text
stringlengths 5
708
| id
int64 1
2.07k
| event
list |
|---|---|---|
患者入院26月余前，因在家做清洁后出现右上腹疼痛，呈间断性隐痛，稍作休息后有所缓解，无肩背部放射性痛，无恶心、呕吐，无咳嗽、咳痰，无咯血、胸痛，无腹胀、腹泻，无畏寒、发热等不适，遂于某医院行超声（2015-9-18）检查示左右肝低回声病灶，超声造影支持肝ca诊断，遂于我院肝胆外科住院治疗，2015-9-25我院行上腹部mr提示肝左外叶左外叶上段结节影、肝右后叶右后叶下段段肿块肿块影考虑肝ca可能，予以保肝、抑酸、静脉营养等对症处理，由于患者自身原因，拒绝进一步治疗出院。 | 450 | [
{
"anatomy_list": [
"右上腹"
],
"character": [
"呈间断性隐痛",
"稍作休息后有所缓解"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"肩",
"背部"
],
"character": [
"放射性"
],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "恶心",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "呕吐",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "咳嗽",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "咳痰",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "咯血",
"tendency": "否定"
},
{
"anatomy_list": [
"胸"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "腹胀",
"tendency": "否定"
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "腹泻",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "畏寒",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "发热",
"tendency": "否定"
},
{
"anatomy_list": [
"左右肝"
],
"character": [
"低回声"
],
"core_name": "病灶",
"tendency": ""
},
{
"anatomy_list": [
"肝"
],
"character": [],
"core_name": "癌",
"tendency": ""
},
{
"anatomy_list": [
"肝左外叶上段"
],
"character": [],
"core_name": "结节影",
"tendency": ""
},
{
"anatomy_list": [
"肝右后叶下段"
],
"character": [],
"core_name": "肿块影",
"tendency": ""
},
{
"anatomy_list": [
"肝"
],
"character": [],
"core_name": "癌",
"tendency": "不确定"
}
] |
1+月前（09-02）行第二次tp方案化疗，24天前（09-27）行第三次tp方案化疗，患者诉后两次化疗期间，有四肢末端麻木，伴轻度恶心，无呕吐，无腹痛、腹泻等不适。 | 1,587 | [
{
"anatomy_list": [
"四肢末端"
],
"character": [],
"core_name": "麻木",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"轻度"
],
"core_name": "恶心",
"tendency": ""
},
{
"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"
}
] |
于2018-10-16、2018-11-07、2018-12-03、2018-12-26在我院行4次化疗，遵医嘱于今日拟于我院行结肠癌术后第5次化疗，门诊遂以"结肠癌术后5月，拟行第5次化疗"收入我科住院治疗。 | 1,997 | [
{
"anatomy_list": [
"结肠"
],
"character": [
"术后"
],
"core_name": "癌",
"tendency": ""
},
{
"anatomy_list": [
"结肠"
],
"character": [
"术后"
],
"core_name": "癌",
"tendency": ""
}
] |
直肠活检（123456）：<直肠>腺癌；补做免疫组化：cdx-2（-）、ca125（+）、wt-1(+)、ck7小灶（+）、ck20（-）、villin（-）、cea（-）、p16弥漫(+)、p53弥漫（强+）、er（+）、pr（-）、pax-2（-）、ki676750%（+）；（直肠）腺癌，结合临床病史和免疫组化符合卵巢癌转移。 | 1,034 | [
{
"anatomy_list": [
"直肠"
],
"character": [],
"core_name": "腺癌",
"tendency": ""
},
{
"anatomy_list": [
"直肠"
],
"character": [],
"core_name": "腺癌",
"tendency": ""
},
{
"anatomy_list": [
"卵巢"
],
"character": [
"转移"
],
"core_name": "癌",
"tendency": ""
}
] |
患者平素月经规则，周期27-30天，经期5-7天，量中，偶有血凝块，无痛经，既往白带正常，无异味。 | 619 | [
{
"anatomy_list": [],
"character": [
"规则"
],
"core_name": "月经",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"量中",
"偶有血凝块"
],
"core_name": "月经",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "痛经",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"正常",
"无异味"
],
"core_name": "白带",
"tendency": ""
}
] |
现为求进一步检查治疗，遂到我院门诊就诊，门诊以“尿潴留，前列腺占位？”收入住院。 | 1,100 | [
{
"anatomy_list": [],
"character": [],
"core_name": "尿潴留",
"tendency": "不确定"
},
{
"anatomy_list": [
"前列腺"
],
"character": [],
"core_name": "占位",
"tendency": "不确定"
}
] |
1、（食管）高分化鳞状细胞癌，侵及食管壁全层，食管壁壁淋巴结未见癌转移（0/5），胃周淋巴结未见癌转移（0/22）。 | 198 | [
{
"anatomy_list": [
"食管"
],
"character": [
"高分化"
],
"core_name": "鳞癌",
"tendency": ""
},
{
"anatomy_list": [
"食管壁全层"
],
"character": [],
"core_name": "侵及",
"tendency": ""
},
{
"anatomy_list": [
"食管壁淋巴结"
],
"character": [
"转移"
],
"core_name": "癌",
"tendency": "否定"
},
{
"anatomy_list": [
"胃周淋巴结"
],
"character": [
"转移"
],
"core_name": "癌",
"tendency": "否定"
}
] |
患者于5月前因右乳癌，于2017-06-02在我院于全麻下行右侧乳腺皮下腺体切除+右侧前哨淋巴结活检，手术顺利，患者术后恢复好，术后病理示：（右乳浸润性癌，非特殊类型（原切片号：123456）活检术后，目前行乳腺切除）送检组织见少量癌组织；（右腋窝蓝染）淋巴结见癌转移（1/1）；（右腋窝、右腋窝深组无蓝染）淋巴结未见癌转移（分别为0/1，0/4）；（右乳晕深部、穿刺孔皮肤、肿瘤表面皮肤）未见癌累及；（左乳）纤维腺瘤；免疫组化示：er80%（+），pr20%（+），cerbb-2（-），p63（-），ki67（由于癌组织太少、掉片，无法显示），p120（+），e-ca（+），mhc（-），caponin（-），p53（-），ck5/6（-）。 | 486 | [
{
"anatomy_list": [
"右乳"
],
"character": [],
"core_name": "癌",
"tendency": ""
},
{
"anatomy_list": [
"右乳"
],
"character": [
"浸润性",
"非特殊类型"
],
"core_name": "癌",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"送检组织见",
"少量"
],
"core_name": "癌组织",
"tendency": ""
},
{
"anatomy_list": [
"右腋窝淋巴结"
],
"character": [
"转移"
],
"core_name": "癌",
"tendency": ""
},
{
"anatomy_list": [
"右腋窝淋巴结",
"右腋窝深组淋巴结"
],
"character": [
"转移"
],
"core_name": "癌",
"tendency": "否定"
},
{
"anatomy_list": [
"右乳晕深部",
"穿刺孔皮肤",
"肿瘤表面皮肤"
],
"character": [
"累及"
],
"core_name": "癌",
"tendency": "否定"
},
{
"anatomy_list": [
"左乳"
],
"character": [],
"core_name": "纤维腺瘤",
"tendency": ""
}
] |
建议住院治疗，患者因自身原因未住院，今日患者再次就诊我科要求住院，门诊即以“声带新生物”收入院治疗。 | 1,390 | [
{
"anatomy_list": [
"声带"
],
"character": [],
"core_name": "新生物",
"tendency": ""
}
] |
现因锁骨上包块来我院门诊就诊，为进一步诊治，收入院。 | 1,420 | [
{
"anatomy_list": [
"锁骨上"
],
"character": [],
"core_name": "包块",
"tendency": ""
}
] |
近1+年来症状逐渐加重,稍活动后即感喘累、气促,多为卧床休息或床旁活动。 | 4 | [
{
"anatomy_list": [],
"character": [
"稍活动后即感"
],
"core_name": "喘累",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"稍活动后即感"
],
"core_name": "气促",
"tendency": ""
}
] |
2天前，患者咳嗽、咳痰较前加重，伴气促，轻度日常活动即感劳累，伴胸痛、盗汗，咳嗽时加重，与活动、饮食无关，无畏寒、发热，无心前区压榨感，无心悸、黑曚、晕厥，伴头昏不适，无头痛、恶心、呕吐，无视物旋转，偶伴耳鸣，无肢体活动障碍、意识障碍等，患者为求进一步诊治，遂来我院，门诊拟“肺炎”收入我科。 | 667 | [
{
"anatomy_list": [],
"character": [
"加重"
],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"加重"
],
"core_name": "咳痰",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "气促",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"轻度日常活动"
],
"core_name": "劳累",
"tendency": ""
},
{
"anatomy_list": [
"胸"
],
"character": [
"咳嗽时加重",
"与活动饮食无关"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"咳嗽时加重",
"与活动饮食无关"
],
"core_name": "盗汗",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "畏寒",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "发热",
"tendency": "否定"
},
{
"anatomy_list": [
"心前区"
],
"character": [],
"core_name": "压榨感",
"tendency": "否定"
},
{
"anatomy_list": [
"心"
],
"character": [],
"core_name": "心悸",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "黒朦",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "晕厥",
"tendency": "否定"
},
{
"anatomy_list": [
"头"
],
"character": [],
"core_name": "头昏",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "恶心",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "呕吐",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "视物旋转",
