text
stringlengths 5
708
| id
int64 1
2.07k
| event
list |
|---|---|---|
约半年前于我院住院诊断为“脑供血不足”。 | 1,833 | [
{
"anatomy_list": [
"脑"
],
"character": [],
"core_name": "供血不足",
"tendency": ""
}
] |
1年前，患者因血糖控制不佳就诊于我科，完善相关检查，诊断为：“2型糖尿病、糖尿病肾病v期、糖尿病性视网膜病变、糖尿病性周围血管病变、慢性肾衰竭（尿毒症期）、冠状动脉粥样硬化性心脏病、右肺癌伴双肺、胸膜转移、慢性阻塞性肺病、高血压3级很高危、高血压性心脏病、慢性胃炎、颈动脉狭窄”，出院后继续使用：“利格列汀片5mg口服1/日，阿卡波糖片50mg口服3/日，甘精胰岛素注射液34iu皮下1/晚，门冬胰岛素注射液(诺和锐笔芯)12iu皮下1/早、10u皮下1/午、12u皮下1/晚，甘精胰岛素注射液34iu皮下1/晚，”降糖治疗。 | 537 | [
{
"anatomy_list": [],
"character": [
"控制不佳"
],
"core_name": "血糖",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"2型"
],
"core_name": "糖尿病",
"tendency": ""
},
{
"anatomy_list": [
"肾"
],
"character": [
"糖尿病",
"v期"
],
"core_name": "肾病",
"tendency": ""
},
{
"anatomy_list": [
"视网膜"
],
"character": [
"糖尿病性"
],
"core_name": "病变",
"tendency": ""
},
{
"anatomy_list": [
"周围血管"
],
"character": [
"糖尿病性"
],
"core_name": "病变",
"tendency": ""
},
{
"anatomy_list": [
"肾"
],
"character": [
"慢性",
"尿毒症期"
],
"core_name": "肾衰竭",
"tendency": ""
},
{
"anatomy_list": [
"冠状动脉",
"心脏"
],
"character": [
"粥样",
"硬化性"
],
"core_name": "心脏病",
"tendency": ""
},
{
"anatomy_list": [
"右上肺"
],
"character": [],
"core_name": "癌",
"tendency": ""
},
{
"anatomy_list": [
"双肺",
"胸膜"
],
"character": [
"转移"
],
"core_name": "癌",
"tendency": ""
},
{
"anatomy_list": [
"肺"
],
"character": [
"慢性",
"阻塞性"
],
"core_name": "肺病",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"很高危",
"3极"
],
"core_name": "高血压",
"tendency": ""
},
{
"anatomy_list": [
"心脏"
],
"character": [
"高血压性"
],
"core_name": "心脏病",
"tendency": ""
},
{
"anatomy_list": [
"胃"
],
"character": [
"慢性"
],
"core_name": "胃炎",
"tendency": ""
},
{
"anatomy_list": [
"颈动脉"
],
"character": [],
"core_name": "狭窄",
"tendency": ""
}
] |
患者3+年前同房后出现少量阴道流血，未予重视，未予特殊处理。 | 1,577 | [
{
"anatomy_list": [
"阴道"
],
"character": [
"少量",
"同房后"
],
"core_name": "出血",
"tendency": ""
}
] |
2、肝内巨大病灶，考虑转移，与前次ct比较肝内病灶明显增大。 | 595 | [
{
"anatomy_list": [
"肝内"
],
"character": [
"巨大"
],
"core_name": "病灶",
"tendency": ""
},
{
"anatomy_list": [
"肝内"
],
"character": [],
"core_name": "转移",
"tendency": "不确定"
},
{
"anatomy_list": [
"肝内"
],
"character": [
"较前明显增大"
],
"core_name": "病灶",
"tendency": ""
}
] |
患者为进一步明确诊断于2018.07.10在某医院行腰椎穿刺，病理诊断：穿刺（腰椎）见腺癌浸润。 | 1,900 | [
{
"anatomy_list": [
"腰椎"
],
"character": [
"浸润"
],
"core_name": "腺癌",
"tendency": ""
}
] |
患者及家属拒绝行放疗及化疗，拒绝行透析治疗，在我科给予保守治疗后出院；4天前，患者无明显诱因出现活动后喘累，咳嗽、咳痰不明显，不伴咯血、胸痛，无畏寒、发热，为进一步治疗送入我科，遂以“肺癌”收入住院 患者自发病以来，精神、食欲较差，睡眠可，大便如常，小便次数增加，体重减轻约4kg。 | 1,957 | [
{
"anatomy_list": [],
"character": [
"活动后"
],
"core_name": "喘累",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"不明显"
],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"不明显"
],
"core_name": "咳痰",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "咯血",
"tendency": "否定"
},
{
"anatomy_list": [
"胸"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "畏寒",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "发热",
"tendency": "否定"
},
{
"anatomy_list": [
"肺"
],
"character": [],
