疗；诱导化疗期间因患者出现头痛等不适，氢化泼尼松预防维甲酸综合征。 | 1,657 | [
{
"anatomy_list": [
"头"
],
"character": [],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"进行性下降"
],
"core_name": "白细胞",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "维甲酸综合征",
"tendency": ""
}
] |
后于2017年9月13日、2017年10月11日行第二、三周期雷替曲塞+奥沙利铂方案化疗，化疗过程顺利，患者未诉特殊不适，院外休息期间，偶感肛门坠胀，无明显腹痛腹胀、畏寒发热、潮热盗汗、尿频、尿急、尿痛、黑便等特殊不适，今患者为行下一周期化疗入院，门诊以“直肠癌”收入我科。 | 1,546 | [
{
"anatomy_list": [
"肛门"
],
"character": [],
"core_name": "坠胀",
"tendency": ""
},
{
"anatomy_list": [
"腹"
],
"character": [
"明显"
],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [
"腹"
],
"character": [
"明显"
],
"core_name": "腹胀",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"明显"
],
"core_name": "畏寒",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"明显"
],
"core_name": "发热",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"明显"
],
"core_name": "潮热",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"明显"
],
"core_name": "盗汗",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"明显"
],
"core_name": "尿频",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"明显"
],
"core_name": "尿急",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"明显"
],
"core_name": "尿痛",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"明显"
],
"core_name": "黑便",
"tendency": "否定"
},
{
"anatomy_list": [
"直肠"
],
"character": [],
"core_name": "癌",
"tendency": ""
}
] |
5、胰、肾未见明显异常 ，门诊以"乙肝肝硬化，肝癌？"收入我科。 | 379 | [
{
"anatomy_list": [
"肝"
],
"character": [
"乙肝"
],
"core_name": "硬化",
"tendency": ""
},
{
"anatomy_list": [
"肝"
],
"character": [],
"core_name": "癌",
"tendency": "不确定"
}
] |
予以“瘿瘤丸”及中药行药物治疗，治疗后一月，患者复查甲状腺彩超示：甲状腺右叶囊性结节（3.2*1.2cm）。 | 918 | [
{
"anatomy_list": [
"甲状腺右叶"
],
"character": [
"囊性"
],
"core_name": "结节",
"tendency": ""
}
] |
入院前2+年，患者无明显诱因出现头昏、乏力，无心悸、黑朦，无皮下瘀斑、瘀点，无牙龈和口腔黏膜出血，无肉眼血尿，无呕血、黑便、便血，无视力障碍，无耳鸣，无头疼、恶心、呕吐，意识障碍，无畏寒、发热，无鼻塞、流涕，无咽痛、咳嗽、咳痰，无腹痛、腹泻，无肛周疼痛，无尿频、尿急、尿痛，无骨关节关节疼痛；患者在某医院行骨髓穿刺活检诊断为骨髓增生异常综合征（未见报告），未治疗。 | 730 | [
{
"anatomy_list": [
"头"
],
"character": [],
"core_name": "头昏",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "乏力",
"tendency": ""
},
{
"anatomy_list": [
"心"
],
"character": [],
"core_name": "心悸",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "黑朦",
"tendency": "否定"
},
{
"anatomy_list": [
"皮下"
],
"character": [],
"core_name": "瘀斑",
"tendency": "否定"
},
{
"anatomy_list": [
"皮下"
],
"character": [],
"core_name": "瘀点",
"tendency": "否定"
},
{
"anatomy_list": [
"牙龈"
],
"character": [],
"core_name": "出血",
"tendency": "否定"
},
{
"anatomy_list": [
"口腔粘膜"
],
"character": [],
"core_name": "出血",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "血尿",
"tendency": "否定"
},
{
"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": "便血",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "视力障碍",
"tendency": "否定"
},
{
"anatomy_list": [
"耳"
],
"character": [],
"core_name": "耳鸣",
"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": [],
"character": [],
"core_name": "意识障碍",
"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": [
"鼻"
],
"character": [],
"core_name": "鼻塞",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "流涕",
"tendency": "否定"
},
{
"anatomy_list": [
"咽"
],
"character": [],
"core_name": "疼痛",
"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": [
"肛周"
],
"character": [],
"core_name": "疼痛",
"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": [
"骨关节"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [
"骨髓"
],
"character": [
"异常"
],
"core_name": "骨髓增生异常综合征",
"tendency": ""
}
] |
无恶心、呕吐、腹痛、腹胀，自述夜间有出汗及发热（未测体温），今日患者为进一步诊治来我院，门诊以“右肺门占位：肿瘤？”收入我科。 | 196 | [
{
"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": [],
"character": [
"夜间"
],
"core_name": "出汗",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"夜间"
],
"core_name": "发热",
"tendency": ""
},
{
"anatomy_list": [
"右肺门"
],
"character": [],
"core_name": "占位",
"tendency": ""
},
{
"anatomy_list": [
"右肺门"
],
"character": [],
"core_name": "肿瘤",
"tendency": "不确定"
}
] |
入院前5+月，患者无明显诱因出现咳嗽、咳痰，为阵发性干咳，痰中带血，为鲜红色，量少，偶有少许黄色粘痰，无胸闷、胸痛及呼吸困难，患者于某医院就诊，完善胸部增强ct示：左肺上叶软组织影伴双肺结节影，考虑肺癌伴转移。 | 274 | [
{
"anatomy_list": [],
"character": [],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "咳痰",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"阵发性",
"干"
],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"带血",
"鲜红色",
"量少"
],
"core_name": "咳痰",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"偶有少许",
"黄色",
"粘"
],
"core_name": "咳痰",
"tendency": ""
},
{
"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": "呼吸困难",
"tendency": "否定"
},
{
"anatomy_list": [
"左肺上叶"
],
"character": [],
"core_name": "软组织影",
"tendency": ""
},
{
"anatomy_list": [
"双肺"
],
"character": [],
"core_name": "结节影",
"tendency": ""
},
{
"anatomy_list": [
"肺"
],
"character": [],
"core_name": "癌",
"tendency": "不确定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "转移",
"tendency": "不确定"
}
] |
基底净，乳头未受累，前哨淋巴结未见癌转移（0/7），前稍0/3、前哨2 0/0、前哨3:0/4，免疫组化：er(++)80%，pr(+)30%，her(-)，p53(+)10%，ki-67（+）60%，术后1周于行化疗1周期（具体方案不详），病情好转出院；于2018-8-22于我院予以tac方案（多西他赛 120mg，环磷酰胺 0.6g，吡柔比星 60mg）化疗，化疗及化疗后无明显恶心、呕吐，无骨髓抑制及神经毒性反应，现为继续化疗，于我院就诊，门诊以“乳腺癌”收住我科。 | 1,243 | [
{
"anatomy_list": [
"乳头"
],
"character": [],
"core_name": "累及",
"tendency": "否定"
},
{
"anatomy_list": [
"前哨淋巴结"
],
"character": [
"转移"
],
"core_name": "癌",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"明显"
],
"core_name": "恶心",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"明显"
],
"core_name": "呕吐",
"tendency": "否定"
},
{
"anatomy_list": [
"骨髓"
],
"character": [],
"core_name": "骨髓抑制",
"tendency": "否定"
},
{
"anatomy_list": [
"神经"
],
"character": [],
"core_name": "毒性反应",
"tendency": "否定"
},
{
"anatomy_list": [
"乳腺"
],
"character": [],
"core_name": "癌",
"tendency": ""
}
] |
现患儿无咳嗽，无进行性面色苍白，无皮肤瘀斑瘀点及鼻衄、牙龈出血等出血表现，无腹痛、腹泻，无关节疼痛，无头痛、呕吐。 | 1,726 | [
{
"anatomy_list": [],
"character": [],
"core_name": "咳嗽",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"进行性",
"面色"
],
"core_name": "苍白",
"tendency": "否定"
},
{
"anatomy_list": [
"皮肤"
],
"character": [],
"core_name": "瘀点",
"tendency": "否定"
},
{
"anatomy_list": [
"皮肤"
],
"character": [],
"core_name": "瘀斑",
"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": [],
"character": [],
"core_name": "出血",
"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": [
"关节"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [
"头"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "呕吐",
"tendency": "否定"
}
] |
今门诊以“右甲状腺甲状腺包块待查”收入我科住院治疗。 | 1,174 | [
{
"anatomy_list": [
"右甲状腺"
],
"character": [],
"core_name": "包块",
"tendency": "不确定"
