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2.07k
| event
list |
|---|---|---|
骨髓检查：可见不典型淋巴细胞，请明确诊断为“非霍奇金淋巴瘤（弥漫大b细胞弥漫大b细胞淋巴瘤iii期）”，病程中患者无发热、盗汗、体重明显下降，无腹痛、腹胀、恶心、呕吐，无咳嗽、咳痰、黄疸等不适，于2016-11-21行r-chop（长春瑞滨40mg，吡柔比星30mg，环磷酰胺1g，泼尼松100mg，美罗华500mg）方案行化疗，化疗过程顺利。 | 567 | [
{
"anatomy_list": [],
"character": [
"骨髓检查可见"
],
"core_name": "不典型淋巴细胞",
"tendency": ""
},
{
"anatomy_list": [
"淋巴"
],
"character": [
"非霍奇金氏"
],
"core_name": "瘤",
"tendency": ""
},
{
"anatomy_list": [
"弥漫大b细胞",
"淋巴"
],
"character": [],
"core_name": "瘤",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "发热",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "盗汗",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"明显"
],
"core_name": "体重下降",
"tendency": "否定"
},
{
"anatomy_list": [
"腹部"
],
"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": [],
"character": [],
"core_name": "咳嗽",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "咳痰",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "黄疸",
"tendency": "否定"
}
] |
患者于入院前10年无明显诱因开始出现尿频、尿急，伴有排尿踌躇，无夜尿增多，无尿线变细、尿不尽、尿滴沥，无尿痛及肉眼血尿。患者未予重视，未予特殊处理。 | 608 | [
{
"anatomy_list": [],
"character": [],
"core_name": "尿频",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "尿急",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "排尿踌躇",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "夜尿增多",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "尿线变细",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "尿不尽",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "尿滴沥",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "尿痛",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "血尿",
"tendency": "否定"
}
] |
后包块逐渐增大，遂到某医院完善乳腺超声、ct、乳腺包块针刺活检等检查后诊断为“左乳腺浸润性癌”，并于2016-3-3日行左乳腺癌改良根治术，术后病理检查：左乳腺浸润性癌。 | 387 | [
{
"anatomy_list": [],
"character": [
"逐渐"
],
"core_name": "包块增大",
"tendency": ""
},
{
"anatomy_list": [
"左乳腺"
],
"character": [
"浸润性"
],
"core_name": "癌",
"tendency": ""
},
{
"anatomy_list": [
"左乳腺"
],
"character": [
"浸润性"
],
"core_name": "癌",
"tendency": ""
}
] |
1周前患者出现咳血不适，主要表现为鼻式咳痰，痰中带血，无气促、发热，无胸痛，无明显嗅觉减退，无面部麻木，无头昏、头痛、视力下降、复视等，于某医院住院治疗，胸部ct提示慢性支气管炎肺气肿、肺大泡。 | 2,067 | [
{
"anatomy_list": [],
"character": [],
"core_name": "咳血",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"鼻式"
],
"core_name": "咳痰",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"带血"
],
"core_name": "咳痰",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "气促",
"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": [],
"character": [
"明显"
],
"core_name": "嗅觉减退",
"tendency": "否定"
},
{
"anatomy_list": [
"面部"
],
"character": [],
"core_name": "麻木",
"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": "视力下降",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "复视",
"tendency": "否定"
},
{
"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": ""
},
{
"anatomy_list": [
"肺"
],
"character": [],
"core_name": "肺大疱",
"tendency": ""
}
] |
纤支镜取肺组织病理诊断：支气管粘膜慢性炎。 | 428 | [
{
"anatomy_list": [
"支气管粘膜"
],
"character": [
"慢性"
],
"core_name": "炎",
"tendency": ""
}
] |
入院前3年，患者活动后出现心累、气促，伴头晕，休息时可缓解，无视物模糊、视物旋转、黑朦、晕厥等，无咳嗽、咳痰，无胸闷、胸痛，无黑朦、恶心、呕吐，无大小便失禁，至当地医院输液（具体不详）后好转出院，入院前3天，患者上述症状加重，伴剑突下疼痛、纳差，不伴肩背部放射痛，进食后加重，伴反酸、嗳气，嗳气后症状稍缓解，不伴呕吐，呕血、黑便等，遂患者至当地医院治疗，无明显好转，为求进一步就诊，遂至我院，门诊以“冠心病”收入我院。 | 2,061 | [
{
"anatomy_list": [],
"character": [
"活动后"
],
"core_name": "心累",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"活动后"
],
"core_name": "气促",
"tendency": ""
},
{
"anatomy_list": [
"头"
],
"character": [
"休息时可缓解"
],
"core_name": "头晕",
"tendency": ""
},
{
"anatomy_list": [
"眼"
],
"character": [],
"core_name": "视物模糊",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "视物旋转",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "黑朦",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "晕厥",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "咳嗽",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "咳痰",
"tendency": "否定"
},
{
"anatomy_list": [
"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": "黑朦",
"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": [
"失禁"
],
"core_name": "大小便失禁",
"tendency": "否定"
},
{
"anatomy_list": [
"剑突下"
],
"character": [],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "纳差",
"tendency": ""
},
{
"anatomy_list": [
"肩背部"
],
"character": [
"放射性"
],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "反酸",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "嗳气",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "呕吐",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "呕血",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "黑便",
"tendency": "否定"
},
{
"anatomy_list": [
"心"
],
"character": [],
"core_name": "冠心病",
"tendency": ""
}
] |
伴头部闷胀感，不伴视物旋转，不伴恶心、呕吐，能持物及行走，，无反应迟钝，无呼之不应，无精神异常，无胡言乱语，无吞咽困难，无饮水呛咳，无四肢抽搐，无大小便失禁，无跌倒外伤。 | 1,477 | [
{
"anatomy_list": [
"头部"
],
"character": [],
"core_name": "闷胀",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "视物旋转",
"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": "反应迟钝",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "呼之不应",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"异常"
],
"core_name": "精神",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "胡言乱语",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "吞咽困难",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"饮水"
