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stringlengths 5
708
| id
int64 1
2.07k
| event
list |
|---|---|---|
体重减轻5斤。 | 1,411 | [
{
"anatomy_list": [],
"character": [],
"core_name": "体重减轻",
"tendency": ""
}
] |
病程中，患者神志清，精神可，饮食睡眠正常，大小便正常，体重无异常变化。 | 114 | [
{
"anatomy_list": [],
"character": [
"清"
],
"core_name": "神志",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"可"
],
"core_name": "精神",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"正常"
],
"core_name": "饮食",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"正常"
],
"core_name": "睡眠",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"正常"
],
"core_name": "大小便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"异常"
],
"core_name": "体重变化",
"tendency": "否定"
}
] |
于2015年8月11日行神经导航下开路探查+左侧前颅底路况沟通肿瘤纤维切除术，术中可见肿瘤位于左侧前颅底，已经将蝶骨脊及眼眶外侧板侵蚀破坏，起源于硬脑膜，硬膜外及硬膜下均可见肿瘤，硬膜下肿瘤呈肉红色，血供丰富，与周围脑组织边界尚清，粘连明显，完整切除肿瘤致肿瘤镜下全切，之后切除眼眶内肿瘤，探查肿瘤位于框内，与周围骨质两联紧密，深部侵及眶外脂肪层，小心游离眼眶内肿瘤后完整切除肿瘤。 | 419 | [
{
"anatomy_list": [
"左侧前颅底"
],
"character": [],
"core_name": "肿瘤",
"tendency": ""
},
{
"anatomy_list": [
"眼眶外侧板",
"蝶骨脊"
],
"character": [],
"core_name": "侵蚀破坏",
"tendency": ""
},
{
"anatomy_list": [
"硬脑膜",
"硬膜外",
"硬膜下"
],
"character": [],
"core_name": "肿瘤",
"tendency": ""
},
{
"anatomy_list": [
"硬膜下"
],
"character": [
"呈肉红色",
"血供丰富",
"与周围脑组织边界尚清",
"粘连明显"
],
"core_name": "肿瘤",
"tendency": ""
},
{
"anatomy_list": [
"眼眶内"
],
"character": [
"与周围骨质两联紧密",
"深部侵及眶外脂肪层"
],
"core_name": "肿瘤",
"tendency": ""
}
] |
2+年前，患者无明显诱因反复出现咳嗽，多为干咳，偶咳白色泡沫痰，偶有发热，体温多为38℃左右，无畏寒、盗汗，无胸闷、胸痛，无咯血，于某医院输液治疗（具体不详）后可好转，未予以进一步检查。 | 544 | [
{
"anatomy_list": [],
"character": [
"反复出现"
],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"干性",
"反复出现"
],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"偶尔",
"白色",
"泡沫痰"
],
"core_name": "咳痰",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"偶有"
],
"core_name": "发热",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"升高",
"偶有"
],
"core_name": "体温",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "畏寒",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "盗汗",
"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": "咯血",
"tendency": "否定"
}
] |
7+月前至某医院医院复查妇科彩超：左附件区可见64mm×35mm的无回声区，查ca125、he4均正常，hpv-dna均阴性，建议手术，患者仍未做。 | 825 | [
{
"anatomy_list": [
"左附件"
],
"character": [],
"core_name": "无回声",
"tendency": ""
}
] |
入院3天前再次出现意识丧失（家属未看到），发病形式、过程不详。 | 740 | [
{
"anatomy_list": [],
"character": [
"家属未看到",
"发病形式",
"过程不详"
],
"core_name": "意识丧失",
"tendency": ""
}
] |
于2019-3-27给予e-chop方案（依托泊苷100mg d1-2、吡柔比星20mg d1-3、环磷酰胺400mg d1-3、地塞米松20mg d1-5、长春新碱1.5mg d1、d8）方案化疗1周期，于2019-4-23、2019-5-17给予re-chop方案（美罗华600mg d1、依托泊苷100mg d1-2、吡柔比星60mg d1、环磷酰胺400mg d1-3、地塞米松20mg d1-5、长春新碱3mg d1）化疗第2周期，化疗后患者出现ii°骨髓抑制，给予升白治疗后骨髓抑制纠正，今日为行下一周期化疗来我科，以“弥漫大b细胞淋巴瘤（iv期 b组）化疗后复发”收入住院治疗。 | 1,072 | [
{
"anatomy_list": [
"骨髓"
],
"character": [
"化疗后",
"ii°"
],
"core_name": "骨髓抑制",
"tendency": ""
},
{
"anatomy_list": [
"骨髓"
],
"character": [
"矫正"
],
"core_name": "骨髓抑制",
"tendency": ""
},
{
"anatomy_list": [
"淋巴",
"大B细胞"
],
"character": [
"弥漫性",
"iv期 b组",
"化疗后",
"复发"
],
"core_name": "瘤",
"tendency": ""
}
] |
院外于某医院行内分泌治疗及抗溶骨治疗，患者近期左侧腰部及下肢疼痛明显，为求进一步治疗，以“乳腺癌 骨转移”收入我科住院治疗。 | 1,291 | [
{
"anatomy_list": [
"左侧腰部",
"下肢"
],
"character": [
"近期",
"明显"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"乳腺",
"骨"
],
"character": [
"骨转移"
],
"core_name": "癌",
"tendency": ""
}
] |
后一直我院随访，肿瘤病灶稳定，1年前前，患者在我科复查腹部mri提示肝右后叶小富血供结节，不排除原发性肝癌hifu术后复发可能，于2013年12月30日行tae治疗，于2014年1月4日在全身麻醉下行原发性肝癌姑息性hifu术，术后患者恢复可，多次复查腹部mri提示肿瘤控制可，现为求再次复查入住我科。 | 1,006 | [
{
"anatomy_list": [],
"character": [
"肿瘤",
"稳定"
],
"core_name": "病灶",
"tendency": ""
},
{
"anatomy_list": [
"肝右后叶"
],
"character": [
"小",
"富血供"
],
"core_name": "结节",
"tendency": ""
},
{
"anatomy_list": [
"肝"
],
"character": [
"原发性",
"hifu术后",
"复发"
],
"core_name": "癌",
"tendency": "不确定"
},
{
"anatomy_list": [],
"character": [
"控制可"
],
"core_name": "肿瘤",
"tendency": ""
}
] |
院外一直口服中成药治疗（具体用药）治疗，并于2011年5月和2011年9月、2012年3月22日和2012年7月到我科复查，行相关检查，提示肿瘤尚无进展。 | 724 | [
{
"anatomy_list": [],
"character": [
"进展"
],
"core_name": "肿瘤",
"tendency": "否定"
}
] |
肠壁上淋巴结见癌转移（1/15）。 | 748 | [
{
"anatomy_list": [
"肠壁上淋巴结"
],
"character": [
"转移"
],
"core_name": "癌",
"tendency": ""
}
] |
到某医院就诊，行胸片示肺上局部钙化钙化灶（未见报告），未予特殊治疗。 | 2,025 | [
{
"anatomy_list": [
"肺上局部"
],
"character": [
"局部"
],
"core_name": "钙化灶",
"tendency": ""
}
] |
患者1+月前出现咳嗽咳痰，咳嗽声音正常，不伴有鸡鸣样咳嗽，不伴有刺激性干咳，咳嗽时有胸痛症状。 | 368 | [
{
"anatomy_list": [],
"character": [],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "咳痰",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"声音正常"
],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"鸡鸣样"
],
"core_name": "咳嗽",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"刺激性",
"干"
],
"core_name": "咳嗽",
"tendency": "否定"
},
{
"anatomy_list": [
"胸"
],
"character": [
"咳嗽时"
],
"core_name": "疼痛",
"tendency": ""
}
] |
后续于2016年12月25日、2017年1月18日、2017年2月15日行3周期原方案原剂量化疗,未见明显骨髓抑制；后于2017年3月14日、2017年4月8日予以吡柔比星50mg d1+紫杉醇240mg d2+环磷酰胺800mg d3化疗；化疗期间患者均无明显恶心、呕吐、骨髓抑制等副反应。 | 20 | [
{
"anatomy_list": [
"骨髓"
],
"character": [
"明显"
],
"core_name": "骨髓抑制",
"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": [
"明显"
],
"core_name": "骨髓抑制",
"tendency": "否定"
}
] |
2+年前（2018年3月）患者于某医院因体检腹部彩超发现左侧肾脏下级占位，左肾积水，无腰痛、无腹胀腹痛，无恶心呕吐，无尿频尿急尿痛，无肉眼血尿等不适。 | 162 | [
