text
stringlengths 5
708
| id
int64 1
2.07k
| event
list |
|---|---|---|
化疗期间无骨髓抑制，；无胃肠道反应，。 | 121 | [
{
"anatomy_list": [
"骨髓"
],
"character": [],
"core_name": "骨髓抑制",
"tendency": "否定"
},
{
"anatomy_list": [
"胃肠道"
],
"character": [],
"core_name": "胃肠道反应",
"tendency": "否定"
}
] |
脾脏血管瘤为软组织肿瘤，免疫组化支持血管肉瘤。 | 1,015 | [
{
"anatomy_list": [
"脾脏"
],
"character": [
"血管"
],
"core_name": "瘤",
"tendency": ""
},
{
"anatomy_list": [
"脾脏"
],
"character": [
"软组织"
],
"core_name": "肿瘤",
"tendency": ""
},
{
"anatomy_list": [
"血管"
],
"character": [],
"core_name": "肉瘤",
"tendency": ""
}
] |
患者入院前2月无明显诱因出现巩膜黄染，尿液颜色加深，如浓茶色，伴全身皮肤瘙痒，无发热，无腰部疼痛及酱油色小便，大便稀糊状，不成形，暗褐色，无陶土样大便，稍感乏力，但不影响生活及工作，无厌油，无纳差，无腹胀，无腹围增大，无鼻腔及牙龈出血，无肝区疼痛，无肩部疼痛，到某医院就诊，行上腹部mr提示：肝门部占位并胆管梗阻。 | 209 | [
{
"anatomy_list": [
"巩膜"
],
"character": [],
"core_name": "黄染",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"颜色加深",
"浓茶色"
],
"core_name": "尿液",
"tendency": ""
},
{
"anatomy_list": [
"全身皮肤"
],
"character": [],
"core_name": "瘙痒",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "发热",
"tendency": "否定"
},
{
"anatomy_list": [
"腰部"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"酱油色"
],
"core_name": "小便",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"稀糊状",
"不成形",
"暗褐色"
],
"core_name": "大便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"陶土样"
],
"core_name": "大便",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"稍感"
],
"core_name": "乏力",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "厌油",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "纳差",
"tendency": "否定"
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "腹胀",
"tendency": "否定"
},
{
"anatomy_list": [
"腹"
],
"character": [
"增大"
],
"core_name": "腹围",
"tendency": "否定"
},
{
"anatomy_list": [
"鼻腔"
],
"character": [],
"core_name": "出血",
"tendency": "否定"
},
{
"anatomy_list": [
"牙龈"
],
"character": [],
"core_name": "出血",
"tendency": "否定"
},
{
"anatomy_list": [
"肝区"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [
"肩部"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [
"肝门"
],
"character": [],
"core_name": "占位",
"tendency": ""
},
{
"anatomy_list": [
"胆管"
],
"character": [],
"core_name": "梗阻",
"tendency": ""
}
] |
口服吉非替尼2周左右自行停止服用及停止止痛药物，服用中草药治疗，1周前，患者全身多处疼痛，较前加重，主要为胸背部及双侧髂骨，再次口服羟考酮缓释片 30mg q12h止痛处理，伴多汗，间断喘累不适，偶有咳嗽、咳痰，自诉数天前痰中带血，无发热，无头晕、头痛，为求进一步治疗，遂至我院就诊，门诊以“肺癌”收入我科。 | 780 | [
{
"anatomy_list": [
"全身多处",
"胸背部及双侧髂骨"
],
"character": [
"较前加重"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "多汗",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"间断"
],
"core_name": "喘累",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"偶有"
],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"偶有"
],
"core_name": "咳痰",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"带血"
],
"core_name": "咳痰",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "发热",
"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": [
"肺"
],
"character": [],
"core_name": "癌",
"tendency": ""
}
] |
患者此次患病以来精神食欲欠佳，大便正常，感尿频尿急，睡眠每日约2-3小时，长期口服中药帮助睡眠，有感活动后喘累、气促，体力逐渐下降，长期发现下午下肢水肿，近来感双侧腰腰部酸痛体力，体重无明显改变。 | 1,835 | [
{
"anatomy_list": [],
"character": [
"欠佳"
],
"core_name": "精神",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"欠佳"
],
"core_name": "食欲",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"正常"
],
"core_name": "大便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "尿急",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "尿频",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"活动后"
],
"core_name": "喘累",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"活动后"
],
"core_name": "气促",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"逐渐"
],
"core_name": "体力下降",
"tendency": ""
},
{
"anatomy_list": [
"下肢"
],
"character": [
"下午"
],
"core_name": "水肿",
"tendency": ""
},
{
"anatomy_list": [
"双侧腰部"
],
"character": [
"酸痛"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "体力活动",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"明显"
],
"core_name": "体重改变",
"tendency": "否定"
}
] |
入院前1+年，患者无明显诱因出现发热，伴咳嗽咳痰，咳白色粘痰，量少，无畏寒寒战，伴头昏、乏力，活动后心累气促，伴牙龈和口腔黏膜溃疡，无皮下瘀斑、瘀点，无肉眼血尿，无呕血、黑便、便血，无视力障碍，无耳鸣，无头疼、恶心、呕吐，意识障碍，无畏寒、发热，无鼻塞、流涕，无咽痛，无腹痛、腹泻，无肛周疼痛，无尿频、尿急、尿痛，无骨关节关节疼痛，患者到某医院就诊，查血常规提示白细胞增高，血红蛋白及血小板降低，进一步完善相关检查诊断“急性白血病m5”，未见相关报告，给予5周期全身化疗（具体方案不详），半年前行自体移植（具体不详），移植术后具体情况不详；2月前，患者家属诉复查血常规提示白细胞增高、贫血、血小板减少（未见报告），给予输血对症治疗，近2月反复出现间断发热，体温情况不详，伴轻微咳嗽咳痰，痰少，患者于当地医院输液对症处理（具体情况不详），2月前患者出现头昏、乏力，无视物旋转，黑朦，伴活动后喘累不适，进行性加重，平素日常活动受限，无端坐呼吸，无夜间阵发性呼吸困难，无呕血黑便，无肉眼血尿，无牙龈出血，无鼻出血，铜梁区大庙镇中心卫生院：血常规：白细胞数5.4*10^9/L;血红蛋白43g/L;血小板数8*10^9/L，我院骨髓涂片：考虑急性髓细胞白血病m5复发。 | 2,042 | [
{
"anatomy_list": [],
"character": [],
"core_name": "发热",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"白色",
"粘性",
"量少"
],
"core_name": "咳痰",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "畏寒",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "寒颤",
"tendency": "否定"
},
{
"anatomy_list": [
"头"
],
"character": [],
"core_name": "头昏",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "乏力",
"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": [
"牙龈",
"口腔"
],
"character": [
"黏膜"
],
"core_name": "溃疡",
"tendency": ""
},
{
"anatomy_list": [
"皮下"
],
"character": [],
"core_name": "瘀斑",
"tendency": "否定"
},
{
"anatomy_list": [
"皮下"
],
"character": [],
"core_name": "瘀点",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "血尿",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "呕血",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "黑便",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "便血",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "视力障碍",
"tendency": "否定"
},
{
"anatomy_list": [
"耳"
],
"character": [],
"core_name": "耳鸣",
"tendency": "否定"
},
{
"anatomy_list": [
"头"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "恶心",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "呕吐",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "意识障碍",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "畏寒",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "发热",
"tendency": "否定"
},
{
"anatomy_list": [
"鼻"
],
"character": [],
"core_name": "鼻塞",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "流涕",
"tendency": "否定"
},
{
"anatomy_list": [
"咽"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "腹泻",
"tendency": "否定"
},
{
"anatomy_list": [
"肛周"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "尿频",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "尿急",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "尿痛",