"tendency": "否定"
},
{
"anatomy_list": [
"耳"
],
"character": [],
"core_name": "耳鸣",
"tendency": ""
},
{
"anatomy_list": [
"肢体"
],
"character": [],
"core_name": "活动障碍",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "意识障碍",
"tendency": ""
},
{
"anatomy_list": [
"肺"
],
"character": [],
"core_name": "肺炎",
"tendency": ""
}
] |
双侧慢性输卵管炎。 | 1,283 | [
{
"anatomy_list": [
"双侧输卵管"
],
"character": [
"慢性"
],
"core_name": "输卵管炎",
"tendency": ""
}
] |
患者于入院前50年无明显诱因出现咳嗽、咳脓痰，伴咯血，约50ml/日，于当地医院就诊，行相关检查提示：支气管扩张，予以药物治疗后上述症状有所好转，但此后咯血症状反复发作约5年左右，均予以抗感染、止血等治疗后好转（具体治疗不详）。 | 70 | [
{
"anatomy_list": [],
"character": [],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"脓痰"
],
"core_name": "咳痰",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"约50ml/日"
],
"core_name": "咯血",
"tendency": ""
},
{
"anatomy_list": [
"支气管"
],
"character": [],
"core_name": "扩张",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"反复发作"
],
"core_name": "咯血",
"tendency": ""
}
] |
阑尾未见癌转移。 | 1,414 | [
{
"anatomy_list": [
"阑尾"
],
"character": [
"转移"
],
"core_name": "癌",
"tendency": "否定"
}
] |
入院前3+月，患者因“双肺结节”于某医院就诊，考虑诊断“左肺腺癌伴全身多处转移”，行左肺上叶肿瘤射频消融术，其余肺内结节考虑原发性肿瘤可能性大，予口服“吉非替尼”治疗。 | 137 | [
{
"anatomy_list": [
"双肺"
],
"character": [],
"core_name": "结节",
"tendency": ""
},
{
"anatomy_list": [
"左肺"
],
"character": [
"全身多处转移"
],
"core_name": "腺癌",
"tendency": "不确定"
},
{
"anatomy_list": [],
"character": [
"原发性"
],
"core_name": "肿瘤",
"tendency": "不确定"
},
{
"anatomy_list": [
"肺"
],
"character": [],
"core_name": "结节",
"tendency": ""
}
] |
ct检查：右肺上叶、双肺下叶背段示多个结节影，炎性结节可能，随访；双肾积水、双侧输尿管全程扩张，左侧输尿管管壁全程增厚，膀胱壁增厚，提示炎变所致可能，结核待排除，请结合临床；右侧附近区示囊性结节，随访。 | 146 | [
{
"anatomy_list": [
"右肺上叶",
"双肺下叶背段"
],
"character": [
"多个"
],
"core_name": "结节影",
"tendency": ""
},
{
"anatomy_list": [
"右肺上叶",
"双肺下叶背段"
],
"character": [
"炎性"
],
"core_name": "结节",
"tendency": "不确定"
},
{
"anatomy_list": [
"双肾"
],
"character": [],
"core_name": "积水",
"tendency": ""
},
{
"anatomy_list": [
"双侧输尿管"
],
"character": [
"全程"
],
"core_name": "扩张",
"tendency": ""
},
{
"anatomy_list": [
"左侧输尿管管壁"
],
"character": [
"全程"
],
"core_name": "增厚",
"tendency": ""
},
{
"anatomy_list": [
"膀胱壁"
],
"character": [],
"core_name": "增厚",
"tendency": ""
},
{
"anatomy_list": [
"膀胱"
],
"character": [],
"core_name": "炎变",
"tendency": "不确定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "结核",
"tendency": "不确定"
},
{
"anatomy_list": [
"右侧附近区"
],
"character": [
"囊性"
],
"core_name": "结节",
"tendency": ""
}
] |
行头颅mri、纤支镜、骨扫描未见异常。 | 1,555 | [
{
"anatomy_list": [],
"character": [],
"core_name": "异常",
"tendency": "否定"
}
] |
患者于4天前前头痛症状加重，伴双眼胀痛，为求进一步诊治，遂入我院，以“高血压病”收入我科。 | 1,202 | [
{
"anatomy_list": [
"头"
],
"character": [
"加重"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"双眼"
],
"character": [
"胀痛"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "高血压",
"tendency": ""
}
] |
入院前2月，患者无意中发现颈前有鸡蛋大小包块，质稍韧，无压痛，活动度可，随吞咽上下移动，无声嘶、饮水呛咳，无食欲亢进，无恶心、呕吐，无吞咽困难、呼吸困难，无发热、畏寒，今患者为求进一步治疗，遂至我院就诊，查彩超提示：双侧甲状腺偏低回声包块，结节性甲状腺肿？甲状腺腺瘤？；查ect提示：1.甲状腺右叶“凉结节”，有供血，结合图像融合考虑：甲状腺腺瘤伴钙化（1）甲状腺腺瘤？2）甲状腺恶性病变不能排除？）。 | 252 | [
{
"anatomy_list": [
"颈前"
],
"character": [
"鸡蛋大小",
"质稍韧",
"活动度可",
"无压痛",
"随吞咽上下移动"
],
"core_name": "包块",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "饮水呛咳",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "声嘶",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "食欲亢进",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "恶心",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "呕吐",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "呼吸困难",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "吞咽困难",
"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": [
"双侧甲状腺"
],
"character": [
"偏低回声"
],
"core_name": "包块",
"tendency": ""
},
{
"anatomy_list": [
"甲状腺"
],
"character": [
"结节性"
],
"core_name": "肿",
"tendency": "不确定"
},
{
"anatomy_list": [
"甲状腺"
],
"character": [],
"core_name": "腺瘤",
"tendency": "不确定"
},
{
"anatomy_list": [
"甲状腺右叶"
],
"character": [
"有供血"
],
"core_name": "凉结节",
"tendency": "不确定"
},
{
"anatomy_list": [
"甲状腺"
],
"character": [],
"core_name": "腺瘤",
"tendency": ""
},
{
"anatomy_list": [
"甲状腺"
],
"character": [],
"core_name": "钙化",
"tendency": ""
},
{
"anatomy_list": [
"甲状腺"
],
"character": [],
"core_name": "腺瘤",
"tendency": "不确定"
},
{
"anatomy_list": [
"甲状腺"
],
"character": [
"恶性"
],
"core_name": "病变",
"tendency": "不确定"
}
] |
患者 2小时 前无明显诱因下开始出现腹部疼痛，肚脐周围疼痛为主，为阵发性绞痛，喜屈曲卧位，伴呕吐，呕吐为胃内容物，为非喷射状，呕吐物无血丝、血凝块。 | 1,229 | [
{
"anatomy_list": [
"腹部",
"肚脐周围"
],
"character": [
"阵发性",
"绞痛"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"呕吐为胃内容物",
"为非喷射状",
"呕吐物无血丝、血凝块"
],
"core_name": "呕吐",
"tendency": ""
}
] |
5.肝右叶后上段病灶，考虑血管瘤可能。 | 683 | [
{
"anatomy_list": [
"肝右叶后上段"
],
"character": [],
"core_name": "病灶",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"血管"
],
"core_name": "瘤",
"tendency": "不确定"
}
] |
入院前1+年，患者无意发现左锁骨上1包包块，约黄豆大小，伴轻压痛，无红肿，无局部皮肤颜色改变，无畏寒、发热，无咳嗽、咳痰，无鼻塞、流涕，无胸闷、胸痛等不适。患者未重视，未就诊。 | 1,551 | [
{
"anatomy_list": [
"左锁骨上"
],
"character": [
"轻微压痛",
"约黄豆大小"
],
"core_name": "包块",
"tendency": ""
},
{
"anatomy_list": [
"左锁骨上"
],
"character": [],
"core_name": "红肿",
"tendency": "否定"
},
{
"anatomy_list": [
"局部皮肤"
],
"character": [],
"core_name": "颜色改变",
"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": "咳嗽",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "咳痰",
"tendency": "否定"
},
{
"anatomy_list": [
"鼻"
],
"character": [],
"core_name": "鼻塞",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "流涕",
"tendency": "否定"
},
{
"anatomy_list": [
"胸"
],
"character": [],
"core_name": "胸闷",
"tendency": "否定"
},
{
"anatomy_list": [
"胸"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
}
] |
患者患病以来，神清，精神、食欲、睡眠欠佳，未解大便，小便正常，体重无明显改变。 | 1,294 | [
{
"anatomy_list": [],
"character": [
"清"
],
"core_name": "神志",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"欠佳"
],
"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": [
"未解"
],
"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"
}
] |
患者因便秘，反复于我科住院，治疗上予以保护消化道黏膜等治疗、予以乳果糖口服液，聚乙二醇导泻对症改善便秘症状、予以莫沙必利片促消化等治疗后好转出院。 | 1,060 | [
{
"anatomy_list": [],
"character": [
"好转"
],
"core_name": "便秘",
"tendency": ""
}
] |
3月前为进一步诊治于我院门诊行诊刮术，术后病检提示：血块和破碎宫内膜显示复杂性增生过长，局灶腺体中到重度不典型增生（血块中夹杂少许增生粘液上皮）。 | 1,580 | [
{
"anatomy_list": [],
"character": [
"复杂性",
"过长"
],
"core_name": "增生",
"tendency": ""
},
{
"anatomy_list": [
"局灶腺体"
],
"character": [
"不典型性",
"中到重度"
],