{
"anatomy_list": [
"左侧肾脏下级"
],
"character": [],
"core_name": "占位",
"tendency": ""
},
{
"anatomy_list": [
"左肾"
],
"character": [],
"core_name": "积水",
"tendency": ""
},
{
"anatomy_list": [
"腰"
],
"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": "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": "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": "血尿",
"tendency": "否定"
}
] |
右上肺肺陈旧性病灶,以纤维化为主；右上肺结节影,考虑为纤维结节可能,不除外肿瘤性病变。食道中下段壁可疑稍增厚。 | 7 | [
{
"anatomy_list": [
"右上肺"
],
"character": [
"陈旧性"
],
"core_name": "病灶",
"tendency": ""
},
{
"anatomy_list": [
"右上肺"
],
"character": [],
"core_name": "纤维化",
"tendency": ""
},
{
"anatomy_list": [
"右上肺"
],
"character": [],
"core_name": "结节影",
"tendency": ""
},
{
"anatomy_list": [
"右上肺"
],
"character": [],
"core_name": "纤维结节",
"tendency": "不确定"
},
{
"anatomy_list": [
"右上肺"
],
"character": [
"肿瘤性"
],
"core_name": "病变",
"tendency": "不确定"
},
{
"anatomy_list": [
"食道中下段壁"
],
"character": [
"稍"
],
"core_name": "增厚",
"tendency": "不确定"
}
] |
现为求进一步诊疗到我院，急诊以“消化道出血原因待查”收入院。 | 1,990 | [
{
"anatomy_list": [
"消化道"
],
"character": [],
"core_name": "出血",
"tendency": "不确定"
}
] |
2018年4月患者发现左侧腹股沟腹股沟包块较前明显增大、增多，左侧腹股沟穿刺病理提示“<左腹股沟淋巴结穿刺活检标本>淋巴组织结构破坏，于组织细胞及淋巴细胞背景中查见散在r-s样细胞，结合免疫组化及t细胞基因重排满负荷经典型霍奇金淋巴瘤（混合细胞亚型）”，全身pet/ct示“腹膜后、盆腔、左侧腹股沟可见多发淋巴结肿大，fdg代谢异常增高”，未行骨髓穿刺检查。 | 852 | [
{
"anatomy_list": [
"左侧腹股沟淋巴结"
],
"character": [
"明显增大、增多"
],
"core_name": "包块",
"tendency": ""
},
{
"anatomy_list": [
"左侧腹股沟淋巴结组织结构"
],
"character": [],
"core_name": "破坏",
"tendency": ""
},
{
"anatomy_list": [
"r-s样细胞"
],
"character": [
"组织细胞及淋巴细胞背景中查见",
"散在"
],
"core_name": "r-s样细胞",
"tendency": ""
},
{
"anatomy_list": [
"淋巴"
],
"character": [
"混合细胞亚型"
],
"core_name": "瘤",
"tendency": ""
},
{
"anatomy_list": [
"淋巴"
],
"character": [
"经典型",
"霍奇金"
],
"core_name": "瘤",
"tendency": ""
},
{
"anatomy_list": [
"腹膜后淋巴结"
],
"character": [
"多发"
],
"core_name": "肿大",
"tendency": ""
},
{
"anatomy_list": [
"盆腔淋巴结"
],
"character": [
"多发"
],
"core_name": "肿大",
"tendency": ""
},
{
"anatomy_list": [
"左侧腹股沟淋巴结"
],
"character": [
"多发"
],
"core_name": "肿大",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"异常增高"
],
"core_name": "fdg代谢",
"tendency": ""
}
] |
现患者为求进一步诊疗，门诊以“冠心病、慢性阻塞性肺疾病、心力衰竭”收入我科住院治疗。 | 815 | [
{
"anatomy_list": [
"心"
],
"character": [],
"core_name": "冠心病",
"tendency": ""
},
{
"anatomy_list": [
"肺"
],
"character": [
"慢性",
"阻塞性"
],
"core_name": "肺疾病",
"tendency": ""
},
{
"anatomy_list": [
"心"
],
"character": [],
"core_name": "心力衰竭",
"tendency": ""
}
] |
今患者为求进一步治疗，至我院门诊就诊，门诊以“膀胱占位”收入我科住院治疗。 | 1,831 | [
{
"anatomy_list": [
"膀胱"
],
"character": [],
"core_name": "占位",
"tendency": ""
}
] |
患者自起病以来，精神可，胃纳略差，大便如常，尿急，体重未见明显下降。 | 1,171 | [
{
"anatomy_list": [],
"character": [
"可"
],
"core_name": "精神",
"tendency": ""
},
{
"anatomy_list": [
"胃"
],
"character": [
"略差"
],
"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": [
"明显"
],
"core_name": "体重下降",
"tendency": "否定"
}
] |
3月余前，患者出现胸前区疼痛，为阵发性胀痛，于夜间采取侧卧位时疼痛明显，休息后自行缓解，无压榨感，无胸闷、心悸、气促，无头痛、头晕，无咳嗽、咯血、呼吸困难，无畏寒、寒战，无潮热、盗汗，无吞咽困难，出现喉部异物感，遂于某中医院就诊，行胸部ct提示：左中上纵膈混杂密度占位影，考虑肿瘤性病变，胸腺瘤（侵袭性）可能；左侧后肋肋胸膜胸膜局限性增厚，不除外胸膜转移可能。 | 1,479 | [
{
"anatomy_list": [
"胸前区"
],
"character": [
"阵发性",
"胀痛",
"夜间采取侧卧位时疼痛明显",
"休息后自行缓解"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"胸前区"
],
"character": [],
"core_name": "压榨感",
"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": "气促",
"tendency": "否定"
},
{
"anatomy_list": [
"头"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [
"头"
],
"character": [],
"core_name": "头晕",
"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": [],
"character": [],
"core_name": "呼吸困难",
"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": [],
"core_name": "潮热",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "盗汗",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "吞咽困难",
"tendency": "否定"
},
{
"anatomy_list": [
"喉部"
],
"character": [],
"core_name": "异物感",
"tendency": ""
},
{
"anatomy_list": [
"左中上纵膈"
],
"character": [
"混杂密度"
],
"core_name": "占位影",
"tendency": ""
},
{
"anatomy_list": [
"左中上纵膈"
],
"character": [
"肿瘤性"
],
"core_name": "病变",
"tendency": "不确定"
},
{
"anatomy_list": [
"胸腺"
],
"character": [
"侵袭性"
],
"core_name": "瘤",
"tendency": "不确定"
},
{
"anatomy_list": [
"左侧后肋",
"肋胸膜"
],
"character": [
"局限性"
],
"core_name": "增厚",
"tendency": ""
},
{
"anatomy_list": [
"胸膜"
],
"character": [],
"core_name": "转移",
"tendency": "不确定"
}
] |
患者自患病以来精神、食欲、睡眠可，大小便正常，近期体重无明显变化。 | 1,693 | [
{
"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": "体重改变",
"tendency": "否定"
}
] |
半月前患者无明显诱因再次血糖控制不佳，监测血糖空腹波动在15-16mm16mmol/L，餐后血糖在21-22mm22mmol/L，患者近期均进食稀饭，现患者有耳鸣，偶有恶心、反酸，无畏寒、发热，无头痛、头晕，无呕吐，有胸闷、心悸，偶有胸痛，伴上腹部不适，伴腹胀、腹泻，无双下肢凹陷性水肿，患者现使用胰岛素剂量为“门冬胰岛素早餐前14u，午餐前14u，晚餐前14u，甘精胰岛素睡前34u”，为进一步治疗就诊，门诊以“糖尿病、糖尿病肾病”收住院治疗。 | 538 | [
{
"anatomy_list": [],
"character": [
"控制不佳"
],
"core_name": "血糖",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"空腹",
"波动",
"升高"
],
"core_name": "血糖",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"餐后",
"波动",
"升高"
],
"core_name": "血糖",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"稀饭"
],
"core_name": "进食",
"tendency": ""
},
{
"anatomy_list": [
"耳"
],
"character": [],
"core_name": "耳鸣",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"偶有"
],