}
] |
患者本次起病以来，精神、睡眠一般，食纳下降，大便如上诉，小便无明显改变，体重无明显变化。 | 729 | [
{
"anatomy_list": [],
"character": [
"一般"
],
"core_name": "精神",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"一般"
],
"core_name": "睡眠",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"下降"
],
"core_name": "食纳",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"明显",
"改变"
],
"core_name": "小便",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"明显"
],
"core_name": "体重改变",
"tendency": "否定"
}
] |
患者于一年前无明显诱因出现大便带血，为暗红色不与大便混合，伴粘液便3月余，大便次数增多，变细，为2-3次/天。 | 1,443 | [
{
"anatomy_list": [],
"character": [
"带血",
"暗红色",
"不与大便混合"
],
"core_name": "大便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"粘液",
"3月余"
],
"core_name": "大便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"次数增多",
"变细",
"2-3次/天"
],
"core_name": "大便",
"tendency": ""
}
] |
入院前2天，患者无明显诱因出现右侧胸背部疼痛，与呼吸活动无关，偶有干咳，无发热，无咯血，无胸闷，无气促、呼吸困难,无潮热、盗汗，无乏力、消瘦，无声嘶，无呛咳等不适，病后患者于当地医院行心电图检查结果“未见明显异常”，建议完善肝胆检查寻找胸背痛病因，于我院行腹部彩超未见明显异常，肝功提示转氨酶稍升高；病程中行胸片检查结果提示“右下肺阴影”，进一步完善胸部ct检查提示：右肺下叶后基底段段团片影，考虑感染性病变可能，肿瘤不除外；为进一步治疗，门诊以“肺部阴影”收入我科。 | 299 | [
{
"anatomy_list": [
"右侧胸背部"
],
"character": [
"与呼吸活动无关"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"偶有",
"干"
],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "发热",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "咯血",
"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": "呼吸困难",
"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": "乏力",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "消瘦",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "声嘶",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "呛咳",
"tendency": "否定"
},
{
"anatomy_list": [
"胸背"
],
"character": [],
"core_name": "疼痛",
"tendency": "不确定"
},
{
"anatomy_list": [],
"character": [
"稍升高"
],
"core_name": "转氨酶",
"tendency": ""
},
{
"anatomy_list": [
"右下肺"
],
"character": [],
"core_name": "阴影",
"tendency": ""
},
{
"anatomy_list": [
"右肺下叶后基底段"
],
"character": [],
"core_name": "团片影",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"感染性"
],
"core_name": "病变",
"tendency": "不确定"
},
{
"anatomy_list": [
"右肺下叶后基底段"
],
"character": [],
"core_name": "肿瘤",
"tendency": "不确定"
},
{
"anatomy_list": [
"肺部"
],
"character": [],
"core_name": "阴影",
"tendency": ""
}
] |
2+天前，患者无明显诱因出现左下腹持续性腹痛，伴呕吐、腹泻，呕吐物为胃内容物，腹泻7次，为黑稀便，无畏寒、发热，无活动后心悸、气促，无咳嗽、咳痰，小便正常，遂就诊于某医院，完善相关辅助检查，腹部超声提示：右肾结石肾结石伴轻度积水，予以相关对症支持治疗（具体治疗不详），无明显缓解，患者自觉症状加重，今日遂于某医院就诊，完善相关辅助检查，彩超提示：1.胆囊结石伴炎变 2.右肾结石 3.子宫实性伴占位性病变（肌瘤）3.左侧附件囊性占位占位性病变（囊肿）4.右下腹低回声低回声区（炎性阑尾？），未行相关治疗，遂于我院就诊，门诊以“腹痛待查”收入我科治疗。 | 1,241 | [
{
"anatomy_list": [
"左下腹"
],
"character": [
"持续性"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"呕吐物为胃内容物"
],
"core_name": "呕吐",
"tendency": ""
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "腹泻",
"tendency": ""
},
{
"anatomy_list": [
"腹"
],
"character": [
"7次"
],
"core_name": "腹泻",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"稀"
],
"core_name": "黑便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "畏寒",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "发热",
"tendency": "否定"
},
{
"anatomy_list": [
"心"
],
"character": [
"活动后"
],
"core_name": "心悸",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"活动后"
],
"core_name": "气促",
"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": [
"正常"
],
"core_name": "小便",
"tendency": ""
},
{
"anatomy_list": [
"右肾"
],
"character": [],
"core_name": "结石",
"tendency": ""
},
{
"anatomy_list": [
"右肾"
],
"character": [
"轻度"
],
"core_name": "积水",
"tendency": ""
},
{
"anatomy_list": [
"胆囊"
],
"character": [],
"core_name": "结石",
"tendency": ""
},
{
"anatomy_list": [
"胆囊"
],
"character": [],
"core_name": "胆囊炎",
"tendency": ""
},
{
"anatomy_list": [
"右肾"
],
"character": [],
"core_name": "结石",
"tendency": ""
},
{
"anatomy_list": [
"子宫"
],
"character": [
"实性",
"占位性"
],
"core_name": "病变",
"tendency": ""
},
{
"anatomy_list": [
"子宫"
],
"character": [],
"core_name": "肌瘤",
"tendency": ""
},
{
"anatomy_list": [
"左侧附件"
],
"character": [
"囊性",
"占位性"
],
"core_name": "病变",
"tendency": ""
},
{
"anatomy_list": [
"左侧附件"
],
"character": [],
"core_name": "囊肿",
"tendency": ""
},
{
"anatomy_list": [
"右下腹"
],
"character": [
"低"
],
"core_name": "回声异常",
"tendency": ""
},
{
"anatomy_list": [
"阑尾"
],
"character": [],
"core_name": "阑尾炎",
"tendency": "不确定"
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "疼痛",
"tendency": ""
}
] |
患者于2016年3月8日行腹腔镜下行全子宫、双侧附件切除术+大网膜、阑尾切除术+盆腔淋巴结清扫术+盆腔转移灶切除术+直肠转移灶切除术，手术经过顺利，术后给予预防感染、止血等治疗，术后一般情况好，标本常规病检，病检（123456）提示：双侧卵巢低分化腺癌、盆腔及直肠见转移灶、右侧盆腔淋巴结见癌转移（1/7）；子宫肌壁间平滑肌瘤。 | 1,692 | [
{
"anatomy_list": [
"双侧卵巢"
],
"character": [
"低分化"
],
"core_name": "腺癌",
"tendency": ""
},
{
"anatomy_list": [
"盆腔",
"直肠"
],
"character": [],
"core_name": "转移灶",
"tendency": ""
},
{
"anatomy_list": [
"右侧盆腔淋巴结"
],
"character": [
"转移"
],
"core_name": "癌",
"tendency": ""
},
{
"anatomy_list": [
"子宫肌壁间"
],
"character": [
"平滑肌"
],
"core_name": "瘤",
"tendency": ""
}
] |
出院后愿定于每3月返院行“亮丙瑞林”抗雄激素激素治疗，1月前前患者无明显诱因出现血尿，为全程淡红色血尿，无血凝块，无尿频、尿急、尿痛，无排尿困难，排尿滴沥、踟蹰，无尿线变细，无发热、寒战、咳嗽、咳痰，无腹痛、腰痛，无恶心、呕吐等不适，我科抗雄激素激素治疗后缓解出院，后每月规律至我院抗雄激素激素治疗。 | 321 | [
{
"anatomy_list": [],
"character": [
"全程淡红色",
"无血凝块"
],
"core_name": "血尿",
"tendency": ""
},
{
"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": "排尿滴沥",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "排尿踟蹰",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "尿线变细",
"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": [],
"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": [
"腰"
],
"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"
}
] |
21天前，患儿行术后第8次化疗结束出院后，不伴发热、不伴腹痛；复查血常规基本正常，今日按疗程入院继续治疗。 | 929 | [
{
"anatomy_list": [],
"character": [],
"core_name": "发热",
"tendency": "否定"
},
{
"anatomy_list": [
"腹部"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
}
] |
2018-03-19全身pet-ct示：子宫切除术后，术区未见明显异常。 | 164 | [
{
"anatomy_list": [
"术区"
],
"character": [
"明显"
],
"core_name": "异常",
"tendency": "否定"
}
] |
5天前因下地干活后出现持续性腹痛，包块增大，平卧休息后缓解，包块消失，患者未予重视及相关诊治，今为求治疗至我院，以“右侧腹股沟疝”收入我科。 | 1,475 | [
{
"anatomy_list": [
"腹"
],
"character": [
"持续性"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"增大",
"平卧休息后缓解",
"消失"
],
"core_name": "包块",
"tendency": ""
},
{
"anatomy_list": [
"右侧腹股沟"
],
"character": [],
"core_name": "疝",
"tendency": ""
}
] |
<右支气管>恶性肿瘤，结合形态及免疫组化符合肺小细胞癌。 | 571 | [
{
"anatomy_list": [
"右支气管"
],
"character": [
"恶性"
],
"core_name": "肿瘤",
"tendency": ""
},
{
"anatomy_list": [
"肺",
"小细胞"
],
"character": [],
"core_name": "癌",
"tendency": ""
}
] |