"tendency": "否定"
},
{
"anatomy_list": [
"骨关节"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"急性",
"m5"
],
"core_name": "白血病",
"tendency": ""
},
{
"anatomy_list": [
"白细胞"
],
"character": [],
"core_name": "白细胞增高",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "血红蛋白降低",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "血小板降低",
"tendency": ""
},
{
"anatomy_list": [
"白细胞"
],
"character": [],
"core_name": "白细胞增高",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"减少"
],
"core_name": "血小板",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "贫血",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"反复间断"
],
"core_name": "发热",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"情况不详"
],
"core_name": "体温",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"轻微"
],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"量少"
],
"core_name": "咳痰",
"tendency": ""
},
{
"anatomy_list": [
"头"
],
"character": [],
"core_name": "头昏",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "乏力",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "黑朦",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "视物旋转",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"活动后",
"进行性加重"
],
"core_name": "喘累",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"平素日常"
],
"core_name": "活动受限",
"tendency": ""
},
{
"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": [],
"character": [],
"core_name": "呕血",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "黑便",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "血尿",
"tendency": "否定"
},
{
"anatomy_list": [
"牙龈"
],
"character": [],
"core_name": "出血",
"tendency": "否定"
},
{
"anatomy_list": [
"鼻"
],
"character": [],
"core_name": "出血",
"tendency": "否定"
},
{
"anatomy_list": [
"髓细胞"
],
"character": [
"急性",
"复发",
"m5"
],
"core_name": "白血病",
"tendency": ""
}
] |
患者6年前诊断高血压病后长期服用阿司匹林肠溶片，每日100mg治疗。 | 1,972 | [
{
"anatomy_list": [],
"character": [],
"core_name": "高血压",
"tendency": ""
}
] |
患者于 5+年 前无意中发现右肩背部肿物，初发时包块大小 约为 2*2cm，边界清，活动可，无压痛。 | 2,029 | [
{
"anatomy_list": [
"右肩背部"
],
"character": [],
"core_name": "肿物",
"tendency": ""
},
{
"anatomy_list": [
"右肩背部"
],
"character": [
"边界清",
"活动可",
"无压痛"
],
"core_name": "包块",
"tendency": ""
}
] |
入院前1天，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，无明显咳痰，活动后稍气促，以爬坡或上楼时明显，活动耐力无明显下降，无发热，无畏寒、寒战，不伴潮热、盗汗，无头痛、咯血，无心悸、胸痛，无恶心、呕吐，无腹痛、腹泻、便血，无颜面及下肢水肿，为进一步治疗遂入我院，我科遂以“咳嗽待诊”收入住院治疗。 | 136 | [
{
"anatomy_list": [],
"character": [
"受凉后",
"阵发性"
],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"高调金属声样"
],
"core_name": "咳嗽",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"鸡鸣样"
],
"core_name": "咳嗽",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"明显"
],
"core_name": "咳痰",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"活动后",
"稍",
"爬坡或上楼时明显"
],
"core_name": "气促",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"明显"
],
"core_name": "活动耐力下降",
"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": "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": [
"头"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "咯血",
"tendency": "否定"
},
{
"anatomy_list": [
"心"
],
"character": [],
"core_name": "心悸",
"tendency": "否定"
},
{
"anatomy_list": [
"胸"
],
"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"
},
{
"anatomy_list": [],
"character": [],
"core_name": "便血",
"tendency": "否定"
},
{
"anatomy_list": [
"颜面"
],
"character": [],
"core_name": "水肿",
"tendency": "否定"
},
{
"anatomy_list": [
"下肢"
],
"character": [],
"core_name": "水肿",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "咳嗽",
"tendency": ""
}
] |
1年前于当地医院检查示：隐血++，6天前患者于当地医院门诊查尿常规示：尿隐血+++，未进行任何治疗，今为进一步诊治，遂至我院门诊就诊，门诊检查提示：隐血+，红细胞形态为非均一型（100%异常红细胞），细菌476.4/ul，尿微量白蛋白 35.6mg/L，尿肌酐 27.3mmol/L，尿α1微球蛋白24.89mg/L，泌尿系彩超未见明显异常，门诊以“血尿原因待查：尿路感染？”收治入科。 | 294 | [
{
"anatomy_list": [
"尿道"
],
"character": [],
"core_name": "感染",
"tendency": "不确定"
}
] |
患病以来，精神、食欲、睡眠欠佳，大便正常，小便如上述，体重无明显变化。 | 143 | [
{
"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": [
"正常"
],
"core_name": "大便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"正常"
],
"core_name": "小便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"明显"
],
"core_name": "体重变化",
"tendency": "否定"
}
] |
左侧腹膜后团块影，fdg代谢增高，倾向于转移。 | 166 | [
{
"anatomy_list": [
"左侧腹膜后"
],
"character": [
"团块"
],
"core_name": "团块影",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"代谢增高"
],
"core_name": "fdg",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "转移",
"tendency": "不确定"
}
] |
１４小时前，患者出现排尿困难，不能排出小便，伴下腹部胀痛，无双下肢水肿，随就诊于我院，门诊以“肺结核”收治入院。 | 984 | [
{
"anatomy_list": [],
"character": [],
"core_name": "排尿困难",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"不能"
],
"core_name": "排出小便",
"tendency": ""
},
{
"anatomy_list": [
"下腹部"
],
"character": [
"胀痛"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"双下肢"
],
"character": [],
"core_name": "水肿",
"tendency": "否定"
},
{
"anatomy_list": [
"肺"
],
"character": [],
"core_name": "结核",
"tendency": ""
}
] |
第1次入院经过入院5+月前患儿因"发热,头痛伴反复呕吐10天,加重1天"于2016年08月01日入院,诊断为1.右侧小脑占位性病变海绵状血管瘤,2.梗阻性脑积水,3.支气管肺炎入院,于2015-08-01行左侧脑室外引流术（储液囊）,术予以予以止血、补液等治疗,2015年08月04日行后颅窝肿瘤切除术,术后营养神经、止血、预防感染、营养支持支持治疗,于2015年08月13日行腰大池引流术。 | 12 | [
{
"anatomy_list": [],
"character": [],
"core_name": "发热",
"tendency": ""
},
{
"anatomy_list": [
"头"
],
"character": [],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"反复"
],
"core_name": "呕吐",
"tendency": ""
},
{
"anatomy_list": [
"右侧小脑"
],
"character": [
"占位性"
],
"core_name": "病变",
"tendency": ""
},
{
"anatomy_list": [
"右侧小脑血管"
],
"character": [
"海绵状"
],
"core_name": "瘤",
"tendency": ""
},
{
"anatomy_list": [
"脑"
],
"character": [
"梗阻性"
],
"core_name": "积水",
"tendency": ""
},
{
"anatomy_list": [
"支气管",
"肺"
],
"character": [],
"core_name": "支气管肺炎",
"tendency": ""
}
] |
无畏寒、发热，无午后潮热、盗汗，双下肢无明显疼痛、麻木、乏力等不适。 | 238 | [
{
"anatomy_list": [],
"character": [],
"core_name": "畏寒",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "发热",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"午后"
],
"core_name": "潮热",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "盗汗",
"tendency": "否定"
},
{
"anatomy_list": [
"双下肢"
],
"character": [
"明显"
],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [
"双下肢"
],
"character": [
"明显"
],
"core_name": "麻木",
"tendency": "否定"
},
{
"anatomy_list": [
"双下肢"
],
"character": [
"明显"
],
"core_name": "乏力",
"tendency": "否定"