"core_name": "增生",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"少许",
"血块中夹杂"
],
"core_name": "增生粘液上皮",
"tendency": ""
}
] |
结合患者病史，考虑患者为卵巢癌术后复发伴左侧腹膜后淋巴结转移，2018-5-15、6-12、7-15、8-11予以1-4周期治疗，具体方案：贝伐单抗400mg1+紫杉醇210mg2+洛铂50mg3，21天。 | 175 | [
{
"anatomy_list": [
"卵巢"
],
"character": [
"术后复发"
],
"core_name": "癌",
"tendency": "不确定"
},
{
"anatomy_list": [
"左侧腹膜后淋巴结"
],
"character": [],
"core_name": "转移",
"tendency": "不确定"
}
] |
肠壁上淋巴结见癌转移（5/10）。 | 53 | [
{
"anatomy_list": [
"肠壁上淋巴结"
],
"character": [
"转移"
],
"core_name": "癌",
"tendency": ""
}
] |
2、（胃体）息肉。 | 2,050 | [
{
"anatomy_list": [
"胃体"
],
"character": [],
"core_name": "息肉",
"tendency": ""
}
] |
1+年前，患者无明显诱因出现右下肢疼痛，为持续性隐痛，可忍受，不影响休息及活动，后自觉右下肢疼痛较前有所加重，影响行走及睡眠，并出现颈部疼痛，转颈等活动受限，就诊我科行头颅mri：脑实质内多发结节状异常信号影，增强后明显环形强化，考虑肺癌脑转移。 | 943 | [
{
"anatomy_list": [
"右下肢"
],
"character": [
"持续性",
"隐痛",
"可忍受",
"不影响休息及活动"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"右下肢"
],
"character": [
"加重",
"影响行走及睡眠"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"颈部"
],
"character": [],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"转颈"
],
"core_name": "活动受限",
"tendency": ""
},
{
"anatomy_list": [
"脑实质"
],
"character": [
"多发",
"结节",
"异常",
"增强后明显环形强化"
],
"core_name": "信号影",
"tendency": ""
},
{
"anatomy_list": [
"肺"
],
"character": [
"脑转移"
],
"core_name": "癌",
"tendency": "不确定"
}
] |
患者于2年前开始出现乏力，食欲下降，精神不振，伴恶心，无呕吐。 | 856 | [
{
"anatomy_list": [],
"character": [],
"core_name": "乏力",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "食欲下降",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"不振"
],
"core_name": "精神",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "恶心",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "呕吐",
"tendency": "否定"
}
] |
1+年前，患者无诱因出现上腹胀不适，完善胸腹部ct提示纵膈淋巴结较前增大，于2019年02月18日开始给予肺部病灶及相关淋巴引流区适形调强放射治疗。 | 1,105 | [
{
"anatomy_list": [
"上腹"
],
"character": [],
"core_name": "腹胀",
"tendency": ""
},
{
"anatomy_list": [
"纵膈淋巴结"
],
"character": [
"较前"
],
"core_name": "增大",
"tendency": ""
}
] |
腹部mri:1.子宫宫颈占位性病变，考虑恶性肿瘤，累及阴道前壁上1/3及宫颈旁组织，伴双侧附件转移。 | 1,224 | [
{
"anatomy_list": [
"子宫宫颈"
],
"character": [
"占位性"
],
"core_name": "病变",
"tendency": ""
},
{
"anatomy_list": [
"子宫宫颈"
],
"character": [
"恶性",
"累及阴道前壁上1/3及宫颈旁组织"
],
"core_name": "肿瘤",
"tendency": "不确定"
},
{
"anatomy_list": [
"双侧附件"
],
"character": [],
"core_name": "转移",
"tendency": ""
}
] |
<宫颈>神经内分泌癌。 | 1,225 | [
{
"anatomy_list": [
"宫颈"
],
"character": [
"神经内分泌"
],
"core_name": "癌",
"tendency": ""
}
] |
行乙状结肠结肠镜见直肠包块伴管腔狭窄（未见原报告）。 | 404 | [
{
"anatomy_list": [
"直肠"
],
"character": [],
"core_name": "包块",
"tendency": ""
},
{
"anatomy_list": [
"直肠管腔"
],
"character": [],
"core_name": "狭窄",
"tendency": ""
}
] |
”胸部ct提示“吻合口下方肿块影，考虑肿瘤复发或转移可能”。 | 1,927 | [
{
"anatomy_list": [
"吻合口下方"
],
"character": [],
"core_name": "肿块影",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"复发"
],
"core_name": "肿瘤",
"tendency": "不确定"
},
{
"anatomy_list": [],
"character": [
"转移"
],
"core_name": "肿瘤",
"tendency": "不确定"
}
] |
患者13年前体检时查肝功异常（具体不详），乙肝标志物阳性（hbsag阳性，余不详），患者未感乏力、纳差等不适，患者未引起重视，自行间断服用“护肝片”治疗。 | 59 | [
{
"anatomy_list": [],
"character": [],
"core_name": "肝功能异常",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"阳性"
],
"core_name": "乙肝标志物",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"阳性"
],
"core_name": "hbsag",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "乏力",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "纳差",
"tendency": "否定"
}
] |
患儿因“诊断急性早幼粒细胞白血病（m3b型 pml/rarαxxxbcr3（+））2年6月，需继续治疗”。 | 504 | [
{
"anatomy_list": [
"早幼粒细胞"
],
"character": [
"急性",
"m3b型",
"pml/rarαxxxbcr3（+）"
],
"core_name": "白血病",
"tendency": ""
}
] |
无禁忌症，行了颈部包块穿刺，2020-10-15手术活检病检（颈部包块）转移性小细胞癌；免疫组化结果：ttf-1（+），ck7（-），napsina（-），ck5/6（-），p63（-），cd56（+），syn（+），cga（+），lca（-），ki676780%（+）。 | 1,109 | [
{
"anatomy_list": [
"颈部"
],
"character": [],
"core_name": "包块",
"tendency": ""
},
{
"anatomy_list": [
"颈部"
],
"character": [
"转移性",
"小细胞"
],
"core_name": "癌",
"tendency": ""
}
] |
考虑患者目前为乳腺癌伴肝肺转移，既往行内分泌治疗及蒽环类化疗后疾病进展，排除化疗禁忌后于2018年11月17日、2018年12月8日给予紫杉醇脂质体180mg单药治疗2周期。 | 1,324 | [
{
"anatomy_list": [
"乳腺"
],
"character": [],
"core_name": "癌",
"tendency": "不确定"
},
{
"anatomy_list": [
"肝",
"肺"
],
"character": [
"转移"
],
"core_name": "癌",
"tendency": "不确定"
}
] |
2+年患者在某医院诊断为“原发性高血压3级很高危”，现使用“氯沙坦氢氯噻嗪1片qd，硝苯地平控释片30mg”控制血压，平时血压控制不详。 | 1,467 | [
{
"anatomy_list": [],
"character": [
"原发性",
"3级",
"很高危"
],
"core_name": "高血压",
"tendency": ""
}
] |
患者于入院前1月，患者无诱因出现食欲减退，伴咳嗽、咳痰，痰液性质不清，无恶心、呕吐，无反酸、嗳气，无腹痛、腹胀、腹泻、黄疸等不适，自行于附近诊所就诊，予以药物对症治疗后咳嗽、咳痰好转，随后出现腹泻，解稀水样便，约3次，无黑便、鲜血便，再次于当地诊所予以“诺氟沙星”对症治疗后腹泻好转，但仍觉食欲差、腹部不适，遂于某医院就诊，予以“黄连素、多酶片、安达”对症治疗后腹部不适好转，但仍觉食欲差。 | 1,486 | [
{
"anatomy_list": [],
"character": [
"减退"
],
"core_name": "食欲",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"痰液性质不清"
],
"core_name": "咳痰",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "恶心",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "呕吐",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "反酸",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "嗳气",
"tendency": "否定"
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "腹胀",
"tendency": "否定"
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "腹泻",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "黄疸",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"好转"
],
"core_name": "咳痰",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"好转"
],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "腹泻",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"稀水样",
"约3次"
],
"core_name": "大便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "黑便",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"鲜"
],
"core_name": "血便",
"tendency": "否定"
},
{
"anatomy_list": [
"腹"
],
"character": [
"好转"
],
"core_name": "腹泻",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"差"
],
"core_name": "食欲",
"tendency": ""
},
{
"anatomy_list": [
"腹部"
],
"character": [],
"core_name": "腹部不适",
"tendency": ""
},
{
"anatomy_list": [
"腹部"
],
"character": [
"好转"
],
"core_name": "腹部不适",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"差"
],
"core_name": "食欲",
"tendency": ""
}
] |
今患者为行进一步诊治转诊于我院，门诊故以“前列腺癌？、前列腺增生、双侧睾丸鞘膜积液”收入我科。 | 1,976 | [
{
"anatomy_list": [
"前列腺"
],
"character": [],
"core_name": "癌",
"tendency": "不确定"
},
{
"anatomy_list": [
"前列腺"
],
"character": [],
"core_name": "增生",
"tendency": ""
},
{
"anatomy_list": [
"双侧睾丸鞘膜"
],
"character": [],
"core_name": "积液",
