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2.07k
| event
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|---|---|---|
遂入住我院行“经腹广泛性全子宫切除术+双侧附件切除术+盆腔淋巴结清扫术”，手术顺利，术后病理诊断：1、宫内膜中分化宫内膜样腺癌，浸及肌层2/3，脉管中见癌栓，神经未见癌侵犯，阴道壁残端，宫颈、颈管未见癌累及，双侧附件未见癌转移。 | 1,581 | [
{
"anatomy_list": [
"肌层2/3"
],
"character": [
"浸及"
],
"core_name": "癌",
"tendency": ""
},
{
"anatomy_list": [
"脉管"
],
"character": [],
"core_name": "癌栓",
"tendency": ""
},
{
"anatomy_list": [
"神经"
],
"character": [
"侵犯"
],
"core_name": "癌",
"tendency": "否定"
},
{
"anatomy_list": [
"宫内膜"
],
"character": [
"中分化",
"内膜样",
"浸及肌层2/3"
],
"core_name": "腺癌",
"tendency": ""
},
{
"anatomy_list": [
"阴道壁残端",
"宫颈",
"宫颈管"
],
"character": [
"累及"
],
"core_name": "癌",
"tendency": "否定"
},
{
"anatomy_list": [
"双侧附件"
],
"character": [
"转移"
],
"core_name": "癌",
"tendency": "否定"
}
] |
7.其他：双侧上颌窦炎症;肝小囊肿；脊柱退行性变。 | 1,908 | [
{
"anatomy_list": [
"双侧上颌窦"
],
"character": [],
"core_name": "炎症",
"tendency": ""
},
{
"anatomy_list": [
"肝"
],
"character": [
"小"
],
"core_name": "囊肿",
"tendency": ""
},
{
"anatomy_list": [
"脊柱"
],
"character": [
"退行性"
],
"core_name": "病变",
"tendency": ""
}
] |
今患者为求进一步治疗再来我院就诊，行乳腺彩超（2020-04-07）示：左侧乳腺实质性肿块，超声bi-rads 3类。 | 1,564 | [
{
"anatomy_list": [
"左侧乳腺"
],
"character": [
"实质性",
"超声bi-rads 3类"
],
"core_name": "肿块",
"tendency": ""
}
] |
患者遂至我院就诊，查彩超（123456）示：膀胱实性占位（考虑膀胱ca），建议进一步检查。门诊医生建议住院治疗，患者拒绝。 | 1,830 | [
{
"anatomy_list": [
"膀胱"
],
"character": [
"实性"
],
"core_name": "占位",
"tendency": ""
},
{
"anatomy_list": [
"膀胱"
],
"character": [],
"core_name": "癌",
"tendency": "不确定"
}
] |
今为行ir间期治疗第2次静脉化疗入院，门诊血常规（2017.01.09）提示wbc 1.98(*10^9/L)，plt 217(*10^9/L)，rbc 2.54(*10^12/L)，hb 80(g/l)，anc 0.83(*10^9/L)；门诊以“急性普通b淋巴细胞淋巴细胞白血病l11型（中危，缓解期）”收入院。 | 366 | [
{
"anatomy_list": [
"b淋巴细胞"
],
"character": [
"急性",
"普通",
"l11型",
"中危",
"缓解期"
],
"core_name": "白血病",
"tendency": ""
}
] |
患者自发病以来，精神可，食欲可，睡眠可，大便如常，小便如常，体重无明显变化。 | 1,651 | [
{
"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": [
"如常"
],
"core_name": "大便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"如常"
],
"core_name": "小便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"明显"
],
"core_name": "体重改变",
"tendency": "否定"
}
] |
患者7年前因感冒发现左颌下颌下包块，如黄豆大小，有触痛，未重视未就医。 | 1,051 | [
{
"anatomy_list": [],
"character": [],
"core_name": "感冒",
"tendency": ""
},
{
"anatomy_list": [
"左颌下"
],
"character": [
"黄豆大小",
"有触痛"
],
"core_name": "包块",
"tendency": ""
}
] |
3月前，患者入我院完善相关辅助检查，未见明显手术禁忌，遂于2017-7-4在局麻+静脉麻醉下行右乳溢血导管及其所属腺体切除术+术中冰冻，病理示：（右乳）导管内癌伴微灶浸润，免疫组化：er局灶（+） pr（－） cerbb-2（++） ki-67（+）5%。 | 969 | [
{
"anatomy_list": [
"右乳"
],
"character": [
"导管内"
],
"core_name": "癌",
"tendency": ""
},
{
"anatomy_list": [
"右乳"
],
"character": [
"微灶"
],
"core_name": "浸润",
"tendency": ""
}
] |
后就诊于我院胸外科，2019/10/28ct检查报告：左肺上叶、下叶背段及右肺中叶散在实性/混合密度影，符合部分肿瘤性病变征象，部分病灶感染性病变待排。 | 1,808 | [
{
"anatomy_list": [
"左肺上叶、下叶背段及右肺中叶"
],
"character": [
"散在",
"实性"
],
"core_name": "密度影",
"tendency": ""
},
{
"anatomy_list": [
"左肺上叶、下叶背段及右肺中叶"
],
"character": [
"散在",
"混合"
],
"core_name": "密度影",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"肿瘤性",
"部分"
],
"core_name": "病变",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"感染性",
"部分病灶"
],
"core_name": "病变",
"tendency": "不确定"
}
] |
患者无腹痛、腹胀，无肝区疼痛等不适。 | 1,004 | [
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "腹胀",
"tendency": "否定"
},
{
"anatomy_list": [
"肝区"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
}
] |
出院后患儿无呕吐,无抽搐,一般情况可。 | 14 | [
{
"anatomy_list": [],
"character": [],
"core_name": "呕吐",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "抽搐",
"tendency": "否定"
}
] |
患者本次发病以来，饮食较差，睡眠尚可，小便正常，2-3天解一次大便，近1年来体重减轻约5kg 。 | 1,745 | [
{
"anatomy_list": [],
"character": [
"较差"
],
"core_name": "饮食",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"尚可"
],
"core_name": "睡眠",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"正常"
],
"core_name": "小便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"减轻"
],
"core_name": "体重",
"tendency": ""
}
] |
并于2016-11-28日行术后第一次tac化疗，2016-12-18行术后第二次tac化疗，化疗过程中有恶心等不适，予以对症处理，缓解后出院。 | 2,007 | [
{
"anatomy_list": [],
"character": [],
"core_name": "恶心",
"tendency": ""
}
] |
2020-4于我院就诊，2020/4/27ct：腹膜后偏左侧占位，结合病史考虑转移可能，病灶包饶腹主动脉、左肾动静脉，伴左侧输尿管、左侧肾上腺、左侧腰大肌受侵可能，邻近腰2、3椎体受侵，左肾受压移位，功能降低，左侧肾盂肾盏扩张积水，左侧输尿管显示不清。 | 180 | [
{
"anatomy_list": [
"腹膜后左侧"
],
"character": [],
"core_name": "占位",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "转移",
"tendency": "不确定"
},
{
"anatomy_list": [
"腹主动脉动脉",
"左肾动脉",
"左肾静脉"
],
"character": [],
"core_name": "病灶",
"tendency": ""
},
{
"anatomy_list": [
"左侧输尿管",
"左侧肾上腺",
"左侧腰大肌"
],
"character": [
"受侵"
],
"core_name": "病灶",
"tendency": "不确定"
},
{
"anatomy_list": [
"腰椎L2、3椎体"
],
"character": [
"受侵"
],
"core_name": "病灶",
"tendency": ""
},
{
"anatomy_list": [
"左肾"
],
"character": [
"受压"
],
"core_name": "移位",
"tendency": ""
},
{
"anatomy_list": [
"左肾"
],
"character": [],
"core_name": "功能降低",
"tendency": ""
},
{
"anatomy_list": [
"左侧肾盂",
"左侧肾盏"
],
"character": [],
"core_name": "扩张积水",
"tendency": ""
},
{
"anatomy_list": [
"左侧输尿管"
],
"character": [],
"core_name": "显示不清",
"tendency": ""
}
] |
患者后于该院会诊病检（未见原报告）提示恶性黑色素瘤。 | 410 | [
{
"anatomy_list": [],
"character": [
"恶性"
],
"core_name": "黑色素瘤",
"tendency": ""
}
] |
于2013年09月23日在腰硬联合麻醉下行经尿道前列腺汽化电切术+双侧睾丸切除术+尿道狭窄扩张术+膀胱结石钬激光碎石术，术后予以心电监护，抗炎止血处理，病检提示（123456）：前列腺腺癌（3+3=6分）术后患者仍有尿频及尿不净感，诉腰背部疼痛，于2013年10月18日来我院治疗，游离前列腺特异抗原：1.14ng/ml，总前列腺特异抗原：10.90ng/ml，予以氟他胺口服行内分泌治疗，每月一次唑来磷酸静脉滴入抗溶骨治疗。 | 1,794 | [
{
"anatomy_list": [
"前列腺"
],
"character": [
"3+3=6分"
],
"core_name": "腺癌",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "尿频",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "尿不净",
"tendency": ""
},
{
"anatomy_list": [
"腰背部"
],
"character": [],
"core_name": "疼痛",
"tendency": ""
}
] |
入院前10+年，患者无明显诱因出现左侧腰腿腿部胀痛，疼痛能忍受，久站、久坐及久行后加重，卧床休息可缓解，不伴双下肢麻木、乏力，无潮热、盗汗，无咳嗽、咳痰，无胸闷、气促，无大小便失禁等；予以腰椎牵引等对症治疗后症状缓解；此后患者左侧腰腿疼痛反反复复，尤以劳累后明显，且逐渐加重，患者自行服用止痛药物（具体不详）后可缓解，仍未重视及进一步检查。 | 1,686 | [
{
"anatomy_list": [
"左侧腰腿部"
],
"character": [
"胀痛",
"久站久坐久行后加重",
"卧床休息可缓解"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"能忍受"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"双下肢"