],
"core_name": "呛咳",
"tendency": "否定"
},
{
"anatomy_list": [
"四肢"
],
"character": [],
"core_name": "抽搐",
"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": [],
"character": [],
"core_name": "跌倒",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "外伤",
"tendency": "否定"
}
] |
后患者转入我院，骨髓检查提示有核细胞增生程度明显活跃，粒系增生减低，以中，后期细胞为主，可见中毒颗粒，红系增生尚可，以中，晚红为主，成熟红细胞呈缗钱状排列，巨核细胞尚可，以产板巨为主，散在血小板可见，浆细胞增生极度活跃，以骨髓瘤瘤细胞为主，可见2-4核浆。 | 1,946 | [
{
"anatomy_list": [],
"character": [
"明显",
"活跃"
],
"core_name": "增生",
"tendency": ""
},
{
"anatomy_list": [
"中，后期细胞为主",
"粒系",
"减低"
],
"character": [],
"core_name": "增生",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "中毒颗粒",
"tendency": ""
},
{
"anatomy_list": [
"中，晚红为主",
"红系"
],
"character": [],
"core_name": "增生",
"tendency": ""
},
{
"anatomy_list": [
"以骨髓瘤瘤细胞为主",
"极度活跃"
],
"character": [
"可见2-4核浆",
"极度活跃"
],
"core_name": "增生",
"tendency": ""
}
] |
无皮肤巩膜黄染，大小便无异常。 | 1,005 | [
{
"anatomy_list": [
"皮肤",
"巩膜"
],
"character": [],
"core_name": "黄染",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"异常"
],
"core_name": "大便",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"异常"
],
"core_name": "小便",
"tendency": "否定"
}
] |
患病以来，患者精神、食欲、睡眠可，大小便正常，近期体重无明显变化。 | 1,272 | [
{
"anatomy_list": [],
"character": [
"可"
],
"core_name": "精神",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"可"
],
"core_name": "食欲",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"可"
],
"core_name": "睡眠",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"正常"
],
"core_name": "大便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"正常"
],
"core_name": "小便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"明显"
],
"core_name": "体重改变",
"tendency": "否定"
}
] |
患者本次发病以来，食欲减退， 神志清醒，精神欠佳，睡眠欠佳，大便正常，小便正常，体重下降约5kg。 | 991 | [
{
"anatomy_list": [],
"character": [
"减退"
],
"core_name": "食欲减退",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"清醒"
],
"core_name": "神志",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"欠佳"
],
"core_name": "精神",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"欠佳"
],
"core_name": "睡眠",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"正常"
],
"core_name": "大便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"正常"
],
"core_name": "小便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "体重下降",
"tendency": ""
}
] |
患者于2月前于某医院检查，行腹部mr提示“肝硬化、脾大；肝脏占位，考虑：小肝癌”，两对半提示“大三阳”。 | 1,720 | [
{
"anatomy_list": [
"肝"
],
"character": [],
"core_name": "硬化",
"tendency": ""
},
{
"anatomy_list": [
"脾"
],
"character": [],
"core_name": "脾大",
"tendency": ""
},
{
"anatomy_list": [
"肝脏"
],
"character": [],
"core_name": "占位",
"tendency": ""
},
{
"anatomy_list": [
"肝"
],
"character": [
"小"
],
"core_name": "癌",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "大三阳",
"tendency": ""
}
] |
2012年于某医院检查诊断“前列腺癌”，行手术治疗后好转，未行放疗或化疗，具体诊治不详，现予“比卡鲁胺、果舍瑞林”控制。 | 1,064 | [
{
"anatomy_list": [
"前列腺"
],
"character": [
"行手术治疗后好转"
],
"core_name": "癌",
"tendency": ""
}
] |
入院前10+年，三次非同日测得血压大于140/？mmhg，最高收缩压达210/?mmhg，平素口服“硝苯地平、氨氯地平”控制血压，血压控制一般（具体不详），入院前6+年，患者出现活动后心累、气促（上坡及上楼时明显），伴胸闷，偶有心悸，休息后可缓解，无头晕、头痛、黑曚，无胸痛、肩部、背部放射痛，无夜间阵发性呼吸困难，无腹痛、腹胀、反酸、恶心、呕吐，无双下肢水肿等症状。 | 1,594 | [
{
"anatomy_list": [],
"character": [
"升高"
],
"core_name": "血压",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"控制一般"
],
"core_name": "血压",
"tendency": ""
},
{
"anatomy_list": [
"心"
],
"character": [
"上坡及上楼时明显",
"活动后"
],
"core_name": "心累",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"上坡及上楼时明显",
"活动后"
],
"core_name": "气促",
"tendency": ""
},
{
"anatomy_list": [
"胸"
],
"character": [],
"core_name": "胸闷",
"tendency": ""
},
{
"anatomy_list": [
"心"
],
"character": [
"休息后可缓解",
"偶有"
],
"core_name": "心悸",
"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": "黒朦",
"tendency": "否定"
},
{
"anatomy_list": [
"胸"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [
"肩部"
],
"character": [
"放射性"
],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [
"肩部",
"背部"
],
"character": [
"放射性"
],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"夜间",
"阵发性"
],
"core_name": "呼吸困难",
"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": "反酸",
"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": [
"双下肢"
],
"character": [],
"core_name": "水肿",
"tendency": "否定"
}
] |
（左）卵巢浆液性囊腺瘤。（左侧）输卵管组织。（右侧）附件组织。 | 1,995 | [
{
"anatomy_list": [
"左卵巢"
],
"character": [
"浆液性"
],
"core_name": "囊腺瘤",
"tendency": ""
}
] |
入院前 1+年前无明显诱因出现咳嗽，无明显缓解。 | 1,244 | [
{
"anatomy_list": [],
"character": [
"明显缓解"
],
"core_name": "咳嗽",
"tendency": "否定"
}
] |
患者本次发病以来，食欲减退，神志清醒，精神尚可，睡眠尚可，大便正常，小便正常，体重无明显变化。 | 1,874 | [
{
"anatomy_list": [],
"character": [
"减退"
],
"core_name": "食欲",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"清醒"
],
"core_name": "神志",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"尚可"
],
"core_name": "精神",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"尚可"
],
"core_name": "睡眠",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"正常"
],
"core_name": "大便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"正常"
],
"core_name": "小便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"明显"
],
"core_name": "体重改变",
"tendency": "否定"
}
] |
遂到我科住院治疗，诊断为“直肠癌”，完善术前准备，于2014-4-23在全麻下行腹腔镜下直肠癌根治术手术（dixon），手术顺利，病检报告（123456）回示：<直肠>中分化腺癌，侵及全层，双侧切缘未见癌累及，肠周脂肪组织中淋巴结见癌转移<3/11>,<肠系膜根部>淋巴结未见癌转移（0/1），术后予以补液、抗感染、抑酸护胃、营养支持、卡络磺止血、雾化祛痰等治疗后好转出院，出院后规律服用“复方斑螯胶囊 bid 3sx0.25g”抗肿瘤。 | 1,041 | [