}
] |
患者本次发病以来，食欲正常， 神志清醒，精神尚可，睡眠欠佳，大便2次每日，小便如上述，体重无明显变化。 | 1,699 | [
{
"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": [
"欠佳"
],
"core_name": "睡眠",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"2次每日"
],
"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"
}
] |
10+年患者反复在受凉后出现咳嗽、咳痰、气促，咳白色粘痰，多在受凉及冬春季节加重，每次持续1-2月，到当地诊所予以“抗感染、化痰”等对症治疗（具体不详）后可好转，当时无发热、畏寒。 | 2,009 | [
{
"anatomy_list": [],
"character": [
"反复",
"在受凉后出现"
],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"反复",
"在受凉后出现"
],
"core_name": "咳痰",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "气促",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"白色",
"粘痰",
"多在受凉及冬春季节加重",
"每次持续1-2月"
],
"core_name": "咳痰",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "发热",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "畏寒",
"tendency": "否定"
}
] |
患者于2017-5-2就诊某医院，建议予以二线化疗，今日患者再次返院化疗，门诊以“升结肠癌术后复发化疗”收入我科。 | 1,936 | [
{
"anatomy_list": [
"升结肠"
],
"character": [
"术后",
"复发",
"化疗"
],
"core_name": "癌",
"tendency": ""
}
] |
入院前1月，患者出现右上腹隐痛，阵发性，可忍受，伴肩部放射痛；有乏力，不影响正常工作及生活；无厌油，无恶心、呕吐，食欲无影响。 | 109 | [
{
"anatomy_list": [
"右上腹"
],
"character": [
"阵发性",
"隐痛",
"可忍受"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"肩部"
],
"character": [
"放射痛"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "乏力",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "厌油",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "恶心",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "呕吐",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"无影响"
],
"core_name": "食欲",
"tendency": ""
}
] |
病程中反复出现呕血、黑便，在我科对症治疗后可好转。 | 858 | [
{
"anatomy_list": [],
"character": [
"反复出现"
],
"core_name": "呕血",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"反复出现"
],
"core_name": "黑便",
"tendency": ""
}
] |
诊断为“类风湿性关节炎”，予以“来氟米特片20mg po. qd、甲氨蝶呤片 7.5mg po. qd、叶酸片 5MG po qd、洛索洛芬钠片 60mg po tid”。建议患者治疗后随访。 | 552 | [
{
"anatomy_list": [
"关节"
],
"character": [
"类风湿性"
],
"core_name": "关节炎",
"tendency": ""
}
] |
院外感纳差、消瘦，饱食后有恶心呕吐不适，无发热、腹痛腹胀、腹泻不适，无皮肤巩膜黄染，当地医院查血示肝功能异常、甲胎蛋白增高。 | 1,369 | [
{
"anatomy_list": [],
"character": [],
"core_name": "纳差",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "消瘦",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"饱食后"
],
"core_name": "恶心",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"饱食后"
],
"core_name": "呕吐",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "发热",
"tendency": "否定"
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "腹胀",
"tendency": "否定"
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "腹泻",
"tendency": "否定"
},
{
"anatomy_list": [
"皮肤"
],
"character": [],
"core_name": "黄染",
"tendency": "否定"
},
{
"anatomy_list": [
"巩膜"
],
"character": [],
"core_name": "黄染",
"tendency": "否定"
},
{
"anatomy_list": [
"肝"
],
"character": [],
"core_name": "肝功异常",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "甲胎蛋白增高",
"tendency": ""
}
] |
3.双肺下叶多个结节，结合胸部检查。 | 1,542 | [
{
"anatomy_list": [
"双肺下叶"
],
"character": [
"多个"
],
"core_name": "结节",
"tendency": ""
}
] |
患者术后先后给予化疗4次，现患者术后恢复可，返院行术后第5次化疗，门诊以“横结肠癌术后化疗”收入我科。 | 810 | [
{
"anatomy_list": [
"横结肠"
],
"character": [
"术后化疗"
],
"core_name": "癌",
"tendency": ""
}
] |
直肠后方肿块影，考虑转移可能性大，侵犯直肠壁。 | 1,847 | [
{
"anatomy_list": [
"直肠后方"
],
"character": [],
"core_name": "肿块影",
"tendency": ""
},
{
"anatomy_list": [
"直肠后方"
],
"character": [],
"core_name": "转移",
"tendency": "不确定"
},
{
"anatomy_list": [
"直肠壁"
],
"character": [],
"core_name": "侵犯",
"tendency": ""
}
] |
手术顺利，术后病检：（食管）腺鳞癌鳞癌（低分化低分化腺癌成分约占60%，低分化鳞癌约占40%），肿瘤侵犯至食管壁外膜，未见明确癌栓及肿瘤侵犯神经，胃组织无癌，上下切缘切缘净。 | 509 | [
{
"anatomy_list": [
"食管"
],
"character": [],
"core_name": "腺鳞癌",
"tendency": ""
},
{
"anatomy_list": [
"食管"
],
"character": [
"低分化"
],
"core_name": "腺癌",
"tendency": ""
},
{
"anatomy_list": [
"食管"
],
"character": [
"低分化"
],
"core_name": "鳞癌",
"tendency": ""
},
{
"anatomy_list": [
"食管壁外膜"
],
"character": [
"侵犯"
],
"core_name": "肿瘤",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"明确"
],
"core_name": "癌栓",
"tendency": "否定"
},
{
"anatomy_list": [
"神经"
],
"character": [
"侵犯"
],
"core_name": "肿瘤",
"tendency": "否定"
},
{
"anatomy_list": [
"胃组织"
],
"character": [],
"core_name": "癌",
"tendency": "否定"
}
] |
术后恢复可，于5月前返院行第一次化疗，后顺利出院，院外无恶心、呕吐、腹痛等不适，现患者入院拟行6次化疗，门诊以“右半结肠非霍奇金氏淋巴瘤（弥漫大b细胞型）根治术后”收入我科。 | 1,009 | [
{
"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": [
"右半结肠",
"淋巴"
],
"character": [
"弥漫性",
"大B细胞"
],
"core_name": "瘤",
"tendency": ""
},
{
"anatomy_list": [
"右半结肠",
"淋巴"
],
"character": [
"非霍奇金氏"
],
"core_name": "瘤",
"tendency": ""
}
] |
3年余前，患者无明显诱因出现左侧胸部疼痛，为阵发性刺痛，吸气及咳嗽时明显，行胸部ct示：左肺癌切除术后改变，及同侧胸腔包裹性积液改变，纵膈小淋巴结显示，于某医院行pet/ct（2011-10-22）提示:1.左肺癌术后；2.近左下肺肺门处结节状状高密度高密度影，fdg代谢增高，考虑炎性增生；3.左侧胸膜增厚并胸腔积液。 | 302 | [
{
"anatomy_list": [
"左侧胸部"
],
"character": [
"阵发性刺痛",
"吸气及咳嗽时明显"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"左肺"
],
"character": [
"左肺癌切除"
],
"core_name": "术后改变",
"tendency": ""
},
{
"anatomy_list": [
"同侧胸腔"
],
"character": [
"包裹性"
],
"core_name": "积液",
"tendency": ""
},
{
"anatomy_list": [
"纵膈小淋巴结"
],
"character": [],
"core_name": "显示",
"tendency": ""
},
{
"anatomy_list": [
"左肺"
],
"character": [
"术后"
],
"core_name": "癌",
"tendency": ""
},
{
"anatomy_list": [
"近左下肺门"
],
"character": [
"结节状",
"高"
],
"core_name": "密度影",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"代谢增高"
],
"core_name": "fdg",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"炎性"
],
"core_name": "增生",
"tendency": "不确定"
},
{
"anatomy_list": [
"左侧胸膜"
],
"character": [],
"core_name": "增厚",
"tendency": ""
},
{
"anatomy_list": [
"胸腔"
],
"character": [],
"core_name": "积液",
"tendency": ""
}
] |
为进一步治疗，今日到我科就诊，查“肝功：谷丙转氨酶560U/L，谷草转氨酶710U/L，谷酰转肽酶183U/L，碱性磷酸酶173U/L；肾功示尿酸687umol/L；血常规：白细胞计数：12.4*10^9/L，中性粒细胞百分比：57.8%，c反应蛋白：75.9mg/L”，门诊以“肺结核，药物性肝炎”收入我科住院治疗。 | 1,894 | [
{
"anatomy_list": [
"肺"
],
"character": [],
"core_name": "结核",
"tendency": ""
},
{
"anatomy_list": [
"肝"
],
"character": [
"药物性"
],
"core_name": "肝炎",
"tendency": ""
}
] |
曾多次在我院呼吸科住院,诊断“慢性支气管炎伴肺气肿”,给予对症治疗后病情缓解。 | 38 | [
{
"anatomy_list": [
"支气管"
],
"character": [
"慢性"
],
"core_name": "支气管炎",
"tendency": ""
},
{
"anatomy_list": [
"肺"
],
"character": [],
"core_name": "肺气肿",
"tendency": ""
}
] |
患者自起病以来，精神可，食欲欠佳，睡眠可，大小便可，体重未见明显下降。 | 720 | [
{
"anatomy_list": [],
"character": [
"可"
],
"core_name": "精神",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"欠佳"
],