"tendency": ""
}
] |
于 我院门诊 行肛门指检查提示 直肠包块待查 ，门诊以“直肠包块”收入我科。 | 343 | [
{
"anatomy_list": [
"直肠"
],
"character": [],
"core_name": "包块",
"tendency": "不确定"
},
{
"anatomy_list": [
"直肠"
],
"character": [],
"core_name": "包块",
"tendency": ""
}
] |
既往有“慢性胃炎”病史20+年，间断服用抑酸护胃药物治疗。 | 139 | [
{
"anatomy_list": [
"胃"
],
"character": [
"慢性",
"病史20+年"
],
"core_name": "胃炎",
"tendency": ""
}
] |
1月来，患者仍诉心累、气促，无咳嗽、咳痰，无心前区压榨感、端坐呼吸等不适。 | 372 | [
{
"anatomy_list": [
"心"
],
"character": [],
"core_name": "心累",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "气促",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "咳嗽",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "咳痰",
"tendency": "否定"
},
{
"anatomy_list": [
"心前区"
],
"character": [],
"core_name": "压榨感",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "端坐呼吸",
"tendency": "否定"
}
] |
患者考虑升结肠肿瘤伴肝肺转移，进一步完善肠镜检查，2020-03-18病检结果回示（病理号：123456）：<升结肠>腺癌。 | 886 | [
{
"anatomy_list": [
"升结肠"
],
"character": [],
"core_name": "肿瘤",
"tendency": "不确定"
},
{
"anatomy_list": [
"肝",
"肺"
],
"character": [],
"core_name": "转移",
"tendency": "不确定"
},
{
"anatomy_list": [
"升结肠"
],
"character": [],
"core_name": "腺癌",
"tendency": ""
}
] |
后膝关节疼痛反反复复、逐渐加重，出现双膝关节疼痛。 | 357 | [
{
"anatomy_list": [
"后膝关节"
],
"character": [
"反反复复",
"逐渐加重"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"双膝关节"
],
"character": [],
"core_name": "疼痛",
"tendency": ""
}
] |
入院前2天，患者无明显诱因出现右下腹疼痛，呈持续性，伴恶心、呕吐、腹胀，诉咽部不适，无腹泻、黑便，无发热、畏寒，无尿频、尿急，无心前区疼痛不适，于当地卫生院治疗，疗效欠佳。 | 1,491 | [
{
"anatomy_list": [
"右下腹"
],
"character": [
"持续性"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "恶心",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "呕吐",
"tendency": ""
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "腹胀",
"tendency": ""
},
{
"anatomy_list": [
"咽部"
],
"character": [],
"core_name": "咽部不适",
"tendency": ""
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "腹泻",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "黑便",
"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": "尿频",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "尿急",
"tendency": "否定"
},
{
"anatomy_list": [
"心前区"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
}
] |
患病以来，患者精神食纳可，睡眠可。 | 912 | [
{
"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": ""
}
] |
宫腔积液。 | 1,608 | [
{
"anatomy_list": [
"宫腔"
],
"character": [],
"core_name": "积液",
"tendency": ""
}
] |
门诊以“稽留流产”收入我科。 | 692 | [
{
"anatomy_list": [],
"character": [
"稽留"
],
"core_name": "流产",
"tendency": ""
}
] |
今为求进一步治疗，就诊于我院门诊，行彩超检查提示：宫颈见偏低回声，子宫实性占位（符合子宫肌瘤声像图改变）。 | 97 | [
{
"anatomy_list": [
"宫颈"
],
"character": [
"偏低"
],
"core_name": "回声",
"tendency": ""
},
{
"anatomy_list": [
"子宫"
],
"character": [
"实性"
],
"core_name": "占位",
"tendency": ""
},
{
"anatomy_list": [
"子宫"
],
"character": [],
"core_name": "肌瘤",
"tendency": ""
}
] |
现患者为求进一步治疗，就诊于我院，门诊以“肝癌？”收入我科。 | 250 | [
{
"anatomy_list": [
"肝"
],
"character": [],
"core_name": "癌",
"tendency": "不确定"
}
] |
2天前于我院复查腹部彩超：右肾结石；双肾积液，双侧输尿管中上段扩张，中下段扩张不明显，建议进一步检查，肝回声不均，盆腔积液，胆、胰、脾未见明显异常。 | 922 | [
{
"anatomy_list": [
"右肾"
],
"character": [],
"core_name": "结石",
"tendency": ""
},
{
"anatomy_list": [
"双肾"
],
"character": [],
"core_name": "积液",
"tendency": ""
},
{
"anatomy_list": [
"双侧输尿管中上段"
],
"character": [],
"core_name": "扩张",
"tendency": ""
},
{
"anatomy_list": [
"双侧输尿管中下段"
],
"character": [
"不明显"
],
"core_name": "扩张",
"tendency": ""
},
{
"anatomy_list": [
"肝"
],
"character": [
"不均"
],
"core_name": "回声",
"tendency": ""
},
{
"anatomy_list": [
"盆腔"
],
"character": [],
"core_name": "积液",
"tendency": ""
},
{
"anatomy_list": [
"胆",
"胰",
"脾"
],
"character": [
"明显"
],
"core_name": "异常",
"tendency": "否定"
}
] |
腋窝淋巴结未见癌转移（0/30）；免疫组化：er 90%(+),pr 90%(+),cerbb-2(1+),p535310%(+),ki676720%(+),p120膜（+），e-cad膜（+），e-cad(+),p63(-),calponin(-),sma(-);术后患者恢复可,于05-15予以tc方案(紫杉醇+环磷酰胺)术后第一次化疗,2018年6月6日行第2次化疗，化疗后诉轻微恶心、呕吐、吞咽困难等不适，予以对症处理后患者好转，今患者为求术后第3次化疗，来我科住院，门诊以“右乳癌术后，第2次化疗后”收入我科住院治疗。 | 2,041 | [
{
"anatomy_list": [
"腋窝淋巴结"
],
"character": [
"转移"
],
"core_name": "癌",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"轻微",
"化疗后"
],
"core_name": "恶心",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"轻微",
"化疗后"
],
"core_name": "呕吐",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"轻微",
"化疗后"
],
"core_name": "吞咽困难",
"tendency": ""
},
{
"anatomy_list": [
"右乳"
],
"character": [
"术后",
"第2次化疗后"
],
"core_name": "癌",
"tendency": ""
}
] |
上述症状逐渐加重，半年前开始出现尿不尽、尿分叉，伴有全程无痛淡红色血尿3-4次，无血凝块排出，自服“前列康、金钱草等”，症状有所缓解，但症状反复，遂于某医院就诊，尿常规提示：红细胞+++；泌尿系彩超提示：膀胱结石、前列腺饱满。 | 609 | [
{
"anatomy_list": [],
"character": [],
"core_name": "尿不尽",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "尿分叉",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"淡红色",
"3-4次",
"无血凝块排出"
],
"core_name": "血尿",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "尿痛",
"tendency": "否定"
},
{
"anatomy_list": [
"膀胱"
],
"character": [],
"core_name": "结石",
"tendency": ""
},
{
"anatomy_list": [
"前列腺"
],
"character": [],
"core_name": "前列腺饱满",
"tendency": ""
}
] |
门诊以“前列腺癌”收治入院。 | 322 | [
{
"anatomy_list": [
"前列腺"
],
"character": [],
"core_name": "癌",
"tendency": ""
}
] |
入院前3年，患者因肝癌于我院行肝癌射频消融术，术中见肝脏萎缩，大小约２３×１２×７ｃｍ，以肝左叶萎缩明显，肝脏色暗红，表面布满大小不等结节，边缘锐利，肝右叶第Ⅷ段位置可扪及一质硬包块，大小约２×３ｃｍ，边界较清晰。 | 718 | [
{
"anatomy_list": [
"肝"
],
"character": [],
"core_name": "癌",
"tendency": ""
},
{
"anatomy_list": [
"肝脏"
],
"character": [],
"core_name": "萎缩",
"tendency": ""
},
{
"anatomy_list": [
"肝左叶"
],
"character": [
"明显"
],
"core_name": "萎缩",
"tendency": ""
},
{
"anatomy_list": [
"肝脏"
],
"character": [],
"core_name": "肝脏色暗红",
"tendency": ""
},
{
"anatomy_list": [
"肝脏表面"
],
"character": [
"大小不等"
],
"core_name": "结节",
"tendency": ""
},
{
"anatomy_list": [
"肝脏"
],
"character": [],
"core_name": "边缘锐利",
"tendency": ""
},
{
"anatomy_list": [
"肝右叶第Ⅷ段"
],
"character": [
"质硬",
"边界较清晰"
],
"core_name": "包块",
"tendency": ""
}
] |
患者于30余年前体检发现乙肝表面抗原阳性，e抗原不详，肝功能正常，无乏力、纳差、身黄等不适，此后未正规检查及治疗，未抗病毒等治疗，亦无乏力、纳差、身黄等不适。 | 108 | [
{
"anatomy_list": [],
"character": [
"阳性"
],
"core_name": "乙肝表面抗原",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "乏力",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "纳差",
"tendency": "否定"
},
{
"anatomy_list": [
"身"
],
"character": [],
"core_name": "黄染",
"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": [
"身"
],
"character": [],
"core_name": "黄染",
"tendency": "否定"
}
] |
诊断“右肺小细胞肺癌广泛期”；于2019-05-22行依托伯苷110mg(d1-d5)+奈达铂140mg(d1)化疗，辅以增强免疫力、护胃、止吐等治疗后好转出院。 | 207 | [