"core_name": "恶心",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"偶有"
],
"core_name": "反酸",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "畏寒",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "发热",
"tendency": "否定"
},
{
"anatomy_list": [
"头"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [
"头"
],
"character": [],
"core_name": "头晕",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "呕吐",
"tendency": "否定"
},
{
"anatomy_list": [
"胸"
],
"character": [],
"core_name": "胸闷",
"tendency": ""
},
{
"anatomy_list": [
"心"
],
"character": [],
"core_name": "心悸",
"tendency": ""
},
{
"anatomy_list": [
"胸"
],
"character": [
"偶有"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"上腹部"
],
"character": [],
"core_name": "不适",
"tendency": ""
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "腹胀",
"tendency": ""
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "腹泻",
"tendency": ""
},
{
"anatomy_list": [
"双下肢"
],
"character": [
"凹陷性"
],
"core_name": "水肿",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "糖尿病",
"tendency": ""
},
{
"anatomy_list": [
"肾"
],
"character": [
"糖尿病"
],
"core_name": "肾病",
"tendency": ""
}
] |
患者 今为进一步诊治，来我院就诊，门诊以"lsil"收入我科。 | 1,402 | [
{
"anatomy_list": [],
"character": [],
"core_name": "低度鳞状上皮内病变",
"tendency": ""
}
] |
1周前出现喘累不适，无明显缓解，胸水b超定位提示：右侧胸腔积液，最大前后径约148mm。 | 1,247 | [
{
"anatomy_list": [],
"character": [
"无明显缓解"
],
"core_name": "喘累",
"tendency": ""
},
{
"anatomy_list": [
"胸"
],
"character": [],
"core_name": "胸水",
"tendency": ""
},
{
"anatomy_list": [
"右侧胸腔"
],
"character": [],
"core_name": "积液",
"tendency": ""
}
] |
无禁忌症，于10.19开始给予颈部转移病灶调强放射治疗，dt:66G/33f，放疗过程中出现放射性皮炎，给予局部外敷康复新促进皮肤修护治疗，建议患者行化疗，患者拒绝。 | 1,110 | [
{
"anatomy_list": [
"颈部"
],
"character": [
"转移"
],
"core_name": "病灶",
"tendency": ""
},
{
"anatomy_list": [
"颈部",
"皮"
],
"character": [
"放射性"
],
"core_name": "皮炎",
"tendency": ""
}
] |
3月前患者无明显诱因出现腰痛，伴尿黄，无腹胀、腹痛，无胸闷、胸痛，无尿频、尿急、尿痛，院外就诊诊断为“肾结石、肝功异常”，当时未予重视，自行院外输液治疗（具体用药及诊断不详）后腰痛缓解，未复查及随访。 | 650 | [
{
"anatomy_list": [
"腰"
],
"character": [],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "尿黄",
"tendency": ""
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "腹胀",
"tendency": "否定"
},
{
"anatomy_list": [
"腹"
],
"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": "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": [
"肾"
],
"character": [],
"core_name": "结石",
"tendency": ""
},
{
"anatomy_list": [
"肝"
],
"character": [],
"core_name": "肝功能异常",
"tendency": ""
},
{
"anatomy_list": [
"腰"
],
"character": [
"输液治疗缓解"
],
"core_name": "疼痛",
"tendency": ""
}
] |
无腹胀、腹痛，恶心、呕吐，无里急后重。患者未予以重视。 | 1,444 | [
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "腹胀",
"tendency": "否定"
},
{
"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": "里急后重",
"tendency": "否定"
}
] |
患者今为求进一步治疗，门诊以“消化道出血”收治我科。 | 1,445 | [
{
"anatomy_list": [
"消化道"
],
"character": [],
"core_name": "出血",
"tendency": ""
}
] |
之后上述症状反复发作，每次发作均无明显诱因，均突然发作，持续数分钟至10+分钟后自行缓解，性质同前，未治疗；近1月来，患者发作频率较前增加，间隔时间减短，约每小时1-2次，持续10+分钟，无胸闷、气促、胸痛，无黑蒙、晕厥、意识障碍，无咯血、呼吸困难等不适。 | 703 | [
{
"anatomy_list": [
"胸"
],
"character": [],
"core_name": "胸闷",
"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": "黑朦",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "晕厥",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"障碍"
],
"core_name": "意识",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "咯血",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "呼吸困难",
"tendency": "否定"
}
] |
原始肿物位于左侧乳房与乳头内侧，大小约为2*2cm。 | 401 | [
{
"anatomy_list": [
"左侧乳房与乳头内侧"
],
"character": [
"原始"
],
"core_name": "肿物",
"tendency": ""
}
] |
发现血压增高5年，血压最高达170/105mmHg，长期口服“苯磺酸氨氯地平”降压，血压控制情况不详。 | 267 | [
{
"anatomy_list": [],
"character": [
"增高"
],
"core_name": "血压",
"tendency": ""
}
] |
患者既往月经规律，自然绝经20+年，绝经后无阴道阴道流血流液。 | 313 | [
{
"anatomy_list": [],
"character": [
"规律"
],
"core_name": "月经",
"tendency": ""
},
{
"anatomy_list": [
"阴道"
],
"character": [
"绝经后"
],
"core_name": "出血",
"tendency": "否定"
},
{
"anatomy_list": [
"阴道"
],
"character": [
"绝经后"
],
"core_name": "流液",
"tendency": "否定"
}
] |
左颈部软组织影，考虑淋巴结转移可能。 | 183 | [
{
"anatomy_list": [
"左颈部"
],
"character": [
"软组织"
],
"core_name": "组织影",
"tendency": ""
},
{
"anatomy_list": [
"淋巴结"
],
"character": [],
"core_name": "转移",
"tendency": "不确定"
}
] |
平时白带较不多，无异味。 | 1,399 | [
{
"anatomy_list": [],
"character": [
"较不多"
],
"core_name": "白带",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"异味"
],
"core_name": "白带",
"tendency": "否定"
}
] |
22月前患者为进一步治疗来我科，完善术前检查，于2015-10-12行原发性肝癌介入术，2015-10-19复查ct提示碘油沉积可，2015-10-23行原发性肝癌姑息性hifu术，术后给予保肝、消炎、增强免疫、抗肿瘤等治疗，患者术后多次复查腹部mr提示肿瘤无复发。 | 451 | [
{
"anatomy_list": [],
"character": [
"可"
],
"core_name": "碘油沉积",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"复发"
],
"core_name": "肿瘤",
"tendency": "否定"
}
] |
入院前10年，患者受凉后咳嗽， 咯白色泡沫痰 ，以晨起明显。 | 1,327 | [
{
"anatomy_list": [],
"character": [
"受凉后"
],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"白色",
"泡沫痰",
"晨起明显"
],
"core_name": "咳痰",
"tendency": ""
}
] |
21年来患者反复心悸、胸痛、胸闷，偶伴心前区疼痛及压榨感，每次持续20秒，呈锐痛，含服硝酸甘油后症状可立即缓解，偶伴头晕、头痛，无视物旋转、一过性黑朦，11年前在我科住院治疗，经冠状动脉造影示lad开口狭窄、并行支架成型术。 | 1,567 | [
{
"anatomy_list": [
"心"
],
"character": [
"反复"
],
"core_name": "心悸",
"tendency": ""
},
{
"anatomy_list": [
"胸"
],
"character": [
"反复"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"胸"