无咽喉部刺痛、饮水呛咳，未到医院进行相关检查，3+年前，患者自觉上述症状加重，并出现右上腹隐痛，呈间断性，进食后明显，不影响日常活动及睡眠，无反酸、烧心，无胸闷、心慌，遂于某医院就诊，行内镜镜检示：贲门ca，慢性萎缩性胃炎，胃镜病检示：贲门口腺癌，倾向于中分化型，于2017-5-4就诊于某医院行腹部ct提示：食管末端及胃底贲门贲门部胃壁明显不规则增厚，局部可见深大溃疡，局部增厚呈肿块状突向腔内生长，肝胃间隙多发肿大淋巴结，考虑转移，肝内散在斑片及结节状低低密度肿块，考虑转移，暂无手术指征，建议患者化疗，患者拒绝。 | 591 | [
{
"anatomy_list": [
"咽喉部"
],
"character": [
"刺痛"
],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"饮水"
],
"core_name": "呛咳",
"tendency": "否定"
},
{
"anatomy_list": [
"右上腹"
],
"character": [
"隐痛",
"间断性",
"进食后明显",
"不影响日常活动及睡眠"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "反酸",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "烧心",
"tendency": "否定"
},
{
"anatomy_list": [
"胸"
],
"character": [],
"core_name": "胸闷",
"tendency": "否定"
},
{
"anatomy_list": [
"心"
],
"character": [],
"core_name": "心慌",
"tendency": "否定"
},
{
"anatomy_list": [
"贲门"
],
"character": [],
"core_name": "癌",
"tendency": ""
},
{
"anatomy_list": [
"胃"
],
"character": [
"慢性",
"萎缩性"
],
"core_name": "胃炎",
"tendency": ""
},
{
"anatomy_list": [
"贲门口"
],
"character": [
"中分化型"
],
"core_name": "腺癌",
"tendency": "不确定"
},
{
"anatomy_list": [
"食管末端",
"胃底",
"贲门胃壁"
],
"character": [
"明显",
"不规则"
],
"core_name": "增厚",
"tendency": ""
},
{
"anatomy_list": [
"食管末端",
"胃底",
"贲门胃壁"
],
"character": [
"深",
"大",
"局部"
],
"core_name": "溃疡",
"tendency": ""
},
{
"anatomy_list": [
"食管末端",
"胃底",
"贲门胃壁"
],
"character": [
"肿块状",
"突向腔内生长",
"局部"
],
"core_name": "增厚",
"tendency": ""
},
{
"anatomy_list": [
"肝胃间隙淋巴结"
],
"character": [
"多发"
],
"core_name": "肿大",
"tendency": ""
},
{
"anatomy_list": [
"肝胃间隙"
],
"character": [],
"core_name": "转移",
"tendency": "不确定"
},
{
"anatomy_list": [
"肝内"
],
"character": [
"散在"
],
"core_name": "斑片",
"tendency": ""
},
{
"anatomy_list": [
"肝内"
],
"character": [
"结节状",
"低密度",
"散在"
],
"core_name": "肿块",
"tendency": ""
},
{
"anatomy_list": [
"肝内"
],
"character": [],
"core_name": "转移",
"tendency": "不确定"
}
] |
标本送常规病检(123456):（左乳）浸润性癌，非特殊类型，ii级6分，局部见导管内癌成分。 | 1,760 | [
{
"anatomy_list": [
"左乳"
],
"character": [
"非特殊类型",
"浸润性",
"ii级6分"
],
"core_name": "癌",
"tendency": ""
},
{
"anatomy_list": [
"左乳"
],
"character": [
"导管内",
"局部"
],
"core_name": "癌",
"tendency": ""
}
] |
化疗期间复查胸部ct提示病灶维持稳定无明显进展。 | 1,941 | [
{
"anatomy_list": [],
"character": [
"明显进展"
],
"core_name": "病灶",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"维持稳定"
],
"core_name": "病灶",
"tendency": ""
}
] |
右输卵管系膜囊肿。双侧卵巢组织。 | 1,284 | [
{
"anatomy_list": [
"右输卵管",
"系膜"
],
"character": [],
"core_name": "囊肿",
"tendency": ""
}
] |
于2016-07-20开始静脉化疗，化疗方案为多西他赛140mg+表柔比星110mg，分两次给药，化疗期间有脱发，无明显骨髓抑制现象，无恶心、呕吐等胃肠道反应。 | 1,194 | [
{
"anatomy_list": [],
"character": [
"化疗期间"
],
"core_name": "脱发",
"tendency": ""
},
{
"anatomy_list": [
"骨髓"
],
"character": [
"明显"
],
"core_name": "骨髓抑制",
"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": [
"胃肠道"
],
"character": [],
"core_name": "胃肠道反应",
"tendency": "否定"
}
] |
化疗过程顺利，未见明显不良反应，现患者为求第5次化疗入我院，门诊以“乳腺癌术后”收入我科。 | 971 | [
{
"anatomy_list": [
"乳腺"
],
"character": [
"术后"
],
"core_name": "癌",
"tendency": ""
}
] |
患者 伴纳差、乏力 ， 不伴大汗淋漓 ， 不伴畏寒、发热 ， 不伴反酸、嗳气 ， 无咳嗽、咳痰 ， 无胸闷、心悸 ， 无尿频、尿急、尿痛等症状 。 | 222 | [
{
"anatomy_list": [],
"character": [],
"core_name": "纳差",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "乏力",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"大汗"
],
"core_name": "出汗",
"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": "反酸",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "嗳气",
"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": [
"胸"
],
"character": [],
"core_name": "胸闷",
"tendency": "否定"
},
{
"anatomy_list": [
"心"
],
"character": [],
"core_name": "心悸",
"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"
}
] |
患病以来，精神、睡眠、食欲可，二便正常，体重无明显减轻。 | 131 | [
{
"anatomy_list": [],
"character": [
"可"
],
"core_name": "精神",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"可"
],
"core_name": "睡眠",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"可"
],
"core_name": "食欲",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"正常"
],
"core_name": "大小便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"明显"
],
"core_name": "体重减轻",
"tendency": "否定"
}
] |
患者遂转诊某医院，行骨髓穿刺涂片（170696Mm1）示浆细胞异常增生，原始及幼稚为主，考虑多发性骨髓瘤。 | 1,707 | [
{
"anatomy_list": [
"浆细胞"
],
"character": [
"异常",
"原始及幼稚为主"
],
"core_name": "增生",
"tendency": ""
},
{
"anatomy_list": [
"骨髓"
],
"character": [
"多发性"
],
"core_name": "瘤",
"tendency": "不确定"
}
] |
泌尿系彩超: 膀胱壁局限性增厚，请结合临床。 | 1,223 | [
{
"anatomy_list": [
"膀胱壁"
],
"character": [
"局限性"
],
"core_name": "增厚",
"tendency": ""
}
] |
自诉病程中有咯鲜血，无血凝块、食物残渣。 | 1,457 | [
{
"anatomy_list": [],
"character": [
"鲜",
"无血凝块、食物残渣。"
],
"core_name": "咯血",
"tendency": ""
}
] |
病程中，患者无头晕、头痛、骨痛，无饮水呛咳、吞咽困难，无胸闷。 | 1,385 | [
{
"anatomy_list": [
"头"
],
"character": [],
"core_name": "头晕",
"tendency": "否定"
},
{
"anatomy_list": [
"头"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [
"骨头"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"饮水"
],
"core_name": "呛咳",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "吞咽困难",
"tendency": "否定"
},
{
"anatomy_list": [
"胸"
],
"character": [],
"core_name": "胸闷",
"tendency": "否定"
}
] |
10天前，患者在负重时突然出现上腹剧烈胀痛，向腰背部放射，伴气促、胸闷，无恶心、呕吐、反酸、嗳气，平卧时胀痛好转，站立、坐位、改变体位时腹痛加重，患者遂到当地医院门诊治疗，行钡餐检查提示胃下垂、胃炎，行腹部彩超提示胆总管扩张，予以“泮托拉唑”等药物治疗后患者腹痛无明显好转，遂到我院就诊，以“胆总管扩张”收入我科。 | 1,646 | [
{
"anatomy_list": [
"上腹"
],
"character": [
"负重时",
"胀痛",
"剧烈",
"突然出现"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"腰背部"
],
"character": [
"放射性"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "气促",
"tendency": ""
},
{
"anatomy_list": [
"胸"
],
"character": [],
"core_name": "胸闷",
"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": "返酸",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "嗳气",
"tendency": "否定"
},
{
"anatomy_list": [
"上腹"
],
"character": [
"胀痛",
"平卧时好转"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"腹"
],
"character": [
"站立、坐位、改变体位时加重"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"胃"
],
"character": [],
"core_name": "下垂",
"tendency": ""
},
{
"anatomy_list": [
"胃"
],
"character": [],
"core_name": "胃炎",
"tendency": ""
},
{
"anatomy_list": [
"胆总管"
],
"character": [],
"core_name": "扩张",
"tendency": ""
},
{
"anatomy_list": [
"上腹"
],
"character": [
"明显好转"
],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [
"胆总管"
],
"character": [],
"core_name": "扩张",
"tendency": ""
}
] |
3、盆腔中等量积液（不除外少许积血）。 | 1,012 | [
{
"anatomy_list": [
"盆腔"
],
"character": [
"中等量"
],
"core_name": "积液",
"tendency": ""
},
{
"anatomy_list": [
"盆腔"
],
"character": [
"少许"
],
"core_name": "积血",
"tendency": "不确定"
}
] |
今为求进一步诊治，遂入我院，门诊以“便血待查”收入我科。 | 868 | [
{
"anatomy_list": [],