"core_name": "食欲",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"可"
],
"core_name": "睡眠",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"可"
],
"core_name": "大小便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"明显"
],
"core_name": "体重下降",
"tendency": "否定"
}
] |
患病以来，精神、食欲、睡眠尚可，大小便正常，体重无明显变化。 | 1,152 | [
{
"anatomy_list": [],
"character": [
"尚可"
],
"core_name": "精神",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"尚可"
],
"core_name": "食欲",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"尚可"
],
"core_name": "睡眠",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"正常"
],
"core_name": "大便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"正常"
],
"core_name": "小便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"明显"
],
"core_name": "体重改变",
"tendency": "否定"
}
] |
1周来自觉左侧乳腺肿块逐渐增大，今日为求进一步诊疗而来我院，门诊以“乳房肿物”收入我科。 | 498 | [
{
"anatomy_list": [
"左侧乳腺"
],
"character": [
"逐渐",
"增大"
],
"core_name": "肿块增大",
"tendency": ""
},
{
"anatomy_list": [
"乳房"
],
"character": [],
"core_name": "肿物",
"tendency": ""
}
] |
2.子宫肌瘤可能，请随诊或mr检查。 | 1,618 | [
{
"anatomy_list": [
"子宫"
],
"character": [],
"core_name": "肌瘤",
"tendency": "不确定"
}
] |
患者男，因“大便性状改变5月，伴腹痛1月，便血2周”入院，于2015-09-14全麻腹腔镜下行直肠癌根治术，手术顺利，术后安返病房，术后病理结果：2015-9-21 组织病理学检查报告：（直肠）溃疡型中分化管状腺癌（含粘液腺癌成份），侵及肠壁全层，两切缘未见癌累及，肠壁淋巴结未见癌转移（0/11）。 | 715 | [
{
"anatomy_list": [],
"character": [
"性状改变"
],
"core_name": "大便",
"tendency": ""
},
{
"anatomy_list": [
"腹部"
],
"character": [],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "便血",
"tendency": ""
},
{
"anatomy_list": [
"直肠"
],
"character": [
"溃疡型",
"中分化",
"管状",
"含粘液腺癌成份",
"侵及肠壁全层"
],
"core_name": "腺癌",
"tendency": ""
},
{
"anatomy_list": [
"肠壁切缘"
],
"character": [
"累及"
],
"core_name": "癌",
"tendency": "否定"
},
{
"anatomy_list": [
"肠壁淋巴结"
],
"character": [
"转移"
],
"core_name": "癌",
"tendency": "否定"
}
] |
于2016-08-11行（左）乳癌保乳术，术后恢复看可，术后予tc方案化疗3次，化疗过程顺利，未出现明显化疗副反应。 | 129 | [
{
"anatomy_list": [],
"character": [
"明显"
],
"core_name": "化疗副反应",
"tendency": "否定"
}
] |
5天前，患者因受凉后出现上述症状加重，咳嗽次数频繁，咳痰色白呈泡沫状，不易咳出，稍微活动则气促，伴下腹部胀痛，疼痛剧烈时汗出，疼痛无转移，自行在药店购买药物口服治疗（具体不详），下腹部胀痛缓解。 | 2,013 | [
{
"anatomy_list": [],
"character": [
"次数频繁"
],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"白色",
"泡沫状",
"不易咳出"
],
"core_name": "咳痰",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"稍微活动"
],
"core_name": "气促",
"tendency": ""
},
{
"anatomy_list": [
"下腹部"
],
"character": [
"剧烈时出汗",
"胀痛",
"无转移"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"下腹部"
],
"character": [
"缓解",
"胀痛"
],
"core_name": "疼痛",
"tendency": ""
}
] |
患者自发病以来， 精神可 ， 食欲一般 ， 睡眠可 ， 大便如常 ， 小便如常 ， 体重无明显变化 。 | 1,364 | [
{
"anatomy_list": [],
"character": [
"可"
],
"core_name": "精神",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"一般"
],
"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"
}
] |
化疗后于外院随访血常规提示ii度骨髓抑制，未行特殊治疗，肝肾功能未见明显异常，现第1次化疗后19天，轻微口腔溃疡，偶有腹部串气样疼痛，轻微腹胀，走路时有下腹坠胀坠胀感，无手足麻木，无畏寒、发热、恶心、呕吐、咳嗽、关节疼痛、心慌气短等不适，全身无淤血淤斑、皮疹，无阴道阴道流血等症状，今来院要求行第二次化疗，门诊以“卵巢高级别浆液性癌iiic期第1次化疗后”收入院。 | 1,863 | [
{
"anatomy_list": [
"骨髓"
],
"character": [
"ii度"
],
"core_name": "骨髓抑制",
"tendency": ""
},
{
"anatomy_list": [
"肝"
],
"character": [
"明显"
],
"core_name": "肝功能异常",
"tendency": "否定"
},
{
"anatomy_list": [
"肾"
],
"character": [
"明显"
],
"core_name": "肾功能异常",
"tendency": "否定"
},
{
"anatomy_list": [
"口腔"
],
"character": [
"轻微"
],
"core_name": "溃疡",
"tendency": ""
},
{
"anatomy_list": [
"腹部"
],
"character": [
"串气样",
"偶有"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"腹"
],
"character": [
"轻微"
],
"core_name": "腹胀",
"tendency": ""
},
{
"anatomy_list": [
"下腹"
],
"character": [
"走路时"
],
"core_name": "坠胀感",
"tendency": ""
},
{
"anatomy_list": [
"手",
"足"
],
"character": [],
"core_name": "麻木",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "畏寒",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "发热",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "恶心",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "呕吐",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "咳嗽",
"tendency": "否定"
},
{
"anatomy_list": [
"关节"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [
"心"
],
"character": [],
"core_name": "心慌",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "气短",
"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": [
"阴道"
],
"character": [],
"core_name": "出血",
"tendency": "否定"
},
{
"anatomy_list": [
"卵巢"
],
"character": [
"高级别",
"浆液性",
"第1次化疗后",
"iiic期"
],
"core_name": "癌",
"tendency": ""
}
] |
入院前4+小时，患者晨起时无明显诱因出现恶心、呕吐，呕吐物约300ml咖啡色胃内容物，同时出现大便失禁，解少许黑色稀大便，伴头晕，自觉发热（未测体温），伴腹痛、腹胀、纳差，无胸闷、心悸、胸痛，无意识障碍，无咳嗽、咳痰等。 | 818 | [
{
"anatomy_list": [],
"character": [],
"core_name": "恶心",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"呕吐物约300ml咖啡色胃内容物"
],
"core_name": "呕吐",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"失禁"
],
"core_name": "大便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"少许",
"黑色",
"稀便"
],
"core_name": "大便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"失禁"
],
"core_name": "大便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"失禁"
],
"core_name": "小便",
"tendency": ""
},
{
"anatomy_list": [
"头"
],
"character": [],
"core_name": "头晕",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "发热",
"tendency": ""
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "腹胀",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "纳差",
"tendency": ""
},
{
"anatomy_list": [
"胸"
],
"character": [],
"core_name": "胸闷",
"tendency": "否定"
},
{
"anatomy_list": [
"心"
],
"character": [],
"core_name": "心悸",
"tendency": "否定"
},
{
"anatomy_list": [
"胸"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "意识障碍",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "咳嗽",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "咳痰",
"tendency": "否定"
}
] |
今患者为行进一步诊治就诊于我院，门诊故以“左肾绞痛”收入我科。 | 1,159 | [
{
"anatomy_list": [
"左肾"
],
"character": [
"绞痛"
],
"core_name": "疼痛",
"tendency": ""
}
] |
分别于2019-12-11、2020-1-4、2020-1-31、2020-2-22行静脉化疗，具体化疗方案为：培美曲塞0.8g+洛铂50mg，化疗过程中，患者稍有恶心、反酸，予以对症处理后好转。 | 1,816 | [
{
"anatomy_list": [],
"character": [
"稍有"
],
"core_name": "恶心",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"稍有"
],
"core_name": "返酸",
"tendency": ""
}
] |
起初咳痰困难，后逐渐咳白色粘痰，伴声音嘶哑、咽喉疼痛，吞咽时更为明显，同时伴有鼻塞。 | 369 | [
{
"anatomy_list": [],
"character": [
"困难"
],
"core_name": "咳痰",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"白色",
"粘性"
],