],
"character": [],
"core_name": "麻木",
"tendency": "否定"
},
{
"anatomy_list": [
"双下肢"
],
"character": [],
"core_name": "乏力",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "潮热",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "盗汗",
"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": [],
"character": [],
"core_name": "气促",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "大小便失禁",
"tendency": "否定"
},
{
"anatomy_list": [
"左侧腰",
"左侧腿"
],
"character": [
"反反复复",
"劳累后明显",
"逐渐加重"
],
"core_name": "疼痛",
"tendency": ""
}
] |
4.双侧胸膜增厚。 | 1,382 | [
{
"anatomy_list": [
"双侧胸膜"
],
"character": [],
"core_name": "增厚",
"tendency": ""
}
] |
病程中患者无胸闷气紧，无头晕头痛，无咳嗽咳痰等症状，今日患者为求术后第二周期化疗入我科。 | 1,787 | [
{
"anatomy_list": [
"胸"
],
"character": [],
"core_name": "胸闷",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "气紧",
"tendency": "否定"
},
{
"anatomy_list": [
"头"
],
"character": [],
"core_name": "头晕",
"tendency": "否定"
},
{
"anatomy_list": [
"头"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "咳嗽",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "咳痰",
"tendency": "否定"
}
] |
门诊以“胸腔积液待查”收入我科住院治疗。 | 665 | [
{
"anatomy_list": [
"胸腔"
],
"character": [],
"core_name": "积液",
"tendency": ""
}
] |
评估为sd，故建议行维持治疗，后自行服用吉非替尼250mg qd，2016年10月复查ct提示病灶稍增大，建议其考虑化疗或行基因检测指导分子靶向治疗，患者及其家属拒绝，继续服用吉非替尼250mg qd治疗。 | 757 | [
{
"anatomy_list": [],
"character": [],
"core_name": "SD",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"稍增大"
],
"core_name": "病灶",
"tendency": ""
}
] |
今为进一步治疗，门诊以“颈椎病”进一步治疗收入院。 | 1,631 | [
{
"anatomy_list": [
"颈椎"
],
"character": [],
"core_name": "颈椎病",
"tendency": ""
}
] |
无畏寒、发热，无咳嗽、咳痰，无心慌、乏力，患者就诊于当地医院，疑为尿路结石，行右侧尿路双j管置入术，术后疼痛未见明显好转。 | 328 | [
{
"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": [
"心"
],
"character": [],
"core_name": "心慌",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "乏力",
"tendency": "否定"
},
{
"anatomy_list": [
"尿路"
],
"character": [],
"core_name": "结石",
"tendency": "不确定"
},
{
"anatomy_list": [],
"character": [
"术后",
"明显好转"
],
"core_name": "疼痛",
"tendency": "否定"
}
] |
入院前20+年患者无明显诱因出现咳嗽、咳痰，为阵发性咳嗽，冷空气刺激后、活动后咳嗽加重，休息后缓解，咳白色泡沫痰,痰量少，较易咳出，无发热,无胸闷、胸痛，无心悸、呼吸困难，无潮热、盗汗、咯血或痰中带血丝,冬春季节、季节变化时症状加重，患者自服"奥亭、抗生素"（具体不详）后，上述症状稍缓解。 | 674 | [
{
"anatomy_list": [],
"character": [],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "咳痰",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"阵发性"
],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"冷空气刺激后加重",
"活动后加重",
"休息后缓解"
],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"白色",
"泡沫痰",
"量少",
"较易咳出"
],
"core_name": "咳痰",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "发热",
"tendency": "否定"
},
{
"anatomy_list": [
"胸"
],
"character": [],
"core_name": "胸闷",
"tendency": "否定"
},
{
"anatomy_list": [
"胸"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [
"心"
],
"character": [],
"core_name": "心悸",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "呼吸困难",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "潮热",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "盗汗",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "咯血",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"带血丝"
],
"core_name": "咳痰",
"tendency": "否定"
}
] |
5+月前，患者因“右侧乳房包块1+年、腋窝及锁骨上淋巴结肿大2+月”就诊于我院普外科，当时查体包块位于全象限，质硬，偶有胀痛，乳头无流脓，溢液，周围皮肤无红肿、热痛；腋窝及锁骨上窝淋巴结约“黄豆”大小；完善彩超示：右侧乳腺实质性肿块伴右侧腋窝淋巴结肿大，超声bi-rads4c类，高度可疑恶性，遂于该科行右乳包块穿刺活检术，术后病理示浸润性癌非特殊类型；于2016.02.28予以tac方案化疗（吡柔比星60mg d1+紫杉醇240mg d2+环磷酰胺800mg d3）；辅以止吐、保肝等治疗，患者未诉明显恶心、呕吐等不适；后患者未遵医嘱定期行化疗；3+月前，患者因“右乳及上肢红肿胀10+天”于普外科1住院治疗，当时右上肢皮温升高，右侧乳腺皮肤呈橘皮样改变，乳头向内凹陷，无皮肤破损及异常流液;予以活血化瘀、消肿、抗感染等治疗，治疗4天后患者因治疗效果较差要求出院，出院后患者于某医院及其他医院就诊，具体诊治情况不详，但未予以放化疗等治疗；患者右上肢肿胀无明显好转，1月前肿胀逐渐加重，肿胀至手背，患者遂于2+天前就诊于某医院，行彩超示右锁骨下静脉起始部部分血栓形成；右乳ca伴双侧腋窝、颈部淋巴结肿大；予以曲马多100mg q12h镇痛治疗，建议回当地医院继续治疗；今患者为求诊治，遂于我院就诊，门诊以“乳腺癌 锁骨下静脉血栓”收入我科住院治疗。 | 998 | [
{
"anatomy_list": [
"右侧乳房"
],
"character": [],
"core_name": "包块",
"tendency": ""
},
{
"anatomy_list": [
"腋窝淋巴结"
],
"character": [],
"core_name": "肿大",
"tendency": ""
},
{
"anatomy_list": [
"锁骨上淋巴结"
],
"character": [],
"core_name": "肿大",
"tendency": ""
},
{
"anatomy_list": [
"全象限"
],
"character": [
"质硬"
],
"core_name": "包块",
"tendency": ""
},
{
"anatomy_list": [
"右侧乳房"
],
"character": [
"胀痛",
"偶有"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"乳头"
],
"character": [],
"core_name": "流脓",
"tendency": "否定"
},
{
"anatomy_list": [
"乳头"
],
"character": [],
"core_name": "溢液",
"tendency": "否定"
},
{
"anatomy_list": [
"右侧乳房"
],
"character": [
"周围皮肤"
],
"core_name": "红",
"tendency": "否定"
},
{
"anatomy_list": [
"右侧乳房"
],
"character": [
"周围皮肤"
],
"core_name": "肿",
"tendency": "否定"
},
{
"anatomy_list": [
"右侧乳房"
],
"character": [
"周围皮肤"
],
"core_name": "发热",
"tendency": "否定"
},
{
"anatomy_list": [
"右侧乳房"
],
"character": [
"周围皮肤"
],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [
"腋窝淋巴结"
],
"character": [
"黄豆大小"
],
"core_name": "增大",
"tendency": ""
},
{
"anatomy_list": [
"锁骨上淋巴结"
],
"character": [
"黄豆大小"
],
"core_name": "增大",
"tendency": ""
},
{
"anatomy_list": [
"右侧乳腺"
],
"character": [
"实质性",
"超声bi-rads4c类",
"高度可疑恶性"
],
"core_name": "肿块",
"tendency": ""
},
{
"anatomy_list": [
"右侧腋窝淋巴结"
],
"character": [
"实质性",
"超声bi-rads4c类",
"高度可疑恶性"
],
"core_name": "肿大",
"tendency": ""
},
{
"anatomy_list": [
"右乳"
],
"character": [
"浸润性",
"非特殊类型"
],
"core_name": "癌",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"明显"
],
"core_name": "恶心",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "呕吐",
"tendency": "否定"
},
{
"anatomy_list": [
"右乳",
"上肢"
],
"character": [],
"core_name": "红肿",
"tendency": ""
},
{
"anatomy_list": [
"右乳",
"上肢"
],
"character": [],
"core_name": "胀",
"tendency": ""
},
{
"anatomy_list": [
"右上肢"
],
"character": [
"升高"
],
"core_name": "皮温",
"tendency": ""
},
{
"anatomy_list": [
"右侧乳腺"
],
"character": [
"橘皮样"
],
"core_name": "改变",
"tendency": ""
},
{
"anatomy_list": [
"乳头"
],
"character": [
"向内"
],
"core_name": "凹陷",
"tendency": ""
},
{
"anatomy_list": [
"乳房"
],
"character": [],
"core_name": "破损",
"tendency": "否定"
},
{
"anatomy_list": [
"乳头"
],
"character": [
"异常"
],
"core_name": "流液",
"tendency": "否定"
},
{
"anatomy_list": [
"右上肢"
],
"character": [
"明显好转"
],
"core_name": "肿胀",