"core_name": "癌",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"较差"
],
"core_name": "精神",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"较差"
],
"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": [],
"core_name": "尿频",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "体重减轻",
"tendency": ""
}
] |
患病以来，精神、睡眠、食欲可，大小便正常，近期体重下降3Kg。 | 1,228 | [
{
"anatomy_list": [],
"character": [
"可"
],
"core_name": "精神",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"可"
],
"core_name": "睡眠",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"可"
],
"core_name": "食欲",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"正常"
],
"core_name": "小便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"正常"
],
"core_name": "大便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "体重下降",
"tendency": ""
}
] |
为避免病情进一步加重，遂于今日来我院急诊科就诊，急诊科以“上消化道出血”收入我科住院治疗。 | 819 | [
{
"anatomy_list": [
"上消化道"
],
"character": [],
"core_name": "出血",
"tendency": ""
}
] |
远、近端切缘及环周切缘未见癌累及。 | 1,856 | [
{
"anatomy_list": [
"远、近端切缘及环周切缘"
],
"character": [
"累及"
],
"core_name": "癌",
"tendency": "否定"
}
] |
1+年前（2015年7月30日），患者因“左眼卡痛不适3月，肿胀、视力下降2月”于某医院眼科住院治疗，行眼眶ct检查提示：左眼眶左上方见不规则软组织密度。 | 417 | [
{
"anatomy_list": [
"左眼"
],
"character": [
"卡痛不适"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"左眼"
],
"character": [],
"core_name": "肿胀",
"tendency": ""
},
{
"anatomy_list": [
"左眼"
],
"character": [],
"core_name": "视力下降",
"tendency": ""
},
{
"anatomy_list": [
"左眼眶左上方"
],
"character": [
"不规则",
"软组织"
],
"core_name": "密度",
"tendency": ""
}
] |
患者于2016-2-26因“上腹部隐痛不适1年行肠镜检查发现结肠肿块10天”就诊某医院，完善术前检查及准备后，于2016-2-17在全麻下行根治性右半结肠癌切除术+肝十二指肠淋巴结清扫+胆道探查t管引流术，手术顺利，术后恢复可，术后诊断：右半结肠低分化腺癌合并粘液腺癌伴肝十二指肠肠淋巴结淋巴结转移，iv期。 | 1,930 | [
{
"anatomy_list": [
"上腹部"
],
"character": [
"隐痛"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"上腹部"
],
"character": [],
"core_name": "上腹部不适",
"tendency": ""
},
{
"anatomy_list": [
"结肠"
],
"character": [],
"core_name": "肿块",
"tendency": ""
},
{
"anatomy_list": [
"右半结肠"
],
"character": [
"低分化"
],
"core_name": "腺癌",
"tendency": ""
},
{
"anatomy_list": [
"右半结肠"
],
"character": [
"粘液",
"iv期"
],
"core_name": "腺癌",
"tendency": ""
},
{
"anatomy_list": [
"肝淋巴结",
"十二指肠淋巴结"
],
"character": [
"转移",
"iv期"
],
"core_name": "腺癌",
"tendency": ""
}
] |
患者自起病以来，精神、睡眠欠佳，胃纳差，大便正常，小便如上述，体重明显下降（5kg）。 | 1,779 | [
{
"anatomy_list": [],
"character": [
"欠佳"
],
"core_name": "精神",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"欠佳"
],
"core_name": "睡眠",
"tendency": ""
},
{
"anatomy_list": [
"胃"
],
"character": [],
"core_name": "纳差",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"正常"
],
"core_name": "大便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"正常"
],
"core_name": "小便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"明显"
],
"core_name": "体重下降",
"tendency": ""
}
] |
患者本次发病以来，食欲正常， 神志清醒，精神尚可，睡眠尚可，大便正常，小便次数增加，体重无明显变化。 | 2,028 | [
{
"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": [],
"core_name": "尿频",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"明显"
],
"core_name": "体重改变",
"tendency": "否定"
}
] |