"core_name": "咳痰",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "声音嘶哑",
"tendency": ""
},
{
"anatomy_list": [
"咽",
"喉"
],
"character": [
"吞咽时更为明显"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "鼻塞",
"tendency": ""
}
] |
<吻合口切缘，另一侧切缘，环周切缘，盆腔左侧壁与肿瘤粘连组织袋>未见癌累及。 | 1,785 | [
{
"anatomy_list": [
"盆腔左侧壁"
],
"character": [
"累及"
],
"core_name": "癌",
"tendency": "否定"
},
{
"anatomy_list": [
"吻合口切缘"
],
"character": [
"累及"
],
"core_name": "癌",
"tendency": "否定"
},
{
"anatomy_list": [
"环周切缘"
],
"character": [
"累及"
],
"core_name": "癌",
"tendency": "否定"
},
{
"anatomy_list": [
"组织袋"
],
"character": [
"累及"
],
"core_name": "癌",
"tendency": "否定"
},
{
"anatomy_list": [
"盆腔左侧壁"
],
"character": [
"肿瘤"
],
"core_name": "粘连",
"tendency": ""
}
] |
无发热、寒战，无潮热、盗汗，无胸痛、咯血，无心累、气促，无恶心、呕吐，无腹胀、腹痛。 | 659 | [
{
"anatomy_list": [],
"character": [],
"core_name": "发热",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "寒颤",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "潮热",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "盗汗",
"tendency": "否定"
},
{
"anatomy_list": [
"胸"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "咯血",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "心累",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "气促",
"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": "腹胀",
"tendency": "否定"
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
}
] |
患者自发病以来， 精神稍差 ， 食欲稍差 ， 睡眠欠佳 ， 大便如常 ， 小便如常 ， 体重无明显变化 。 | 399 | [
{
"anatomy_list": [],
"character": [
"稍差"
],
"core_name": "精神",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"稍差"
],
"core_name": "食欲",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"欠佳"
],
"core_name": "睡眠",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"如常"
],
"core_name": "大便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"如常"
],
"core_name": "小便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"明显"
],
"core_name": "体重变化",
"tendency": "否定"
}
] |
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。 | 318 | [
{
"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": "体重变化",
"tendency": "否定"
}
] |
4.右肺中叶及左肺下小结节影，fdg代谢未见异常增高，建议随访观察。 | 1,905 | [
{
"anatomy_list": [
"右肺中叶及左肺下叶"
],
"character": [
"小"
],
"core_name": "结节影",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"异常增高"
],
"core_name": "fdg代谢",
"tendency": "否定"
}
] |
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 。 | 107 | [
{
"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1周，患者不明诱因出现活动后气短，爬坡上楼明显，休息缓解，间断有咳嗽，咯少许白色粘痰，无胸痛及放射痛，无胸闷、心悸，无夜间阵发性呼吸困难及端坐呼吸，无发热，无咯血及咯黄痰等，于外院体检心电图提示：窦性心律，t波改变，遂进一步在我院门诊就诊，查冠脉cta：左回旋支近段管壁可见非钙化斑块，管腔轻度狭窄。 | 265 | [
{
"anatomy_list": [],
"character": [
"活动后",
"爬坡上楼明显",
"休息缓解"
],
"core_name": "气短",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"间断"
],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"少许",
"白色",
"粘性"
],
"core_name": "咳痰",
"tendency": ""
},
{
"anatomy_list": [
"胸"
],
"character": [],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"放射性"
],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [
"胸"
],
"character": [],
"core_name": "胸闷",
"tendency": "否定"
},
{
"anatomy_list": [
"心"
],
"character": [],
"core_name": "心悸",
"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": "发热",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "咯血",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"黄色"
],
"core_name": "咳痰",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "t波改变",
"tendency": ""
},
{
"anatomy_list": [
"左回旋支近段管壁"
],
"character": [
"非钙化"
],
"core_name": "斑块",
"tendency": ""
},
{
"anatomy_list": [
"左回旋支近段管腔"
],
"character": [
"轻度"
],
"core_name": "狭窄",
"tendency": ""
}
] |
1周前患者无明显诱因出现大便困难，肛门坠胀，无便血、黑便、腹泻等，无恶心、呕吐、腹胀、畏寒、发热，遂在当地诊所予以药物治疗（具体用药不详）无明显好转。 | 1,871 | [
{
"anatomy_list": [],
"character": [],
"core_name": "大便困难",
"tendency": ""
},
{
"anatomy_list": [
"肛门"
],
"character": [],
"core_name": "坠胀",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "便血",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "黑便",
"tendency": "否定"
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "腹泻",
"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": "腹胀",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "畏寒",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "发热",
"tendency": "否定"
}
] |
今日患者为进一步诊治就诊于我院门诊，查血压：174/101mmhg，后患者为求进一步诊治，门诊拟“高血压”收入我科。 | 1,429 | [
{
"anatomy_list": [],
"character": [],
"core_name": "高血压",
"tendency": ""
}
] |
5+月前，患者因受凉后出现咳嗽、咳痰，咳白色粘液痰，伴胸痛，以左侧为甚，为持续胀痛，夜间未影响睡眠，无咯血；稍活动即感心累、气促，无恶心、呕吐、发热、寒战，无低热、盗汗等不适，遂再次来我院，完善胸部ct提示肺部包块较前有所增大，故再次予以按tp方案化疗（药物总量为：多西他赛 110mg+奈达铂 120mg）；化疗期间及化疗结束后患者无恶心、呕吐、肢端麻木及骨髓抑制等不适，于2015年11月10日来我院，复查胸部ct提示为肺部包块较前有所增大，故更换化疗方案为gp方案（药物总量为 吉西他滨 3.2g、顺铂 120mg），建议其化疗结束后可到上级医院放疗，但患者本人及家属均拒绝。 | 1,534 | [
{
"anatomy_list": [],
"character": [],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"白色",
"粘液"
],
"core_name": "咳痰",
"tendency": ""
},
{
"anatomy_list": [
"胸"
],
"character": [
"持续胀痛",
"以左侧为甚",
"夜间未影响睡眠"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "咯血",
"tendency": "否定"
},
{
"anatomy_list": [
"心"
],
"character": [
"稍微活动后"
],
"core_name": "心累",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"稍微活动后"
],
"core_name": "气促",
"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": "发热",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "寒颤",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"低"
],
"core_name": "发热",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "盗汗",
"tendency": "否定"
},
{
"anatomy_list": [
"肺部"
],
"character": [
"较前增大"
],
"core_name": "包块",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "恶心",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "呕吐",
"tendency": "否定"
},
{
"anatomy_list": [
"肢端"
],
"character": [],
"core_name": "麻木",
"tendency": "否定"
},
{
"anatomy_list": [
"骨髓"
],
"character": [],
"core_name": "骨髓抑制",
"tendency": "否定"
},
{
"anatomy_list": [
"肺部"
],
"character": [
"较前增大"
],
"core_name": "包块",
"tendency": ""
}
] |
肿瘤位于乙状结肠下段，肿瘤侵出浆膜，大小约5*6cm，并可疑侵犯盆腔左侧壁，剖视肿瘤累及管腔全周，表面溃疡形成，致不全性肠梗阻，系膜内未扪及确切肿大淋巴结。 | 1,783 | [
{
"anatomy_list": [
"乙状结肠下段"
],
"character": [],
"core_name": "肿瘤",
"tendency": ""
},
{
"anatomy_list": [
"浆膜"
],
"character": [
"侵出"
],
"core_name": "肿瘤",
"tendency": ""
},
{
"anatomy_list": [
"盆腔左侧壁"
],
"character": [
"侵犯"
],
"core_name": "肿瘤",
"tendency": "不确定"
},
{
"anatomy_list": [
"管腔全周"
],
"character": [
"累及"
],
"core_name": "肿瘤",
"tendency": ""
},
{
"anatomy_list": [