"tendency": "否定"
},
{
"anatomy_list": [
"右上肢"
],
"character": [
"逐渐加重"
],
"core_name": "肿胀",
"tendency": ""
},
{
"anatomy_list": [
"手背"
],
"character": [],
"core_name": "肿胀",
"tendency": ""
},
{
"anatomy_list": [
"右锁骨下静脉"
],
"character": [
"部分"
],
"core_name": "血栓形成",
"tendency": ""
},
{
"anatomy_list": [
"右乳"
],
"character": [],
"core_name": "癌",
"tendency": ""
},
{
"anatomy_list": [
"双侧腋窝淋巴结"
],
"character": [],
"core_name": "肿大",
"tendency": ""
},
{
"anatomy_list": [
"颈部淋巴结"
],
"character": [],
"core_name": "肿大",
"tendency": ""
},
{
"anatomy_list": [
"乳腺"
],
"character": [],
"core_name": "癌",
"tendency": ""
},
{
"anatomy_list": [
"锁骨下静脉"
],
"character": [],
"core_name": "血栓",
"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，体重减少约3kg。 | 1,442 | [
{
"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": [],
"core_name": "体重减轻",
"tendency": ""
}
] |
1+月前，患者自行发现右乳房乳房包块，为8点钟方向，约黄豆大小，质硬，活动度欠佳，无发热，无皮肤红肿、无皮肤橘皮样改变，无乳头溢液，无压痛。 | 132 | [
{
"anatomy_list": [
"右乳"
],
"character": [
"8点钟方向",
"约黄豆大小",
"质硬",
"活动度欠佳"
],
"core_name": "包块",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "发热",
"tendency": "否定"
},
{
"anatomy_list": [
"皮肤"
],
"character": [],
"core_name": "红肿",
"tendency": "否定"
},
{
"anatomy_list": [
"皮肤"
],
"character": [
"橘皮样"
],
"core_name": "改变",
"tendency": "否定"
},
{
"anatomy_list": [
"乳头"
],
"character": [],
"core_name": "溢液",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "压痛",
"tendency": "否定"
}
] |
诊断为“宫颈癌”，遂收入住院治疗，入院后查ct:宫颈改变，考虑宫颈癌，病变与直肠及膀胱分界不清，膀胱壁稍均匀增厚。 | 1,221 | [
{
"anatomy_list": [
"宫颈"
],
"character": [],
"core_name": "癌",
"tendency": ""
},
{
"anatomy_list": [
"宫颈"
],
"character": [],
"core_name": "改变",
"tendency": ""
},
{
"anatomy_list": [
"宫颈"
],
"character": [],
"core_name": "癌",
"tendency": "不确定"
},
{
"anatomy_list": [],
"character": [
"与直肠及膀胱分界不清"
],
"core_name": "病变",
"tendency": ""
},
{
"anatomy_list": [
"膀胱壁"
],
"character": [
"稍",
"均匀"
],
"core_name": "增厚",
"tendency": ""
}
] |
入院前2+年，患者无明显诱因出现剑突下疼痛，伴嗳气、反酸，有咳嗽、咳痰伴胸背部疼痛，呈胀痛，评分：7分，无加重缓解因素，无胸闷、咯血、呼吸困难，无潮热、盗汗、疲乏、消瘦，无畏寒、发热，于我院消化内科就诊，完善胸部ct：左肺下叶软组织块块影，考虑肺ca；遂转入我科。 | 1,937 | [
{
"anatomy_list": [
"剑突下"
],
"character": [],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "嗳气",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "反酸",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "咳痰",
"tendency": ""
},
{
"anatomy_list": [
"胸背部"
],
"character": [],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"胸背部"
],
"character": [
"胀痛",
"评分：7分"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"胸"
],
"character": [],
"core_name": "胸闷",
"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": "潮热",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "盗汗",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "疲乏",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "消瘦",
"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": [
"左肺下叶软组织"
],
"character": [],
"core_name": "块影",
"tendency": ""
},
{
"anatomy_list": [
"肺"
],
"character": [],
"core_name": "癌",
"tendency": "不确定"
}
] |
于2016-07-21行“麦默通微创旋切术”手术治疗，术后病检提示：（左乳）粘液癌，免疫组化：e-ca(+),gatf-3(+),gcdpf(+),mammaglobi(+)，34βe12(+)，c-erbb-2(1+)，er(-),pr(-),p63(-)。 | 128 | [
{
"anatomy_list": [
"左乳"
],
"character": [],
"core_name": "粘液癌",
"tendency": ""
}
] |
入院前2月，患者因右侧乳腺肿块，于某医院就诊，行乳腺彩超示：右乳1点腺体边缘异常回声，性质待定？右侧腋下组淋巴结淋巴结肿大，性质待定？进一步行胸部ct：右乳结节，穿刺活检示浸润性癌，诊断为右乳癌ct2n0M0，明确有手术指针，无明显手术禁忌症后，于2018-7-16行前哨淋巴结探查及活检术+保留胸肌式右乳癌扩大根治术，术后病检：右乳浸润性癌，非特殊性，脉管内未见明确癌栓。 | 1,242 | [
{
"anatomy_list": [
"右侧乳腺"
],
"character": [],
"core_name": "肿块",
"tendency": ""
},
{
"anatomy_list": [
"右乳1点腺体边缘"
],
"character": [
"异常"
],
"core_name": "回声",
"tendency": "不确定"
},
{
"anatomy_list": [
"右侧腋下组淋巴结"
],
"character": [],
"core_name": "肿大",
"tendency": "不确定"
},
{
"anatomy_list": [
"右乳"
],
"character": [],
"core_name": "结节",
"tendency": ""
},
{
"anatomy_list": [
"右乳"
],
"character": [
"浸润性"
],
"core_name": "癌",
"tendency": ""
},
{
"anatomy_list": [
"右乳"
],
"character": [
"ct2n0M0"
],
"core_name": "癌",
"tendency": ""
},
{
"anatomy_list": [
"脉管内"
],
"character": [],
"core_name": "癌栓",
"tendency": "否定"
},
{
"anatomy_list": [
"右乳"
],
"character": [
"浸润性"
],
"core_name": "癌",
"tendency": ""
}
] |
患者自起病以来，精神可，胃纳较差，大便如常，小便如常，体重未见明显下降。 | 1,632 | [
{
"anatomy_list": [],
"character": [
"可"
],
"core_name": "精神",
"tendency": ""
},
{
"anatomy_list": [
"胃"
],
"character": [
"较差"
],
"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"
}
] |
入院前1-年，患者无明显诱因出现大便次数增多，约5-6次/天，大便稀塘，量少，不成形，吃油腻食物后加重，清淡饮食时稍缓解，时有肛门坠胀，伴腹胀，排气后腹胀可缓解，无腹痛、呕血、黑便，无头昏、头痛、发热，无恶心、呕吐、食欲下降等症状，于2014-04-16某医院就诊，行电子乙状结肠结肠镜示：直肠癌？取病理活检示直肠腺癌，建议转上级医院就诊。 | 1,040 | [
{
"anatomy_list": [],
"character": [
"次数增多",
"约5-6次/天"
],
"core_name": "大便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"稀塘",
"量少",
"不成形",
"吃油腻食物后加重",
"清淡饮食时稍缓解"
],
"core_name": "大便",
"tendency": ""
},
{
"anatomy_list": [
"肛门"
],
"character": [
"时有"
],
"core_name": "坠胀",
"tendency": ""
},
{
"anatomy_list": [
"腹"
],
"character": [
"排气后缓解"
],
"core_name": "腹胀",
"tendency": ""
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "疼痛",
"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": [
"头"
],
"character": [],
"core_name": "头昏",
"tendency": "否定"
},
{
"anatomy_list": [
"头"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "发热",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "恶心",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "呕吐",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"下降"
],
"core_name": "食欲",
"tendency": "否定"
},
{
"anatomy_list": [
"直肠"
],
"character": [],
"core_name": "癌",
"tendency": "不确定"
},
{
"anatomy_list": [
"直肠"
],
"character": [],
"core_name": "腺癌",
"tendency": ""
}
] |
1月前，患者出现右上腹胀，未到医院检查治疗。 | 1,129 | [
{
"anatomy_list": [
"右上腹"
],
"character": [],
"core_name": "腹胀",
"tendency": ""
}
] |
2020-7-29患者进一步于我院就诊，行妇科彩超示：宫颈体积增大(4.7×4.3cm)，回声及血流改变，考虑：ca。 | 1,607 | [
{
"anatomy_list": [
"宫颈"
],
"character": [
"体积"
],
"core_name": "增大",
"tendency": ""
},
{
"anatomy_list": [
"宫颈"
],
"character": [
"改变"
],
"core_name": "回声",
"tendency": ""
},
{
"anatomy_list": [
"宫颈"
],
"character": [
"改变"
],
"core_name": "血流",
"tendency": ""