"character": [],
"core_name": "便血",
"tendency": ""
}
] |
现患者为求复发后第三次化疗，遂以“卵巢中低分化浆液性腺癌iii期术后第八次化疗后复发伴直肠转移第二次化疗后”收入我科住院治疗。 | 1,039 | [
{
"anatomy_list": [
"卵巢"
],
"character": [
"中低分化",
"浆液性",
"术后",
"iii期",
"第八次化疗后复发"
],
"core_name": "腺癌",
"tendency": ""
},
{
"anatomy_list": [
"直肠"
],
"character": [
"第二次化疗后"
],
"core_name": "转移",
"tendency": ""
}
] |
住院期间血常规提示重度贫血，予以红细胞悬液400ml后好转；期间口服氨酚羟考酮止痛治疗，未规律服药，疼痛控制差；期间出现背部、颈部多发水泡，请皮肤科会诊后考虑免疫性大疱性皮病可能，疱疹病毒感染待排，建议行皮肤活检，患者及家属拒绝。 | 1,711 | [
{
"anatomy_list": [],
"character": [
"重度"
],
"core_name": "贫血",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"控制差"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"背部",
"颈部"
],
"character": [
"多发"
],
"core_name": "水泡",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"免疫性",
"大疱性"
],
"core_name": "皮病",
"tendency": "不确定"
},
{
"anatomy_list": [],
"character": [
"疱疹病毒"
],
"core_name": "感染",
"tendency": "不确定"
}
] |
8月前，患者无明显诱因出现咳嗽、咳痰加重，为黄白色粘液痰，量多，偶有低热、盗汗，无咯血、胸痛等不适，自服“感冒药”后无好转。 | 977 | [
{
"anatomy_list": [],
"character": [
"加重"
],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"加重"
],
"core_name": "咳痰",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"黄白色",
"粘液",
"量多"
],
"core_name": "咳痰",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"偶有",
"低"
],
"core_name": "发热",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"偶有"
],
"core_name": "盗汗",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "咯血",
"tendency": "否定"
},
{
"anatomy_list": [
"胸"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
}
] |
高血压病史7年，血压最高180/？mmhg，目前规律口服降压药（具体不详），血压未监测。 | 1,962 | [
{
"anatomy_list": [],
"character": [
"7年"
],
"core_name": "高血压",
"tendency": ""
}
] |
彩超（腹部+泌尿系）：胆囊壁增厚，左侧腹腔季肋部混合型包块。 | 520 | [
{
"anatomy_list": [
"胆囊壁"
],
"character": [],
"core_name": "增厚",
"tendency": ""
},
{
"anatomy_list": [
"左侧腹腔季肋部"
],
"character": [
"混合型"
],
"core_name": "包块",
"tendency": ""
}
] |
患者于1月前，因受凉出现咳嗽、咳痰，咯白色粘液痰，夜间较多，伴轻度乏力、纳差，步行平路感劳累，无畏寒、发热，无胸痛、胸闷，无头昏、头痛，无恶心、呕吐，无身黄、眼黄，无皮疹等不适，患者就诊于当地诊所，予以抗炎药物治疗3天（具体不详），患者症状未有缓解，故就诊于某医院，查胸部ct示“双肺感染”（未见报告），予以抗炎、止咳等对症治疗20天后复查胸部ct示病情好转（未见报告）出院，但患者自诉症状缓解不明显。 | 666 | [
{
"anatomy_list": [],
"character": [
"受凉后"
],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"受凉后"
],
"core_name": "咳痰",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"白色",
"粘液",
"夜间增多"
],
"core_name": "咳痰",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"轻度"
],
"core_name": "乏力",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "纳差",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"步行平路"
],
"core_name": "劳累",
"tendency": ""
},
{
"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": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [
"胸"
],
"character": [],
"core_name": "胸闷",
"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": "恶心",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "呕吐",
"tendency": "否定"
},
{
"anatomy_list": [
"身"
],
"character": [],
"core_name": "黄染",
"tendency": "否定"
},
{
"anatomy_list": [
"眼"
],
"character": [],
"core_name": "黄染",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "皮疹",
"tendency": "否定"
},
{
"anatomy_list": [
"双肺"
],
"character": [],
"core_name": "感染",
"tendency": ""
}
] |
尿正常，无血尿。 | 1,297 | [
{
"anatomy_list": [],
"character": [
"正常"
],
"core_name": "小便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "血尿",
"tendency": "否定"
}
] |
患者自患病以来，精神、食欲、睡眠可，大小便正常，体重无明显变化。 | 363 | [
{
"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": "大小便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"明显"
],
"core_name": "体重变化",
"tendency": "否定"
}
] |
1周前无明显诱因出现进行性纳差，每日少量流质，全身乏力，进食后腹胀、一般营养状态差，偶感上腹部隐痛；否认咳嗽、咳痰；无发热；肛门有排气，t管每日引流600ml左右褐色液体，门诊以“胰腺癌术后”收入我科。 | 1,409 | [
{
"anatomy_list": [],
"character": [
"进行性"
],
"core_name": "纳差",
"tendency": ""
},
{
"anatomy_list": [
"全身"
],
"character": [],
"core_name": "乏力",
"tendency": ""
},
{
"anatomy_list": [
"腹"
],
"character": [
"进食后"
],
"core_name": "腹胀",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"差"
],
"core_name": "营养状态",
"tendency": ""
},
{
"anatomy_list": [
"上腹部"
],
"character": [
"隐痛"
],
"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": "发热",
"tendency": "否定"
},
{
"anatomy_list": [
"肛门"
],
"character": [],
"core_name": "排气",
"tendency": ""
},
{
"anatomy_list": [
"胰腺"
],
"character": [
"术后"
],
"core_name": "癌",
"tendency": ""
}
] |
考虑肺癌可能，予 对症支持 等治疗。 | 429 | [
{
"anatomy_list": [
"肺"
],
"character": [],
"core_name": "癌",
"tendency": "不确定"
}
] |
近来发现右肩背部肿物 逐渐增大致4*5cm 。 | 2,030 | [
{
"anatomy_list": [
"右肩背部"
],
"character": [
"逐渐增大"
],
"core_name": "肿物",
"tendency": ""
}
] |
2月前改用奥西替尼治疗，住院期间予以唑来磷酸抗溶骨治疗，同时口服羟考酮缓释片 10mg q12h，疼痛控制可。 | 1,910 | [
{
"anatomy_list": [],
"character": [
"控制可"
],
"core_name": "疼痛",
"tendency": ""
}
] |
患者本次发病以来，食欲下降， 神志清醒，精神欠佳，睡眠尚可，大便正常，小便正常，体重减少。 | 543 | [
{
"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": [
"正常"
],
"core_name": "小便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "体重减少",
"tendency": ""
}
] |
7月前患者给予亚砷酸氯化钠(伊泰达)注射液 10mg 静滴14天，6月前予以口服维甲酸 20mg bid*14天维持治疗，5月前行亚砷酸氯化钠(伊泰达)注射液 10mg 静滴14天维持化疗，3月余前复查骨髓检查示增生性骨髓象；fish：pml/rara（双色双融合）(15/17)：未见异常；腰穿脑脊液未见异常细胞。现为维持化疗入院。 | 2,039 | [
{
"anatomy_list": [],
"character": [],
"core_name": "fish：pml/rara（双色双融合）(15/17)异常",
"tendency": "否定"
},
{
"anatomy_list": [
"骨髓"
],
"character": [
"增生性"
],
"core_name": "骨髓象",
"tendency": ""
}
] |
2015-12-08于某医院复查，肿瘤标记物示：cea9.91ng/ml、ca125 45.8U/ml，故继续予以培美曲塞900mg（具体治疗不详）维持治疗，过程顺利，无骨髓抑制后好转出院。 | 964 | [
{
"anatomy_list": [
"骨髓"
],
"character": [],
"core_name": "骨髓抑制",
"tendency": "否定"
}
] |
1月余前患者无明显诱因出现咳嗽咳痰，咳白色泡沫样痰，伴左侧胸部隐痛，胸痛与呼吸无关，逐渐出现气喘，伴乏力纳差，伴盗汗，无发热寒战，无午后低热，无咳血，无咳大量脓痰，无声音嘶哑，无呼吸困难，夜间可平卧，无吞咽困难，无头晕头痛，无恶心呕吐，无关节疼痛，无乏力浮肿，患者遂于某医院就诊，完善相关检查示血象升高，胸部ct示“1.左下肺空洞病灶，脓肿？癌性空洞？2.左侧肺门肺门淋巴结增大，3.左侧胸腔少量积液”，给予“帕拉西林他唑巴坦+莫西沙星+奥硝唑”抗感染治疗，患者上述症状未见明显好转，并于2016-5-4夜间出现发热，最高高体温为38.6℃，现患者为求进一步诊治来我院，门诊以“肺空洞待查”收治入院。 | 1,663 | [
{
"anatomy_list": [],
"character": [],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "咳痰",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"白色",
"泡沫样"
],
"core_name": "咳痰",
"tendency": ""
},
{
"anatomy_list": [
"左侧胸部"
],
"character": [
"隐痛"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"胸部"
],
"character": [
"与呼吸无关"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "气喘",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "乏力",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "纳差",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "盗汗",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "发热",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "寒颤",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"午后",