"管腔全周"
],
"character": [
"表面"
],
"core_name": "溃疡",
"tendency": ""
},
{
"anatomy_list": [
"肠"
],
"character": [
"不完全性"
],
"core_name": "梗阻",
"tendency": ""
},
{
"anatomy_list": [
"系膜内淋巴结"
],
"character": [],
"core_name": "肿大",
"tendency": "否定"
}
] |
宫颈活检：宫颈3点鳞状上皮乳头瘤样增生，建议免疫组化3项协助诊断。 | 1,396 | [
{
"anatomy_list": [
"宫颈3点鳞状上皮"
],
"character": [
"乳头瘤样"
],
"core_name": "增生",
"tendency": ""
}
] |
患者自起病以来，精神可，胃纳略差，大便如常，小便如常，体重未见明显下降。 | 1,757 | [
{
"anatomy_list": [],
"character": [
"可"
],
"core_name": "精神",
"tendency": ""
},
{
"anatomy_list": [
"胃"
],
"character": [
"略差"
],
"core_name": "胃纳",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"如常"
],
"core_name": "大便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"如常"
],
"core_name": "小便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"明显"
],
"core_name": "体重下降",
"tendency": "否定"
}
] |
无腰痛，无尿急、尿痛等，无肉眼血尿，无畏寒发热，未引起患者重视。 | 1,096 | [
{
"anatomy_list": [
"腰"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "尿急",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "尿痛",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "血尿",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "畏寒",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "发热",
"tendency": "否定"
}
] |
患者本次发病以来，食欲减退， 神志清醒，精神尚可，睡眠尚可，大便正常，小便正常，体重无明显变化。 | 205 | [
{
"anatomy_list": [],
"character": [
"减退"
],
"core_name": "食欲",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"清醒"
],
"core_name": "神志",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"尚可"
],
"core_name": "精神",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"尚可"
],
"core_name": "睡眠",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"正常"
],
"core_name": "大便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"正常"
],
"core_name": "小便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"明显"
],
"core_name": "体重变化",
"tendency": "否定"
}
] |
无腹痛、黑便，便后无肛门出血。 | 727 | [
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "黑便",
"tendency": "否定"
},
{
"anatomy_list": [
"肛门"
],
"character": [
"便后"
],
"core_name": "出血",
"tendency": ""
}
] |
入院前6+月患者无明显诱因出现排便、排尿困难，排便无力，大便干结成块状，便后感肛周抽痛。 | 237 | [
{
"anatomy_list": [],
"character": [],
"core_name": "排便困难",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "排尿困难",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "排便无力",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"干结",
"成块状"
],
"core_name": "大便",
"tendency": ""
},
{
"anatomy_list": [
"肛周"
],
"character": [
"便后"
],
"core_name": "抽痛",
"tendency": ""
}
] |
院外多次随访上腹部ct+增强、电子胃镜，未见明显异常。 | 2,052 | [
{
"anatomy_list": [
"上腹部"
],
"character": [
"明显"
],
"core_name": "异常",
"tendency": "否定"
}
] |
2+月前患者无明显诱因出现间断头晕不适，自测血压110-120/60-70mmHg，不伴耳鸣、眩晕、头痛、面红、恶心、呕吐，不伴咳嗽、咳痰、鼻塞、流涕、畏寒、寒战、发热，无胸闷、胸痛、咽部紧缩感、压榨感、肩背部放射痛，无腹痛、腹泻、呕血、黑便、尿频、尿急、尿痛不适。 | 474 | [
{
"anatomy_list": [
"头"
],
"character": [
"间断"
],
"core_name": "头晕",
"tendency": ""
},
{
"anatomy_list": [
"耳"
],
"character": [],
"core_name": "耳鸣",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "眩晕",
"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": [
"面"
],
"character": [],
"core_name": "面红",
"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": [
"鼻"
],
"character": [],
"core_name": "鼻塞",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "流涕",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "畏寒",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "寒颤",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "发热",
"tendency": "否定"
},
{
"anatomy_list": [
"胸"
],
"character": [],
"core_name": "胸闷",
"tendency": "否定"
},
{
"anatomy_list": [
"胸"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [
"咽部"
],
"character": [],
"core_name": "紧缩感",
"tendency": "否定"
},
{
"anatomy_list": [
"咽部"
],
"character": [],
"core_name": "压榨感",
"tendency": "否定"
},
{
"anatomy_list": [
"肩背部"
],
"character": [
"放射性"
],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "腹泻",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "呕血",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "黑便",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "尿频",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "尿急",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "尿痛",
"tendency": "否定"
}
] |
患者于入院前10天无明显诱因出现头晕，呈昏沉感，伴右耳发堵、闷胀感，自觉站立不稳、行走漂浮，伴右侧脑鸣，无视物旋转、恶心、呕吐，无头痛，无复视，无言语不清、饮水呛咳及复视，无肢体麻木、无力及抽搐，无心悸、胸闷、黑蒙，无意识丧失及大小便失禁，症状持续存在，与体位改变无明显相关，于我院门诊行头部ct检查提示双侧基底节区多发腔隙性脑梗塞，予以输液治疗（具体不详），症状缓解不明显，今为求进一步诊治，遂来我院，门诊以“腔隙性脑梗塞”收入我科。 | 1,981 | [
{
"anatomy_list": [
"头"
],
"character": [],
"core_name": "头晕",
"tendency": ""
},
{
"anatomy_list": [
"头"
],
"character": [],
"core_name": "昏沉感",
"tendency": ""
},
{
"anatomy_list": [
"右耳"
],
"character": [],
"core_name": "发堵",
"tendency": ""
},
{
"anatomy_list": [
"右耳"
],
"character": [],
"core_name": "闷胀感",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"不稳"
],
"core_name": "站立",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"漂浮"
],
"core_name": "行走",
"tendency": ""
},
{
"anatomy_list": [
"右侧脑"
],
"character": [],
"core_name": "脑鸣",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "视物旋转",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "恶心",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "呕吐",
"tendency": "否定"
},
{
"anatomy_list": [
"头"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "复视",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "言语不清",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"饮水"
],
"core_name": "呛咳",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "复视",
"tendency": "否定"
},
{
"anatomy_list": [
"肢体"
],
"character": [],
"core_name": "麻木",
"tendency": "否定"
},
{
"anatomy_list": [
"肢体"
],
"character": [],
"core_name": "无力",
"tendency": "否定"
},
{
"anatomy_list": [
"肢体"
],
"character": [],
"core_name": "抽搐",
"tendency": "否定"
},
{
"anatomy_list": [
"心"
],
"character": [],
"core_name": "心悸",
"tendency": "否定"
},
{
"anatomy_list": [
"胸"
],
"character": [],
"core_name": "胸闷",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "黑朦",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "意识丧失",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"失禁"
],
"core_name": "大小便失禁",
"tendency": "否定"
},
{
"anatomy_list": [
"双侧基底节区"
],
"character": [
"多发性",
"腔隙性"
],
"core_name": "脑梗塞",
"tendency": ""
},
{
"anatomy_list": [
"脑"
],
"character": [
"腔隙性"
],
"core_name": "梗塞",
"tendency": ""
}
] |
原始包块：左乳11点钟距乳头约3cm处腺体层内可见一低回声区，范围约2.0*1.5cm，见3个低回声结节，其中一个大小约2.3*1.4cm。 | 82 | [