患者自发病以来， 精神、食欲、睡眠较差 ， 大小便如常 ， 体重无明显变化 。 | 1,334 | [
{
"anatomy_list": [],
"character": [
"较差"
],
"core_name": "精神",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"较差"
],
"core_name": "食欲",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"较差"
],
"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"
}
] |
入院前6月，患者因无明显诱因出现阴道不规则点滴出血，色鲜红，伴少量阴道流液，无腹痛、腹胀，不伴畏寒发热、咳嗽咳痰、外阴瘙痒，不伴尿频、尿急等不适症状，患者于当地某医院就诊，给予抗感染等治疗（具体不详）治疗1周，当时上述症状稍缓解，此后未再继续治疗，此后每个月仍出现不规则流血、流液症状，量逐渐增多。 | 695 | [
{
"anatomy_list": [
"阴道"
],
"character": [
"不规则",
"色鲜红",
"点滴"
],
"core_name": "出血",
"tendency": ""
},
{
"anatomy_list": [
"阴道"
],
"character": [
"少量"
],
"core_name": "流液",
"tendency": ""
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "腹胀",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "畏寒",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "发热",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "咳嗽",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "咳痰",
"tendency": "否定"
},
{
"anatomy_list": [
"外阴"
],
"character": [],
"core_name": "瘙痒",
"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": [
"阴道"
],
"character": [
"不规则",
"量逐渐增多"
],
"core_name": "出血",
"tendency": ""
},
{
"anatomy_list": [
"阴道"
],
"character": [
"不规则",
"量逐渐增多"
],
"core_name": "流液",
"tendency": ""
}
] |
糖尿病病史5年，自诉经药物治疗后血糖恢复正常，已停药，血糖未正规监测。 | 1,964 | [
{
"anatomy_list": [],
"character": [
"5年"
],
"core_name": "糖尿病",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"恢复正常"
],
"core_name": "血糖",
"tendency": ""
}
] |
患者本次发病以来，无进食，神志清醒，精神尚可，睡眠尚可，大便如上述，小便正常，近1年体重减少约10kg。 | 1,992 | [
{
"anatomy_list": [],
"character": [
"无"
],
"core_name": "进食",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"清醒"
],
"core_name": "神志",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"尚可"
],
"core_name": "精神",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"尚可"
],
"core_name": "睡眠",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"正常"
],
"core_name": "大便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"正常"
],
"core_name": "小便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "体重减轻",
"tendency": ""
}
] |
末次月经：2016年07月13日，经期约8天，量较前增多，色鲜红，无痛经。 | 93 | [
{
"anatomy_list": [],
"character": [
"较前增多"
],
"core_name": "经量",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"色鲜红"
],
"core_name": "月经",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "痛经",
"tendency": "否定"
}
] |
入院前15+月，患者于某妇幼保健院体检行（2018-6-7）乳腺彩超示：1、双乳乳腺轻度增生（bi-rads分类：2类）。 | 577 | [
{
"anatomy_list": [
"双乳乳腺"
],
"character": [
"轻度",
"bi-rads分类：2类"
],
"core_name": "增生",
"tendency": ""
}
] |
半天前患者性交后出现右下腹胀痛，平卧位减轻，无明显加重趋势，有肛门坠胀，无阴道阴道流血、流液，无畏寒、发热，无头晕、头痛，无恶心、呕吐，无心悸、胸闷，无尿频、尿急、尿痛等不适。 | 466 | [
{
"anatomy_list": [
"右下腹"
],
"character": [
"胀痛",
"平卧位减轻",
"无明显加重趋势"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"肛门"
],
"character": [],
"core_name": "坠胀",
"tendency": ""
},
{
"anatomy_list": [
"阴道"
],
"character": [],
"core_name": "出血",
"tendency": "否定"
},
{
"anatomy_list": [
"阴道"
],
"character": [],