{
"anatomy_list": [
"直肠"
],
"character": [],
"core_name": "癌",
"tendency": ""
},
{
"anatomy_list": [
"直肠"
],
"character": [
"中分化",
"侵及全层"
],
"core_name": "腺癌",
"tendency": ""
},
{
"anatomy_list": [
"直肠双侧切缘"
],
"character": [
"累及"
],
"core_name": "癌",
"tendency": "否定"
},
{
"anatomy_list": [
"肠周淋巴结"
],
"character": [
"转移",
"脂肪组织"
],
"core_name": "癌",
"tendency": ""
},
{
"anatomy_list": [
"肠系膜根部淋巴结"
],
"character": [
"转移"
],
"core_name": "癌",
"tendency": "否定"
}
] |
入院 前4天 ，患者无明显诱因出现头昏伴阵发视物旋转，眩晕与体位变化有关，于起床时较为明显，每次眩晕症状持续约10秒钟左右，经休息可好转，缓解期自诉走路时仍头昏；患者伴恶心、呕吐胃内容物，发病以来共呕吐9次，无咖啡色样物质，无喷射性呕吐；无耳鸣、耳胀、听力下降；无意识丧失、鼻唇沟变浅，无饮水呛咳、吞咽困难、肢体麻木、肢体无力；发病前无感冒受凉，余无特殊不适，曾于当地医院就诊，予以止吐、抗眩晕等对症治疗，具体用药不详，患者症状稍好转；为求进一步诊治，遂入我院门诊就诊；完善头ct平扫：1.右侧额叶片状低密度影，2.双侧上颌窦炎。 | 283 | [
{
"anatomy_list": [
"头"
],
"character": [],
"core_name": "头昏",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"阵发"
],
"core_name": "视物旋转",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"与体位变化有关",
"于起床时较为明显",
"持续约10秒钟左右",
"经休息可好转"
],
"core_name": "眩晕",
"tendency": ""
},
{
"anatomy_list": [
"头"
],
"character": [
"缓解期",
"走路时"
],
"core_name": "头昏",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "恶心",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"胃内容物"
],
"core_name": "呕吐",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"9次",
"无咖啡色样物质",
"无喷射性呕吐"
],
"core_name": "呕吐",
"tendency": ""
},
{
"anatomy_list": [
"耳"
],
"character": [],
"core_name": "耳鸣",
"tendency": "否定"
},
{
"anatomy_list": [
"耳"
],
"character": [],
"core_name": "耳胀",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "听力下降",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "意识丧失",
"tendency": "否定"
},
{
"anatomy_list": [
"鼻唇沟"
],
"character": [],
"core_name": "变浅",
"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": [
"肢体"
],
"character": [],
"core_name": "麻木",
"tendency": "否定"
},
{
"anatomy_list": [
"肢体"
],
"character": [],
"core_name": "无力",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"发病前"
],
"core_name": "感冒",
"tendency": "否定"
},
{
"anatomy_list": [
"右侧额叶"
],
"character": [
"片状",
"低"
],
"core_name": "密度影",
"tendency": ""
},
{
"anatomy_list": [
"双侧上颌窦"
],
"character": [],
"core_name": "颌窦炎",
"tendency": ""
}
] |
近段时间，患者感双侧下颌下下颌下淋巴结进行性增大，但无红肿、疼痛。 | 1,460 | [
{
"anatomy_list": [
"双侧下颌下淋巴结"
],
"character": [
"进行性"
],
"core_name": "增大",
"tendency": ""
},
{
"anatomy_list": [
"双侧下颌下淋巴结"
],
"character": [],
"core_name": "红肿",
"tendency": "否定"
},
{
"anatomy_list": [
"双侧下颌下淋巴结"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
}
] |
吻合口未见癌累及，其中见一枚淋巴结，未见癌转移。贲门旁淋巴结送检为血管脂肪组织。 | 1,921 | [
{
"anatomy_list": [
"吻合口"
],
"character": [
"累及"
],
"core_name": "癌",
"tendency": "否定"
},
{
"anatomy_list": [
"吻合口淋巴结"
],
"character": [
"转移"
],
"core_name": "癌",
"tendency": "否定"
}
] |
（右）卵巢囊性滤泡，术后好转出院。 | 1,996 | [
{
"anatomy_list": [
"右卵巢"
],
"character": [
"囊状"
],
"core_name": "滤泡",
"tendency": ""
}
] |
肠周脂肪中淋巴结未见癌转移（0/13）。 | 1,786 | [
{
"anatomy_list": [
"肠周脂肪淋巴结"
],
"character": [
"转移"
],
"core_name": "癌",
"tendency": "否定"
}
] |
（建议做相关免疫组化明确）会诊：（左肺上叶舌段）肺腺癌。 | 276 | [
{
"anatomy_list": [
"左肺上叶舌段",
"肺"
],
"character": [],
"core_name": "腺癌",
"tendency": ""
}
] |
双肾结石，左肾囊肿。 | 771 | [
{
"anatomy_list": [
"双肾"
],
"character": [],
"core_name": "结石",
"tendency": ""
},
{
"anatomy_list": [
"左肾"
],
"character": [],
"core_name": "囊肿",
"tendency": ""
}
] |
于2015-06-24行奥沙利铂+雷替曲塞方案化疗一次，化疗反应轻。 | 101 | [
{
"anatomy_list": [],
"character": [
"轻"
],
"core_name": "化疗反应",
"tendency": ""
}
] |
肝内少许小囊肿可能。 | 596 | [
{
"anatomy_list": [
"肝内"
],
"character": [
"小",
"少许"
],
"core_name": "囊肿",
"tendency": "不确定"
}
] |
胸12椎体上缘许莫氏结节。 | 804 | [
{
"anatomy_list": [
"胸12椎体上缘"
],
"character": [],
"core_name": "许莫氏结节",
"tendency": ""
}
] |
4年前我院行“肾动脉交感神经射频消融术”，术后半年，患者血压逐步降低，但患者仍口服“坎地沙坦、呋塞米、螺内酯”等降压、改善心室重构药物，自测血压约116/66mmHg左右。 | 473 | [
{
"anatomy_list": [],
"character": [
"逐步降低"
],
"core_name": "血压",
"tendency": ""
}
] |
某医院骨扫描结果回示：胸中段、左侧肩关节、右侧第7后肋近腋后线处、t3、右侧骶髂关节处、左侧坐骨支呈散在分布的多发的形态各异的放射性浓聚，考虑转移性骨肿瘤。 | 1,438 | [
{
"anatomy_list": [
"胸中段",
"左侧坐骨支",
"左侧肩关节",
"骶髂关节",
"右侧第7后肋近腋后线处",
"t3"
],
"character": [
"散在",
"多发",
"放射性"
],
"core_name": "浓聚",
"tendency": ""
},
{
"anatomy_list": [
"骨"
],
"character": [
"转移性"
],
"core_name": "肿瘤",
"tendency": "不确定"
}
] |
患者本次发病以来，食欲下降， 神志清醒，精神欠佳，睡眠欠佳，大便正常，小便正常，体重减少。 | 1,673 | [
{
"anatomy_list": [],
"character": [],
"core_name": "食欲下降",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"清醒"
],
"core_name": "神志",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"欠佳"
],
"core_name": "精神",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"欠佳"
],
"core_name": "睡眠",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"正常"
],
"core_name": "大便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"正常"
],
"core_name": "小便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"减少"
],
"core_name": "体重",
"tendency": ""
}
] |
入院前2天,患者受凉后再次出现气促,并咳嗽,痰液粘稠,不易咳出,遂就诊于我院,为进一步治疗,门诊以“慢阻肺急性期”收入我科。 | 10 | [
{
"anatomy_list": [],
"character": [
"受凉"
],
"core_name": "气促",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"痰液粘稠",
"不易咳出"
],
"core_name": "咳痰",
"tendency": ""
},
{
"anatomy_list": [
"肺"
],
"character": [
"急性期",
"慢性",
"阻塞性"
],
"core_name": "肺疾病",