],
"character": [
"反复"
],
"core_name": "胸闷",
"tendency": ""
},
{
"anatomy_list": [
"心前区"
],
"character": [
"偶"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"心前区"
],
"character": [
"偶"
],
"core_name": "压榨感",
"tendency": ""
},
{
"anatomy_list": [
"心前区"
],
"character": [
"锐痛"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"头"
],
"character": [
"偶"
],
"core_name": "头晕",
"tendency": ""
},
{
"anatomy_list": [
"头"
],
"character": [
"偶"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"一过性"
],
"core_name": "黑朦",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "视物旋转",
"tendency": "否定"
},
{
"anatomy_list": [
"冠状动脉lad开口"
],
"character": [],
"core_name": "狭窄",
"tendency": ""
}
] |
后患者颈部包块逐渐增大，2020年10月开始出现咳嗽、咳痰，咳白色粘痰，咳嗽剧烈时伴有呼吸困难。 | 482 | [
{
"anatomy_list": [
"颈部"
],
"character": [
"逐渐",
"增大"
],
"core_name": "包块增大",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "咳痰",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"白色",
"粘性"
],
"core_name": "咳痰",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"咳嗽剧烈时"
],
"core_name": "呼吸困难",
"tendency": ""
}
] |
患者本次发病以来，食欲下降，感进食后饱胀不适。 | 1,313 | [
{
"anatomy_list": [],
"character": [
"下降"
],
"core_name": "食欲",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"进食后"
],
"core_name": "饱胀",
"tendency": ""
}
] |
入院前半年，患者站立时扪及右侧腹股沟区一大拇指大小包块，质地较软，移动可，可回纳，活动后伴右侧腹股沟区胀痛，取平卧位可明显减轻，不伴腹痛、腹胀、恶心、呕吐、肛门停止排便排气等，患者未予重视及相关诊治。 | 1,473 | [
{
"anatomy_list": [
"右侧腹股沟区"
],
"character": [
"一大拇指大小",
"质地较软",
"移动可",
"可回纳"
],
"core_name": "包块",
"tendency": ""
},
{
"anatomy_list": [
"右侧腹股沟区"
],
"character": [
"活动后胀痛",
"平卧位可明显减轻"
],
"core_name": "疼痛",
"tendency": ""
},
{
"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": "恶心",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "呕吐",
"tendency": "否定"
},
{
"anatomy_list": [
"肛门"
],
"character": [],
"core_name": "排便",
"tendency": "否定"
},
{
"anatomy_list": [
"肛门"
],
"character": [],
"core_name": "排气",
"tendency": "否定"
}
] |
2017-3-9某医院复查肠镜示：结肠癌术后表现。 | 1,932 | [
{
"anatomy_list": [
"结肠"
],
"character": [
"术后"
],
"core_name": "癌",
"tendency": ""
}
] |
4.肝囊肿。 | 1,262 | [
{
"anatomy_list": [
"肝"
],
"character": [],
"core_name": "囊肿",
"tendency": ""
}
] |
2017-8-16 ect检查报告：全身骨显像 与2017-5-5全身骨显像比较：1.出现新增病灶：左侧第5前肋肋缘，考虑肋骨损伤可能大。 | 459 | [
{
"anatomy_list": [
"左侧第5前肋肋缘"
],
"character": [
"新增"
],
"core_name": "病灶",
"tendency": ""
},
{
"anatomy_list": [
"肋骨"
],
"character": [
"可能大"
],
"core_name": "损伤",
"tendency": "不确定"
}
] |
治疗上予以禁食水、补液、胃肠减压、灌肠等治疗后腹痛、腹胀症状明显缓解，后请我科会诊后转入我科治疗，请肛肠科会诊行直肠病灶活检提示腺癌。 | 1,544 | [
{
"anatomy_list": [
"腹"
],
"character": [
"明显缓解"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"腹"
],
"character": [
"明显缓解"
],
"core_name": "腹胀",
"tendency": ""
},
{
"anatomy_list": [
"直肠"
],
"character": [],
"core_name": "腺癌",
"tendency": ""
}
] |
遂于我院行胸部ct提示肺内占位（具体报告未见）；后患者于某医院行ct引导下经皮肺穿刺活检术，术后病理示：非小细胞肺癌；行基因检测未见阳性突变。 | 381 | [
{
"anatomy_list": [
"肺内"
],
"character": [],
"core_name": "占位",
"tendency": ""
},
{
"anatomy_list": [
"肺"
],
"character": [],
"core_name": "非小细胞癌",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"阳性"
],
"core_name": "突变",
"tendency": "否定"
}
] |
入院前4月，患者无明显诱因出现右腿疼痛，为持续性，无阵发性加重，活动时明显，不伴下肢麻木等不适，患者就诊于我院，腰椎mri示腰椎间盘突出症、骨盆多发骨质破坏。 | 1,704 | [
{
"anatomy_list": [
"右腿"
],
"character": [
"持续性",
"无阵发性加重",
"活动时明显"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"下肢"
],
"character": [],
"core_name": "麻木",
"tendency": "否定"
},
{
"anatomy_list": [
"腰椎间盘"
],
"character": [],
"core_name": "突出症",
"tendency": ""
},
{
"anatomy_list": [
"骨盆"
],
"character": [
"多发"
],
"core_name": "骨质破坏",
"tendency": ""
}
] |
入院前1年，患者出现口干，进食干食需用水送服，伴反复腮腺炎，患者仍未重视，故未治疗。 | 932 | [
{
"anatomy_list": [
"口"
],
"character": [
"进食干食需用水送服"
],
"core_name": "口干",
"tendency": ""
},
{
"anatomy_list": [
"腮腺"
],
"character": [
"反复"
],
"core_name": "腮腺炎",
"tendency": ""
}
] |
入院前2日发现患儿无明显诱因发热，以高热为主，最高高体温39.8℃，自行予退烧药口服后，体温能降至正常。 | 902 | [
{
"anatomy_list": [],
"character": [],
"core_name": "发热",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"高"
],
"core_name": "发热",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"升高"
],
"core_name": "体温",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"降至正常",
"予退烧药口服后"
],
"core_name": "体温",
"tendency": ""
}
] |
入院前4月，患者无明显诱因出现胸闷，诉活动后明显，偶有心前区压榨感，胸闷明显时伴有呼吸困难，休息后胸闷好转，患者无咳嗽、咳痰，无发热，无咯血，偶有胸部刺痛，偶有午后潮热及夜间盗汗，无明显乏力、消瘦，无声嘶，无呛咳，无心慌、心悸，无下肢水肿等不适，病后患者未重视，未行特殊治疗，患者胸闷仍反复发作，现患者胸闷仍明显，遂来我院，门诊胸部ct结果提示“左上肺结节：考虑纤维灶可能，肺部肿瘤不除外”，为进一步诊治，门诊以“左肺结节”收入我科。 | 1,404 | [
{
"anatomy_list": [
"胸"
],
"character": [
"活动后明显"
],
"core_name": "胸闷",
"tendency": ""
},
{
"anatomy_list": [
"心前区"
],
"character": [],
"core_name": "压榨感",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "呼吸困难",
"tendency": ""
},
{
"anatomy_list": [
"胸"
],
"character": [
"休息后好转"
],
"core_name": "胸闷",
"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": [],
"character": [],
"core_name": "咯血",
"tendency": "否定"
},
{
"anatomy_list": [
"胸部"
],
"character": [
"刺痛"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"午后"
],
"core_name": "潮热",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"夜间"
],
"core_name": "盗汗",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"明显"
],
"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": [
"心"
],
"character": [],
"core_name": "心慌",