},
{
"anatomy_list": [
"宫颈"
],
"character": [],
"core_name": "癌",
"tendency": ""
}
] |
入院前2+月，患者因右乳包块入我院就诊，于2018-04-28行“右乳包块切除+术中冰冻”，术中冰冻回报示恶性，遂于全麻下行右乳改良根治术；术后病检提示:(右乳)浸润性癌，非特殊类型，ii级7分。乳头未见累及。 | 2,040 | [
{
"anatomy_list": [
"右乳"
],
"character": [],
"core_name": "包块",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"恶性"
],
"core_name": "包块",
"tendency": ""
},
{
"anatomy_list": [
"右乳"
],
"character": [
"浸润性",
"非特殊类型",
"ii级7分"
],
"core_name": "癌",
"tendency": ""
},
{
"anatomy_list": [
"乳头"
],
"character": [
"累及"
],
"core_name": "癌",
"tendency": ""
}
] |
术后病理提示：<左下肺>浸润性腺癌，以腺泡状生长方式为主，另见乳头状生长方式约占5%。 | 1,809 | [
{
"anatomy_list": [
"左下肺"
],
"character": [
"浸润性",
"腺泡状生长方式为主",
"乳头状生长方式约占5%"
],
"core_name": "腺癌",
"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，小便如上诉，体重无明显变化。 | 298 | [
{
"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": [
"如上诉"
],
"core_name": "小便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"明显"
],
"core_name": "体重变化",
"tendency": "否定"
}
] |
无黑朦，无抽搐，无意识障碍，无恶心呕吐，无厌油，大便正常，呈黄色，成型，近1周，精神欠佳，伴全身乏力。 | 1,968 | [
{
"anatomy_list": [],
"character": [],
"core_name": "黑朦",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "抽搐",
"tendency": "否定"
},
{
"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": [],
"character": [],
"core_name": "厌油",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"正常",
"黄色",
"成型"
],
"core_name": "大便",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"欠佳"
],
"core_name": "精神",
"tendency": ""
},
{
"anatomy_list": [
"全身"
],
"character": [],
"core_name": "乏力",
"tendency": ""
}
] |
门诊以“急性早幼粒细胞性白血病”收入我科住院治疗。 | 1,662 | [
{
"anatomy_list": [],
"character": [
"急性",
"早幼粒细胞"
],
"core_name": "白血病",
"tendency": ""
}
] |
化疗间歇期患者仍觉头昏、乏力等不适，考虑疾病未缓解，排除化疗禁忌，于2019.12.20开始行阿扎胞苷联合半量tag方案化疗，具体为：阿扎胞苷 140mg qd d1-7，阿糖胞苷 20mg ih bid d1-10,吡柔比星 10mg 隔天一次 ivgtt，化疗第88天复查血常规示三系明显减少，且患者自觉头昏、乏力等不适较前加重，故予暂停使用阿糖胞苷化疗，后多次复查血常规示三系极低，且伴肺部感染、肛周脓肿，予反复输注悬浮红细胞、血小板、抗感染等治疗后未再发热，但复查血常规示三系仍低，患者要求出院，遂办理自动出院。 | 1,503 | [
{
"anatomy_list": [
"头"
],
"character": [],
"core_name": "头昏",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "乏力",
"tendency": ""
},
{
"anatomy_list": [
"头"
],
"character": [
"较前加重"
],
"core_name": "头昏",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"较前加重"
],
"core_name": "乏力",
"tendency": ""
},
{
"anatomy_list": [
"肺部"
],
"character": [],
"core_name": "感染",
"tendency": ""
},
{
"anatomy_list": [
"肛周"
],
"character": [],
"core_name": "脓肿",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "发热",
"tendency": "否定"
}
] |
入院前5月余于我院诊断“（左扁桃体）结合he及组化非霍奇金氏淋巴瘤（弥漫大“b”）”，现已行5次行chop方案化疗（泼尼松片，长春瑞滨（盖诺）注射液，环磷酰胺粉针、多柔比星粉针（山西））化疗，化疗期间无明显头昏、头痛、恶心、呕吐等不适。 | 742 | [
{
"anatomy_list": [
"左扁桃体"
],
"character": [
"弥漫大“b”"
],
"core_name": "瘤",
"tendency": ""
},
{
"anatomy_list": [
"左扁桃体",
"淋巴"
],
"character": [
"非霍奇金氏"
],
"core_name": "瘤",
"tendency": ""
},
{
"anatomy_list": [
"头"
],
"character": [
"化疗期间",
"明显"
],
"core_name": "头昏",
"tendency": "否定"
},
{
"anatomy_list": [
"头"
],
"character": [
"化疗期间",
"明显"
],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"化疗期间",
"明显"
],
"core_name": "恶心",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"化疗期间",
"明显"
],
"core_name": "呕吐",
"tendency": "否定"
}
] |
5年前，患者于外院体检时发现血尿酸偏高（具体不详），以后每次查血尿酸均高于正常值，院外口服“小苏打”治疗，血尿酸水平控制可，近2天前，患者进食大量高蛋白饮食后，出现左足第一足趾关节红肿伴疼痛，压痛明显，有明显痛风结节，伴右手第3、4、5指关节及左手第2、3、4、5指关节关节红肿，轻压痛，病程中患者未诉右足趾关节疼痛，未诉腰痛等不适。 | 1,078 | [
{
"anatomy_list": [],
"character": [
"偏高",
"高于正常值"
],
"core_name": "血尿酸",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"大量"
],
"core_name": "进食",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"控制可"
],
"core_name": "血尿酸水平",
"tendency": ""
},
{
"anatomy_list": [
"左足第一足趾关节"
],
"character": [],
"core_name": "红肿",
"tendency": ""
},
{
"anatomy_list": [
"左足第一足趾关节"
],
"character": [],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"左足第一足趾关节"
],
"character": [
"明显"
],
"core_name": "压痛",
"tendency": ""
},
{
"anatomy_list": [
"左足第一足趾关节"
],
"character": [
"明显"
],
"core_name": "痛风结节",
"tendency": ""
},
{
"anatomy_list": [
"右手第3、4、5指关节",
"左手2、3、4、5指关节"
],
"character": [],
"core_name": "红肿",
"tendency": ""
},
{
"anatomy_list": [
"右手第3、4、5指关节",
"左手2、3、4、5指关节"
],
"character": [
"轻"
],
"core_name": "压痛",
"tendency": ""
},
{
"anatomy_list": [
"右足趾关节"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [
"腰"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
}
] |
3.右肺中叶内侧段及左肺上叶下舌段纤维灶。 | 1,621 | [
{
"anatomy_list": [
"右肺中叶内侧段"
],
"character": [],
"core_name": "纤维灶",
"tendency": ""
},
{
"anatomy_list": [
"左肺上叶下舌段"
],
"character": [],
"core_name": "纤维灶",
"tendency": ""
}
] |
患者于1月前发现右侧睾丸睾丸增大，无尿痛及肉眼血尿及脓尿；无发热、畏寒、恶心、呕吐、头昏、头痛、胸痛、胸闷、心慌、心悸、腹痛、腹泻等不适；于某医院门诊就诊，行阴囊彩超提示右侧睾丸内不均质回声，未予以进一步治疗。 | 1,746 | [
{
"anatomy_list": [
"右侧睾丸"
],
"character": [],
"core_name": "增大",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "尿痛",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "血尿",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "脓尿",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "发热",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "畏寒",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "恶心",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "呕吐",
"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": [
"胸"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [
"胸"
],
"character": [],
"core_name": "胸闷",
"tendency": "否定"
},
{
"anatomy_list": [
"心"
],
"character": [],
"core_name": "心慌",
"tendency": "否定"
},
{
"anatomy_list": [
"心"
],
"character": [],
"core_name": "心悸",
"tendency": "否定"
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "腹泻",
"tendency": "否定"
},
{
"anatomy_list": [
"右侧睾丸内"
],
"character": [
"不均质"
],
"core_name": "回声",
"tendency": ""
}
] |
心电图：窦性心律；完全性右束支传导阻滞。 | 1,599 | [
{
"anatomy_list": [
"心"
],
"character": [],
"core_name": "窦性心律",
"tendency": ""
},
{
"anatomy_list": [
"右束支"
],
"character": [
"完全性"
],
"core_name": "传导阻滞",
"tendency": ""
}
] |
患者于3+月前在我院诊断左侧乳腺癌，充分术前准备，于2019-02-11病人于全麻下行了左侧乳腺癌改良根治术，术后病人恢复较好，患者无恶心、呕吐，无心慌气短。 | 1,049 | [
{
"anatomy_list": [
"左侧乳腺"
],
"character": [],
"core_name": "癌",