"tendency": ""
}
] |
出院后患者时有咳嗽、痰少，偶有右侧胸部切口轻微疼痛，无畏寒、发热，无咯血、呼吸困难等不适。 | 1,530 | [
{
"anatomy_list": [],
"character": [],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"少"
],
"core_name": "咳痰",
"tendency": ""
},
{
"anatomy_list": [
"右侧胸部切口"
],
"character": [
"轻微"
],
"core_name": "疼痛",
"tendency": ""
},
{
"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": "咯血",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "呼吸困难",
"tendency": "否定"
}
] |
2天前，患者于我院就诊，门诊完善胃镜检查提示：贲门溃疡性病变，病理报告提示：贲门粘膜慢性溃疡性炎，肝功提示：alt 58U/L，ggt 93U/L，肾功、血常规未见异常，予以抑酸护胃等治疗后症状无缓解，今为进一步诊治，再次就诊于我院，门诊以“巨大溃疡”收入我科。 | 1,877 | [
{
"anatomy_list": [
"贲门"
],
"character": [
"溃疡型"
],
"core_name": "病变",
"tendency": ""
},
{
"anatomy_list": [
"贲门粘膜"
],
"character": [
"慢性",
"溃疡型"
],
"core_name": "贲门粘膜炎",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"巨大"
],
"core_name": "溃疡",
"tendency": ""
},
{
"anatomy_list": [
"肾"
],
"character": [],
"core_name": "肾功能异常",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"异常"
],
"core_name": "血常规",
"tendency": "否定"
}
] |
现患者偶有咳嗽、咳痰，无畏寒、发热，无腹痛、腹胀等不适，患者为求进一步诊治遂至我院，门诊以“肺癌”收入我科。 | 768 | [
{
"anatomy_list": [],
"character": [
"偶有"
],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"偶有"
],
"core_name": "咳痰",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "畏寒",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "发热",
"tendency": "否定"
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "腹胀",
"tendency": "否定"
},
{
"anatomy_list": [
"肺"
],
"character": [],
"core_name": "癌",
"tendency": ""
}
] |
患者1月前出现尿黄（呈深黄色），家人发现其眼黄、身黄，伴乏力、纳差（食量约为原来1/3），无厌油、恶心、呕吐，无腹痛、腹胀，无大便颜色变浅，无皮肤瘙痒，患者未予以重视，未做任何处理。 | 1,775 | [
{
"anatomy_list": [],
"character": [
"深黄色"
],
"core_name": "尿黄",
"tendency": ""
},
{
"anatomy_list": [
"身"
],
"character": [],
"core_name": "黄染",
"tendency": ""
},
{
"anatomy_list": [
"眼"
],
"character": [],
"core_name": "黄染",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "乏力",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"食量约为原来1/3"
],
"core_name": "纳差",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "厌油",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "恶心",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "呕吐",
"tendency": "否定"
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "腹胀",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"颜色变浅"
],
"core_name": "大便",
"tendency": "否定"
},
{
"anatomy_list": [
"皮肤"
],
"character": [],
"core_name": "瘙痒",
"tendency": "否定"
}
] |
今为继续治疗来我院，未行第3次类克输注，门诊以“幼年特发性关节炎”收入院。 | 76 | [
{
"anatomy_list": [
"关节"
],
"character": [
"幼年",
"特发性"
],
"core_name": "关节炎",
"tendency": ""
}
] |
入院前1天，患者再次出现小便不能自解情况，伴有下腹部持续性胀痛，患者感症状不能忍受，今日于我科门诊就诊，门诊以“尿潴留”收入我科住院治疗。 | 1,897 | [
{
"anatomy_list": [],
"character": [
"不能自解"
],
"core_name": "小便",
"tendency": ""
},
{
"anatomy_list": [
"下腹部"
],
"character": [
"持续性",
"胀痛",
"不能忍受"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "尿潴留",
"tendency": ""
}
] |
20天前患者因喘累不适就诊于我院，完善胸部彩超示：大量胸腔积液；遂行胸腔穿刺抽液并胸腔内局部注射“顺铂、艾迪”化疗药物治疗，后喘累不适好转出院。 | 989 | [
{
"anatomy_list": [],
"character": [],
"core_name": "喘累",
"tendency": ""
},
{
"anatomy_list": [
"胸腔"
],
"character": [
"大量"
],
"core_name": "积液",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"好转"
],
"core_name": "喘累",
"tendency": ""
}
] |
17月余前，患者因“左下腹痛1月余，加重半月。 | 1,633 | [
{
"anatomy_list": [
"左下腹"
],
"character": [],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"左下腹"
],
"character": [
"加重"
],
"core_name": "疼痛",
"tendency": ""
}
] |
患者自起病以来,精神可,胃纳可,大便如常,小便如常,体重未见明显下降。 | 58 | [
{
"anatomy_list": [],
"character": [
"可"
],
"core_name": "精神",
"tendency": ""
},
{
"anatomy_list": [
"胃"
],
"character": [
"可"
],
"core_name": "胃纳",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"如常"
],
"core_name": "大便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"如常"
],
"core_name": "小便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"明显"
],
"core_name": "体重下降",
"tendency": "否定"
}
] |
患者于4年前因“间断吞咽困难，进食梗阻感”于某医院行胃镜检查提示“食道中下段癌”，病理活检提示“鳞癌”，行胸部ct提示“食道中下段占位及纵膈多处淋巴结转移”，遂入住某医院行“电视胸腔镜探查，下段食管癌段食管癌切除，脾切除和胃食管左侧颈部侧-侧吻合术”，术后病检提示：食管下段髓质型低-中等分化鳞癌，予以抗感染、祛痰、营养支持等治疗后好转出院。 | 2,046 | [
{
"anatomy_list": [],
"character": [
"间断"
],
"core_name": "吞咽困难",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"进食"
],
"core_name": "梗阻感",
"tendency": ""
},
{
"anatomy_list": [
"食道中段下段"
],
"character": [],
"core_name": "癌",
"tendency": ""
},
{
"anatomy_list": [
"食道中段下段"
],
"character": [],
"core_name": "鳞癌",
"tendency": ""
},
{
"anatomy_list": [
"食道中段下段"
],
"character": [],
"core_name": "占位",
"tendency": ""
},
{
"anatomy_list": [
"纵膈淋巴结"
],
"character": [
"多处淋巴结"
],
"core_name": "转移",
"tendency": ""
},
{
"anatomy_list": [
"食管下段"
],
"character": [
"髓质型",
"低-中等分化"
],
"core_name": "鳞癌",
"tendency": ""
}
] |
患者自发病以来，精神可，食欲欠佳，睡眠欠佳，大便如常，小便如常，体重下降明显。 | 948 | [
{
"anatomy_list": [],
"character": [
"可"
],
"core_name": "精神",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"欠佳"
],
"core_name": "食欲",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"欠佳"
],
"core_name": "睡眠",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"如常"
],
"core_name": "大便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"如常"
],
"core_name": "小便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"明显"
],
"core_name": "体重下降",
"tendency": ""
}
] |