{
"anatomy_list": [
"右肺",
"小细胞"
],
"character": [
"广泛期"
],
"core_name": "癌",
"tendency": ""
}
] |
遂于肾内科住院治疗，查免疫球蛋白轻链(κ ）/免疫球蛋白轻链(γ）=0.81，骨髓涂片示多发性骨髓瘤可能，免疫固定电泳：lam型m蛋白血症，当时肾功能：cr：539.7umol/L，血红蛋白：81g/l，考虑iii期。 | 1,488 | [
{
"anatomy_list": [
"骨髓"
],
"character": [
"多发性",
"iii期"
],
"core_name": "瘤",
"tendency": "不确定"
}
] |
2、左乳囊性无回声区：囊肿可能（bi-rads分类：2类）。 | 578 | [
{
"anatomy_list": [
"左乳"
],
"character": [
"囊性无回声区",
"bi-rads分类：2类"
],
"core_name": "囊肿",
"tendency": "不确定"
}
] |
前哨淋巴结活检阴性，术后诊断病理诊断为：（左乳）浸润性导管癌，淋巴结未见癌转移（0/9），免疫组化：er（+++）＞75%pr（+++）＞75%cerbb-2（+） ki-67（++）。 | 816 | [
{
"anatomy_list": [
"左乳"
],
"character": [
"浸润性"
],
"core_name": "导管癌",
"tendency": ""
},
{
"anatomy_list": [
"淋巴结"
],
"character": [
"转移"
],
"core_name": "癌",
"tendency": "否定"
}
] |
化疗期间有轻度胃肠道反应及骨髓抑制，给予对症治疗后好转。 | 433 | [
{
"anatomy_list": [
"胃肠道"
],
"character": [
"化疗期间",
"轻度"
],
"core_name": "胃肠道反应",
"tendency": ""
},
{
"anatomy_list": [
"骨髓"
],
"character": [
"化疗期间",
"轻度"
],
"core_name": "骨髓抑制",
"tendency": ""
}
] |
ct检查提示:1.右肺下叶小结节；2.纵隔及心膈角淋巴结显示；3.主动脉及冠状动脉壁钙化；4.肝内胆管及胆总管轻度扩张；5.乙状结肠远段及直肠上段改变，考虑肿瘤性病变，周围脂肪间隙模糊，邻近肠系膜淋巴结显示，右侧盆壁及肠系膜根部淋巴结淋巴结肿大；6.右上腹上腹部腹膜结节状增厚，考虑转移可能；7.“卵巢癌术后”：子宫及双侧附件术后缺如；8.腰5双侧椎弓峡部裂。 | 1,033 | [
{
"anatomy_list": [
"右肺下叶"
],
"character": [
"小"
],
"core_name": "结节",
"tendency": ""
},
{
"anatomy_list": [
"主动脉",
"冠状动脉壁"
],
"character": [],
"core_name": "钙化",
"tendency": ""
},
{
"anatomy_list": [
"胆总管",
"肝内胆管"
],
"character": [
"轻度"
],
"core_name": "扩张",
"tendency": ""
},
{
"anatomy_list": [
"乙状结肠远段",
"直肠上段"
],
"character": [],
"core_name": "改变",
"tendency": ""
},
{
"anatomy_list": [
"乙状结肠远段",
"直肠上段"
],
"character": [
"肿瘤性"
],
"core_name": "病变",
"tendency": "不确定"
},
{
"anatomy_list": [
"周围脂肪"
],
"character": [],
"core_name": "间隙模糊",
"tendency": ""
},
{
"anatomy_list": [
"右侧盆壁淋巴结",
"肠系膜根淋巴结"
],
"character": [],
"core_name": "肿大",
"tendency": ""
},
{
"anatomy_list": [
"右上腹腹膜"
],
"character": [
"结节状"
],
"core_name": "增厚",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "转移",
"tendency": "不确定"
},
{
"anatomy_list": [
"卵巢"
],
"character": [
"术后"
],
"core_name": "癌",
"tendency": ""
},
{
"anatomy_list": [
"双侧附件",
"子宫"
],
"character": [
"术后"
],
"core_name": "缺如",
"tendency": ""
},
{
"anatomy_list": [
"腰椎L5双侧"
],
"character": [],
"core_name": "椎弓峡部裂",
"tendency": ""
}
] |
1月前，患者无明显诱因出现咳嗽、咳痰，咳白色粘液痰，量少，痰可咳出，伴吞咽呛咳，心累、气促明显，活动后明显加重，走平路时即可出现心累气促症状，无咯血及咯粉红色泡沫痰，无胸痛及心前区压榨感，无夜间阵发性呼吸困难及端坐呼吸，无畏寒、发热，无潮热、盗汗，无恶心、呕吐，无腹痛、腹泻，患者遂至当地卫生院治疗，予以口服药物及抗生素输液治疗（具体情况不详），患者症状无缓解，今日患者症状加重，喘累明显，为求进一步治疗，遂今日来我院就诊，以“慢性阻塞性肺疾病急性加重期”收入我科住院治疗。 | 1,307 | [
{
"anatomy_list": [],
"character": [],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "咳痰",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"白色",
"粘液",
"量少",
"可咳出"
],
"core_name": "咳痰",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"吞咽"
],
"core_name": "呛咳",
"tendency": ""
},
{
"anatomy_list": [
"心"
],
"character": [
"明显",
"活动后加重",
"走平路时即可出现"
],
"core_name": "心累",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"明显",
"活动后加重",
"走平路时即可出现"
],
"core_name": "气促",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "咯血",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"粉红色",
"泡沫痰"
],
"core_name": "咳痰",
"tendency": "否定"
},
{
"anatomy_list": [
"胸"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [
"心前区"
],
"character": [],
"core_name": "压榨感",
"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": [],
"character": [],
"core_name": "畏寒",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "发热",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "潮热",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "盗汗",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "恶心",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "呕吐",
"tendency": "否定"
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "腹泻",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"明显"
],
"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": ""
}
] |
治疗过程中，患者出现呼吸急促、血氧饱和度显著下降等危急症征，转入我院中心icu，后病情好转后转回我科继续治疗，待患者病情好转后，再次予以维甲酸，治疗过程中患者出现左侧胸痛、呼吸困难，经全科病例讨论后，考虑有维甲酸综合征可能，故停用维甲酸，给予无创呼吸机、地塞米松、人免疫球蛋白、亚胺培南、血小板等对症支持治疗，经治疗后患者呼吸困难缓解，即撤除呼吸机，逐渐将激素减量，调整抗生素，病情稳定后，予以亚砷酸化疗。 | 1,354 | [
{
"anatomy_list": [],
"character": [
"急促"
],
"core_name": "呼吸",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"显著下降"
],
"core_name": "血氧饱和度",
"tendency": ""
},
{
"anatomy_list": [
"左侧胸"
],
"character": [],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "呼吸困难",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "维甲酸综合征",
"tendency": "不确定"
},
{
"anatomy_list": [],
"character": [
"缓解"
],
"core_name": "呼吸困难",
"tendency": ""
}
] |
患者病情恢复可，患者今遵医嘱返院行第1次化疗，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 。 | 338 | [
{
"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": "体重变化",
"tendency": "否定"
}
] |
入院前5天，患者无明显诱因感四肢乏力，伴行走不能，伴双上肢不自主抖动，咳嗽、咳痰，伴吞咽困难，不伴头痛、恶心、呕吐、耳鸣，无意识障碍、肢体活动障碍及言语障碍，无饮水呛咳，无大小便失禁，无发热、鼻涕、畏寒，无心慌、胸闷、大汗、面色苍白，无明显缓解加重因素，上述症状持续存在，患者及家属未予重视，未诊治。 | 807 | [
{
"anatomy_list": [
"四肢"
],
"character": [],
"core_name": "乏力",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"不能"
],
"core_name": "行走",
"tendency": ""
},
{
"anatomy_list": [
"双上肢"
],
"character": [
"不自主"
],
"core_name": "抖动",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "咳痰",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "吞咽困难",
"tendency": ""
},
{
"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": [
"耳"
],
"character": [],
"core_name": "耳鸣",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "意识障碍",
"tendency": "否定"
},
{
"anatomy_list": [
"肢体"
],
"character": [],
"core_name": "活动障碍",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "言语障碍",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"饮水"
],
"core_name": "呛咳",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"失禁"
],
"core_name": "大小便",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "发热",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"无"
],
"core_name": "鼻涕",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "畏寒",
"tendency": "否定"
},
{
"anatomy_list": [
"心"
],
"character": [],
"core_name": "心慌",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "憋闷",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "大汗",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"面色"
],
"core_name": "苍白",
"tendency": "否定"
}
] |
20年前患者因受凉后出现咳嗽，咳白色泡沫痰，无咯血，无活动后喘累，无胸痛、胸闷，无潮热、盗汗，无发热、寒颤，无夜间阵发性呼吸困难，无双下肢水肿。 | 624 | [