"core_name": "流液",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "畏寒",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "发热",
"tendency": "否定"
},
{
"anatomy_list": [
"头"
],
"character": [],
"core_name": "头晕",
"tendency": "否定"
},
{
"anatomy_list": [
"头"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "恶心",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "呕吐",
"tendency": "否定"
},
{
"anatomy_list": [
"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": "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"
}
] |
今为求进一步放疗，门诊以“乳腺癌”收入我科住院治疗。 | 1,765 | [
{
"anatomy_list": [
"乳腺"
],
"character": [],
"core_name": "癌",
"tendency": ""
}
] |
于我院胸外科行化疗4次，化疗过程中有白细胞降低、恶心、食欲减差、腹泻症状，予以抑酸护胃、升白细胞等治疗后好转。 | 202 | [
{
"anatomy_list": [
"白细胞"
],
"character": [],
"core_name": "白细胞降低",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "恶心",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"减差"
],
"core_name": "食欲",
"tendency": ""
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "腹泻",
"tendency": ""
}
] |
查体左侧颊部见一核桃大小的肿物，表面有溃烂面，疼痛明显，质地硬，活动度差，活检示左颊部鳞癌，请我科会诊后建议完善分期检查并转我科继续治疗，完善头颅mri及胸腹部ct未见确切转移，颌面部ct提示左侧颊癌伴邻近上、下颌骨骨质破坏吸收，周围多发淋巴结肿大淋巴结肿大转移。 | 1,424 | [
{
"anatomy_list": [
"左侧颊"
],
"character": [
"核桃大小",
"表面有溃烂面",
"疼痛明显",
"质地硬",
"活动度差"
],
"core_name": "肿物",
"tendency": ""
},
{
"anatomy_list": [
"左颊"
],
"character": [],
"core_name": "鳞癌",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "转移",
"tendency": "否定"
},
{
"anatomy_list": [
"左侧颊"
],
"character": [],
"core_name": "癌",
"tendency": ""
},
{
"anatomy_list": [
"邻近上、下颌骨"
],
"character": [],
"core_name": "骨质破坏吸收",
"tendency": ""
},
{
"anatomy_list": [
"周围淋巴结"
],
"character": [
"多发",
"转移"
],
"core_name": "肿大",
"tendency": ""
}
] |
具体诊治过程不详，患者为求进一步诊治，转至我院就诊，门诊以“膀胱占位，性质待查？”收入我院泌尿科住院治疗，查ect示：1.全身骨多处异常放射性浓聚，融合骨显像考虑：全身广泛性转移性骨肿瘤。 | 1,844 | [
{
"anatomy_list": [
"膀胱"
],
"character": [],
"core_name": "占位",
"tendency": "不确定"
},
{
"anatomy_list": [
"全身",
"骨"
],
"character": [
"广泛性",
"转移性"
],
"core_name": "肿瘤",
"tendency": ""
},
{
"anatomy_list": [
"全身",
"骨"
],
"character": [
"异常放射性",
"多处"
],
"core_name": "浓聚",
"tendency": ""
},
{
"anatomy_list": [
"骨"
],
"character": [],
"core_name": "骨融合",
"tendency": ""
}
] |
病程中患者偶感后腰部阵发性疼痛，可耐受，无放射痛，无尿频、尿急、尿痛，疼痛与体位、活动度无关。 | 249 | [
{
"anatomy_list": [
"后腰部"
],
"character": [
"偶感",
"阵发性",
"可耐受"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"放射痛"
],
"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": [],
"character": [
"与体位、活动度无关"
],
"core_name": "疼痛",
"tendency": ""
}
] |
6.双肾囊肿（bosniak Ⅰ级）。 | 1,264 | [
{
"anatomy_list": [
"双肾"
],
"character": [
"bosniak Ⅰ级"
],
"core_name": "囊肿",
"tendency": ""
}
] |
<5、10组，6组，7组，9组，9组，10组，12组>淋巴结未见癌转移（分别为0/2、0/3、0/3、0/1、0/1、0/4、0/3）。 | 1,812 | [
{
"anatomy_list": [
"5、10组，6组，7组，9组，9组，10组，12组淋巴结"
],
"character": [
"转移"
],
"core_name": "癌",
"tendency": "否定"
}
] |
患者入院前7年患者无明显诱因出现多饮、多尿、视物模糊、体重下降，无泡沫尿、手足麻木、间歇性跛行等症状，查血糖升高，诊断为“2型糖尿病”，后长期口服药物降糖治疗，未监测血糖水平。 | 1,371 | [
{
"anatomy_list": [],
"character": [],