此后咳嗽、咳痰症状反复发作，每年发作时间大于3个月，两年前受凉后出现间断咳黄色粘稠脓痰,痰量较之前稍有增加，活动后加重，曾反复于我院住院治疗，诊断为“慢性阻塞性肺疾病、肺气肿”予以积极抗感染、解痉、化痰等化疗治疗后好转出院，病程中无劳力性心累呼吸困难，无夜间阵发性呼吸困难，无端坐呼吸，无咳粉红色泡沫痰，无双下肢水肿，无夜尿增多，无便秘、腹泻、腹胀，无黄疸、厌油、乏力、纳差。 | 675 | [
{
"anatomy_list": [],
"character": [
"反复发作"
],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"反复发作"
],
"core_name": "咳痰",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"受凉后",
"间断",
"黄色",
"粘稠",
"脓痰",
"痰量较之前稍有增加",
"活动后加重"
],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [
"肺"
],
"character": [
"慢性",
"阻塞性"
],
"core_name": "肺疾病",
"tendency": ""
},
{
"anatomy_list": [
"肺"
],
"character": [],
"core_name": "肺气肿",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"劳累性"
],
"core_name": "心累",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"劳累性"
],
"core_name": "呼吸困难",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"夜间",
"阵发性"
],
"core_name": "呼吸困难",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "端坐呼吸",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"粉红色",
"泡沫痰"
],
"core_name": "咳痰",
"tendency": "否定"
},
{
"anatomy_list": [
"双下肢"
],
"character": [],
"core_name": "水肿",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "夜尿增多",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "便秘",
"tendency": "否定"
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "腹泻",
"tendency": "否定"
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "腹胀",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "黄疸",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "厌油",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "乏力",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "纳差",
"tendency": "否定"
}
] |
门诊遂以“右肺鳞癌，化疗后骨髓抑制”收治入院。 | 549 | [
{
"anatomy_list": [
"右肺"
],
"character": [],
"core_name": "鳞癌",
"tendency": ""
},
{
"anatomy_list": [
"骨髓"
],
"character": [
"化疗后"
],
"core_name": "骨髓抑制",
"tendency": ""
}
] |
现患儿一般情况可,今再次入院,拟行储液囊拔除术。 | 16 | [
{
"anatomy_list": [],
"character": [
"可"
],
"core_name": "一般情况",
"tendency": ""
}
] |
<胰头上方>淋巴结见癌转移（1/1）慢性胆囊炎。 | 1,343 | [
{
"anatomy_list": [
"胰头上方淋巴结"
],
"character": [
"转移"
],
"core_name": "癌",
"tendency": ""
},
{
"anatomy_list": [
"胆囊"
],
"character": [
"慢性"
],
"core_name": "胆囊炎",
"tendency": ""
}
] |
2019-5月无明显诱因扪及右下腹包块，质地硬，无明显疼痛感，无畏寒发热，无咳嗽咳痰，无头晕疼痛，无腹泻腹痛，于2019-6就诊于某肿瘤医院，行肠镜提示“结肠肝区和横结肠肿瘤，病检提示腺癌”，行右下腹肿块穿刺明确为腺癌。 | 2,055 | [
{
"anatomy_list": [
"右下腹"
],
"character": [
"质地硬",
"无明显疼痛感"
],
"core_name": "包块",
"tendency": ""
},
{
"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": "咳嗽",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "咳痰",
"tendency": "否定"
},
{
"anatomy_list": [
"头"
],
"character": [],
"core_name": "头晕",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "腹泻",
"tendency": "否定"
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [
"结肠肝区",
"横结肠"
],
"character": [],
"core_name": "肿瘤",
"tendency": ""
},
{
"anatomy_list": [
"结肠肝区",
"横结肠"
],
"character": [],
"core_name": "腺癌",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "腺癌",
"tendency": ""
}
] |
入院前1月，患者因下肢静脉曲张于我院行“双下肢大隐静脉高位结扎＋抽拨＋evlt术”，术前查肝功：谷丙转氨酶 107U/L ↑，谷草转氨酶 95U/L ↑，碱性磷酸酶 218U/L ↑，γ-谷胺酰转移酶 289U/L ↑，前白蛋白 192mg/L ↓，无皮肤瘙痒等不适，未做特殊处理。 | 933 | [
{
"anatomy_list": [
"下肢静脉"
],
"character": [],
"core_name": "曲张",
"tendency": ""
},
{
"anatomy_list": [
"皮肤"
],
"character": [],
"core_name": "瘙痒",
"tendency": "否定"
}
] |
3.右肺上叶及左肺下叶下叶钙化灶。 | 681 | [
{
"anatomy_list": [
"右肺上叶",
"左肺下叶"
],
"character": [],
"core_name": "钙化灶",
"tendency": ""
}
] |
2+月前，患者无明显诱因出现咳嗽、咳痰，咳嗽以阵发性咳嗽为主，无犬吠样咳嗽及鸡鸣样回声，咳痰呈白色泡沫痰，痰量多，痰中偶带鲜红色血丝，晨起时较重，日间减轻，夜间可平卧入睡，活动后略感气促。 | 658 | [
{
"anatomy_list": [],
"character": [],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "咳痰",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"阵发性"
],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"犬吠样"
],
"core_name": "咳嗽",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"鸡鸣样回声"
],
"core_name": "咳嗽",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"白色",
"泡沫痰",
"痰量多"
],
"core_name": "咳痰",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"偶带鲜红色血丝"
],
"core_name": "咳痰",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"晨起时较重",
"日间减轻"
],
"core_name": "咳痰",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"活动后",
"略感"
],
"core_name": "气促",
"tendency": ""
}
] |
腹部彩超：肝内实性结节，血管瘤可能，肝实质回声增粗、不均质。建议患者到上级医院就诊。 | 979 | [
{
"anatomy_list": [
"肝内"
],
"character": [
"实性"
],
"core_name": "结节",
"tendency": ""
},
{
"anatomy_list": [
"肝内"
],
"character": [
"血管"
],
"core_name": "瘤",
"tendency": "不确定"
},
{
"anatomy_list": [
"肝实质"
],
"character": [
"增粗",
"不均质"
],
"core_name": "回声",
"tendency": ""
}
] |
入院前 5+月 ，患者无明显诱因感 右侧胸痛 ，偶有咳嗽，偶有少许白色粘痰，不伴咳血，感活动后心累、气促，不咯黄脓痰及铁锈色痰，不伴畏寒、寒战、高热，不伴潮热、盗汗及午后低热。 | 425 | [
{
"anatomy_list": [
"右侧胸"
],
"character": [],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"偶有"
],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"偶有",
"少许",
"白色",
"粘"
],
"core_name": "咳痰",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "咳血",
"tendency": "否定"
},
{
"anatomy_list": [
"心"
],
"character": [
"活动后"
],
"core_name": "心累",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"活动后"
],
"core_name": "气促",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"黄脓",
"铁锈色"
],