"低"
],
"core_name": "发热",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "咳血",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"大量",
"脓痰"
],
"core_name": "咳痰",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "声音嘶哑",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "呼吸困难",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "吞咽困难",
"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": "恶心",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "呕吐",
"tendency": "否定"
},
{
"anatomy_list": [
"关节"
],
"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": [
"升高"
],
"core_name": "血象",
"tendency": ""
},
{
"anatomy_list": [
"左下肺"
],
"character": [
"空洞"
],
"core_name": "病灶",
"tendency": ""
},
{
"anatomy_list": [
"左下肺"
],
"character": [],
"core_name": "脓肿",
"tendency": "不确定"
},
{
"anatomy_list": [],
"character": [
"癌性"
],
"core_name": "空洞",
"tendency": "不确定"
},
{
"anatomy_list": [
"左侧肺门淋巴结"
],
"character": [],
"core_name": "增大",
"tendency": ""
},
{
"anatomy_list": [
"左侧胸腔"
],
"character": [
"少量"
],
"core_name": "积液",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "发热",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"升高"
],
"core_name": "体温",
"tendency": ""
},
{
"anatomy_list": [
"肺"
],
"character": [],
"core_name": "空洞",
"tendency": "不确定"
}
] |
3.右侧胸膜增厚、粘连。 | 761 | [
{
"anatomy_list": [
"右侧胸膜"
],
"character": [],
"core_name": "增厚",
"tendency": ""
},
{
"anatomy_list": [
"右侧胸膜"
],
"character": [],
"core_name": "粘连",
"tendency": ""
}
] |
2017-2无明显诱因出现腰部胀痛，休息后自行缓解，2017-3-27复查ca-12578.1u/ml，2017-04-24ca-125152.3u/ml，he444.43pmol/l，妇科彩超提示双侧髂血管血管旁低回声，考虑：淋巴结？盆腔积液，考虑“卵巢癌术后化疗后复发”，于2017-4-27在我科行腹腔镜探查术+盆腔肿瘤切除术+肠粘连松解术+盆腔粘连松解术+输尿管镜检查+右侧输尿管双j管置入术，术后病检结果：<左侧阴道前壁、右侧阴道前壁>血管扩张充血，血管管壁增厚，未见肿瘤组织。 | 708 | [
{
"anatomy_list": [
"腰部"
],
"character": [
"胀痛",
"休息后自行缓解"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"双侧髂血管旁"
],
"character": [
"低"
],
"core_name": "回声",
"tendency": ""
},
{
"anatomy_list": [
"盆腔"
],
"character": [],
"core_name": "积液",
"tendency": ""
},
{
"anatomy_list": [
"卵巢"
],
"character": [
"术后化疗后",
"复发"
],
"core_name": "癌",
"tendency": "不确定"
},
{
"anatomy_list": [
"右侧左侧阴道前壁前壁血管"
],
"character": [],
"core_name": "扩张",
"tendency": ""
},
{
"anatomy_list": [
"右侧左侧阴道前壁前壁血管"
],
"character": [],
"core_name": "血管充血",
"tendency": ""
},
{
"anatomy_list": [
"血管管壁"
],
"character": [],
"core_name": "增厚",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "肿瘤组织",
"tendency": "否定"
}
] |
患者2天前无明显诱因出现头昏、心悸，头昏程度中等，伴四肢麻木、乏力，伴轻度步态不稳，心悸间断发作，休息后可缓解。 | 1,112 | [
{
"anatomy_list": [
"头"
],
"character": [],
"core_name": "头昏",
"tendency": ""
},
{
"anatomy_list": [
"心"
],
"character": [],
"core_name": "心悸",
"tendency": ""
},
{
"anatomy_list": [
"头"
],
"character": [
"程度中等"
],
"core_name": "头昏",
"tendency": ""
},
{
"anatomy_list": [
"四肢"
],
"character": [],
"core_name": "麻木",
"tendency": ""
},
{
"anatomy_list": [
"四肢"
],
"character": [],
"core_name": "乏力",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"轻度"
],
"core_name": "步态不稳",
"tendency": ""
},
{
"anatomy_list": [
"心"
],
"character": [
"间断发作",
"休息后可缓解"
],
"core_name": "心悸",
"tendency": ""
}
] |
入院后腹部ct检查提示：乙状结肠降结肠交界处局部肠壁增厚，管腔狭窄，浆膜面毛糙，遂行左半结肠根治性切除术，术后恢复好，病理提示t4n0M0。 | 847 | [
{
"anatomy_list": [
"乙状结肠降结肠交界处"
],
"character": [
"局部",
"肠壁"
],
"core_name": "增厚",
"tendency": ""
},
{
"anatomy_list": [
"乙状结肠降结肠交界处管腔"
],
"character": [],
"core_name": "狭窄",
"tendency": ""
},
{
"anatomy_list": [
"乙状结肠降结肠交界处浆膜面"
],
"character": [],
"core_name": "毛糙",
"tendency": ""
}
] |
患者诉此后多次体检复查腹部彩超，均提示胆囊结石，患病以来，患者诉气候变化时右上腹有轻微疼痛，服用消炎利胆片稍有缓解，故患者未予进一步治疗。 | 910 | [
{
"anatomy_list": [
"胆囊"
],
"character": [],
"core_name": "结石",
"tendency": ""
},
{
"anatomy_list": [
"右上腹"
],
"character": [
"轻微"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"右上腹"
],
"character": [
"服用消炎利胆片稍有缓解"
],
"core_name": "疼痛",
"tendency": ""
}
] |
1天前，患者再次出现胸痛明显家属见状遂来我院，以“肺癌”收入我科。 | 1,536 | [
{
"anatomy_list": [
"胸"
],
"character": [
"明显"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"肺"
],
"character": [],
"core_name": "癌",
"tendency": ""
}
] |
患者于半月前受凉后出现阵发性咳嗽、咳黄色粘稠痰，右侧胸部阵发性隐痛，以剧烈咳嗽时为重，痛时尚能忍受，无转移性疼痛，无放射样疼痛，无畏寒、发热，无潮热、盗汗，无恶心、呕吐，无胸闷及呼吸困难，求诊于当地某社区卫生服务站予“抗感染”等治疗后（具体不详）症状无缓解。 | 1,840 | [
{
"anatomy_list": [],
"character": [
"阵发性",
"受凉后"
],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"黄色",
"粘稠痰"
],
"core_name": "咳痰",
"tendency": ""
},
{
"anatomy_list": [
"右侧胸部"
],
"character": [
"阵发性",
"隐痛",
"剧烈咳嗽时为重",
"尚能忍受"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"转移性"
],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"放射样"
],
"core_name": "疼痛",
"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": "潮热",
"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": "胸闷",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "呼吸困难",
"tendency": "否定"
}
] |
术后恢复可，规律行化疗及口服抗肿瘤药物，定期复查，入院前2年余因肝癌复发于我院行介入手术，现因患者门诊复查afp升高，为进一步诊断及治疗，遂来我院就诊，患者患病以来精神尚可，饮食差，二便正常。 | 719 | [
{
"anatomy_list": [
"肝"
],
"character": [
"复发"
],
"core_name": "癌",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"升高"
],
"core_name": "afp",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"尚可"
],
"core_name": "精神",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"差"
],
"core_name": "饮食",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"正常"
],
"core_name": "大小便",
"tendency": ""
}
] |
5天前患者再次咳嗽、咳痰加重，为白色泡沫痰，伴活动后传来不适，患者今日为求进一步诊治就诊于我院，胸片提示：1、右肺下叶病灶，多考虑炎症；2、右侧胸腔积液。 | 664 | [
{
"anatomy_list": [],
"character": [
"加重"
],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"加重"
],
"core_name": "咳痰",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"白色",
"泡沫痰"
],
"core_name": "咳痰",
"tendency": ""
},
{
"anatomy_list": [
"右肺下叶"
],
"character": [],
"core_name": "病灶",
"tendency": ""
},
{
"anatomy_list": [
"右肺下叶"
],
"character": [],
"core_name": "炎症",
"tendency": "不确定"
},
{
"anatomy_list": [
"右侧胸腔"
],
"character": [],
"core_name": "积液",
"tendency": ""
}
] |
4.“宫颈ca复查”：现子宫颈部增大，宫颈右前缘结节，累及邻近膀胱壁及右侧输尿管，伴近端输尿管及肾盂肾盏扩张。 | 1,207 | [
{
"anatomy_list": [
"宫颈"
],
"character": [],
"core_name": "癌",
"tendency": ""
},
{
"anatomy_list": [
"子宫颈部"
],
"character": [],
"core_name": "增大",
"tendency": ""
},
{
"anatomy_list": [
"宫颈右前缘"
],
"character": [],
"core_name": "结节",
"tendency": ""
},
{
"anatomy_list": [
"膀胱壁",
"右侧输尿管"
],
"character": [],
"core_name": "累及",
"tendency": ""
},
{
"anatomy_list": [
"近端输尿管",
"肾盏",
"肾盂"
],
"character": [],
"core_name": "扩张",
"tendency": ""
}
] |
左侧输尿管及膀胱腔腔内双j管影，上端位置偏低。 | 181 | [
{
"anatomy_list": [