"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": "心慌",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "气短",
"tendency": "否定"
}
] |
入院前半年，患者受凉后出现阵发性咳嗽，非高调金属声样咳嗽及鸡鸣样咳嗽，昼夜均较频繁，咳少许白色粘痰，未见咯血，无明显呼吸困难，无畏寒、发热，无潮热、盗汗，无胸痛、声嘶，无皮疹及关节红肿，无恶心、呕吐、腹痛、腹泻、便血，无颜面及下肢水肿，间断在当地医院治疗（具体不详）后病情未有缓解，随来我院就医，门诊以"咳嗽原因待查"收入住院治疗。 | 1,151 | [
{
"anatomy_list": [],
"character": [
"受凉后",
"阵发性",
"非高调金属声样",
"鸡鸣样",
"昼夜均较频繁"
],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"白色",
"粘性",
"少许"
],
"core_name": "咳痰",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "咯血",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"明显"
],
"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"
},
{
"anatomy_list": [],
"character": [],
"core_name": "潮热",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "盗汗",
"tendency": "否定"
},
{
"anatomy_list": [
"胸"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "声嘶",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "皮疹",
"tendency": "否定"
},
{
"anatomy_list": [
"关节"
],
"character": [],
"core_name": "红肿",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "恶心",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "呕吐",
"tendency": "否定"
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "腹泻",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "便血",
"tendency": "否定"
},
{
"anatomy_list": [
"颜面",
"下肢"
],
"character": [],
"core_name": "水肿",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "咳嗽",
"tendency": ""
}
] |
骨髓活检符合急性早幼粒细胞白血病。 | 2,034 | [
{
"anatomy_list": [
"早幼粒细胞"
],
"character": [
"急性"
],
"core_name": "白血病",
"tendency": ""
}
] |
无胸闷、心悸及心前区压榨感。 | 590 | [
{
"anatomy_list": [
"胸"
],
"character": [],
"core_name": "胸闷",
"tendency": "否定"
},
{
"anatomy_list": [
"心"
],
"character": [],
"core_name": "心悸",
"tendency": "否定"
},
{
"anatomy_list": [
"心前区"
],
"character": [],
"core_name": "压榨感",
"tendency": "否定"
}
] |
7天前，患者于我院门诊体检时行钼靶发现左乳乳头后方一小结节，大小约为0.6*0.8cm。 | 1,590 | [
{
"anatomy_list": [
"左乳乳头后方"
],
"character": [
"小",
"一"
],
"core_name": "结节",
"tendency": ""
}
] |
12天前患者单位体检行超声发现左肾积水，就诊于我院门诊，行泌尿系超声检查提示：1、膀胱右后壁输尿管开口区域低回声结节，建议进一步检查。 | 436 | [
{
"anatomy_list": [
"左肾"
],
"character": [],
"core_name": "积水",
"tendency": ""
},
{
"anatomy_list": [
"膀胱右后壁输尿管开口区域"
],
"character": [
"低回声"
],
"core_name": "结节",
"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，体重无明显变化。 | 1,478 | [
{
"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": [
"明显"
],
"core_name": "体重改变",
"tendency": "否定"
}
] |
结合术中情况及术后病检诊断：卵巢高级别浆液性癌iiic期，术后转入我科，于2020-7-3行紫杉醇（白蛋白结合型）210mg+卡铂600mg静脉化疗，化疗反应轻，化疗后有脱发、无明显恶心、呕吐，食欲可，全身无淤血淤斑、皮疹，有轻微口腔溃疡等症状。 | 1,862 | [
{
"anatomy_list": [
"卵巢"
],
"character": [
"高级别",
"浆液性",
"iiic期"
],
"core_name": "癌",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"化疗后"
],
"core_name": "脱发",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"明显"
],
"core_name": "恶心",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "呕吐",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"可"
],
"core_name": "食欲",
"tendency": "否定"
},
{
"anatomy_list": [
"全身"
],
"character": [],
"core_name": "瘀血",
"tendency": "否定"
},
{
"anatomy_list": [
"全身"
],
"character": [],
"core_name": "瘀斑",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "皮疹",
"tendency": "否定"
},
{
"anatomy_list": [
"口腔"
],
"character": [
"轻微"
],
"core_name": "溃疡",
"tendency": ""
}
] |
3、（胃食管食管残端）未见癌累及。 | 200 | [
{
"anatomy_list": [
"胃",
"食管",
"食管残端"
],
"character": [
"累及"
],
"core_name": "癌",
"tendency": "否定"
}
] |
入院前12小时患者无明显诱因再次出现解不成形黑便，量约250g，无心悸、一过性黑蒙、乏力、四肢发冷不适。 | 952 | [
{
"anatomy_list": [],
"character": [
"不成形",
"黑"
],
"core_name": "大便",
"tendency": ""
},
{
"anatomy_list": [
"心"
],
"character": [],
"core_name": "心悸",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"一过性"
],
"core_name": "黑朦",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "乏力",
"tendency": "否定"
},
{
"anatomy_list": [
"四肢"
],
"character": [],
"core_name": "发冷",
"tendency": ""
}
] |
10年前，患者口服药物欠佳，故改为口服药物联合皮下注射胰岛素，自述血糖控制良好。 | 1,274 | [
{
"anatomy_list": [],
"character": [
"控制良好"
],
"core_name": "血糖",
"tendency": ""
}
] |
诊断为急性髓系白血病（m3），于2016-11-17日行化疗，方案：维a酸+亚砷酸+米托蒽醌方案，并辅以水化、碱化尿液、止吐等治疗。 | 1,656 | [
{
"anatomy_list": [],
"character": [
"急性",
"髓系",
"M3"
],
"core_name": "白血病",
"tendency": ""
}
] |
现患者一般情况可，诉轻微咳嗽，少量白痰，为求进一步诊疗而来，门诊以“肺癌术后”收治入科。 | 1,818 | [
{
"anatomy_list": [],
"character": [
"轻微"
],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"少量",
"白痰"
],
"core_name": "咳痰",
"tendency": ""
},
{
"anatomy_list": [
"肺"
],
"character": [
"术后"
],
"core_name": "癌",
"tendency": ""
}
] |
院外，患者仍感上腹部隐痛不适，2017-9-8于我院行胸腹部ct提示肝实质内数个稍低密度肿块影及结节影，考虑转移性肿瘤可能；胃贲门贲门区胃壁增厚，软组织影增多，考虑胃癌可能，伴小弯侧多发肿大淋巴结肿大淋巴结影，为治疗入住我科，评估无明显化疗禁忌症后，于2017.10.25、2017.11.15、2017.12.15、2018.1.9、2018.2.7、2018.3.14行tp方案（紫杉醇240mg+奥沙利铂200mg）行6周期化疗，过程顺利，无特殊不适，期间患者复查胸腹部ct提示病灶缩小，疗效评价pr，但患者未再继续治疗。 | 592 | [
{
"anatomy_list": [
"上腹部"
],
"character": [
"隐痛"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"肝实质内"
],
"character": [
"数个",
"稍低密度"
],
"core_name": "肿块影",
"tendency": ""
},
{
"anatomy_list": [
"肝实质内"
],
"character": [
"数个",
"稍低密度"
],
"core_name": "结节影",
"tendency": ""
},
{
"anatomy_list": [
"肝"
],
"character": [
"转移性"
],
"core_name": "肿瘤",
"tendency": "不确定"
},
{
"anatomy_list": [
"胃贲门区胃壁"
],
"character": [],
"core_name": "增厚",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"增多"
],
"core_name": "软组织影",
"tendency": ""
},
{
"anatomy_list": [
"胃"
],
"character": [],
"core_name": "癌",
"tendency": "不确定"
},
{
"anatomy_list": [
"胃小弯"
],
"character": [
"多发",
"肿大"
],
"core_name": "淋巴结影",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"缩小"
],
"core_name": "病灶",
"tendency": ""
}
] |
11年前，患者再次出现咳嗽、咳痰，伴胸闷、气促，伴低热、盗汗，无咯血、胸痛，无乏力、纳差、消瘦等。 | 974 | [
{
"anatomy_list": [],
"character": [],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "咳痰",
"tendency": ""
},
{
"anatomy_list": [
"胸"
],
"character": [],
"core_name": "胸闷",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "气促",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"低"
],
"core_name": "发热",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "盗汗",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "咯血",
"tendency": "否定"
},
{
"anatomy_list": [