"core_name": "咳痰",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "畏寒",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "寒颤",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"高"
],
"core_name": "发热",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "潮热",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "盗汗",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"午后",
"低"
],
"core_name": "发热",
"tendency": "否定"
}
] |
至我院行纤支镜活检，病检结果（2015-01-21）示：<右下叶下叶支气管活检>腺癌。 | 752 | [
{
"anatomy_list": [
"右下叶支气管"
],
"character": [],
"core_name": "腺癌",
"tendency": ""
}
] |
20+天前患者无诱因出现阴道少量流血，色暗红，质中，偶有少量血凝块，无腹痛、腹胀、畏寒、发热、头昏、心慌等不适，患者未予重视未诊治；阴道流血持续至今，遂来我院就诊，门诊以"阴道流血待查：功能失调性子宫出血？子宫内膜癌？"收入我科。 | 335 | [
{
"anatomy_list": [
"阴道"
],
"character": [
"少量",
"色暗红",
"质中",
"偶有少量血凝块"
],
"core_name": "出血",
"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": "畏寒",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "发热",
"tendency": "否定"
},
{
"anatomy_list": [
"头"
],
"character": [],
"core_name": "头昏",
"tendency": "否定"
},
{
"anatomy_list": [
"心"
],
"character": [],
"core_name": "心慌",
"tendency": "否定"
},
{
"anatomy_list": [
"阴道"
],
"character": [
"持续至今"
],
"core_name": "出血",
"tendency": ""
},
{
"anatomy_list": [
"阴道"
],
"character": [],
"core_name": "出血",
"tendency": "不确定"
},
{
"anatomy_list": [
"子宫"
],
"character": [
"功能失调性"
],
"core_name": "出血",
"tendency": "不确定"
},
{
"anatomy_list": [
"子宫内膜"
],
"character": [],
"core_name": "癌",
"tendency": "不确定"
}
] |
2020-12-7患者感右下腹部下腹部疼痛，向右下腹放射。 | 2,058 | [
{
"anatomy_list": [
"右下腹部",
"下腹部"
],
"character": [],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"右下腹"
],
"character": [
"放射性"
],
"core_name": "疼痛",
"tendency": ""
}
] |
鼻咽双侧壁稍厚，fdg代谢增高，建议鼻镜检查。 | 167 | [
{
"anatomy_list": [
"鼻咽双侧壁"
],
"character": [
"稍"
],
"core_name": "壁厚",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"代谢增高"
],
"core_name": "fdg",
"tendency": ""
}
] |
其后间断一段时间无明显诱因再次出现少量阴道流血，未就医。 | 1,579 | [
{
"anatomy_list": [
"阴道"
],
"character": [
"少量"
],
"core_name": "出血",
"tendency": ""
}
] |
患者目前无咳嗽，无肝区疼痛，无骨关节关节疼痛。 | 415 | [
{
"anatomy_list": [],
"character": [],
"core_name": "咳嗽",
"tendency": "否定"
},
{
"anatomy_list": [
"肝区"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [
"骨关节"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
}
] |
术后剖视子宫：子宫腔后壁及底部一大小约为4*3*2cm菜花样包块，病灶浸及浅肌层，子宫内膜菲薄；术后继续予以抗感染、止血等处理，术后病检（123456）结果提示：子宫内膜样腺癌（3级），侵及深肌层（近浆膜层），宫颈内口及双侧宫旁未见癌累及，（左髂总、右髂总、左盆腔、右盆腔）淋巴结未见癌转移（0/3、0/2、0/9、0/13）。 | 1,282 | [
{
"anatomy_list": [
"子宫腔后壁",
"子宫腔底部"
],
"character": [
"菜花样"
],
"core_name": "包块",
"tendency": ""
},
{
"anatomy_list": [
"浅肌层"
],
"character": [
"浸及"
],
"core_name": "病灶",
"tendency": ""
},
{
"anatomy_list": [
"子宫内膜"
],
"character": [],
"core_name": "子宫内膜菲薄",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"子宫内膜样",
"3级"
],
"core_name": "腺癌",
"tendency": ""
},
{
"anatomy_list": [
"深肌层",
"近浆膜层"
],
"character": [
"侵及"
],
"core_name": "腺癌",
"tendency": ""
},
{
"anatomy_list": [
"宫颈内口",
"双侧宫旁"
],
"character": [
"累及"
],
"core_name": "癌",
"tendency": "否定"
},
{
"anatomy_list": [
"左盆腔淋巴结",
"右盆腔淋巴结",
"左髂总淋巴结",
"右髂总淋巴结"
],
"character": [
"转移"
],
"core_name": "癌",
"tendency": "否定"
}
] |
1+周前，患者再次出现咳嗽、咯痰，伴活动后喘累，无胸闷、胸痛、咯血、呼吸困难，无畏寒、发热等。 | 383 | [
{
"anatomy_list": [],
"character": [
"再次"
],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"再次"
],
"core_name": "咯痰",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"活动后"
],
"core_name": "喘累",
"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": "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": "发热",
"tendency": "否定"
}
] |
伴下腹部疼痛 ， 疼痛呈阵发性隐痛 ， 无放射痛 。 | 340 | [
{
"anatomy_list": [
"下腹部"
],
"character": [],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"下腹部"
],
"character": [
"阵发性",
"隐痛"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"下腹部"
],
"character": [
"放射性"
],
"core_name": "疼痛",
"tendency": "否定"
}
] |
3天前复查ct提示：1.肝内多发稍低密度小结节并可疑强化；2.双肺多发结节，转移瘤可能。现患者为求进一步治疗入院。 | 1,317 | [
{
"anatomy_list": [
"肝内"
],
"character": [
"多发",
"小",
"稍低密度"
],
"core_name": "结节",
"tendency": ""
},
{
"anatomy_list": [
"肝内"
],
"character": [
"强化"
],
"core_name": "结节",
"tendency": "不确定"
},
{
"anatomy_list": [
"双肺"
],
"character": [
"多发"
],
"core_name": "结节",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"转移"
],
"core_name": "瘤",
"tendency": "不确定"
}
] |
已于我科行规律化疗5次，未诉特殊不适，现患者一般情况可，无腹痛、腹胀、恶心、呕吐、畏寒、发热等症状，拟行第6次化疗入院。 | 848 | [
{
"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": [],
"character": [],
"core_name": "畏寒",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "发热",
"tendency": "否定"
}
] |
院外每日解不成形软便２－３次，无血便，无腹泻、肛门坠胀等不适。 | 726 | [
{
"anatomy_list": [],
"character": [
"不成形",
"软"
],
"core_name": "大便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"带血"
],
"core_name": "大便",
"tendency": "否定"
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "腹泻",
"tendency": "否定"
},
{
"anatomy_list": [
"肛门"
],
"character": [],
"core_name": "坠胀",
"tendency": "否定"
}
] |
入院前3-月，患者因诊断为“左侧乳腺癌”。 | 1,647 | [
{
"anatomy_list": [
"左侧乳腺"
],
"character": [],
"core_name": "癌",
"tendency": ""
}
] |
门诊以“直肠癌术后”收入我科。 | 1,318 | [
{
"anatomy_list": [
"直肠"
],
"character": [
"术后"
],
"core_name": "癌",
"tendency": ""
}
] |
发现高血压3年，最高血压160/？mmhg，患者自行服用“硝苯地平”降压，未规律监测血压。 | 192 | [
{
"anatomy_list": [],
"character": [
"3年"
],
"core_name": "高血压",
"tendency": ""
}
] |