{
"anatomy_list": [],
"character": [
"原始"
],
"core_name": "包块",
"tendency": ""
},
{
"anatomy_list": [
"左乳11点钟距乳头约3cm处腺体层内"
],
"character": [
"低"
],
"core_name": "回声区",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"低回声",
"3个"
],
"core_name": "结节",
"tendency": ""
}
] |
腋窝淋巴结见癌转移（7/17）。 | 118 | [
{
"anatomy_list": [
"腋窝淋巴结"
],
"character": [
"转移"
],
"core_name": "癌",
"tendency": ""
}
] |
此后患者一周行3次规律透析，未再诉心累气促。 | 1,376 | [
{
"anatomy_list": [
"心"
],
"character": [],
"core_name": "心累",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "气促",
"tendency": "否定"
}
] |
病程中患者无发热，无头晕、头痛，无心慌、乏力、心悸、胸闷、呼吸困难，无黑朦、四肢阙冷、出冷汗等不适。 | 316 | [
{
"anatomy_list": [],
"character": [],
"core_name": "发热",
"tendency": "否定"
},
{
"anatomy_list": [
"头"
],
"character": [],
"core_name": "头晕",
"tendency": "否定"
},
{
"anatomy_list": [
"头"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [
"心"
],
"character": [],
"core_name": "心慌",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "乏力",
"tendency": "否定"
},
{
"anatomy_list": [
"心"
],
"character": [],
"core_name": "心悸",
"tendency": "否定"
},
{
"anatomy_list": [
"胸"
],
"character": [],
"core_name": "胸闷",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "呼吸困难",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "黑朦",
"tendency": "否定"
},
{
"anatomy_list": [
"四肢"
],
"character": [],
"core_name": "阙冷",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"冷"
],
"core_name": "出汗",
"tendency": "否定"
}
] |
全身骨显像、腹部彩超暂未见明确异常。 | 24 | [
{
"anatomy_list": [
"全身骨",
"腹部"
],
"character": [
"明确"
],
"core_name": "异常",
"tendency": "否定"
}
] |
全腹部ct增强：1.脾脏明显增大伴多发低密度低密度结节影，2.腹膜后及双侧腹股沟淋巴结增大。 | 566 | [
{
"anatomy_list": [
"脾脏"
],
"character": [
"增大"
],
"core_name": "增大",
"tendency": ""
},
{
"anatomy_list": [
"脾脏"
],
"character": [
"多发",
"低密度"
],
"core_name": "结节影",
"tendency": ""
},
{
"anatomy_list": [
"腹膜后淋巴结",
"双侧腹股沟淋巴结"
],
"character": [],
"core_name": "增大",
"tendency": ""
}
] |
患儿无发热、咳嗽，无恶心、呕吐，无腹痛、腹泻等不适。 | 1,138 | [
{
"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": "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"
}
] |
骨扫描未见明显异常，提示肿瘤进展，于10.26、11.17行dpf方案化疗2周期（多西他赛100mg+奈达铂100mg+氟尿嘧啶3.75g)，过程顺利，无特殊不适，现为继续化疗，门诊以胃癌收住我科。 | 605 | [
{
"anatomy_list": [
"骨"
],
"character": [
"明显"
],
"core_name": "异常",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"进展"
],
"core_name": "肿瘤",
"tendency": ""
},
{
"anatomy_list": [
"胃"
],
"character": [],
"core_name": "癌",
"tendency": ""
}
] |
今日再次入院拟给予术后第三周期化疗，此次以“手术后恶性肿瘤化学化学治疗”入住我科。 | 1,650 | [
{
"anatomy_list": [],
"character": [
"手术后",
"恶性",
"化学治疗"
],
"core_name": "肿瘤",
"tendency": ""
}
] |
（2018-1-11 我院）电子肠镜：直肠新生物。 | 1,030 | [
{
"anatomy_list": [
"直肠"
],
"character": [],
"core_name": "新生物",
"tendency": ""
}
] |
1余月前患者摔倒后胸痛加重，疼痛范围为双侧胸部及肩背部、颈部，呈持续性胀痛，程度重，近1月体重较少约2kg，余情况同前，至某医院就诊查胸片示：左侧第5肋骨骨折。 | 289 | [
{
"anatomy_list": [
"胸"
],
"character": [
"摔倒后加重"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"双侧胸部",
"肩",
"背部",
"颈部"
],
"character": [
"呈持续性胀痛",
"程度重"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "体重减少",
"tendency": ""
},
{
"anatomy_list": [
"左侧第5肋骨"
],
"character": [],
"core_name": "骨折",
"tendency": ""
}
] |
入院前2月余，患者以“乙状结肠癌”收入我科，完善相关检查，积极术前准备，在全麻下行“腹腔镜辅助下乙状结肠癌根治术”；术后予以抗感染，止血，补液等对症处理，患者病情逐渐好转。 | 1,682 | [
{
"anatomy_list": [
"乙状结肠"
],
"character": [],
"core_name": "癌",
"tendency": ""
}
] |
病人病情恢复可，带管出院，2019-12-11我院局麻下行超选择性肝动脉造影+超选择性肝动脉灌注化疗，术后予以抗感染、护胃、对症支持治疗，术后一直口服靶向药物，定期输入信迪利单抗治疗，5天前患者出现全身乏力，食欲差，无腹痛腹胀等不适，现为求进一步治疗，门诊以“肝癌术后复发”收入我科。 | 394 | [
{
"anatomy_list": [],
"character": [
"全身"
],
"core_name": "乏力",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"差"
],
"core_name": "食欲",
"tendency": ""
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "腹胀",
"tendency": "否定"
},
{
"anatomy_list": [
"肝"
],
"character": [
"术后复发"
],
"core_name": "癌",
"tendency": ""
}
] |
今为进一步治疗遂来我科，门诊以“食管吻合口狭窄”收住入院。 | 204 | [
{
"anatomy_list": [
"食管吻合口"
],
"character": [],
"core_name": "狭窄",
"tendency": ""
}
] |
病程中患者无头痛及头晕，无鼻衄，无咳嗽、咳痰。 | 1,890 | [
{
"anatomy_list": [
"头"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [
"头"
],
"character": [],
"core_name": "头晕",
"tendency": "否定"
},
{
"anatomy_list": [
"鼻"
],
"character": [],
"core_name": "鼻衄",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "咳嗽",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "咳痰",
"tendency": "否定"
}
] |
患者自起病以来，精神可，胃纳可，排便困难，小便如常，体重未见明显下降。 | 334 | [
{
"anatomy_list": [],
"character": [
"可"
],
"core_name": "精神",
"tendency": ""
},
{
"anatomy_list": [
"胃"
],
"character": [
"可"
],
"core_name": "胃纳",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "排便困难",
"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"
}
] |
1周前，患者无诱因出现咳嗽、咳痰，痰为黄色脓痰，无痰中带血丝及咯血，无畏寒、发热。 | 945 | [
{
"anatomy_list": [],
"character": [],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"黄色",
"脓"
],
"core_name": "咳痰",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"带血丝"
],
"core_name": "咳痰",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "咯血",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "畏寒",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "发热",
"tendency": "否定"
}
] |
患者为求进一步治疗，门诊以“左肾肿瘤”收入我科。 | 1,198 | [
{
"anatomy_list": [
"左肾"
],
"character": [],
"core_name": "肿瘤",
"tendency": ""
}
] |
不伴恶心、反酸，无呕吐。 | 555 | [
{
"anatomy_list": [],
"character": [],
"core_name": "恶心",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "反酸",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "呕吐",
"tendency": "否定"
}
] |
上腹部ct示：肝硬化，弥漫再生结节，门脉高压，脾大，腹腔积液，肝右后叶后上段富血供结节，不典型增生结节？早期肝癌？请结合mri检查；胆囊小结石；腹膜后及腹腔内多发肿大淋巴结；左肾盂肾盂输尿管、左肾结石；左肾积水；双肾囊肿”，无畏寒、发热，无咳嗽、咳痰，无胸闷、气促、呼吸困难，无腹胀、腹痛，未特殊治疗，现为进一步诊疗门诊以“肝硬化失代偿期”收入我科住院治疗。 | 653 | [
{
"anatomy_list": [
"肝"
],
"character": [],
"core_name": "硬化",
"tendency": ""
},
{
"anatomy_list": [
"肝"
],
"character": [
"弥漫",
"再生"
],
"core_name": "结节",
"tendency": ""
},
{
"anatomy_list": [
"门脉"
],
"character": [],
"core_name": "门脉高压",
"tendency": ""
},
{
"anatomy_list": [
"脾"
],
"character": [],
"core_name": "脾大",
"tendency": ""
},
{
"anatomy_list": [
"腹腔"
],
"character": [],
"core_name": "积液",
"tendency": ""
},
{
"anatomy_list": [
"肝右后叶后上段"
],
"character": [
"富血供"
],
"core_name": "结节",
"tendency": ""
},
{
"anatomy_list": [
"肝右后叶后上段"
],
"character": [
"不典型增生"
],
"core_name": "结节",
"tendency": "不确定"
},
{
"anatomy_list": [
"肝"
],
"character": [
"早期"
],