"左侧输尿管",
"膀胱腔内"
],
"character": [],
"core_name": "双j管影",
"tendency": ""
},
{
"anatomy_list": [
"左侧输尿管上端"
],
"character": [],
"core_name": "位置偏低",
"tendency": ""
}
] |
综合考虑：不除外黄体破裂。 | 1,013 | [
{
"anatomy_list": [
"黄体"
],
"character": [],
"core_name": "破裂",
"tendency": "不确定"
}
] |
入院前3+年,患者患“肺结核”,服药8月,后出现快步活动后气促,休息后缓解,平时轻量活动可耐受,偶咳,不剧,痰少,未正规检查治疗。 | 3 | [
{
"anatomy_list": [
"肺"
],
"character": [],
"core_name": "结核",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"快步活动后",
"休息后",
"缓解"
],
"core_name": "气促",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"休息后缓解"
],
"core_name": "气促",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"轻量"
],
"core_name": "活动可耐受",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"偶",
"不剧"
],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"少"
],
"core_name": "咳痰",
"tendency": ""
}
] |
此次病程中精神较差，饮食稍差，大便如上述，小便正常，体重无明显改变。 | 862 | [
{
"anatomy_list": [],
"character": [
"较差"
],
"core_name": "精神",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"稍差"
],
"core_name": "进食",
"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"
}
] |
3.右侧胸膜增厚。 | 755 | [
{
"anatomy_list": [
"右侧胸膜"
],
"character": [],
"core_name": "增厚",
"tendency": ""
}
] |
入院前 10天 ，患者再次因受凉后咳嗽，喘息加重，咯少许 黄色粘痰 ，伴双下肢轻度水肿。 | 1,332 | [
{
"anatomy_list": [],
"character": [
"加重",
"受凉后"
],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"加重",
"受凉后"
],
"core_name": "气喘",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"黄色",
"粘痰",
"少许"
],
"core_name": "咳痰",
"tendency": ""
},
{
"anatomy_list": [
"双下肢"
],
"character": [
"轻度"
],
"core_name": "水肿",
"tendency": ""
}
] |
于为进一步治疗，患者于今日就诊于我科，门诊以“霍奇金淋巴瘤”收住入院。 | 854 | [
{
"anatomy_list": [
"淋巴"
],
"character": [
"霍奇金"
],
"core_name": "瘤",
"tendency": ""
}
] |
1天前因“血尿”来我院门诊就诊，查“血常规：白细胞计数：3.3*10^9/L ，红细胞计数：4.16*10^12/L ，血红蛋白浓度：127g/L ，血小板计数：58*10^9/L ，淋巴细胞百分比：20.5%，中性粒细胞百分比：69.5%；尿常规：胆红素++，红细胞8214个/UL，白细胞++，蛋白质+++，隐血+++。 | 651 | [
{
"anatomy_list": [],
"character": [],
"core_name": "血尿",
"tendency": ""
}
] |
查无明显手术禁忌后于2017-9-28在局麻超声引导下行右乳包块麦默通旋切术+肿物切除+快速冰冻活检术。 | 134 | [
{
"anatomy_list": [
"右乳"
],
"character": [],
"core_name": "包块",
"tendency": ""
}
] |
4+年前，患者因排尿不畅就诊，查前列腺psa升高，行穿刺活检诊断“前列腺癌”，给予内分泌治疗后，排尿不畅症状好转。 | 2,019 | [
{
"anatomy_list": [],
"character": [],
"core_name": "排尿不畅",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"升高"
],
"core_name": "前列腺psa",
"tendency": ""
},
{
"anatomy_list": [
"前列腺"
],
"character": [],
"core_name": "癌",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"好转"
],
"core_name": "排尿不畅",
"tendency": ""
}
] |
2020/5/95/9Mmr检查报告：上腹部平扫磁共振胰胆管成像(mrcp); 1、肝左叶、肝门部及胆总管上段区域异常信号，考虑：肿瘤性病变继发高位胆道梗阻可能性大，建议ct增强扫描。 | 1,132 | [
{
"anatomy_list": [
"肝左叶",
"肝门部",
"胆总管上段"
],
"character": [
"异常"
],
"core_name": "信号",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"肿瘤性"
],
"core_name": "病变",
"tendency": "不确定"
},
{
"anatomy_list": [
"胆道"
],
"character": [
"高位",
"继发"
],
"core_name": "梗阻",
"tendency": "不确定"
}
] |
ctu(256层)(2015-03-09):膀胱占位性病变，考虑膀胱癌可能性大，右侧输尿管受侵。 | 1,845 | [
{
"anatomy_list": [
"膀胱"
],
"character": [
"占位性"
],
"core_name": "病变",
"tendency": ""
},
{
"anatomy_list": [
"膀胱"
],
"character": [],
"core_name": "癌",
"tendency": "不确定"
},
{
"anatomy_list": [
"右侧输尿管"
],
"character": [
"受侵"
],
"core_name": "癌",
"tendency": ""
}
] |
诉化疗期间2+周前患者无明显诱因出现双臀部、腰背部及双下肢大腿前侧疼痛以左侧为着，自感站立、行走后缓解，休息后加重，夜间疼痛加重较明显，患者无双下肢麻木、乏力，无恶心、呕吐、畏寒、发热、头痛、胸闷、胸痛、咳嗽、咯血、腹痛、腹胀、尿频、尿急、尿痛，无大小便失禁等不适，在我院行ect：左侧髂骨异常放射性浓聚，转移性骨肿瘤可能性大，骨科行腰椎及骨盆mri检查提示：左侧髂骨异常信号，多系肿瘤性病变。 | 1,289 | [
{
"anatomy_list": [
"双臀部",
"腰背部",
"双下肢大腿前侧"
],
"character": [
"站立、行走后缓解",
"休息后加重",
"夜间疼痛加重较明显"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"双下肢"
],
"character": [],
"core_name": "麻木",
"tendency": "否定"
},
{
"anatomy_list": [
"双下肢"
],
"character": [],
"core_name": "乏力",
"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": "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": [
"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": "咳嗽",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "咯血",
"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": [],
"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": [
"失禁"
],
"core_name": "大便",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"失禁"
],
"core_name": "小便",
"tendency": "否定"
},
{
"anatomy_list": [
"左侧髂骨"
],
"character": [
"异常",
"放射性"
],
"core_name": "浓聚",
"tendency": ""
},
{
"anatomy_list": [
"骨"
],
"character": [
"转移性"
],
"core_name": "肿瘤",
"tendency": "不确定"
},
{
"anatomy_list": [
"左侧髂骨"
],
"character": [
"异常"
],
"core_name": "信号",
"tendency": ""
},
{
"anatomy_list": [
"左侧髂骨"
],
"character": [
"肿瘤性"
],
"core_name": "病变",
"tendency": ""
}
] |
患者自意识障碍以来, 精神差 ,未进食, 大、小便未排 , 体重无明显变化 。 | 2 | [
{
"anatomy_list": [],
"character": [],
"core_name": "意识障碍",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"差"
],
"core_name": "精神",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "进食",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"未排"
],
"core_name": "大小便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"明显"
],
"core_name": "体重变化",
"tendency": "否定"
}
] |
5年余前，患者无明显诱因出现咳嗽，咳白色粘痰，不带血丝，无咯血，无潮热、盗汗，无心慌、胸闷，无声音嘶哑等不适，在某医院行胸片检查提示左肺占位，考虑肺癌，于2009-11-24在我院心胸外科行左上肺叶切除+淋巴结清扫术，术后病检提示：左上肺肺腺癌。 | 300 | [
{
"anatomy_list": [],
"character": [],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"白色",
"粘",
"不带血丝"
],
"core_name": "咳痰",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "咯血",
"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": [
"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": "声音嘶哑",
"tendency": "否定"
},
{
"anatomy_list": [
"左肺"
],
"character": [],
"core_name": "占位",
"tendency": ""
},
{
"anatomy_list": [
"肺"
],
"character": [],
"core_name": "癌",
"tendency": "不确定"
},
{
"anatomy_list": [
"左上肺"
],
"character": [],
"core_name": "腺癌",
"tendency": ""
}
] |
现患者无恶心、呕吐等不适，今日为行第二次化疗来我院，门诊以“右肺小细胞肺癌”收治入院。 | 208 | [
{
"anatomy_list": [],
"character": [],
"core_name": "恶心",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "呕吐",
"tendency": "否定"
},
{
"anatomy_list": [
"右肺",
"小细胞"
],
"character": [],
"core_name": "癌",
"tendency": ""
}
] |
入院前4小时，患者感中上腹疼痛较前加重，阵发性加重，尚能忍受，无放射痛，无大汗、心悸，无恶心、呕吐，无畏寒、发热等不适，遂到我院就诊，门诊以“腹痛待查”收入我科住院治疗。 | 1,640 | [
{
"anatomy_list": [
"中上腹"
],
"character": [
"较前加重",
"阵发性加重",
"尚能忍受"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"放射性"
],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "大汗",
"tendency": "否定"
},
{
"anatomy_list": [
"心"
],
"character": [],
"core_name": "心悸",
"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": "畏寒",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "发热",