"tendency": "否定"
},
{
"anatomy_list": [
"心"
],
"character": [],
"core_name": "心悸",
"tendency": "否定"
},
{
"anatomy_list": [
"下肢"
],
"character": [],
"core_name": "水肿",
"tendency": "否定"
},
{
"anatomy_list": [
"胸"
],
"character": [
"反复发作"
],
"core_name": "胸闷",
"tendency": ""
},
{
"anatomy_list": [
"胸"
],
"character": [
"明显"
],
"core_name": "胸闷",
"tendency": ""
},
{
"anatomy_list": [
"左上肺"
],
"character": [],
"core_name": "结节",
"tendency": ""
},
{
"anatomy_list": [
"左上肺"
],
"character": [],
"core_name": "纤维灶",
"tendency": "不确定"
},
{
"anatomy_list": [
"肺部"
],
"character": [],
"core_name": "肿瘤",
"tendency": "不确定"
},
{
"anatomy_list": [
"左肺"
],
"character": [],
"core_name": "结节",
"tendency": ""
}
] |
患者既往于我院行同步放化疗及后装治疗后复查盆腔ct提示宫颈病灶明显减小，鳞癌癌细胞抗原已降至正常范围内，但盆腔ct提示宫颈形状不规则、仍有强化；妇科检查示：宫颈表现颗粒状增生、触血，前穹隆消失，右侧穹隆变浅。 | 1,624 | [
{
"anatomy_list": [
"宫颈"
],
"character": [
"明显",
"减小"
],
"core_name": "病灶",
"tendency": ""
},
{
"anatomy_list": [
"宫颈"
],
"character": [
"仍有强化"
],
"core_name": "形态不规则",
"tendency": ""
},
{
"anatomy_list": [
"宫颈"
],
"character": [
"颗粒状"
],
"core_name": "增生",
"tendency": ""
},
{
"anatomy_list": [
"宫颈"
],
"character": [],
"core_name": "出血",
"tendency": ""
},
{
"anatomy_list": [
"宫颈前穹隆"
],
"character": [],
"core_name": "消失",
"tendency": ""
},
{
"anatomy_list": [
"宫颈右侧穹隆"
],
"character": [],
"core_name": "变浅",
"tendency": ""
}
] |
患者lmp：2020-3-20，停经40+天自测尿hcg阳性，就诊于某卫生院，超声提示宫内未见孕囊，次日就诊于某医院，血hcg阳性（具体数值不详）、孕酮偏低。 | 686 | [
{
"anatomy_list": [],
"character": [],
"core_name": "停经",
"tendency": ""
},
{
"anatomy_list": [
"宫内"
],
"character": [
"未见"
],
"core_name": "孕囊",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"阳性"
],
"core_name": "血hcg",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"阳性"
],
"core_name": "尿hcg",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"偏低"
],
"core_name": "孕酮",
"tendency": ""
}
] |
入院前4天，患者无明显诱因出现腰背部酸胀，弯腰、负重及久坐后加重，卧床休息后可缓解；双下肢无放射痛，无麻木、乏力。 | 269 | [
{
"anatomy_list": [
"腰背部"
],
"character": [
"弯腰、负重及久坐后加重",
"卧床休息后可缓解"
],
"core_name": "酸胀",
"tendency": ""
},
{
"anatomy_list": [
"双下肢"
],
"character": [
"放射性"
],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "麻木",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "乏力",
"tendency": "否定"
}
] |
13月前，患者在左锁骨上触一大小约2x3cm的包块，体表包块b超提示：临床扪及包块处探及低回声结节，性质待定，考虑肿大淋巴结可能。 | 305 | [
{
"anatomy_list": [
"左锁骨上"
],
"character": [],
"core_name": "包块",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "包块",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"低回声"
],
"core_name": "结节",
"tendency": ""
},
{
"anatomy_list": [
"淋巴结"
],
"character": [],
"core_name": "肿大",
"tendency": "不确定"
}
] |
2020/6/1ct：腹膜后偏左侧占位，结合病史考虑转移瘤伴周围结构多发侵犯，与2020-04-27片对比，肿块较前缩小，胃内较多积液、积气。 | 185 | [
{
"anatomy_list": [
"腹膜后偏左侧"
],
"character": [],
"core_name": "占位",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"转移"
],
"core_name": "瘤",
"tendency": "不确定"
},
{
"anatomy_list": [
"周围结构"
],
"character": [
"多发"
],
"core_name": "侵犯",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"较前缩小"
],
"core_name": "肿块",
"tendency": ""
},
{
"anatomy_list": [
"胃内"
],
"character": [
"较多"
],
"core_name": "积液",
"tendency": ""
},
{
"anatomy_list": [
"胃内"
],
"character": [
"较多"
],
"core_name": "积气",
"tendency": ""
}
] |
患者本次发病以来,食欲正常,神志清醒,精神尚可,睡眠尚可,大便正常,小便正常,体重无明显变化。 | 46 | [
{
"anatomy_list": [],
"character": [
"正常"
],
"core_name": "食欲",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"清醒"
],
"core_name": "神志",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"尚可"
],
"core_name": "精神",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"尚可"
],
"core_name": "睡眠",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"正常"
],
"core_name": "大便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"正常"
],
"core_name": "小便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"明显"
],
"core_name": "体重变化",
"tendency": "否定"
}
] |
进一步完善肾脏ct示：左肾下极占位，大小约3cm，考虑肿瘤性病变，透明细胞癌可能。 | 1,197 | [
{
"anatomy_list": [
"左肾下极"
],
"character": [],
"core_name": "占位",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"肿瘤性"
],
"core_name": "病变",
"tendency": "不确定"
},
{
"anatomy_list": [
"透明细胞"
],
"character": [],
"core_name": "癌",
"tendency": "不确定"
}
] |
１周前，患者出现咳嗽、咳痰较前加重，伴活动后喘累气促，进食减少，食欲差，伴全身乏力，无恶心、呕吐，无心悸、胸闷，无胸痛，无咯血，无发热，未重视。 | 983 | [
{
"anatomy_list": [],
"character": [
"加重"
],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"加重"
],
"core_name": "咳痰",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"活动后"
],
"core_name": "喘累",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"活动后"
],
"core_name": "气促",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "进食减少",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"差"
],
"core_name": "食欲",
"tendency": ""
},
{
"anatomy_list": [
"全身"
],
"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": [
"心"
],
"character": [],
"core_name": "心悸",
"tendency": "否定"
},
{
"anatomy_list": [
"胸"
],
"character": [],
"core_name": "胸闷",
"tendency": "否定"
},
{
"anatomy_list": [
"胸"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "咯血",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "发热",
"tendency": "否定"
}
] |
今患者为进一步明确诊治来我院，门诊以“糖尿病”收入我科。 | 1,277 | [
{
"anatomy_list": [],
"character": [],
"core_name": "糖尿病",
"tendency": ""
}
] |