{
"anatomy_list": [],
"character": [
"受凉后"
],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"白色",
"泡沫痰"
],
"core_name": "咳痰",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "咯血",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"活动后"
],
"core_name": "喘累",
"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": [],
"character": [],
"core_name": "潮热",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "盗汗",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "发热",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "寒颤",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"夜间",
"阵发性"
],
"core_name": "呼吸困难",
"tendency": "否定"
},
{
"anatomy_list": [
"双下肢"
],
"character": [],
"core_name": "水肿",
"tendency": "否定"
}
] |
患者平素月经尚规律,初潮12岁,经期7天,周期30天,lmp2019-06-23,经量中等,无明显痛经。 | 42 | [
{
"anatomy_list": [],
"character": [
"规律",
"初潮12岁"
],
"core_name": "月经",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"中等"
],
"core_name": "经量",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"明显"
],
"core_name": "痛经",
"tendency": "否定"
}
] |
无发热、盗汗、咯血、胸闷、胸痛、心悸、双下肢水肿等，来我院就诊，门诊以“慢性阻塞性肺疾病伴有急性加重”收入院。 | 191 | [
{
"anatomy_list": [],
"character": [],
"core_name": "发热",
"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": [
"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": [
"双下肢"
],
"character": [],
"core_name": "水肿",
"tendency": "否定"
},
{
"anatomy_list": [
"肺"
],
"character": [
"慢性",
"阻塞性",
"急性加重"
],
"core_name": "肺疾病",
"tendency": ""
}
] |
患者自起病以来，精神可，胃纳可，大便次数增多，小便如常，体重下降5kg。 | 1,195 | [
{
"anatomy_list": [],
"character": [
"可"
],
"core_name": "精神",
"tendency": ""
},
{
"anatomy_list": [
"胃"
],
"character": [
"可"
],
"core_name": "胃纳",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"次数增多"
],
"core_name": "大便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"如常"
],
"core_name": "小便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "体重下降",
"tendency": ""
}
] |
于2017-4-12至某肿瘤医院行纤支镜检查提示：（右肺上叶刷片）查见腺癌细胞。 | 777 | [
{
"anatomy_list": [
"右肺上叶"
],
"character": [],
"core_name": "腺癌细胞",
"tendency": ""
}
] |
2、双肺散在感染；右肺中叶支气管扩张，以“冠心病？”收入我科进一步治疗。 | 266 | [
{
"anatomy_list": [
"双肺"
],
"character": [
"散在"
],
"core_name": "感染",
"tendency": ""
},
{
"anatomy_list": [
"右肺中叶",
"支气管"
],
"character": [],
"core_name": "扩张",
"tendency": ""
},
{
"anatomy_list": [
"心"
],
"character": [],
"core_name": "冠心病",
"tendency": "不确定"
}
] |
3月余前患者无明显诱因发现左乳下方约1cm*1cm大小包块，活动度稍差，质地较硬，无红肿、压痛，表面皮肤无破溃，无乳头渗血渗液、无发热乏力，无咳嗽咳痰，无胸闷胸痛，无四肢疼痛，未予以重视。 | 386 | [
{
"anatomy_list": [
"左乳下方"
],
"character": [
"活动度稍差",
"质地较硬"
],
"core_name": "包块",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "红肿",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "压痛",
"tendency": "否定"
},
{
"anatomy_list": [
"表面皮肤"
],
"character": [],
"core_name": "破溃",
"tendency": "否定"
},
{
"anatomy_list": [
"乳头"
],
"character": [],
"core_name": "渗血",
"tendency": "否定"
},
{
"anatomy_list": [
"乳头"
],
"character": [],
"core_name": "渗液",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "发热",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "乏力",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "咳嗽",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "咳痰",
"tendency": "否定"
},
{
"anatomy_list": [
"胸"
],
"character": [],
"core_name": "胸闷",
"tendency": "否定"
},
{
"anatomy_list": [
"胸"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [
"四肢"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
}
] |
患者自身无特殊不适，无畏寒、发热，无皮肤黏膜出血,无咳嗽、咳痰及咽痛，无胸闷、气促，无晕厥及意识障碍。 | 1,729 | [
{
"anatomy_list": [],
"character": [],
"core_name": "畏寒",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "发热",
"tendency": "否定"
},
{
"anatomy_list": [
"皮肤黏膜"
],
"character": [],
"core_name": "出血",
"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": [
"咽"
],
"character": [],
"core_name": "疼痛",
"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": "晕厥",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "意识障碍",
"tendency": "否定"
}
] |
入院前 1年,患者于“某医院”发现“肺癌”,后至我院行“化疗”,4小时前,患者突发呼之不应,呼吸急促,伴口吐白沫、四肢抽搐,双眼向上凝视,无大小便失禁 ,未经治疗,家属呼120急诊入院,急诊以“意识障碍待诊”收入我科。 | 1 | [
{
"anatomy_list": [
"肺"
],
"character": [],
"core_name": "癌",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"突发"
],
"core_name": "呼之不应",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "呼吸急促",
"tendency": ""
},
{
"anatomy_list": [
"口"
],
"character": [],
"core_name": "口吐白沫",
"tendency": ""
},
{
"anatomy_list": [
"四肢"
],
"character": [],
"core_name": "抽搐",
"tendency": ""
},
{
"anatomy_list": [
"双眼"
],
"character": [
"向上"
],
"core_name": "凝视",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"失禁"
],
"core_name": "大小便",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "意识障碍",
"tendency": "不确定"
}
] |
半月后疑为胆囊结石，遂在腹腔镜下行胆囊切除术。 | 329 | [
{
"anatomy_list": [
"胆囊"
],
"character": [],
"core_name": "结石",
"tendency": "不确定"
}
] |
1+月前患者受凉后咳嗽、咳白痰，自行予以“止咳”治疗症状无缓解，就诊于某医院输液治疗（具体不详），症状稍缓解，诉活动后气促、喘累。 | 193 | [
{
"anatomy_list": [],
"character": [
"受凉后"
],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"白痰",
"受凉后"
],
"core_name": "咳痰",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"活动后"
],
"core_name": "气促",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"活动后"
],
"core_name": "喘累",
"tendency": ""
}
] |
1周前患者上述症状加重，伴气促，无呕血及黑便，为进一步诊治，今日来我院就诊，门诊以“贫血待诊”收入我科。 | 773 | [
{
"anatomy_list": [],
"character": [],
"core_name": "气促",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "呕血",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "黑便",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "贫血",
"tendency": ""
}
] |
此后反复于我科予以输血治疗，未再行化疗；之后多处因贫血于我科输血改善贫血治疗。 | 87 | [
{
"anatomy_list": [],
"character": [],
"core_name": "贫血",
"tendency": ""
}
] |
头颅mr：1.双侧额叶、侧脑室周围少许缺血灶。 | 1,612 | [
{
"anatomy_list": [
"双侧额叶",
"侧脑室周围"
],
"character": [
"少许"
],
"core_name": "缺血灶",
"tendency": ""
}
] |
2、肝内散在小结节影，囊肿？遂以“肺部病灶待诊”收治入院。 | 1,075 | [
{
"anatomy_list": [
"肝内"
],
"character": [
"散在",
"小"
],
"core_name": "结节影",
"tendency": ""
},
{
"anatomy_list": [
"肝内"
],
"character": [],
"core_name": "囊肿",
"tendency": "不确定"
},
{
"anatomy_list": [
"肺部"
],
"character": [],
"core_name": "病灶",
"tendency": "不确定"
}
] |
结合患者病史考虑淋巴结转移，病情进展，遂于2014-09-25、2014-10-28、2014-11-25、2014-12-22、2015-01-21行“吉西他滨1000mg d1，d8”方案化疗，化疗后患者左锁骨上锁骨上包块稍有缩小，化疗副反应较小，于2015.5.12在超声引导下行左颈部颈部转移转移性肿瘤放射性粒子植入术，术后患者一般情况可。 | 306 | [
{
"anatomy_list": [
"淋巴结"
],
"character": [],
"core_name": "转移",