"core_name": "癌",
"tendency": "不确定"
},
{
"anatomy_list": [
"胆囊"
],
"character": [
"小"
],
"core_name": "结石",
"tendency": ""
},
{
"anatomy_list": [
"腹膜后淋巴结",
"腹膜内淋巴结"
],
"character": [
"多发"
],
"core_name": "肿大",
"tendency": ""
},
{
"anatomy_list": [
"左肾盂",
"输尿管",
"左肾"
],
"character": [],
"core_name": "结石",
"tendency": ""
},
{
"anatomy_list": [
"左肾"
],
"character": [],
"core_name": "积水",
"tendency": ""
},
{
"anatomy_list": [
"双肾"
],
"character": [],
"core_name": "囊肿",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "畏寒",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "发热",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "咳嗽",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "咳痰",
"tendency": "否定"
},
{
"anatomy_list": [
"胸"
],
"character": [],
"core_name": "胸闷",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "气促",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "呼吸困难",
"tendency": "否定"
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "腹胀",
"tendency": "否定"
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [
"肝"
],
"character": [
"失代偿期"
],
"core_name": "硬化",
"tendency": ""
}
] |
患者腰背部疼痛伴活动受限，明显影响患者生活质量，为进一步治疗，就诊于我科门诊，行腰椎mr：1、腰椎退行性变；腰2-骶1椎间盘膨出。 | 803 | [
{
"anatomy_list": [
"腰背部"
],
"character": [],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"腰背部"
],
"character": [
"明显影响患者生活质量"
],
"core_name": "活动受限",
"tendency": ""
},
{
"anatomy_list": [
"腰椎"
],
"character": [
"退行性"
],
"core_name": "病变",
"tendency": ""
},
{
"anatomy_list": [
"腰2-骶1椎间盘"
],
"character": [],
"core_name": "膨出",
"tendency": ""
}
] |
今日为行放疗来我科，遂以"左 肺鳞癌 "收入我科。 | 615 | [
{
"anatomy_list": [
"左肺"
],
"character": [],
"core_name": "鳞癌",
"tendency": ""
}
] |
体重无明显减轻。 | 264 | [
{
"anatomy_list": [],
"character": [
"明显"
],
"core_name": "体重减轻",
"tendency": "否定"
}
] |
入我院妇科治疗，行腹腔探查术,术中冰冻切片示卵巢低分化腺癌，行全子宫切除＋双侧附件切除＋大网膜切除＋阑尾切除术，术后病理报告：1.（右卵巢）低分化浆液性乳头状囊腺癌，子宫未见癌累及；2.（左卵巢）低分化浆液性乳头状腺癌，左输卵管未见癌累及；3.网膜组织见癌转移。 | 1,121 | [
{
"anatomy_list": [
"卵巢"
],
"character": [
"低分化"
],
"core_name": "腺癌",
"tendency": ""
},
{
"anatomy_list": [
"右卵巢"
],
"character": [
"低分化",
"浆液性",
"乳头状"
],
"core_name": "囊腺癌",
"tendency": ""
},
{
"anatomy_list": [
"左卵巢"
],
"character": [
"低分化",
"浆液性",
"乳头状"
],
"core_name": "腺癌",
"tendency": ""
},
{
"anatomy_list": [
"左输卵管"
],
"character": [
"累及"
],
"core_name": "癌",
"tendency": "否定"
},
{
"anatomy_list": [
"网膜组织"
],
"character": [
"转移"
],
"core_name": "癌",
"tendency": ""
}
] |
3月前，患者无明显诱因出现左侧腰部腰部胀痛，疼痛不剧烈，能忍受，反复出现，能自行缓解，疼痛和体位、活动无关，无尿频尿急及尿末痛，无恶心呕吐，无寒战发热，无肉眼血尿。 | 435 | [
{
"anatomy_list": [
"左侧腰部"
],
"character": [
"胀痛",
"不剧烈",
"能忍受",
"反复出现",
"能自行缓解",
"和体位、活动无关"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "尿频",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "尿急",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"末"
],
"core_name": "尿痛",
"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": "寒颤",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "发热",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "血尿",
"tendency": "否定"
}
] |
入院前1年，患者无明显诱因出现反复咳嗽，伴咯血，以痰中带血为主，量约15ml/日。 | 890 | [
{
"anatomy_list": [],
"character": [
"反复"
],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "咯血",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"带血"
],
"core_name": "咳痰",
"tendency": ""
}
] |
2.左足未见明显异常。 | 585 | [
{
"anatomy_list": [
"左足"
],
"character": [
"明显"
],
"core_name": "异常",
"tendency": "否定"
}
] |
故诊断为“前列腺癌伴骨转移”。 | 1,951 | [
{
"anatomy_list": [
"前列腺"
],
"character": [],
"core_name": "癌",
"tendency": ""
},
{
"anatomy_list": [
"骨"
],
"character": [
"转移"
],
"core_name": "癌",
"tendency": ""
}
] |
入院前3月，患者因诊断为“右侧乳腺癌”。 | 670 | [
{
"anatomy_list": [
"右侧乳腺"
],
"character": [],
"core_name": "癌",
"tendency": ""
}
] |
乳腺钼靶：右乳占位，考虑乳腺ca可能大。 | 1,186 | [
{
"anatomy_list": [
"右乳"
],
"character": [],
"core_name": "占位",
"tendency": ""
},
{
"anatomy_list": [
"乳腺"
],
"character": [],
"core_name": "癌",
"tendency": "不确定"
}
] |
体重下降6kg。 | 901 | [
{
"anatomy_list": [],
"character": [],
"core_name": "体重下降",
"tendency": ""
}
] |
三尖瓣关闭不全（轻度），pasp：35mm。 | 602 | [
{
"anatomy_list": [
"三尖瓣"
],
"character": [
"轻度"
],
"core_name": "关闭不全",
"tendency": ""
}
] |
入院前4+年，患者常规体检行胸部ct提示：右下肺块状软组织密度影，呈分叶状，大小约23.5*30.2mm，考虑肺癌。 | 1,101 | [
{
"anatomy_list": [
"右下肺",
"软组织"
],
"character": [
"块状",
"分叶状"
],
"core_name": "密度影",
"tendency": ""
},
{
"anatomy_list": [
"肺"
],
"character": [],
"core_name": "癌",
"tendency": "不确定"
}
] |
患者后于某中医院行盆腔ct提示骨盆多处骨转移；胸部ct提示双侧胸腔积液、胸椎多处骨质破坏。 | 1,706 | [
{
"anatomy_list": [
"骨盆"
],
"character": [
"多处",
"骨"
],
"core_name": "转移",
"tendency": ""
},
{
"anatomy_list": [
"双侧胸腔"
],
"character": [],
"core_name": "积液",
"tendency": ""
},
{
"anatomy_list": [
"胸椎"
],
"character": [
"多处"
],
"core_name": "骨质破坏",
"tendency": ""
}
] |
3天前患者因受凉，咳嗽、咳痰加重，咳白色泡沫痰，量多，无臭味。 | 443 | [
{
"anatomy_list": [],
"character": [
"因受凉",
"加重"
],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"因受凉",
"加重"
],
"core_name": "咳痰",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"白色",
"泡沫",
"量多",
"无臭味"
],
"core_name": "咳痰",
"tendency": ""
}
] |
患者入院前3月因颈腰椎间盘突出入某医院住院治疗期间行颈部彩超时发现甲状腺右叶包块，不伴声嘶、吞咽困难，不伴低热、盗汗、高热。 | 916 | [
{
"anatomy_list": [
"颈椎间盘"
],
"character": [],
"core_name": "突出",
"tendency": ""
},
{
"anatomy_list": [
"甲状腺右叶"
],
"character": [],
"core_name": "包块",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "声嘶",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "吞咽困难",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"低"
],
"core_name": "发热",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "盗汗",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"高"
],
"core_name": "发热",
"tendency": "否定"
}
] |
2019年2月初患者自觉头昏、乏力不适，患者就诊于某医院并行骨髓等检查（具体报告未见），遂调整伊马替尼为进口达沙替尼治疗控制病情，但头昏、乏力不适改善不明显，多次复查血常规提示白细胞下降不明显，2019年9月30日患者于某医院复查血常规提示：白细胞总数153.11×109/l，红细胞计数2.97×1012/l，血红蛋白88g/L，血小板28×109/l，建议患者住院治疗，因无床患者遂就诊于我院，门诊以“慢性髓细胞白血病”收住入院。 | 1,182 | [
{
"anatomy_list": [
"头"
],
"character": [],
"core_name": "头昏",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "乏力",
"tendency": ""
},
{
"anatomy_list": [
"头"
],
"character": [
"改善明显"
],
"core_name": "头昏",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"改善明显"
],
"core_name": "乏力",
"tendency": "否定"
},
{
"anatomy_list": [
"白细胞"
],
"character": [
"明显"
],
"core_name": "白细胞下降",
"tendency": "否定"
},
{
"anatomy_list": [
"髓细胞"
],
"character": [
"慢性",
"髓细胞"
],
"core_name": "白血病",
"tendency": ""
}
] |