"tendency": "否定"
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "疼痛",
"tendency": "不确定"
}
] |
c14呼气试验阳性。 | 261 | [
{
"anatomy_list": [],
"character": [
"阳性"
],
"core_name": "c14呼气试验",
"tendency": ""
}
] |
故昨日于我院门诊复查病理切片，结果示：子宫腔低分化腺癌，倾向于子宫内膜桨液性乳头状腺癌。 | 1,143 | [
{
"anatomy_list": [
"子宫腔"
],
"character": [
"低分化"
],
"core_name": "腺癌",
"tendency": ""
},
{
"anatomy_list": [
"子宫内膜"
],
"character": [
"乳头状",
"桨液性"
],
"core_name": "腺癌",
"tendency": "不确定"
}
] |
入院前1+月，患者自觉关节肿痛较前加重，四肢水肿，双手指指关节活动较前僵硬，有晨僵现象，偶有咳嗽，咳少量白色粘痰，无咽痛、流涕，无畏寒、发热，无颜面浮肿，无明显活动后心累、气促，无胸闷、胸痛等不适，患者遂于我院中医科就诊，予以止痛、中药调理等对症治疗，经治疗后未见明显好转，遂于某医院就诊，完善类风湿因子：306.0IU/ml；抗环瓜氨酸肽抗体抗体：120.71U/ml；抗角蛋白抗体阴性；血沉93mm/h；抗ra33抗体、抗o未见明显异常。 | 551 | [
{
"anatomy_list": [
"关节"
],
"character": [
"较前加重"
],
"core_name": "肿痛",
"tendency": ""
},
{
"anatomy_list": [
"四肢"
],
"character": [],
"core_name": "水肿",
"tendency": ""
},
{
"anatomy_list": [
"双手指",
"指关节"
],
"character": [
"较前"
],
"core_name": "僵硬",
"tendency": ""
},
{
"anatomy_list": [
"双手指",
"指关节"
],
"character": [],
"core_name": "晨僵",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"偶有"
],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"少量",
"白色",
"粘性"
],
"core_name": "咳痰",
"tendency": ""
},
{
"anatomy_list": [
"咽"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "流涕",
"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": [
"颜面"
],
"character": [],
"core_name": "浮肿",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"明显",
"活动后"
],
"core_name": "气促",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"明显",
"活动后"
],
"core_name": "心累",
"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": [
"明显异常"
],
"core_name": "抗o",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"明显异常"
],
"core_name": "抗ra33抗体",
"tendency": "否定"
}
] |
10年 来病情进行性加重，咳嗽，喘息发作渐趋频繁。 | 1,329 | [
{
"anatomy_list": [],
"character": [
"发作渐趋频繁"
],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"发作渐趋频繁"
],
"core_name": "喘息",
"tendency": ""
}
] |
到在当地检查彩超提示：甲状腺肿瘤。 | 105 | [
{
"anatomy_list": [
"甲状腺"
],
"character": [],
"core_name": "肿瘤",
"tendency": ""
}
] |
入院前3+月，患者因“黑便3+天，呕血10+小时”入我院消化内科，行胃镜提示残胃胃巨大溃疡；病理（123456）检查提示：胃体腺癌。 | 99 | [
{
"anatomy_list": [],
"character": [],
"core_name": "黑便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"10+小时"
],
"core_name": "呕血",
"tendency": ""
},
{
"anatomy_list": [
"胃"
],
"character": [],
"core_name": "残胃",
"tendency": ""
},
{
"anatomy_list": [
"胃"
],
"character": [
"巨大"
],
"core_name": "溃疡",
"tendency": ""
},
{
"anatomy_list": [
"胃体"
],
"character": [],
"core_name": "腺癌",
"tendency": ""
}
] |
1月余前，患者自觉尿色逐渐加深，呈浓茶色尿，不伴腹痛、恶心、呕吐，无乏力、纳差等不适，无皮肤巩膜黄染，无全身皮肤巩膜黄染，无白陶土样大便，无黑朦、晕厥等不适。 | 1,722 | [
{
"anatomy_list": [],
"character": [
"浓茶色",
"色逐渐加深"
],
"core_name": "小便",
"tendency": ""
},
{
"anatomy_list": [
"腹"
],
"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": [],
"character": [],
"core_name": "乏力",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "纳差",
"tendency": "否定"
},
{
"anatomy_list": [
"皮肤",
"巩膜"
],
"character": [],
"core_name": "黄染",
"tendency": "否定"
},
{
"anatomy_list": [
"全身皮肤",
"巩膜"
],
"character": [],
"core_name": "黄染",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"白陶土样"
],
"core_name": "大便",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "黑朦",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "晕厥",
"tendency": "否定"
}
] |
1月前患者因反复夜尿增多3月入院，伴有排尿困难加重，表现为排尿踌躇、尿线变细、射程变短，伴有尿频、尿急，无明显尿痛，无血尿，无腰痛、腹痛、无腹痛、腹泻，不伴发热、寒战，无潮热、盗汗、乏力，无头晕、头痛，无心慌、胸闷、胸痛，无呕血、便血，无双下肢水肿、无骨痛等异常，行psa提示为：总前列腺特异性抗原(t-psa)185.00ng/ml↑mr检查报告：1.前列腺增大，中央带及外周带散在异常信号影，考虑前列腺癌，累及膀胱及精囊腺，伴淋巴结转移；2.慢性膀胱炎。 | 1,949 | [
{
"anatomy_list": [],
"character": [
"反复"
],
"core_name": "夜尿增多",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"加重"
],
"core_name": "排尿困难",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "排尿踌躇",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"尿线"
],
"core_name": "变细",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "射程变短",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "尿频",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "尿急",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"明显"
],
"core_name": "尿痛",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "血尿",
"tendency": "否定"
},
{
"anatomy_list": [
"腰"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "疼痛",
"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": "发热",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "寒颤",
"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": "乏力",
"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": [
"心"
],
"character": [],
"core_name": "心慌",
"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": "呕血",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "便血",
"tendency": "否定"
},
{
"anatomy_list": [
"双下肢"
],
"character": [],
"core_name": "水肿",
"tendency": "否定"
},
{
"anatomy_list": [
"骨"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [
"前列腺"
],
"character": [],
"core_name": "增大",
"tendency": ""
},
{
"anatomy_list": [
"前列腺中央带及外周"
],
"character": [
"散在"
],
"core_name": "异常信号影",
"tendency": ""
},
{
"anatomy_list": [
"前列腺"
],
"character": [],
"core_name": "癌",
"tendency": ""
},
{
"anatomy_list": [
"膀胱",
"精囊腺"
],
"character": [
"累及"
],
"core_name": "癌",
"tendency": ""
},
{
"anatomy_list": [
"淋巴结"
],
"character": [
"转移"
],
"core_name": "癌",
"tendency": ""
},
{
"anatomy_list": [
"膀胱"
],
"character": [
"慢性"
],
"core_name": "膀胱炎",
"tendency": ""
}
] |
患者为求进一步诊治到我院就诊，门诊以“右股骨髁病变待查”收入我科住院治疗。 | 362 | [
{
"anatomy_list": [
"右股骨髁"
],
"character": [],
"core_name": "病变",
"tendency": "不确定"
}
] |
2+月前患者无明显诱因出现全身乏力，后逐渐出现黑便，量多，呈糊状，偶有粘液，无脓血，伴有心慌、头晕、乏力，无恶心、呕吐，无畏寒发热等不适，来我院就诊，诊断“直肠癌术后伴肝转移，小肠转移转移性肿瘤可疑”，予行tace术后，术后在我科予（奥沙利铂 200mg d1+替吉奥 60mg bid d1-d14）方案化疗2周期，化疗后无不适，今为行化疗，遂来我院就诊，门诊以“直肠癌”收入我科住院治疗。 | 1,093 | [
{
"anatomy_list": [
"全身"
],
"character": [],
"core_name": "乏力",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"量多",
"糊状"
],
"core_name": "黑便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"偶有粘液"
],
"core_name": "大便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"脓血"
],
"core_name": "大便",
"tendency": "否定"
},
{
"anatomy_list": [
"心"
],
"character": [],
"core_name": "心慌",
"tendency": ""
},
{
"anatomy_list": [
"头"
],
"character": [],
"core_name": "头晕",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "乏力",
"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": [
"直肠"
],
"character": [
"术后"
],
"core_name": "癌",
"tendency": ""
},
{
"anatomy_list": [
"肝"
],
"character": [
"直肠癌术后"
],