"core_name": "多饮",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "多尿",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "视物模糊",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "体重下降",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "泡沫尿",
"tendency": "否定"
},
{
"anatomy_list": [
"手",
"足"
],
"character": [],
"core_name": "麻木",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"间歇性"
],
"core_name": "跛行",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"升高"
],
"core_name": "血糖",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"2型"
],
"core_name": "糖尿病",
"tendency": ""
}
] |
患者遂于8月前至我科住院治疗，门诊以“耐药肺结核、胸腔积液待查”收入住院。 | 980 | [
{
"anatomy_list": [
"肺"
],
"character": [
"耐药"
],
"core_name": "结核",
"tendency": ""
},
{
"anatomy_list": [
"胸腔"
],
"character": [],
"core_name": "积液",
"tendency": ""
}
] |
20年前，患者偶测血糖发现血糖升高，无明显口干、多饮、多尿、体重减轻等症状，遂行ogtt检查明确诊断为“2型糖尿病”。 | 1,273 | [
{
"anatomy_list": [],
"character": [
"升高"
],
"core_name": "血糖",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"明显"
],
"core_name": "口干",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"明显"
],
"core_name": "多饮",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"明显"
],
"core_name": "多尿",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"明显"
],
"core_name": "体重减轻",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"2型"
],
"core_name": "糖尿病",
"tendency": ""
}
] |
患者自行买药服用后咳嗽稍有好转。 | 516 | [
{
"anatomy_list": [],
"character": [
"稍有好转"
],
"core_name": "咳嗽",
"tendency": ""
}
] |
半月前患者受凉后咳嗽、咳痰加重，咳白色粘痰，量多，伴气促，无咯血。 | 1,523 | [
{
"anatomy_list": [],
"character": [
"受凉后",
"加重"
],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"受凉后",
"加重",
"白色",
"粘",
"量多"
],
"core_name": "咳痰",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "气促",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "咯血",
"tendency": "否定"
}
] |
患者2天前进食辛辣食物后，突发脐周疼痛疼痛不适，呈持续性胀痛，不能缓解，无腰背部放射。 | 554 | [
{
"anatomy_list": [
"脐周"
],
"character": [
"进食辛辣食物后",
"突发",
"不适",
"持续性胀痛",
"不能缓解",
"无腰背部放射"
],
"core_name": "疼痛",
"tendency": ""
}
] |
变换体位时疼痛明显。 | 800 | [
{
"anatomy_list": [],
"character": [
"变换体位时明显"
],
"core_name": "疼痛",
"tendency": ""
}
] |
患者24小时前无明显诱因出现左侧腰背部疼痛，呈持续性胀痛，疼痛可忍受，休息后可稍缓解，无放射痛，无畏寒、发热，无恶心、呕吐，无尿频、尿痛等不适，就诊于当地医院查尿液检查提示：镜下血尿（患者口诉）。 | 1,157 | [
{
"anatomy_list": [
"左侧腰背部"
],
"character": [
"持续性",
"胀痛",
"可忍受",
"休息后可稍缓解"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"放射性"
],
"core_name": "疼痛",
"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": "尿频",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "尿痛",
"tendency": "否定"
}
] |
无胸闷、胸痛，夜间喜高枕卧位，无阵发性呼吸困难，患者未行特殊诊治。 | 946 | [
{
"anatomy_list": [
"胸"
],
"character": [],
"core_name": "胸闷",
"tendency": "否定"
},
{
"anatomy_list": [
"胸"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"阵发性"
],
"core_name": "呼吸困难",
"tendency": "否定"
}
] |
患者自发病以来，精神、食欲差，睡眠可，大便结燥，小便如常，近半年体重减轻约10kg。 | 795 | [
{
"anatomy_list": [],
"character": [
"差"
],
"core_name": "精神",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"差"
],
"core_name": "食欲",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"可"
],
"core_name": "睡眠",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"结燥"