化疗过程顺利，后再入我院行第2次化疗，方案为dp方案（多西他赛120mg+顺铂130mg静脉化疗），化疗过程患者出现便秘不适，今患者诉右侧髋部疼痛较前明显，为复查就诊于我院门诊，门诊拟“右上肺肺腺癌”收住院治疗。 | 1,441 | [
{
"anatomy_list": [],
"character": [
"化疗过程"
],
"core_name": "便秘",
"tendency": ""
},
{
"anatomy_list": [
"右侧髋部"
],
"character": [
"较前明显"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"右上肺"
],
"character": [],
"core_name": "腺癌",
"tendency": ""
}
] |
骨扫描：左肩关节、胸骨、脊柱（约胸55椎体及上位颈椎明显）、右侧髋臼多发异常显像剂浓聚灶，考虑肿瘤骨转移，予以止痛对症后患者疼痛控制。 | 944 | [
{
"anatomy_list": [
"左肩关节"
],
"character": [
"多发",
"异常",
"显像剂"
],
"core_name": "浓聚灶",
"tendency": ""
},
{
"anatomy_list": [
"胸骨"
],
"character": [
"多发",
"异常",
"显像剂"
],
"core_name": "浓聚灶",
"tendency": ""
},
{
"anatomy_list": [
"脊柱"
],
"character": [
"多发",
"异常",
"显像剂",
"约胸55椎体及上位颈椎明显"
],
"core_name": "浓聚灶",
"tendency": ""
},
{
"anatomy_list": [
"右侧髋臼"
],
"character": [
"多发",
"异常",
"显像剂"
],
"core_name": "浓聚灶",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"骨转移"
],
"core_name": "肿瘤",
"tendency": "不确定"
},
{
"anatomy_list": [],
"character": [
"控制"
],
"core_name": "疼痛",
"tendency": ""
}
] |
2+月前，患者出现双侧肩胛骨骨疼痛，疼痛剧烈，口服吗啡疼痛无明显缓解，于9月5日在我科行右侧肩胛骨放疗，累计放疗：dt：30G/10f，患者疼痛缓解出院。 | 1,851 | [
{
"anatomy_list": [
"双侧肩胛骨"
],
"character": [],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"双侧肩胛骨"
],
"character": [
"剧烈"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"缓解"
],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"缓解"
],
"core_name": "疼痛",
"tendency": ""
}
] |
为进一步诊治，遂来我科住院，门诊以“上消化道出血，肝硬化失代偿”收入我科。 | 861 | [
{
"anatomy_list": [
"上消化道"
],
"character": [],
"core_name": "出血",
"tendency": ""
},
{
"anatomy_list": [
"肝"
],
"character": [
"失代偿"
],
"core_name": "硬化",
"tendency": ""
}
] |
（左乳左、右、上、下、后切缘）未见癌累及。 | 1,761 | [
{
"anatomy_list": [
"左乳左、右、上、下、后切缘"
],
"character": [
"累及"
],
"core_name": "癌",
"tendency": "否定"
}
] |
1+月前患者排尿不畅症状明显，并伴排尿费力，尿频、尿急、尿痛，尿不尽，尿线变细，排尿滴沥，偶有全身疼痛感。 | 2,021 | [
{
"anatomy_list": [],
"character": [
"明显"
],
"core_name": "排尿不畅",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "排尿费力",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "尿频",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "尿急",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "尿痛",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "尿不尽",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "尿线变细",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "排尿滴沥",
"tendency": ""
},
{
"anatomy_list": [
"全身"
],
"character": [
"偶有"
],
"core_name": "疼痛",
"tendency": ""
}
] |
入院前7年，患者体检中发现发现血压升高，最高血压180+/？mmhg，长期予以苯磺酸氨氯地平5mg qd降压，自诉近期血压控制在150-160/？mmhg，有视物模糊不适；入院前6年，患者无意间发现左侧第一跖趾关节及左侧膝关节出现无痛性结节，未重视及处理。 | 872 | [
{
"anatomy_list": [],
"character": [
"升高"
],
"core_name": "血压",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "视物模糊",
"tendency": ""
},
{
"anatomy_list": [
"左侧第1跖趾关节"
],
"character": [
"无痛性"
],
"core_name": "结节",
"tendency": ""
},
{
"anatomy_list": [
"左侧膝关节"
],
"character": [
"无痛性"
],
"core_name": "结节",
"tendency": ""
}
] |
入院5+年前患者无明显诱因出现咳嗽、咳痰、喘累，痰为白色泡沫痰，无潮热、盗汗，病程中冬春季易发，每年持续时间大于3月，患者未予重视。 | 1,518 | [
{
"anatomy_list": [],
"character": [],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"白色",
"泡沫痰"
],
"core_name": "咳痰",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "喘累",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "潮热",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "盗汗",
"tendency": "否定"
}
] |
5+年前，患者述腰背部伴双侧大腿前侧间断性痛，疼痛尚可忍受，无麻木、乏力不能行走，患者未予以重视，自服药物或膏药治疗（具体用药不详）后缓解，其后间断疼痛，为予以特别重视，自行好转，患者10+月前我院体检发现乳腺包块，其后于某医院行spect检查提示：左侧髂骨异常成骨增强灶，考虑肿瘤骨转移可能性大，于行新辅助化疗后于某医院行左侧乳腺癌保乳术，术后病检提示：（左侧乳腺）浸润性癌，非特殊类型。iii级。 | 1,288 | [
{
"anatomy_list": [
"双侧大腿前侧",
"腰部",
"背部"
],
"character": [
"间断性",
"尚可忍受"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"双侧大腿"
],
"character": [],
"core_name": "麻木",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "乏力",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "行走障碍",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"间断"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"乳腺"
],
"character": [],
"core_name": "包块",
"tendency": ""
},
{
"anatomy_list": [
"左侧髂骨"
],
"character": [
"异常成骨"
],
"core_name": "增强灶",
"tendency": ""
},
{
"anatomy_list": [
"骨"
],
"character": [
"转移"
],
"core_name": "肿瘤",
"tendency": "不确定"
},
{
"anatomy_list": [
"左侧乳腺"
],
"character": [
"浸润性",
"非特殊类型",
"iii级"
],
"core_name": "癌",
"tendency": ""
}
] |
院外期间仍有烦渴、多饮，全身乏力，胸闷怕冷等症状。 | 235 | [
{
"anatomy_list": [],
"character": [],
"core_name": "烦渴",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "多饮",
"tendency": ""
},
{
"anatomy_list": [
"全身"
],
"character": [],
"core_name": "乏力",
"tendency": ""
},
{
"anatomy_list": [
"胸"
],
"character": [],
"core_name": "胸闷",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "怕冷",
"tendency": ""
}
] |
诊断为“中央型肺癌肺癌伴淋巴结转移”，未行手术及放化疗，经抗感染、止咳、祛痰等对症支持治疗后，病情好转后出院。症状反复发生，未见明显加重。 | 1,701 | [
{
"anatomy_list": [
"肺"
],
"character": [
"中央型"
],
"core_name": "癌",
"tendency": ""
},
{
"anatomy_list": [
"淋巴结"
],
"character": [
"转移"
],
"core_name": "癌",
"tendency": ""
}
] |
无化疗禁忌症，分别于2016-3-11、2016-4-1、2016-4-22行tp方案（紫杉醇240mg+奈达铂140mg）化疗，化疗后出现明显骨髓抑制，予以生白细胞治疗后好转出院，院外未诉特殊不适。 | 1,286 | [
{
"anatomy_list": [
"骨髓"
],
"character": [
"明显"
],
"core_name": "骨髓抑制",
"tendency": ""
}
] |
患者期间仍感右上胸部针刺样疼痛，阵发性，呼吸咳嗽加重，可向肩背部放射，未予以特殊处理。 | 963 | [
{
"anatomy_list": [
"右上胸部"
],
"character": [
"针刺样",
"阵发性"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"加重"