"core_name": "转移",
"tendency": ""
},
{
"anatomy_list": [
"小肠"
],
"character": [
"转移性"
],
"core_name": "肿瘤",
"tendency": "不确定"
},
{
"anatomy_list": [
"直肠"
],
"character": [],
"core_name": "癌",
"tendency": ""
}
] |
现患者腹痛腹部明显缓解，肛门排气排便 ，为进一步诊疗，门诊以“降结肠癌伴不全性肠梗阻？”收入我科。 | 225 | [
{
"anatomy_list": [
"腹"
],
"character": [
"明显缓解"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"降结肠"
],
"character": [],
"core_name": "癌",
"tendency": "不确定"
},
{
"anatomy_list": [
"肠"
],
"character": [
"不全性"
],
"core_name": "梗阻",
"tendency": "不确定"
}
] |
患者自起病情加重以来，精神可，胃纳可，大便如常，尿急、小便如常，体重未见明显下降。 | 679 | [
{
"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": [],
"core_name": "尿急",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"如常"
],
"core_name": "小便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"明显"
],
"core_name": "体重下降",
"tendency": "否定"
}
] |
10+天前患者因左侧腰痛，于某医院就诊，提示左肾积水，予以输液、止痛等对症治疗，为进一步诊疗来我科，以“神经纤维瘤”收治我科。 | 618 | [
{
"anatomy_list": [
"左侧腰"
],
"character": [],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"左肾"
],
"character": [],
"core_name": "积水",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"神经纤维"
],
"core_name": "瘤",
"tendency": ""
}
] |
入院前11月余，患者无明显诱因出现口腔双侧颊粘膜及舌头表面血泡、胸壁及左侧大腿内侧等处皮肤散在瘀斑，伴有阵发性头痛，不伴视物旋转，不伴头昏，不伴恶心、呕吐，不伴关节肌肉肌肉疼痛，不伴发热，于某医院查凝血象提示：PT 17.9s,APTT23.1s, pta55%, fbg 0.31g/L. 血常规示wbc：2.24×10^9/L，hb：113g/L，plt：30 ×109/l，n：36.0%，考虑诊断不详，予以输液治疗（具体不详）未见明显好转，遂来我院行骨髓检查示：急性早幼粒细胞白血病可能。 | 2,033 | [
{
"anatomy_list": [
"口腔双侧颊粘膜"
],
"character": [
"表面"
],
"core_name": "血泡",
"tendency": ""
},
{
"anatomy_list": [
"舌头"
],
"character": [
"表面"
],
"core_name": "血泡",
"tendency": ""
},
{
"anatomy_list": [
"胸壁皮肤"
],
"character": [
"散在"
],
"core_name": "瘀斑",
"tendency": ""
},
{
"anatomy_list": [
"左侧大腿内侧"
],
"character": [
"散在"
],
"core_name": "瘀斑",
"tendency": ""
},
{
"anatomy_list": [
"头"
],
"character": [
"阵发性"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "视物旋转",
"tendency": "否定"
},
{
"anatomy_list": [
"头"
],
"character": [],
"core_name": "头昏",
"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": [
"关节",
"肌肉"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "发热",
"tendency": "否定"
},
{
"anatomy_list": [
"早幼粒细胞"
],
"character": [
"急性"
],
"core_name": "白血病",
"tendency": "不确定"
}
] |
逐渐出现反复乏力、腹胀、恶心、反酸、餐后呕吐、胸闷、气促等，无头晕、头痛、眩晕，无心悸、黑蒙、心前区疼痛，无发热、腹痛、黑便，无肢端麻木及针刺痛等。 | 535 | [
{
"anatomy_list": [],
"character": [
"反复"
],
"core_name": "乏力",
"tendency": ""
},
{
"anatomy_list": [
"腹"
],
"character": [
"反复"
],
"core_name": "腹胀",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"反复"
],
"core_name": "恶心",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"反复"
],
"core_name": "反酸",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"餐后",
"反复"
],
"core_name": "呕吐",
"tendency": ""
},
{
"anatomy_list": [
"胸"
],
"character": [
"反复"
],
"core_name": "胸闷",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"反复"
],
"core_name": "气促",
"tendency": ""
},
{
"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": "眩晕",
"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": [
"心前区"
],
"character": [],
"core_name": "疼痛",
"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": [],
"character": [],
"core_name": "黑便",
"tendency": "否定"
},
{
"anatomy_list": [
"肢端"
],
"character": [],
"core_name": "麻木",
"tendency": "否定"
},
{
"anatomy_list": [
"肢端"
],
"character": [
"针刺痛"
],
"core_name": "疼痛",
"tendency": "否定"
}
] |
今为行第2次hd-mtx化疗入院，门诊以“急性白血病”收入院。 | 1,507 | [
{
"anatomy_list": [],
"character": [
"急性"
],
"core_name": "白血病",
"tendency": ""
}
] |
住院期间完善相关检查，胸部ct增强检查（2020-10-10）：右肺上叶前段结节并空洞形成，考虑：1.肿瘤2.结核及其他感染待排。 | 1,527 | [
{
"anatomy_list": [
"右肺上叶前段"
],
"character": [],
"core_name": "结节",
"tendency": ""
},
{
"anatomy_list": [
"右肺上叶前段"
],
"character": [],
"core_name": "空洞形成",
"tendency": ""
},
{
"anatomy_list": [
"右肺上叶前段"
],
"character": [],
"core_name": "结核",
"tendency": "不确定"
},
{
"anatomy_list": [
"右肺上叶前段"
],
"character": [
"其他"
],
"core_name": "感染",
"tendency": "不确定"
},
{
"anatomy_list": [
"肺"
],
"character": [],
"core_name": "肿瘤",
"tendency": "不确定"
}
] |
此后患者上述关节疼痛反复发作，性质同前，并累及出现左侧膝关节、双侧掌指关节，每次发作自行予以秋水仙碱、止痛药（泰国产、具体成分不详）或别嘌呤醇、非布司他口服，疼痛缓解后停药，未监测尿酸变化。 | 871 | [
{
"anatomy_list": [
"关节"
],
"character": [
"反复"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"左侧膝关节"
],
"character": [
"累及"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"双侧掌指关节"
],
"character": [
"累及"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"关节"
],
"character": [
"缓解"
],
"core_name": "疼痛",
"tendency": ""
}
] |
但今日无明显诱因感胸痛加重,性质同前,持续时间约1小时才缓解,今为求进一步诊治入院,门诊查“肝肾功、心酶、电解质、血常规及肌钙蛋白正常；胸部ct双肺气肿；双肺多发感染性病变,继发性肺结核可能（增殖、纤维化、空洞）；左肺下叶背段段结节影,肿瘤不能除外,建议进一步检查,左肺上叶尖后段真菌感染可能；双肺肺中叶炎性病变,纤维灶肌肺大疱形成,左肺下叶叶间质性纤维化,纵膈多发淋巴结显示伴钙化,双侧胸膜增厚；心电图正常”,为进一步诊治入院,门诊以“肺部感染”收入院。 | 41 | [
{
"anatomy_list": [
"胸"
],
"character": [
"加重",
"持续时间约1小时才缓解缓解",
"性质同前"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"双肺"
],
"character": [],
"core_name": "肺气肿",
"tendency": ""
},
{
"anatomy_list": [
"双肺"
],
"character": [
"多发",
"感染性"
],
"core_name": "病变",
"tendency": ""
},
{
"anatomy_list": [
"肺"
],
"character": [
"继发性",
"增殖",
"纤维化",
"空洞"
],
"core_name": "结核",
"tendency": "不确定"
},
{
"anatomy_list": [
"左肺下叶背段"
],
"character": [],
"core_name": "结节影",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "肿瘤",
"tendency": "不确定"
},
{
"anatomy_list": [
"左肺上叶尖后段"
],
"character": [],
"core_name": "真菌感染",
"tendency": "不确定"
},
{
"anatomy_list": [
"双肺肺中叶"
],
"character": [
"炎性"
],
"core_name": "病变",
"tendency": ""
},
{
"anatomy_list": [
"肺"
],
"character": [
"纤维灶肌",
"形成"
],
"core_name": "肺大疱",
"tendency": ""
},
{
"anatomy_list": [
"左肺下叶"
],
"character": [
"间质性"
],
"core_name": "纤维化",
"tendency": ""
},
{
"anatomy_list": [
"纵膈淋巴结"
],
"character": [
"钙化",
"多发"
],
"core_name": "显示",
"tendency": ""
},
{
"anatomy_list": [
"双侧胸膜"
],
"character": [
"增厚"
],
"core_name": "增厚",
"tendency": ""
},
{
"anatomy_list": [
"肺部"
],
"character": [],
"core_name": "感染",
"tendency": ""
}
] |
3年余前患者无明显诱因出现反复右下腹隐痛，无进行性加重，排气后可暂时缓解，无阴道阴道流血流液，无肛门坠胀，无畏寒发热，无恶心、呕吐，无尿频、尿急及尿痛，院外口服消炎药（具体不详）无明显缓解。 | 1,119 | [
{
"anatomy_list": [
"右下腹"
],
"character": [
"隐痛",
"反复",
"排气后可暂时缓解"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"右下腹"
],
"character": [
"隐痛",
"进行性加重"
],
"core_name": "疼痛",
"tendency": "否定"
},
{
"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": [
"肛门"
],
"character": [],
"core_name": "坠胀",
"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": "恶心",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "呕吐",
"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"
}
] |