"胸"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "乏力",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "纳差",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "消瘦",
"tendency": "否定"
}
] |
为进一步诊治入我院，门诊以“膀胱结石、前列腺增生”收入我科。 | 610 | [
{
"anatomy_list": [
"膀胱"
],
"character": [],
"core_name": "结石",
"tendency": ""
},
{
"anatomy_list": [
"前列腺"
],
"character": [],
"core_name": "增生",
"tendency": ""
}
] |
后患者出院继续左氧氟沙星抗感染治疗，患者自觉症状缓解不明显，遂来我院就诊，门诊以“肺炎”收治入院。 | 678 | [
{
"anatomy_list": [
"肺"
],
"character": [],
"core_name": "肺炎",
"tendency": ""
}
] |
本次入院前3月余，患者因“咳嗽、痰中带血2周”于我院住院治疗，患者一般情况良好，无畏寒、发热，无咯血、胸痛、呼吸困难，无胸闷、气促、心悸，无头晕、头痛，无恶心、呕吐，无腹痛、腹泻等不适。 | 1,526 | [
{
"anatomy_list": [],
"character": [],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"带血"
],
"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": [],
"character": [],
"core_name": "咯血",
"tendency": "否定"
},
{
"anatomy_list": [
"胸"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "呼吸困难",
"tendency": "否定"
},
{
"anatomy_list": [
"胸"
],
"character": [],
"core_name": "胸闷",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "气促",
"tendency": "否定"
},
{
"anatomy_list": [
"心"
],
"character": [],
"core_name": "心悸",
"tendency": "否定"
},
{
"anatomy_list": [
"头"
],
"character": [],
"core_name": "头晕",
"tendency": "否定"
},
{
"anatomy_list": [
"头"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "恶心",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "呕吐",
"tendency": "否定"
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "腹泻",
"tendency": "否定"
}
] |
患者5月前因“间歇性中上腹疼痛6月，再发10天”入我院治疗，完善相关检查后考虑诊断“胰腺恶性肿瘤”。 | 1,665 | [
{
"anatomy_list": [
"中上腹"
],
"character": [
"间歇性",
"再发"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"胰腺"
],
"character": [
"恶性"
],
"core_name": "肿瘤",
"tendency": "不确定"
}
] |
入院前1天有腹泻，2次/天，呈黄色稀水便，无粘液及血丝，无里急后重感，无发热，无呕吐；无咳嗽，无进行性面色苍白，无出血倾向，无结膜充血、眼痒等表现。 | 365 | [
{
"anatomy_list": [
"腹"
],
"character": [
"呈黄色稀水便",
"无粘液及血丝"
],
"core_name": "腹泻",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "里急后重感",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "发热",
"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": [
"面"
],
"character": [
"进行性"
],
"core_name": "面色苍白",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"倾向"
],
"core_name": "出血",
"tendency": "否定"
},
{
"anatomy_list": [
"结膜"
],
"character": [],
"core_name": "充血",
"tendency": "否定"
},
{
"anatomy_list": [
"眼"
],
"character": [],
"core_name": "痒",
"tendency": "否定"
}
] |
为求进一步治疗，遂于今日与我院门诊，门诊以“左乳包块待查”收治入院。 | 1,593 | [
{
"anatomy_list": [
"左乳"
],
"character": [],
"core_name": "包块",
"tendency": "不确定"
}
] |
11周前（2016年12月）患者再次于某医院复查，ct见双肺多发结节，考虑转移，仍未进一步治疗，院外休息。 | 1,452 | [
{
"anatomy_list": [
"双肺"
],
"character": [
"多发"
],
"core_name": "结节",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "转移",
"tendency": "不确定"
}
] |
入院前9年患者体检时发现乙肝表面抗原阳性，自诉肝功轻度异常（具体不详），无明显乏力、纳差等不适，患者自行长期口服中药治疗（具体治疗方案不详），并长期随访肝功等检查。 | 148 | [
{
"anatomy_list": [],
"character": [
"阳性"
],
"core_name": "乙肝表面抗原",
"tendency": ""
},
{
"anatomy_list": [
"肝"
],
"character": [
"轻度"
],
"core_name": "肝功能异常",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"明显"
],
"core_name": "乏力",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"明显"
],
"core_name": "纳差",
"tendency": "否定"
}
] |
5+月前（2020-1-22）开始出现双下肢活动障碍。 | 178 | [
{
"anatomy_list": [
"双下肢"
],
"character": [],
"core_name": "活动障碍",
"tendency": ""
}
] |
遂于我院门诊就诊，行血图分析示：白细胞数目：17.53×109/l 中性粒细胞百分比：88.9％，后以“aecopd”收住入院，给予抗感染、解痉平喘、止咳祛痰等对症治疗后，上述症状缓解出院，出院后1天即感咳嗽咳痰、喘累，故再次以“慢性阻塞性肺疾病 急性加重期”收治入院。 | 1,681 | [
{
"anatomy_list": [
"肺"
],
"character": [
"慢性",
"阻塞性",
"急性加重期"
],
"core_name": "肺疾病",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "咳痰",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "喘累",
"tendency": ""
},
{
"anatomy_list": [
"肺"
],
"character": [
"慢性",
"阻塞性",
"急性加重期"
],
"core_name": "肺疾病",
"tendency": ""
}
] |
患者入院20余天欠无明显原因出现咳嗽、咳痰，呈阵发性发作，痰粘稠不易咳出，咳出痰为白色黏痰，伴食欲不振，全身乏力，活动后明显，无发热、畏寒，无喘累，无肩背部放射痛，无反酸、恶心、呕吐，无腹痛、腹泻，双下肢不肿，自行购买药物（具体不详）处理上述症状缓解不明显。 | 1,743 | [
{
"anatomy_list": [],
"character": [
"阵发性发作"
],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"阵发性发作"
],
"core_name": "咳痰",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"不易咳出",
"粘稠"
],
"core_name": "咳痰",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"白色",
"黏痰"
],
"core_name": "咳痰",
"tendency": ""
},
{
"anatomy_list": [
"全身"
],
"character": [
"活动后明显"
],
"core_name": "乏力",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"不振"
],
"core_name": "食欲",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "发热",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "畏寒",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "喘累",
"tendency": "否定"
},
{
"anatomy_list": [
"肩",
"背部"
],
"character": [
"放射性"
],
"core_name": "疼痛",
"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": [
"腹"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "腹泻",
"tendency": "否定"
},
{
"anatomy_list": [
"双下肢"
],
"character": [],
"core_name": "肿",
"tendency": "否定"
}
] |
上述症状逐渐加重，伴食欲下降，进食少，今家属带患者进一步诊治，遂到我科门诊就诊，门诊以“慢性酒精性神经病”收入我科住院治疗。 | 808 | [
{
"anatomy_list": [],
"character": [],
"core_name": "食欲下降",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "进食少",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"慢性",
"酒精性"
],
"core_name": "神经病",
"tendency": ""
}
] |
现患者仍有腹胀，遂于今日到我院就诊，门诊以“直肠癌”收入我科住院治疗。 | 1,044 | [
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "腹胀",
"tendency": ""
},
{
"anatomy_list": [
"直肠"
],
"character": [],
"core_name": "癌",
"tendency": ""
}
] |
随后到某肿瘤医院就诊，经完善相关检查，胸部ct提示双肺结节，考虑良性可能性大，但不能除外恶性，患者及家属手术意愿强烈，无绝对手术禁忌症，于2017年10月26日行胸腹腔镜联合食管癌根治术+胸膜烙断术+肠粘连松解术。 | 508 | [
{
"anatomy_list": [
"双肺"
],
"character": [
"良性",
"恶性"
],
"core_name": "结节",
"tendency": "不确定"
}
] |
4月余前,患者因“发现右乳包块伴乳房胀痛1+年”就诊于我院普外科1,行彩超、钼钯等检查,提示右乳占位性病变,考虑乳腺癌,完善胸片、骨ect、腹部彩超等辅查后,于2016年11月11日行右乳包块切除+术中冰冻+右乳癌改良根治术,术中见：右乳包块直径约3.5cm大小,位于右乳外侧腺体内,质硬,无明显包膜,边界不清。 | 17 | [
{
"anatomy_list": [
"右乳"
],
"character": [],
"core_name": "包块",
"tendency": ""
},
{
"anatomy_list": [
"乳房"
],
"character": [
"胀痛"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"右乳"
],
"character": [
"占位性"
],
"core_name": "病变",