],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [
"肩背部"
],
"character": [
"放射性"
],
"core_name": "疼痛",
"tendency": ""
}
] |
遂于我院行乳腺b超检查提示：左侧乳腺2点钟方向距乳头约40mm处可见大小约24*22mm低回声包块，边界不清不规则 。 | 497 | [
{
"anatomy_list": [
"左侧乳腺2点钟方向距乳头约40mm处"
],
"character": [
"低回声",
"边界不清不规则"
],
"core_name": "包块",
"tendency": ""
}
] |
2年前患者于外院行辅助检查，考虑诊断为“肝癌”，遂行肝癌切除术，住院期间因患者肾功能差，改用“替比夫定”抗病毒治疗。 | 91 | [
{
"anatomy_list": [
"肝"
],
"character": [],
"core_name": "癌",
"tendency": "不确定"
},
{
"anatomy_list": [
"肾"
],
"character": [],
"core_name": "肾功能差",
"tendency": ""
}
] |
与2018-8-29片比较：病灶较明显增大。 | 1,026 | [
{
"anatomy_list": [],
"character": [
"明显",
"增大"
],
"core_name": "病灶",
"tendency": ""
}
] |
入院前3+年，患者排尿时出现全程血尿，鲜红色，伴尿频、尿急及尿痛，行b超检查提示前列腺增生。 | 1,792 | [
{
"anatomy_list": [],
"character": [
"鲜红色"
],
"core_name": "血尿",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "尿频",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "尿急",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "尿痛",
"tendency": ""
},
{
"anatomy_list": [
"前列腺"
],
"character": [],
"core_name": "增生",
"tendency": ""
}
] |
2.甲状腺左叶上份稍低密度影，结合图像融合考虑：结节性甲状腺中可能。 | 253 | [
{
"anatomy_list": [
"甲状腺左叶上"
],
"character": [
"稍低"
],
"core_name": "密度影",
"tendency": ""
},
{
"anatomy_list": [
"甲状腺"
],
"character": [
"结节性"
],
"core_name": "肿",
"tendency": "不确定"
}
] |
就诊于某医院整形美容科，行浅表淋巴结超声提示：左侧腹股沟腹股沟区可见数个低回声结节结节影，较大者大小约5.7×2.7cm，并行左侧腹股沟腹股沟区淋巴结淋巴结活检，活检病理提示：（左侧腹股沟淋巴结）淋巴组织增生，建议免疫组化进一步诊断。患者随后未行任何检查及治疗。 | 851 | [
{
"anatomy_list": [
"左侧腹股沟"
],
"character": [
"数个",
"低回声"
],
"core_name": "结节影",
"tendency": ""
},
{
"anatomy_list": [
"左侧腹股沟淋巴结组织"
],
"character": [],
"core_name": "增生",
"tendency": ""
}
] |
现患儿精神食欲可，大便2次/天，稀水样，无血丝及粘液，小便黄清，尿量无减少。 | 367 | [
{
"anatomy_list": [],
"character": [
"可"
],
"core_name": "精神",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"可"
],
"core_name": "食欲",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"2次/天",
"稀水样",
"无血丝及粘液"
],
"core_name": "大便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"黄清"
],
"core_name": "小便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"无减少"
],
"core_name": "尿量",
"tendency": ""
}
] |
病程中患者精神、饮食稍差，大小便正常，体重无明显下降。 | 1,088 | [
{
"anatomy_list": [],
"character": [
"稍差"
],
"core_name": "精神",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"稍差"
],
"core_name": "饮食",
"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": "体重下降",
"tendency": "否定"
}
] |
入院前5-月，患者因"升结肠癌"于2019-03-19全麻下行腹腔镜下右半结肠癌根治术（扩大）、腹腔镜下肠粘连松解术，手术顺利，术后病检（右半结肠）粘液腺癌，侵及肠壁全层。 | 636 | [
{
"anatomy_list": [
"升结肠"
],
"character": [],
"core_name": "癌",
"tendency": ""
},
{
"anatomy_list": [
"右半结肠"
],
"character": [
"粘液",
"侵及肠壁"
],
"core_name": "腺癌",
"tendency": ""
}
] |
现患者为求第五次新辅助化疗，就诊于我院，门诊以“胰腺癌伴肝转移”收住入院。 | 1,670 | [
{
"anatomy_list": [
"胰腺"
],
"character": [],
"core_name": "癌",
"tendency": ""
},
{
"anatomy_list": [
"肝"
],
"character": [
"转移"
],
"core_name": "癌",
"tendency": ""
}
] |
胸片：双下肺少许感染，主动脉球少许钙化，胸椎退行性变。 | 519 | [
{
"anatomy_list": [
"双下肺"
],
"character": [
"少许"
],
"core_name": "感染",
"tendency": ""
},
{
"anatomy_list": [
"主动脉球"
],
"character": [
"少许"
],
"core_name": "钙化",
"tendency": ""
},
{
"anatomy_list": [
"胸椎"
],
"character": [
"退行性"
],
"core_name": "病变",
"tendency": ""
}
] |
患者入院前10年无明显诱因出现排尿踌躇、费力、不尽感,夜尿4-5次，尿线无力、分叉、变细、终末滴沥，未予重视，未予特殊处理，7年前患者到某医院行前列腺电切术，术后排尿困难症状无明显改善，夜尿7-8次，6年前患者出现排尿困难加重，排尿费力，偶有尿线中断，排尿滴沥明显，患者遂到某医院就诊，予以扩尿道2次，患者排尿困难稍有改善。 | 1,080 | [
{
"anatomy_list": [],
"character": [
"踌躇",
"费力",
"不尽感"
],
"core_name": "排尿",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"4-5次"
],
"core_name": "夜尿",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "尿线无力",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "尿线分叉",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "尿线变细",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"终末滴沥"
],
"core_name": "排尿",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"术后",
"无明显改善"
],
"core_name": "排尿困难",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"7-8次"
],
"core_name": "夜尿",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"加重"
],
"core_name": "排尿困难",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "排尿费力",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"偶有"
],
"core_name": "尿线中断",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"明显"
],
"core_name": "排尿滴沥",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"稍有改善"
],
"core_name": "排尿困难",
"tendency": ""
}
] |
与患者及家属沟通可选择的治疗方案，计划予以dp方案（多西他赛+顺铂）化疗，于2020-04-02、2020-04-24予以2周期dp方案化疗（多西他赛100mg1+顺铂50mg1-2，q3w），化疗期间出现恶心、食欲下降，予以奥美拉唑抑酸，昂丹司琼止吐等治疗后缓解。 | 217 | [
{
"anatomy_list": [],
"character": [],
"core_name": "恶心",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"下降"
],
"core_name": "食欲",
"tendency": ""
}
] |
患者住院期间多次输注血小板、悬浮红细胞，输注过程中及输注后均无不良反应。 | 1,658 | [
{
"anatomy_list": [],
"character": [
"输注过程中"
],
"core_name": "不良反应",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"输注后"
],
"core_name": "不良反应",
"tendency": "否定"
}
] |
无畏寒发热，无胸闷气紧，无心慌心悸，无黑便便血血便，无肉眼血尿。 | 1,131 | [
{
"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": "气紧",
"tendency": "否定"
},
{
"anatomy_list": [
"心"
],
"character": [],
"core_name": "心慌",
"tendency": "否定"
},
{
"anatomy_list": [
"心"
],
"character": [],