],
"core_name": "大便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"如常"
],
"core_name": "小便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "体重减轻",
"tendency": ""
}
] |
1年前患者因“咳嗽、咯痰伴呼吸困难”，曾在我院住院明确诊断为“1.肺部感染 2.喉癌术后3气管切开术后 4肺气肿 5.左肺肺大泡 6.亚临床甲状腺功能减退。 | 441 | [
{
"anatomy_list": [],
"character": [],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "咳痰",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "呼吸困难",
"tendency": ""
},
{
"anatomy_list": [
"肺部"
],
"character": [],
"core_name": "感染",
"tendency": ""
},
{
"anatomy_list": [
"喉"
],
"character": [
"术后"
],
"core_name": "癌",
"tendency": ""
},
{
"anatomy_list": [
"肺"
],
"character": [],
"core_name": "肺气肿",
"tendency": ""
},
{
"anatomy_list": [
"左肺"
],
"character": [],
"core_name": "肺大疱",
"tendency": ""
},
{
"anatomy_list": [
"甲状腺"
],
"character": [
"亚临床"
],
"core_name": "甲状腺功能减退",
"tendency": ""
}
] |
门诊以“右侧睾丸肿瘤”收入我科。 | 1,747 | [
{
"anatomy_list": [
"右侧睾丸"
],
"character": [],
"core_name": "肿瘤",
"tendency": ""
}
] |
入院前2小时患者出现恶心后晕厥，伴有意识丧失，持续时间约1分1分钟，有面色发白、四肢发冷、畏寒等不适，无呕血、血便、粘液脓血便等不适。 | 953 | [
{
"anatomy_list": [],
"character": [],
"core_name": "恶心",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "晕厥",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "意识丧失",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"面色"
],
"core_name": "发白",
"tendency": ""
},
{
"anatomy_list": [
"四肢"
],
"character": [],
"core_name": "发冷",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "畏寒",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "呕血",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "血便",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"脓血",
"粘液"
],
"core_name": "大便",
"tendency": "否定"
}
] |
患者自患病以来精神、食欲及睡眠欠佳，大便正常，尿量减少，自觉体重较前增加。 | 531 | [
{
"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": [
"减少"
],
"core_name": "尿量",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "体重较前增加",
"tendency": ""
}
] |
慢性宫颈炎。 | 1,285 | [
{
"anatomy_list": [
"宫颈"
],
"character": [
"慢性"
],
"core_name": "宫颈炎",
"tendency": ""
}
] |
予以mri检查提示“膝关节骨性关节炎、半月板损伤、右股骨髁病变性质待定”。 | 361 | [
{
"anatomy_list": [
"膝关节"
],
"character": [
"骨性"
],
"core_name": "关节炎",
"tendency": ""
},
{
"anatomy_list": [
"半月板"
],
"character": [],
"core_name": "损伤",
"tendency": ""
},
{
"anatomy_list": [
"右股骨髁"
],
"character": [],
"core_name": "病变",
"tendency": "不确定"
}
] |
患者本次发病以来，食欲减退， 神志清醒，精神欠佳，睡眠尚可，大便正常，小便正常，体重无明显变化。 | 1,427 | [
{
"anatomy_list": [],
"character": [
"减退"
],
"core_name": "食欲",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"清醒"
],
"core_name": "神志",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"欠佳"
],
"core_name": "精神",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"尚可"
],
"core_name": "睡眠",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"正常"
],
"core_name": "大便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"正常"
],
"core_name": "小便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"明显"
],
"core_name": "体重改变",
"tendency": ""
}
] |
30年来病情进行性加重，咳嗽，咳痰发作渐趋频繁。 | 791 | [