"tendency": "不确定"
},
{
"anatomy_list": [
"左锁骨上"
],
"character": [
"化疗后",
"稍"
],
"core_name": "包块缩小",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"较小"
],
"core_name": "化疗副反应",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"可"
],
"core_name": "一般情况",
"tendency": ""
}
] |
入院2天前患者右侧小腿湿疹处挠破皮后右小腿突发红肿、胀痛，疼痛为阵发性，可耐受。 | 1,788 | [
{
"anatomy_list": [
"右侧小腿"
],
"character": [],
"core_name": "湿疹",
"tendency": ""
},
{
"anatomy_list": [
"右侧小腿"
],
"character": [
"挠"
],
"core_name": "破皮",
"tendency": ""
},
{
"anatomy_list": [
"右小腿"
],
"character": [
"突发"
],
"core_name": "红肿",
"tendency": ""
},
{
"anatomy_list": [
"右小腿"
],
"character": [
"可耐受",
"阵发性"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"右小腿"
],
"character": [
"胀痛"
],
"core_name": "疼痛",
"tendency": ""
}
] |
1年前患者无明显诱因出现右侧胸痛，呈阵发性隐痛，持续性加重，咳嗽加重，故于某医院就诊呼吸科，行肺部穿刺活检涂片结果示：找到癌细胞（腺癌），后转胸外科行胸腔镜手术，术中见右肺上、中、下叶及胸壁、膈肌广泛播散粟粒样结节，右肺中叶前段一结节，质硬，大小约2*2cm,与心包脂肪脂肪垫粘连密切，右肺下叶后基底段一结节，质硬，大小约1*2cm。 | 958 | [
{
"anatomy_list": [
"右侧胸"
],
"character": [
"阵发性隐痛",
"持续性加重"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"加重"
],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [
"细胞"
],
"character": [
"腺癌"
],
"core_name": "癌",
"tendency": ""
},
{
"anatomy_list": [
"右肺上中下叶"
],
"character": [
"广泛",
"播散",
"粟粒样"
],
"core_name": "结节",
"tendency": ""
},
{
"anatomy_list": [
"胸壁"
],
"character": [
"广泛",
"播散",
"粟粒样"
],
"core_name": "结节",
"tendency": ""
},
{
"anatomy_list": [
"膈肌"
],
"character": [
"广泛",
"播散",
"粟粒样"
],
"core_name": "结节",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"质硬",
"与心包脂肪脂肪垫粘连密切"
],
"core_name": "结节",
"tendency": ""
},
{
"anatomy_list": [
"右肺下叶后基底段"
],
"character": [
"质硬"
],
"core_name": "结节",
"tendency": ""
}
] |
左室壁运动弥漫性减弱，左室收缩功能减退。 | 471 | [
{
"anatomy_list": [
"左室壁"
],
"character": [
"弥漫性"
],
"core_name": "运动减弱",
"tendency": ""
},
{
"anatomy_list": [
"左室"
],
"character": [
"减退"
],
"core_name": "收缩功能减退",
"tendency": ""
}
] |
患者气道狭窄诊断明确，于2019年12月6日镇静镇痛+喉罩下行支气管镜检查+气道介入治疗，镜下诊断声门下至气管中下段可见多发新生物，活检钳清理、冷冻，针形电刀电切、激光消融、apc治疗，于2019年12月10日镇痛镇定下行坏死清理术，术后患者喘累症状明显好转，于2019-12-12在我院行tp方案化疗一周期（多西他赛120mg+奈达铂120mg），于2020-1-3日镇静镇痛+喉罩下行支气管镜检查+气道介入治疗，镜下诊断：声门下至气管中下段可见多发新生物、apc治疗，于2020-1-6镇痛镇定下行坏死清理术，建议患者到当地某医院行全身治疗，目前患者无明显呼吸困难，无痰中带血，今为求化疗来我院门诊就诊，门诊以“肺癌 气道鳞癌”收入我科。 | 835 | [
{
"anatomy_list": [
"气道"
],
"character": [],
"core_name": "狭窄",
"tendency": ""
},
{
"anatomy_list": [
"声门下至气管中下段"
],
"character": [
"多发"
],
"core_name": "新生物",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"明显好转"
],
"core_name": "喘累",
"tendency": ""
},
{
"anatomy_list": [
"声门下至气管中下段"
],
"character": [
"多发"
],
"core_name": "新生物",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"明显"
],
"core_name": "呼吸困难",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"带血"
],
"core_name": "咳痰",
"tendency": "否定"
},
{
"anatomy_list": [
"肺"
],
"character": [],
"core_name": "癌",
"tendency": ""
},
{
"anatomy_list": [
"气道"
],
"character": [],
"core_name": "鳞癌",
"tendency": ""
}
] |
半天前于我院常规体检，行乳腺彩超示：1.左乳极低回声结节，考虑纤维腺瘤可能；2.双乳乳管样回声，考虑扩张乳管可能；3.双侧乳腺增生。bi-radsⅢ级。 | 325 | [
{
"anatomy_list": [
"左乳"
],
"character": [
"极低回声"
],
"core_name": "结节",
"tendency": ""
},
{
"anatomy_list": [
"左乳"
],
"character": [
"纤维"
],
"core_name": "腺瘤",
"tendency": "不确定"
},
{
"anatomy_list": [
"双乳"
],
"character": [
"乳管样"
],
"core_name": "回声",
"tendency": ""
},
{
"anatomy_list": [
"乳管"
],
"character": [],
"core_name": "扩张",
"tendency": "不确定"
},
{
"anatomy_list": [
"双侧乳腺"
],
"character": [],
"core_name": "增生",
"tendency": ""
}
] |
15天前患者再次因受凉后出现咳嗽、咳白色黏痰，无痰中带血，伴活动后喘累、反酸、嗳气、腹胀不适，无发热、畏寒、寒战，无潮热、盗汗、胸痛、咯血，无端坐呼吸、夜间阵发性呼吸困难，无双下肢水肿。 | 627 | [
{
"anatomy_list": [],
"character": [
"受凉后"
],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"白色",
"粘"
],
"core_name": "咳痰",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"带血"
],
"core_name": "咳痰",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"活动后"
],
"core_name": "喘累",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "返酸",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "嗳气",
"tendency": ""
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "腹胀",
"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": "寒颤",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "潮热",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "盗汗",
"tendency": "否定"
},
{
"anatomy_list": [
"胸"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "咯血",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "端坐呼吸",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"夜间",
"阵发性"
],
"core_name": "呼吸困难",
"tendency": "否定"
},
{
"anatomy_list": [
"双下肢"
],
"character": [],
"core_name": "水肿",
"tendency": "否定"
}
] |
于2015-01-05到某医院，完善相关检查“胸部ct(256层)(2016-01-05):1.双肺下叶基底段炎性病变，请随访复查 2.右肺中叶纤维灶，右侧斜裂胸膜增厚 3.右肺门结节影，淋巴结肿大？建议结合增强ct检查 4.纵隔多发淋巴结淋巴结增大 5.右侧少量胸腔胸腔积液，双侧胸膜增厚；胸部增强ct(256层)(2016-01-09):1、右肺下叶炎性病变，建议治疗后复查 2、左肺上叶纤维灶 3、气管前间隙、主肺动脉窗、后心膈角及双侧肺门见多发肿大淋巴结，右肺门软组织软组织影，肿瘤性病变不能除外，建议进一步检查 4、右侧胸腔少量积液 5、心包积液 6、扫描范围胰腺后方淋巴结淋巴结肿大；纤支镜检查见右肺开口处可见粘膜下有隆起，表面光滑，右肺中叶支气管中叶支气管管腔呈外压性狭窄，表面光滑，表面凹凸不平，未见充血水肿及新生物，肺灌洗液找抗酸杆菌：阴性，肺灌洗液培养：正常菌群生长，纤支镜刷检：送检刷片见大量纤毛柱状上皮和少量炎症细胞，送检灌洗液涂片见大量柱状上皮，少量组织细胞和炎症细胞，部分细胞轻度异型；经皮肺穿刺活检：肉芽肿炎，活检组织抗酸杆菌染色阴性”，诊断“1、右肺门病灶待查？2、双侧肺炎”，给予抗炎治疗（具体不详），症状缓解，为求进一步治疗，遂到某医院胸外科住院治疗，诊断为“1、右肺、右侧胸壁、右纵膈慢性肉芽肿性炎2、双肺肺炎”，于2016-02-01在全麻下胸腔镜下行右肺病损切除术，右侧胸壁结节切除术，右纵膈淋巴结纵膈淋巴结切除术，好转后出院，出院时ct（某医院 2016-02-11）示：右下肺术后，右肺部分缺如，残余右肺感染，右侧胸腔积液并包裹，右侧胸腔局部少许积气，左侧胸腔少量积液。 | 660 | [
{
"anatomy_list": [
"双肺下叶基底段"
],
"character": [
"炎性"
],
"core_name": "病变",
"tendency": ""
},
{
"anatomy_list": [
"右肺中叶"
],
"character": [],
"core_name": "纤维灶",
"tendency": ""
},
{
"anatomy_list": [
"右侧斜裂胸膜"
],
"character": [],
"core_name": "增厚",
"tendency": ""
},
{
"anatomy_list": [
"右肺门"
],
"character": [],
"core_name": "结节影",
"tendency": ""
},
{
"anatomy_list": [
"肺门淋巴结"
],
"character": [],
"core_name": "肿大",
"tendency": "不确定"
},
{
"anatomy_list": [
"纵隔淋巴结"
],
"character": [
"多发"
],
"core_name": "增大",
"tendency": ""
},
{
"anatomy_list": [
"右胸腔"
],
"character": [
"少量"
],
"core_name": "积液",
"tendency": ""
},
{
"anatomy_list": [
"双侧胸膜"
],
"character": [],
"core_name": "增厚",
"tendency": ""
},
{
"anatomy_list": [
"右肺下叶"
],
"character": [
"炎性"
],
"core_name": "病变",
"tendency": ""
},
{
"anatomy_list": [
"左肺上叶"
],
"character": [],
"core_name": "纤维灶",
"tendency": ""
},
{
"anatomy_list": [
"气管前间隙淋巴结"
],
"character": [
"多发"
],
"core_name": "肿大",
"tendency": ""
},
{
"anatomy_list": [
"主肺动脉窗淋巴结"
],
"character": [
"多发"
],