"tendency": ""
},
{
"anatomy_list": [
"乳腺"
],
"character": [],
"core_name": "癌",
"tendency": "不确定"
},
{
"anatomy_list": [
"右乳"
],
"character": [],
"core_name": "包块",
"tendency": ""
},
{
"anatomy_list": [
"右乳外侧腺体内"
],
"character": [
"质硬",
"无明显包膜",
"边界不清"
],
"core_name": "包块",
"tendency": ""
}
] |
入院前1+月，患者自觉心悸、心前区紧闷不适，活动后心累、气促不适，偶感心前区刺痛，无肩部放射痛，口服速效救心丸后好转，无黑曚、晕厥，无腹胀、纳差、恶心、呕吐等不适，遂就诊于我科，完善相关辅助检查后诊断为“1.冠心病 缺血性心肌病 心脏扩大 心功能iii级 2.原发性高血压病3级 很高危 3.高血压性心脏病 心脏扩大 心功能iii级 4.2型糖尿病 5.左肺下叶实性病灶 6.转移性肝ca？7.肝囊肿 8.前列腺增生症”；予以对症处置后好转出院。 | 1,601 | [
{
"anatomy_list": [
"心"
],
"character": [],
"core_name": "心悸",
"tendency": ""
},
{
"anatomy_list": [
"心前区"
],
"character": [],
"core_name": "紧闷",
"tendency": ""
},
{
"anatomy_list": [
"心"
],
"character": [
"活动后",
"不适"
],
"core_name": "心累",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"活动后",
"不适"
],
"core_name": "气促",
"tendency": ""
},
{
"anatomy_list": [
"心前区"
],
"character": [
"偶有",
"刺痛"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"肩部"
],
"character": [
"放射性"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "黑朦",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "晕厥",
"tendency": "否定"
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "腹胀",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"减少"
],
"core_name": "纳差",
"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": [
"冠状动脉",
"心脏"
],
"character": [
"粥样",
"硬化性"
],
"core_name": "心脏病",
"tendency": ""
},
{
"anatomy_list": [
"心肌"
],
"character": [
"缺血性"
],
"core_name": "心肌病",
"tendency": ""
},
{
"anatomy_list": [
"心脏"
],
"character": [
"扩大"
],
"core_name": "扩大",
"tendency": ""
},
{
"anatomy_list": [
"心"
],
"character": [
"iii级"
],
"core_name": "心功能",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"很高危",
"原发性",
"3级"
],
"core_name": "高血压",
"tendency": ""
},
{
"anatomy_list": [
"心脏"
],
"character": [
"高血压性"
],
"core_name": "心脏病",
"tendency": ""
},
{
"anatomy_list": [
"心脏"
],
"character": [
"扩大"
],
"core_name": "扩大",
"tendency": ""
},
{
"anatomy_list": [
"心"
],
"character": [
"iii级"
],
"core_name": "心功能",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"2型"
],
"core_name": "糖尿病",
"tendency": ""
},
{
"anatomy_list": [
"左肺下叶"
],
"character": [
"实性"
],
"core_name": "病灶",
"tendency": ""
},
{
"anatomy_list": [
"肝"
],
"character": [
"转移性"
],
"core_name": "癌",
"tendency": "不确定"
},
{
"anatomy_list": [
"肝"
],
"character": [],
"core_name": "囊肿",
"tendency": ""
},
{
"anatomy_list": [
"前列腺"
],
"character": [],
"core_name": "增生",
"tendency": ""
}
] |
院外患者诉右下肢肿胀不适,今为求下一周期化疗,以"宫颈癌"收入我科住院治疗。 | 1,213 | [
{
"anatomy_list": [
"右下肢"
],
"character": [],
"core_name": "肿胀",
"tendency": ""
},
{
"anatomy_list": [
"宫颈"
],
"character": [],
"core_name": "癌",
"tendency": ""
}
] |
入院6+月前患者因“腹部疼痛1月”入院，入院后完善相关辅助检查后考虑横结肠癌，未见绝对手术禁忌症，向患者家属交代病情后家属要求手术，于2020.4.4全麻下行横结肠癌根治性切除术，手术顺利，术后继续给予抗感染，补液，营养支持，雾化祛痰等对症治疗后，术后活检为：横结肠结肠黏膜中分化管状腺癌，部分为黏液腺癌，肿瘤侵犯肠壁全层（t3），血管内未见癌栓，横结肠近端及远端切缘未见癌组织，肠系膜淋巴结未见癌转移（0/15）。 | 809 | [
{
"anatomy_list": [
"腹部"
],
"character": [],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"横结肠"
],
"character": [],
"core_name": "癌",
"tendency": "不确定"
},
{
"anatomy_list": [
"横结肠"
],
"character": [
"中分化",
"管状",
"结肠黏膜"
],
"core_name": "腺癌",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"黏液"
],
"core_name": "腺癌",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"侵犯肠壁全层（t3）"
],
"core_name": "肿瘤",
"tendency": ""
},
{
"anatomy_list": [
"血管内"
],
"character": [],
"core_name": "癌栓",
"tendency": "否定"
},
{
"anatomy_list": [
"横结肠近端切缘",
"横结肠远端切缘"
],
"character": [],
"core_name": "癌组织",
"tendency": "否定"
},
{
"anatomy_list": [
"肠系膜淋巴结"
],
"character": [
"转移"
],
"core_name": "癌",
"tendency": "否定"
}
] |
后包块逐渐增大，久站及剧烈咳嗽时突出较明显，仍伴有间歇性胀痛，可回纳，不伴畏寒、发热，不伴下肢静脉静脉扩张、迂曲，不伴潮热、盗汗等不适。 | 1,474 | [
{
"anatomy_list": [],
"character": [
"逐渐增大",
"久站及剧烈咳嗽时突出较明显",
"间歇性胀痛",
"可回纳"
],
"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": [
"下肢静脉"
],
"character": [],
"core_name": "扩张",
"tendency": "否定"
},
{
"anatomy_list": [
"下肢静脉"
],
"character": [],
"core_name": "迂曲",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "潮热",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "盗汗",
"tendency": "否定"
}
] |
2017-01-09就诊于我院行胃镜检查提示：1.胃窦病变待查。 | 1,253 | [
{
"anatomy_list": [
"胃窦"
],
"character": [],
"core_name": "病变",
"tendency": "不确定"
}
] |
遂到我院门诊就诊，完善胃镜及病理活检：“食管新生物”鳞状细胞癌（123456）。 | 1,559 | [
{
"anatomy_list": [
"食管"
],
"character": [],
"core_name": "新生物",
"tendency": ""
},
{
"anatomy_list": [
"食管",
"鳞状细胞"
],
"character": [],
"core_name": "癌",
"tendency": ""
}
] |
患者于2年前常因气候变化，受凉后出现咳嗽、咳痰，咳白色泡沫痰，经抗感染、支气管解痉、化痰对症治疗后缓解。 | 439 | [
{
"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",
"泡沫"
],
"core_name": "咳痰",
"tendency": ""
}
] |
为进一步诊治门诊以“尿毒症”收入我科。 | 33 | [
{
"anatomy_list": [],
"character": [],
"core_name": "尿毒症",
"tendency": ""
}
] |
入院前5+月，患儿因“间断发热半月,发现面色苍白1周”于我院就诊，经骨髓micm分型诊断为“急性普通b淋巴细胞淋巴细胞白血病l11型（中危）”，确诊至今按cccg-all-2015化疗方案已经完成dex+vdlp、cat、mm巩固化疗第1-4次hd-mtx、ir间期第1次静脉化疗。 | 364 | [
{
"anatomy_list": [],
"character": [
"间断"
],
"core_name": "发热",
"tendency": ""
},
{
"anatomy_list": [
"面"
],
"character": [],
"core_name": "面色苍白",
"tendency": ""
},
{
"anatomy_list": [
"b淋巴细胞"
],
"character": [
"急性",
"普通",
"中危",
"l11型"
],
"core_name": "白血病",
"tendency": ""
}
] |
遂到我院妇产科就诊，我院病理科会诊，病检（123456）：腺癌。 | 1,280 | [
{
"anatomy_list": [],
"character": [],
"core_name": "腺癌",
"tendency": ""
}
] |
曾于我院住院治疗，诊断为“冠心病（心绞痛型）、腔隙性脑梗死”，给予活血、扩冠、营养心肌等处理后好转出院，出院后未正规服用冠心病二级预防药物，但平素症状不明显。 | 1,165 | [
{
"anatomy_list": [
"冠状动脉",
"心脏"
],
"character": [
"硬化性",
"粥样",
"心绞痛型"
],
"core_name": "心脏病",
"tendency": ""
},
{
"anatomy_list": [
"脑"
],
"character": [
"腔隙性"
],
"core_name": "梗塞",
"tendency": ""
}
] |
术后诊断：1.子宫内膜癌（Ⅰc期）；2.子宫腺肌症。 | 1,585 | [
{
"anatomy_list": [
"子宫内膜"
],
"character": [
"Ⅰc期"
],
"core_name": "癌",
"tendency": ""
},
{
"anatomy_list": [
"子宫"
],
"character": [],
"core_name": "腺肌症",
"tendency": ""
}
] |
入院2天前患者无明显诱发出现腰部疼痛，呈间歇性胀痛，不伴双下肢放射痛及麻木症状，症状在弯腰活动及起卧翻身时明显，平卧休息时可稍缓解，院外行局部按摩后症状暂时缓解，自行在家中休息2天后腰痛无缓解，进行性加重，严重影响日常生活，为进一步治疗，遂来我科就诊，门诊以“腰痛待查？”收治入院。 | 1,961 | [
{
"anatomy_list": [
"腰部"
],
"character": [
"间歇性",
"胀痛"