"core_name": "心悸",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "黑便",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "血便",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "便血",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "血尿",
"tendency": "否定"
}
] |
术后口服“替格瑞洛90mg bid”治疗，入院前12小时（2017-11-04 22:00），患者自觉剑突下绞痛，伴胸骨后哽咽感及喉部不适，持续约20分20分钟左右，无胸痛、胸部压榨感，无大汗、乏力，无头昏、头痛，无黑曚、意识障碍，含服“速效救心丸”可缓解，入院前8小时，患者再次感剑突下不适，稍疼痛，持续约10分10分钟，后自行缓解，入院前3小时，患者自行口服“阿司匹林300mg、替格瑞洛180mg”后入我院，以“冠心病”收入我科。 | 1,215 | [
{
"anatomy_list": [
"剑突下"
],
"character": [
"绞痛"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"胸骨后"
],
"character": [],
"core_name": "哽咽感",
"tendency": ""
},
{
"anatomy_list": [
"喉部"
],
"character": [],
"core_name": "喉部不适",
"tendency": ""
},
{
"anatomy_list": [
"胸"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [
"胸部"
],
"character": [],
"core_name": "压榨感",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"大汗"
],
"core_name": "出汗",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "乏力",
"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": "黒朦",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "意识障碍",
"tendency": "否定"
},
{
"anatomy_list": [
"剑突下"
],
"character": [],
"core_name": "剑突下不适",
"tendency": ""
},
{
"anatomy_list": [
"剑突下"
],
"character": [
"稍"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"冠状动脉",
"心脏"
],
"character": [
"硬化性",
"粥样"
],
"core_name": "心脏病",
"tendency": ""
}
] |
门诊以“肺占位性病变”收住院治疗。 | 126 | [
{
"anatomy_list": [
"肺"
],
"character": [
"占位性"
],
"core_name": "病变",
"tendency": ""
}
] |
伴心悸、胸闷，无发热、无潮热、盗汗，无咳血、咯血，无胸痛。 | 444 | [
{
"anatomy_list": [
"心"
],
"character": [],
"core_name": "心悸",
"tendency": ""
},
{
"anatomy_list": [
"胸"
],
"character": [],
"core_name": "胸闷",
"tendency": ""
},
{
"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": "咳血",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "咯血",
"tendency": "否定"
},
{
"anatomy_list": [
"胸"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
}
] |
完善胸部ct提示左肺下野片团影，慢性炎症？肿瘤待排。 | 1,553 | [
{
"anatomy_list": [
"左肺下野"
],
"character": [
"片"
],
"core_name": "团影",
"tendency": ""
},
{
"anatomy_list": [
"左肺下野"
],
"character": [
"慢性"
],
"core_name": "炎症",
"tendency": "不确定"
},
{
"anatomy_list": [
"左肺下野"
],
"character": [],
"core_name": "肿瘤",
"tendency": "不确定"
}
] |
患者1年前因进行性吞咽困难在我院胸外科住院，2015年03月28日胸部ct：1.食管下段改变，考虑食管癌可能性大，考虑食管肿瘤，于2015年03月31日在全麻下行胸-腹腔镜食管癌根治术+食管-胃颈部吻合+空肠造瘘术，术后病检：（食管）高分化鳞状细胞癌。 | 197 | [
{
"anatomy_list": [],
"character": [
"进行性"
],
"core_name": "吞咽困难",
"tendency": ""
},
{
"anatomy_list": [
"食管下段"
],
"character": [],
"core_name": "改变",
"tendency": ""
},
{
"anatomy_list": [
"食管"
],
"character": [],
"core_name": "癌",
"tendency": "不确定"
},
{
"anatomy_list": [
"食管"
],
"character": [],
"core_name": "肿瘤",
"tendency": "不确定"
},
{
"anatomy_list": [
"食管"
],
"character": [
"高分化"
],
"core_name": "鳞癌",
"tendency": ""
}
] |
患者4月多前无明显诱因出现双肩关节疼痛，伴双上臂上举困难，未予特殊治疗，2月余前受凉后出现流涕，伴咳嗽咳痰，偶有脓痰，于当地诊所服用中药后疼痛稍好转，继出现左踝关节关节肿痛，于某医院就诊，行踝关节平片、查肾功提示尿酸 178umol/L，未予进一步处理。 | 1,837 | [
{
"anatomy_list": [
"双肩关节"
],
"character": [],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"双上臂"
],
"character": [],
"core_name": "上举困难",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"受凉后"
],
"core_name": "流涕",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "咳痰",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"偶有",
"脓痰"
],
"core_name": "咳痰",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"服用中药后稍好转"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"左踝关节"
],
"character": [
"肿痛"
],
"core_name": "疼痛",
"tendency": ""
}
] |
今患者为进一步治疗食道赘生物遂于我院门诊求诊，门诊以“食道肿瘤”收入我科住院治疗。 | 1,192 | [
{
"anatomy_list": [
"食道"
],
"character": [],
"core_name": "赘生物",
"tendency": ""
},
{
"anatomy_list": [
"食道"
],
"character": [],
"core_name": "肿瘤",
"tendency": ""
}
] |
曾连续2年以上发作，每次发作均在3月以上，诊断为“慢性支气管炎、肺气肿”。 | 789 | [
{
"anatomy_list": [
"支气管"
],
"character": [
"慢性"
],
"core_name": "支气管炎",
"tendency": ""
},
{
"anatomy_list": [
"肺"
],
"character": [],
"core_name": "肺气肿",
"tendency": ""
}
] |
门诊拟“腰椎压缩性骨折”收住我科。 | 806 | [
{
"anatomy_list": [
"腰椎"
],
"character": [
"压缩性"
],
"core_name": "骨折",
"tendency": ""
}
] |
患者于1月前，因不慎受凉后出现咳嗽，咳痰，痰为白色粘液痰，无发热、胸痛、潮热、盗汗，无乏力等不适，曾在我院诊断为“肺炎”，予“头孢米诺抗感染，氨溴索止咳化痰”等治疗后好转，未坚持治疗，仍间断咳嗽、咳痰。 | 1,671 | [
{
"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"
],
"core_name": "咳痰",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "发热",
"tendency": "否定"
},
{
"anatomy_list": [
"胸"
],
"character": [],
"core_name": "疼痛",
"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": [
"肺"
],
"character": [],
"core_name": "肺炎",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"间断"
],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"间断"
],
"core_name": "咳痰",
"tendency": ""
}
] |
入院前1+天，患者因胸背部疼痛于我院门诊就诊，行胸部ct示：1.双肺下叶多发结节，性质待定，请结合其他进一步检查。 | 1,379 | [
{
"anatomy_list": [
"胸部",
"背部"
],
"character": [],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"双肺下叶"
],
"character": [
"多发"
],
"core_name": "结节",
"tendency": ""
}
] |
多次于外院就诊，行心脏彩超检查示：左房、左室增大，伴左室壁肥厚，主动脉深部增宽。 | 470 | [
{
"anatomy_list": [
"左房",
"左室"
],
"character": [],
"core_name": "增大",
"tendency": ""
},
{
"anatomy_list": [
"左室壁"
],
"character": [],
"core_name": "肥厚",
"tendency": ""
},
{
"anatomy_list": [
"主动脉深部"
],
"character": [],
"core_name": "增宽",
"tendency": ""
}
] |