"core_name": "肿大",
"tendency": ""
},
{
"anatomy_list": [
"后心膈角淋巴结"
],
"character": [
"多发"
],
"core_name": "肿大",
"tendency": ""
},
{
"anatomy_list": [
"双侧肺门角淋巴结"
],
"character": [
"多发"
],
"core_name": "肿大",
"tendency": ""
},
{
"anatomy_list": [
"右肺门"
],
"character": [],
"core_name": "软组织影",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"正常"
],
"core_name": "菌群生长",
"tendency": ""
},
{
"anatomy_list": [
"右肺门"
],
"character": [
"肿瘤性"
],
"core_name": "病变",
"tendency": "不确定"
},
{
"anatomy_list": [
"右侧胸腔"
],
"character": [
"少量"
],
"core_name": "积液",
"tendency": "不确定"
},
{
"anatomy_list": [
"心包"
],
"character": [],
"core_name": "积液",
"tendency": ""
},
{
"anatomy_list": [
"胰腺后方淋巴结"
],
"character": [],
"core_name": "肿大",
"tendency": ""
},
{
"anatomy_list": [
"右肺开口处"
],
"character": [
"表面光滑"
],
"core_name": "隆起",
"tendency": ""
},
{
"anatomy_list": [
"右肺中叶支气管"
],
"character": [
"外压性",
"光滑",
"凹凸不平",
"未见充血水肿",
"未见新生物"
],
"core_name": "狭窄",
"tendency": ""
},
{
"anatomy_list": [
"纤毛柱状上皮",
"细胞"
],
"character": [
"少量",
"大量"
],
"core_name": "炎症细胞",
"tendency": ""
},
{
"anatomy_list": [
"柱状上皮",
"组织细胞",
"部分细胞"
],
"character": [
"少量",
"大量",
"轻度异型"
],
"core_name": "部分细胞轻度异型",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "肉芽肿炎",
"tendency": ""
},
{
"anatomy_list": [
"右肺门"
],
"character": [],
"core_name": "病灶",
"tendency": ""
},
{
"anatomy_list": [
"双侧肺"
],
"character": [],
"core_name": "肺炎",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"缓解"
],
"core_name": "症状",
"tendency": ""
},
{
"anatomy_list": [
"右肺"
],
"character": [
"慢性",
"肉芽肿性"
],
"core_name": "右肺炎",
"tendency": ""
},
{
"anatomy_list": [
"右侧胸壁"
],
"character": [
"慢性",
"肉芽肿性"
],
"core_name": "右侧胸壁炎",
"tendency": ""
},
{
"anatomy_list": [
"右纵膈"
],
"character": [
"慢性",
"肉芽肿性"
],
"core_name": "右纵隔炎",
"tendency": ""
},
{
"anatomy_list": [
"双肺"
],
"character": [],
"core_name": "肺炎",
"tendency": ""
},
{
"anatomy_list": [
"右下肺"
],
"character": [
"术后"
],
"core_name": "术后",
"tendency": ""
},
{
"anatomy_list": [
"右肺"
],
"character": [
"部分"
],
"core_name": "缺如",
"tendency": ""
},
{
"anatomy_list": [
"右肺"
],
"character": [
"残余"
],
"core_name": "感染",
"tendency": ""
},
{
"anatomy_list": [
"右侧胸腔"
],
"character": [
"包裹"
],
"core_name": "积液",
"tendency": ""
},
{
"anatomy_list": [
"右侧胸腔"
],
"character": [
"局部",
"少许"
],
"core_name": "积气",
"tendency": ""
},
{
"anatomy_list": [
"左侧胸腔"
],
"character": [
"少量"
],
"core_name": "积液",
"tendency": ""
}
] |
诊断为“弥漫大b细胞淋巴瘤iv期 b组”，于某医院血液科给予r-chop方案行全身化疗8周期（具体时间及药物剂量不详），化疗期间及化疗后无明显胃肠道反应、神经毒性、骨髓抑制等毒副症状。 | 1,070 | [
{
"anatomy_list": [
"淋巴"
],
"character": [
"弥漫性",
"大B细胞"
],
"core_name": "瘤",
"tendency": ""
},
{
"anatomy_list": [
"胃肠道"
],
"character": [
"明显",
"化疗期间",
"化疗后"
],
"core_name": "胃肠道反应",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"明显",
"化疗期间",
"化疗后"
],
"core_name": "神经毒性",
"tendency": "否定"
},
{
"anatomy_list": [
"骨髓"
],
"character": [
"明显",
"化疗期间",
"化疗后"
],
"core_name": "骨髓抑制",
"tendency": "否定"
}
] |
06月27日、07月25日及8月15日行dp方案化疗3周期（多西他赛220mg+卡铂1200mg），09.16复查胸部ct提示纵膈淋巴结稍增大，故于2017.09.17、2017.10.10、2017.11.09、2017.12.13、2018.01.16更换化疗方案为dp（多西他赛590mg，顺铂600mg），化疗期间及化疗后无明显胃肠道反、骨髓抑制等毒副症状。 | 1,940 | [
{
"anatomy_list": [
"纵膈淋巴结"
],
"character": [
"稍"
],
"core_name": "增大",
"tendency": ""
},
{
"anatomy_list": [
"胃",
"肠"
],
"character": [
"明显",
"化疗后",
"化疗期间"
],
"core_name": "胃肠道反应",
"tendency": "否定"
},
{
"anatomy_list": [
"骨髓"
],
"character": [
"明显",
"化疗后",
"化疗期间"
],
"core_name": "骨髓抑制",
"tendency": "否定"
}
] |
患者 1天 前无明显诱因下开始出现 腹部 疼痛 ， 疼痛呈胀痛伴阵发性加重 ， 无放射痛 。 | 396 | [
{
"anatomy_list": [
"腹部"
],
"character": [
"疼痛呈胀痛",
"伴阵发性加重"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"腹部"
],
"character": [
"放射痛"
],
"core_name": "疼痛",
"tendency": "否定"
}
] |
于6月24日给予第3疗程“阿扎胞苷”方案化疗，多次复查血常规未见血象恢复，后长期于我科输血维持治疗。 | 1,740 | [
{
"anatomy_list": [],
"character": [
"恢复"
],
"core_name": "血象",
"tendency": "否定"
}
] |
放疗后于04月16日起给予dp方案化疗3周期（药物总量：多西他赛360mg，奈达铂360mg），2019-07-03给予gp方案化疗1周期（药物总量：吉西他滨1.4g d1、d8，洛铂60mg），过程顺利，患者无恶心、呕吐等特殊不适。 | 1,106 | [
{
"anatomy_list": [],
"character": [],
"core_name": "恶心",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "呕吐",
"tendency": "否定"
}
] |
病检回示：左侧前颅底颅眶沟通腺样囊性癌（实体型）。 | 420 | [
{
"anatomy_list": [
"左侧前颅底"
],
"character": [
"颅眶沟通",
"腺样囊性",
"实体型"
],
"core_name": "癌",
"tendency": ""
}
] |
4于月前患者无明显诱因出现肝区隐痛，为间断性疼痛，活动后可稍缓解，无乏力纳差，无恶心呕吐，无咳嗽咳痰，患者自诉食用水果等食物之后出现腹泻，每天4-6次，为黄色稀便，患者遂到当地医院就诊，查肝功异常：alt/ast10.23/15.4715.47U/L，tb/db 22.14/2.102.10umol/L，腹部彩超提示：肝硬化、脾大、门脉高压，胆囊壁粗糙前光滑，上腹部ct提示：肝硬化，肝右叶低密度结节：1.血管瘤？小肝癌？其他？2.脾脏明显增大，3.胆囊见高密度影，胆囊结石可能大，遂到我科就诊，完善腹部mr（2013-9-17）：腹部mr增强 1.肝硬化，少量腹水，脾大，门脉高压，侧枝循环开放。 | 61 | [
{
"anatomy_list": [
"肝区"
],
"character": [
"隐痛",
"间断性",
"活动后可稍缓解"
],
"core_name": "疼痛",
"tendency": ""
},
{
"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": "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": [
"食用水果等食物之后",
"黄色",
"稀便"
],
"core_name": "腹泻",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "肝功能异常",
"tendency": ""
},
{
"anatomy_list": [
"肝"
],
"character": [],
"core_name": "硬化",
"tendency": ""
},
{
"anatomy_list": [
"脾"
],
"character": [],
"core_name": "脾大",
"tendency": ""
},
{
"anatomy_list": [
"门脉"
],
"character": [],
"core_name": "门脉高压",
"tendency": ""
},
{
"anatomy_list": [
"胆囊壁"
],
"character": [],
"core_name": "欠光滑",
"tendency": ""
},
{
"anatomy_list": [
"胆囊壁"
],
"character": [],
"core_name": "粗糙",
"tendency": ""
},
{
"anatomy_list": [
"肝"
],
"character": [],
"core_name": "硬化",
"tendency": ""
},
{
"anatomy_list": [
"肝右叶"
],
"character": [
"低密度"
],
"core_name": "结节",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "血管瘤",
"tendency": "不确定"
},
{
"anatomy_list": [
"肝"
],
"character": [
"小"
],
"core_name": "癌",
"tendency": "不确定"
},
{
"anatomy_list": [
"脾脏"
],
"character": [
"明显"
],
"core_name": "增大",
"tendency": ""
},
{
"anatomy_list": [
"胆囊"
],
"character": [
"高"
],
"core_name": "密度影",
"tendency": ""
},
{
"anatomy_list": [
"胆囊"
],
"character": [],
"core_name": "结石",
"tendency": "不确定"
},
{
"anatomy_list": [
"肝"
],
"character": [],
"core_name": "硬化",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"少量"
],
"core_name": "腹水",
"tendency": ""
},
{
"anatomy_list": [
"脾"
],
"character": [],
"core_name": "脾大",
"tendency": ""
},
{
"anatomy_list": [
"门脉"
],
"character": [],
"core_name": "门脉高压",
"tendency": ""
},
{
"anatomy_list": [
"侧支循环"
],
"character": [],
"core_name": "侧支循环开放",
"tendency": ""
}
] |