],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [
"双下肢"
],
"character": [
"放射性"
],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [
"双下肢"
],
"character": [],
"core_name": "麻木",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"腰活动及起卧翻身时明显",
"平卧休息时可稍缓解"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"腰部"
],
"character": [
"休息后无缓解",
"进行性加重",
"严重影响日常生活"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"腰"
],
"character": [],
"core_name": "疼痛",
"tendency": "不确定"
}
] |
9月余前，患者规律随访，行mri检查提示肿瘤复发，遂于2016-11-28在全麻下行“1.原发性肝癌hifu术；2.人工胸水注射术；3.b超引导下肝癌放射性粒子植入术+pei术”，术后患者恢复可。 | 452 | [
{
"anatomy_list": [],
"character": [
"复发"
],
"core_name": "肿瘤",
"tendency": ""
}
] |
患者遂转诊某中医院，行“小针刀”治疗后右腿疼痛较前无明显好转。 | 1,705 | [
{
"anatomy_list": [
"右腿"
],
"character": [
"较前无明显好转"
],
"core_name": "疼痛",
"tendency": ""
}
] |
行左侧颈部淋巴结淋巴结活检提示：非霍奇金氏淋巴瘤（弥漫大b细胞淋巴瘤）可能性大。 | 564 | [
{
"anatomy_list": [
"淋巴"
],
"character": [
"非霍奇金氏"
],
"core_name": "瘤",
"tendency": "不确定"
},
{
"anatomy_list": [
"弥漫大b细胞",
"淋巴"
],
"character": [],
"core_name": "瘤",
"tendency": "不确定"
}
] |
入院前1-年（2016年10月），患者无诱因出现咳嗽、咳痰，为白色粘痰伴偶痰中带血，呈暗红色，偶为刺激性咳嗽，痰量少，不易咳出，无胸闷、胸痛、咯血、呼吸困难，无潮热、盗汗、疲乏、消瘦，无畏寒、发热。 | 612 | [
{
"anatomy_list": [],
"character": [],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"白色",
"粘性"
],
"core_name": "咳痰",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"带血",
"暗红色",
"偶尔"
],
"core_name": "咳痰",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"刺激性",
"偶尔"
],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"量少",
"不易咳出"
],
"core_name": "咳痰",
"tendency": ""
},
{
"anatomy_list": [
"胸"
],
"character": [],
"core_name": "胸闷",
"tendency": "否定"
},
{
"anatomy_list": [
"胸"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "咯血",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "呼吸困难",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "潮热",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "盗汗",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "疲乏",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "消瘦",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "畏寒",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "发热",
"tendency": "否定"
}
] |
今患者再次到我院门诊就诊，门诊以“肝硬化”收入我科住院治疗。 | 1,048 | [
{
"anatomy_list": [
"肝"
],
"character": [],
"core_name": "硬化",
"tendency": ""
}
] |
无明显食欲下降。 | 1,955 | [
{
"anatomy_list": [],
"character": [
"明显"
],
"core_name": "食欲下降",
"tendency": "否定"
}
] |
入院前10月（2018-06），患者因“感右大腿伴右侧外阴肿胀不适”就诊于我院门诊，完善相关辅助检查，妇科彩超（2018-06-27 我院）提示：宫颈占位，考虑宫颈癌；彩超检查（2018-06-27 我院）：右侧腹股沟区皮下水肿，右侧腹股沟区可见肿大淋巴结，考虑淋巴结反应性增生；患者遂就诊我院妇科，行内窥镜检查（2018-06-28）提示：宫颈癌，厚的醋酸白色上皮，取活检结果回示（病理号：123456）：（宫颈）鳞状细胞癌；免疫组化：p16(+)，ki676790%（+）；建议患者立即入院，完善相关辅助检查，明确具体分期，行下一步治疗，患者及家属商量后表示拒绝；院外自行予以中药（具体不详）治疗，未予以手术、放化疗等积极抗肿瘤治疗，未定期复查；院外患者右侧下肢及右侧外阴肿胀不适进行性加重，偶有出血，量少，现患者下腹部胀痛不适，难以忍受，影响睡眠，为求进一步治疗，遂到我科就诊，行ct检查(2019-02-15):1.右肺下叶后基底段纤维灶。 | 1,203 | [
{
"anatomy_list": [
"右侧外阴",
"右大腿"
],
"character": [],
"core_name": "肿胀",
"tendency": ""
},
{
"anatomy_list": [
"宫颈"
],
"character": [],
"core_name": "占位",
"tendency": ""
},
{
"anatomy_list": [
"宫颈"
],
"character": [],
"core_name": "癌",
"tendency": "不确定"
},
{
"anatomy_list": [
"右侧腹股沟区皮下"
],
"character": [],
"core_name": "水肿",
"tendency": ""
},
{
"anatomy_list": [
"右侧腹股沟区",
"淋巴结"
],
"character": [],
"core_name": "肿大",
"tendency": ""
},
{
"anatomy_list": [
"淋巴结"
],
"character": [
"反应性"
],
"core_name": "增生",
"tendency": "不确定"
},
{
"anatomy_list": [
"宫颈"
],
"character": [],
"core_name": "癌",
"tendency": ""
},
{
"anatomy_list": [
"宫颈"
],
"character": [],
"core_name": "鳞癌",
"tendency": ""
},
{
"anatomy_list": [
"右侧下肢",
"右侧外阴"
],
"character": [
"进行性加重"
],
"core_name": "肿胀",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"偶有",
"量少"
],
"core_name": "出血",
"tendency": ""
},
{
"anatomy_list": [
"下腹部"
],
"character": [
"胀痛",
"难以忍受",
"影响睡眠"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"右肺下叶后基底段"
],
"character": [],
"core_name": "纤维灶",
"tendency": ""
}
] |
2015年6月因上述症状来我院行胃镜检查示“慢性非萎缩性胃炎”肠镜示：“结肠多发性息肉”，行“结肠息肉电凝术”，症状有所缓解。 | 1,059 | [
{
"anatomy_list": [
"胃"
],
"character": [
"慢性",
"非萎缩性"
],
"core_name": "胃炎",
"tendency": ""
},
{
"anatomy_list": [
"结肠"
],
"character": [
"多发性"
],
"core_name": "息肉",
"tendency": ""
}
] |
3天前患者感右侧肩关节疼痛，活动受限 今为求进一步治疗来我院门诊就诊，门诊以“前列腺癌骨转移”收入我科8+年患者无明显诱因出现咳嗽、咳痰，咳白色粘液痰，伴活动后心累、气促，心前区不适，持续约2分2分钟，休息后可缓解，平路快走及爬楼梯后尤甚，无发热、寒战，无咯血、胸痛，无咯粉红色泡沫痰，无夜间阵发性呼吸困难及端坐呼吸，无双下肢水肿。 | 1,797 | [
{
"anatomy_list": [
"右侧肩关节"
],
"character": [],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"右侧肩关节"
],
"character": [],
"core_name": "活动受限",
"tendency": ""
},
{
"anatomy_list": [
"前列腺"
],
"character": [
"骨转移"
],
"core_name": "癌",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "咳痰",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"白色",
"粘液痰"
],
"core_name": "咳痰",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"活动后"
],
"core_name": "心累",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"活动后"
],
"core_name": "气促",
"tendency": ""
},
{
"anatomy_list": [
"心前区"
],
"character": [
"持续约2分钟",
"休息后可缓解",
"平路快走及爬楼梯后尤甚"
],
"core_name": "心前区不适",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "发热",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "寒颤",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "咯血",
"tendency": "否定"
},
{
"anatomy_list": [
"胸"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"粉红色",
"泡沫痰"
],
"core_name": "咳痰",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"夜间",
"阵发性"
],
"core_name": "呼吸困难",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "端坐呼吸",
"tendency": "否定"
},
{
"anatomy_list": [
"下肢"
],
"character": [],
"core_name": "水肿",
"tendency": "否定"
}
] |
心脏彩超：右心及左房增大。 | 598 | [
{
"anatomy_list": [
"右心",
"左房"
],
"character": [],
"core_name": "增大",
"tendency": ""
}
] |
卵巢癌术后改变；腹膜后异常信号影，考虑转移性肿瘤伴左侧输尿管上段侵犯可能性大。 | 173 | [
{
"anatomy_list": [
"卵巢"
],
"character": [
"术后改变"
],
"core_name": "癌",
"tendency": ""
},
{
"anatomy_list": [
"腹膜后"
],
"character": [],
"core_name": "异常信号影",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"转移性"
],
"core_name": "肿瘤",
"tendency": "不确定"
},
{
"anatomy_list": [
"左侧输尿管上段"
],
"character": [
"侵犯"
],
"core_name": "肿瘤",
"tendency": "不确定"
}
] |