1-月前（2020/5/24）患者上下楼梯时不慎滑倒，右侧胸背部着地致右肩、胸背部剧烈疼痛，右肩不能活动，呼吸胸闷、疼痛明显，右侧头部磕伤疼痛，无意识障碍，无恶心呕吐，无全身其它部位明显疼痛。 | 1,511 | [
{
"anatomy_list": [
"右肩",
"胸背部"
],
"character": [
"剧烈"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"右肩"
],
"character": [],
"core_name": "活动",
"tendency": "否定"
},
{
"anatomy_list": [
"胸"
],
"character": [
"呼吸"
],
"core_name": "胸闷",
"tendency": ""
},
{
"anatomy_list": [
"胸"
],
"character": [
"明显"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"右侧头部"
],
"character": [
"磕伤"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "意识障碍",
"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": [
"全身其它部位"
],
"character": [
"明显"
],
"core_name": "疼痛",
"tendency": "否定"
}
] |
门诊以“肺部感染”收入我科。 | 521 | [
{
"anatomy_list": [
"肺部"
],
"character": [],
"core_name": "感染",
"tendency": ""
}
] |
1年前患者出现双下肢水肿，伴活动后气促，无胸闷、胸痛，伴夜间阵发性呼吸困难，入我院诊治，查肌酐 276.5umol/L，诊断为“1.2型糖尿病糖尿病糖尿病肾病 糖尿病周围神经病变 糖尿病视网膜病变；2.慢性肾功能不全（失代偿期） 肾性贫血；3.原发性高血压3级高血压3级极高危极高危组 高血压心脏病 左房左室大 心功能iii级”，给予控制血糖、降压、护肾等对症支持治疗，患者病情好转后出院。 | 1,372 | [
{
"anatomy_list": [
"双下肢"
],
"character": [],
"core_name": "水肿",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"活动后"
],
"core_name": "气促",
"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": [
"夜间",
"阵发性"
],
"core_name": "呼吸困难",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"2型"
],
"core_name": "糖尿病",
"tendency": ""
},
{
"anatomy_list": [
"肾"
],
"character": [
"糖尿病"
],
"core_name": "肾病",
"tendency": ""
},
{
"anatomy_list": [
"周围神经"
],
"character": [
"糖尿病"
],
"core_name": "周围神经病变",
"tendency": ""
},
{
"anatomy_list": [
"视网膜"
],
"character": [
"糖尿病"
],
"core_name": "病变",
"tendency": ""
},
{
"anatomy_list": [
"肾"
],
"character": [
"慢性",
"失代偿期"
],
"core_name": "肾功能不全",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"肾性"
],
"core_name": "贫血",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"原发性",
"极高危",
"3级"
],
"core_name": "高血压",
"tendency": ""
},
{
"anatomy_list": [
"心脏"
],
"character": [
"高血压"
],
"core_name": "心脏病",
"tendency": ""
},
{
"anatomy_list": [
"左房",
"左室"
],
"character": [],
"core_name": "左房左室大",
"tendency": ""
},
{
"anatomy_list": [
"心"
],
"character": [
"iii级"
],
"core_name": "心功能",
"tendency": ""
}
] |
1+年前，患者诉头昏、乏力加重，伴活动后气促，遂入某医院就诊，再次行骨髓穿刺活检（未见报告）确诊为骨髓增生异常综合征-rcmd，予以改善病态造血、促进造血等对症治疗，患者症状缓解出院，院外口服维a酸1片tid、沙利度胺2片qn治疗，于2016年05月20日复查骨髓穿刺检查示骨髓病态造血无明显改善，遂于2016年06月07日予以小剂量地西他滨治疗（药物总量：96mg），又于2016年07月25日复查骨髓穿刺检查示原始及单核细胞比例增高，占4%（nec:21%），考虑aml-m6，再次予以小剂量地西他滨治疗（药物总量：160mg），于2016年08月12日复查骨髓穿刺检查示原始细胞比例有所下降，粒红巨三系病态造血现象仍可见，予以地西他滨+依托泊苷+阿糖胞苷+gcsf方案化疗（具体时间及药物剂量不详），同时予以输血小板、红细胞治疗，化疗后出现iii度骨髓抑制，予以升白细胞治疗后恢复正常，化疗期间及化疗后无明显恶心、呕吐等毒副反应。 | 731 | [
{
"anatomy_list": [
"头"
],
"character": [
"加重"
],
"core_name": "头昏",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"加重"
],
"core_name": "乏力",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"活动后"
],
"core_name": "气促",
"tendency": ""
},
{
"anatomy_list": [
"骨髓"
],
"character": [
"异常"
],
"core_name": "骨髓增生异常综合征",
"tendency": ""
},
{
"anatomy_list": [
"骨髓"
],
"character": [
"明显改善"
],
"core_name": "病态造血",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "aml-m6",
"tendency": "不确定"
},
{
"anatomy_list": [
"骨髓"
],
"character": [
"化疗后",
"iii度"
],
"core_name": "骨髓抑制",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"明显",
"化疗期间及化疗后"
],
"core_name": "恶心",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"明显",
"化疗期间及化疗后"
],
"core_name": "呕吐",
"tendency": "否定"
}
] |
肠周淋巴结未见癌转移（0/11）。 | 1,857 | [
{
"anatomy_list": [
"肠周淋巴结"
],
"character": [
"转移"
],
"core_name": "癌",
"tendency": "否定"
}
] |
今患者为求下一周期化疗入我院，遂以“左肺鳞癌化疗后”收治入院。 | 1,304 | [
{
"anatomy_list": [
"左肺"
],
"character": [
"化疗后"
],
"core_name": "鳞癌",
"tendency": ""
}
] |
患儿入院前5+月前因“步态异常8月”第一次入院，入院考虑诊断1.左侧肢体中枢性偏瘫 2.右侧基底基底节丘脑生殖细胞瘤？于1月7日行第一次诊断性化疗，于1月30日行第二次诊断性化疗，3月份在某医院行放疗治疗，今日到本院门诊就诊，为求第三次化疗，门诊以“肿瘤化疗”收入院。 | 1,295 | [
{
"anatomy_list": [],
"character": [
"8月"
],
"core_name": "步态异常",
"tendency": ""
},
{
"anatomy_list": [
"左侧肢体"
],
"character": [
"中枢性"
],
"core_name": "偏瘫",
"tendency": ""
},
{
"anatomy_list": [
"右侧基底",
"基底节",
"丘脑"
],
"character": [
"生殖细胞"
],
"core_name": "瘤",
"tendency": "不确定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "肿瘤",
"tendency": ""
}
] |
入院前数天，患者感呼吸困难较前加重，静息状态下仍有呼吸困难，伴双下肢水肿，四肢乏力，伴咳嗽、咳痰，痰为白色泡沫痰，感腹胀，进食后加重，饭量较前减少，尿量减少，无头晕头疼，无左肩部放射痛，无黑朦晕厥，自诉予以“消肿药”治疗后呼吸困难无明显缓解，为求进一步诊治，遂于我院急诊科就诊，完善心电图“心房纤颤”，心肌损伤标志物“ctni＜0.50ng/ml，ck-mb＜3.0ng/ml,myo＜50ng/ml”，急诊心脏彩超提示“全心增大。 | 527 | [
{
"anatomy_list": [],
"character": [
"较前加重"
],
"core_name": "呼吸困难",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"静息状态下仍有"
],
"core_name": "呼吸困难",
"tendency": ""
},
{
"anatomy_list": [
"双下肢"
],
"character": [],
"core_name": "水肿",
"tendency": ""
},
{
"anatomy_list": [
"四肢"
],
"character": [],
"core_name": "乏力",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"白色泡沫"
],
"core_name": "咳痰",
"tendency": ""
},
{
"anatomy_list": [
"腹"
],
"character": [
"进食后加重"
],
"core_name": "腹胀",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"较前减少"
],
"core_name": "饭量",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"减少"
],
"core_name": "尿量",
"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": [
"左肩部"
],
"character": [
"放射性"
],
"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": [
"明显缓解"
],
"core_name": "呼吸困难",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "心房纤颤",
"tendency": ""
},
{
"anatomy_list": [
"全心"
],
"character": [],
"core_name": "全心增大",
"tendency": ""
}
] |
入院前1月，患者腹胀明显，进食后腹痛明显，伴大便干结，纳差、厌油，无恶心、呕吐，无呕血、便血，遂于某医院住院治疗，予以抑酸护胃、抗感染等治疗，行“伽马刀治疗肝转移转移肿瘤”完成一个疗程后出院。 | 1,043 | [
{
"anatomy_list": [
"腹"
],
"character": [
"明显"
],
"core_name": "腹胀",
"tendency": ""
},
{
"anatomy_list": [
"腹"
],
"character": [
"明显",
"进食后"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"干结"
],
"core_name": "大便性状",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "纳差",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "厌油",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "恶心",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "呕吐",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "呕血",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "便血",
"tendency": "否定"
},
{
"anatomy_list": [
"肝"
],
"character": [
"转移"
],
"core_name": "肿瘤",
"tendency": ""
}
] |
行阴道镜示高级别病变，遂行行宫颈活检术，术后病检回示：<颈管>血凝块及炎性渗出物中见散碎颈管组织显示慢性炎症。 | 632 | [
{
"anatomy_list": [
"宫颈"
],
"character": [
"高级别"
],
"core_name": "病变",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"血凝块及炎性渗出物中见"
],
"core_name": "散碎颈管组织",
"tendency": ""
},
{
"anatomy_list": [
"宫颈管"
],
"character": [
"慢性"
],
"core_name": "炎症",
"tendency": ""
}
] |
患病以来，患者精神、睡眠、饮食可，大、小便正常，体重无明显变化。 | 1,387 | [
{
"anatomy_list": [],
"character": [
"可"
],
"core_name": "精神",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"可"
],
"core_name": "睡眠",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"可"
],
"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"
}
] |
患者3月前，因“反复便血2+月”到我院就诊，行肠镜检查提示直肠癌，积极术前准备，于2020年01月02日在手术室全麻下行了腹腔镜探查+腹腔镜辅助下经腹会阴联合直肠癌根治术。 | 345 | [
{
"anatomy_list": [],
"character": [
"反复"
],
"core_name": "便血",
"tendency": ""
},
{
"anatomy_list": [
"直肠"
],
"character": [],
"core_name": "癌",
"tendency": ""
}
] |
诊断为右乳浸润性癌 pT2n3M0 iii期 luminal b型 her-2阴性型,于2016年11月28日行tac方案化疗（吡柔比星50mg d1+紫杉醇210mg d2+环磷酰胺800mg d3）,辅以止吐等处理,患者未诉明显恶心、呕吐等不适。 | 19 | [
{
"anatomy_list": [
"右乳"
],
"character": [
"浸润性",
"iii期",
" luminal b型",
" her-2阴性型"
],
"core_name": "癌",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"明显"
],
"core_name": "恶心",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"明显"
],
"core_name": "呕吐",
"tendency": "否定"
}
] |
2、胆囊切端未见癌累及。 | 1,751 | [
{
"anatomy_list": [
"胆囊切端"
],
"character": [
"累及"
],
"core_name": "癌",
"tendency": "否定"
}
] |
2个多月前患者再次出现右耳流脓，到当地医院就诊，予以口服药物及耳道冲洗（具体不详）治疗后，右耳溢液无明显好转且伴血性分泌物。 | 1,018 | [
{
"anatomy_list": [
"右耳"
],
"character": [],
"core_name": "流脓",
"tendency": ""
},
{
"anatomy_list": [
"右耳"
],
"character": [
"无明显好转",
"伴血性分泌物"
],
"core_name": "溢液",
"tendency": ""
}
] |
4月29日以“骨髓增生异常综合征”收住院进一步检查，查血常规“白细胞2.36×10^9/L↓、血红蛋白88g↓、血小板计数112×10^9/”，骨髓“骨髓增生明显活跃，粒系占34%；骨髓铁染色细胞内铁88%，细胞外铁(++)；外周血片白细胞分类中性比例低，红细胞大小不均可见异形红细胞；结论：与2015.9.9比粒系减少，红系增多，巨核增多”。 | 1,731 | [
{
"anatomy_list": [
"骨髓"
],
"character": [],
"core_name": "骨髓增生异常综合征",
"tendency": ""
},
{
"anatomy_list": [
"骨髓"
],
"character": [
"明显活跃"
],
"core_name": "增生",
"tendency": ""
},
{
"anatomy_list": [
"红细胞"
],
"character": [
"大小不均"
],
"core_name": "红细胞大小不均",
"tendency": ""
},
{
"anatomy_list": [
"红细胞"
],
"character": [],
"core_name": "异形红细胞",
"tendency": ""
},
{
"anatomy_list": [
"粒系"
],
"character": [
"减少"
],
"core_name": "粒系减少",
"tendency": ""
},
{
"anatomy_list": [
"红系"
],
"character": [
"增多"
],
"core_name": "红系增多",
"tendency": ""
},
{
"anatomy_list": [
"巨核"
],
"character": [
"增多"
],
"core_name": "巨核增多",
"tendency": ""
}
] |
1月余前,患者因“反复痰中带血2月”入我院耳鼻喉科就诊,行胸部ct平扫（2014-10-14）示：右下肺块影,肿瘤性病变待除外,进一步行胸部ct增强（2014-10-19）示：右肺下叶片块影,考虑中央型肺ca可能大,伴右肺下叶阻塞性炎症,右肺门及纵隔淋巴结明显肿大。 | 23 | [
{
"anatomy_list": [],
"character": [
"反复",
"带血"
],
"core_name": "咳痰",
"tendency": ""
},
{
"anatomy_list": [
"右下肺"
],
"character": [],
"core_name": "块影",
"tendency": ""
},
{
"anatomy_list": [
"右下肺"
],
"character": [
"肿瘤性"
],
"core_name": "病变",
"tendency": "不确定"
},
{
"anatomy_list": [
"右肺下叶"
],
"character": [],
"core_name": "片块影",
"tendency": ""
},
{
"anatomy_list": [
"肺"
],
"character": [
"中央型"
],
"core_name": "癌",
"tendency": "不确定"
},
{
"anatomy_list": [
"右肺下叶"
],
"character": [
"阻塞性"
],
"core_name": "炎症",
"tendency": ""
},
{
"anatomy_list": [
"右肺门淋巴结",
"纵隔淋巴结"
],
"character": [
"明显"
],
"core_name": "肿大",
"tendency": ""
}
] |
骨髓活检结果报告单（123456）：结合免疫组化,符合小b细胞淋巴瘤。 | 48 | [
{
"anatomy_list": [
"小b细胞",
"淋巴"
],
"character": [],
"core_name": "瘤",
"tendency": ""
}
] |
2天前患者腹痛加重，伴恶心、呕吐，呕吐物为淡黄色胃内容物，量不多，不伴喷射性呕吐，患者就诊于某医院，行全腹部ct示：1、小肠积气积液，稍显扩张 2、回盲部壁增厚，回盲部淋巴结淋巴结肿大。 | 330 | [
{
"anatomy_list": [
"腹"
],
"character": [
"加重"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "恶心",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"呕吐物为淡黄色胃内容物，量不多"
],
"core_name": "呕吐",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"喷射性"
],
"core_name": "呕吐",
"tendency": "否定"
},
{
"anatomy_list": [
"小肠"
],
"character": [],
"core_name": "积气",
"tendency": ""
},
{
"anatomy_list": [
"小肠"
],
"character": [],
"core_name": "积液",
"tendency": ""
},
{
"anatomy_list": [
"小肠"
],
"character": [
"稍显"
],
"core_name": "扩张",
"tendency": ""
},
{
"anatomy_list": [
"回盲部壁"
],
"character": [],
"core_name": "增厚",
"tendency": ""
},
{
"anatomy_list": [
"回盲部淋巴结"
],
"character": [],
"core_name": "肿大",
"tendency": ""
}
] |