{
"anatomy_list": [],
"character": [
"渐趋频繁"
],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"渐趋频繁"
],
"core_name": "咳痰",
"tendency": ""
}
] |
入院前18小时，患者于服用“头痛粉”后出现呕吐1次，呕吐非喷射样呕吐，呕吐物为鲜血样物，无胆汁样物及隔夜宿食，量约100ml，伴恶心、干呕10余次。 | 1,986 | [
{
"anatomy_list": [],
"character": [],
"core_name": "呕吐",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"非喷射样"
],
"core_name": "呕吐",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"鲜血样",
"无胆汁样物及隔夜宿食",
"量约100ml"
],
"core_name": "呕吐物",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "恶心",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "干呕",
"tendency": ""
}
] |
8月22日患者在某妇幼保健院检查阴道镜：宫颈未见明显异常，建议hpv检查。 | 1,395 | [
{
"anatomy_list": [
"宫颈"
],
"character": [
"明显"
],
"core_name": "异常",
"tendency": "否定"
}
] |
10月前，患者无明显诱因出现尿频、尿急、尿痛伴双侧腰痛、便秘，无畏寒、发热，无恶心、呕吐，无腹胀、腹痛，无咳嗽、咳痰，无胸痛、胸闷，无心悸、气促，至某医院行泌尿系彩超检查（2015-03-05），提示：1.右肾积水；2.右肾包膜下少量积液；3.右侧输尿管上段扩张；4.膀胱内弱回声区，内有供血。 | 1,843 | [
{
"anatomy_list": [],
"character": [],
"core_name": "尿频",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "尿急",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "尿痛",
"tendency": ""
},
{
"anatomy_list": [
"双侧腰"
],
"character": [],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "便秘",
"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": "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"
},
{
"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": "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": [],
"core_name": "气促",
"tendency": "否定"
},
{
"anatomy_list": [
"右肾"
],
"character": [],
"core_name": "积水",
"tendency": ""
},
{
"anatomy_list": [
"右肾包膜下"
],
"character": [
"少量"
],
"core_name": "积液",
"tendency": ""
},
{
"anatomy_list": [
"右侧输尿管上段"
],
"character": [
"扩张"
],
"core_name": "扩张",
"tendency": ""
},
{
"anatomy_list": [
"膀胱内"
],
"character": [
"弱"
],
"core_name": "回声区",
"tendency": ""
}
] |
今为进一步治疗门诊以“冠状动脉粥样硬化性心脏病”收入我科住院治疗。 | 1,086 | [
{
"anatomy_list": [
"冠状动脉",
"心脏"
],
"character": [
"粥样",
"硬化性"
],
"core_name": "冠状动脉粥样硬化性心脏病",
"tendency": ""
}
] |
患者本次发病以来，食欲下降，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。 | 219 | [
{
"anatomy_list": [],
"character": [
"下降"
],
"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"
}
] |
不伴恶心、呕吐、腹胀、黑便。 | 518 | [
{
"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": "黑便",
"tendency": "否定"
}
] |
双侧骶韧带未见癌转移。 | 1,582 | [
{
"anatomy_list": [
"双侧骶韧带"
],
"character": [
"转移"
],
"core_name": "癌",
"tendency": "否定"
}
] |
遂于2014-3-5、3-27、2014-4-23、2014-5-15、2014-6-20行五周期化疗（紫杉醇脂质体180mg1+奈达铂50mg1，40mg2 q3w）,患者出现轻度消化道反应，给予对症处理后好转，后复查ca-125持续下降，胸腹部ct未见明显异常。 | 1,125 | [
{
"anatomy_list": [
"消化道"
],
"character": [
"轻度"
],
"core_name": "消化道反应",
"tendency": ""
}
] |
为求进一步诊治今来我院就诊，门诊以“髓母细胞瘤术后化疗”收入院。 | 1,139 | [
{
"anatomy_list": [],
"character": [
"化疗"
],
"core_name": "髓母细胞瘤",
"tendency": ""
}
] |
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 ， 体重减轻 。 | 344 | [
{
"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": [],
"core_name": "体重减轻",
"tendency": ""
}
] |
4.左侧胸腔少量积液，较5+月前病灶明显增大，期间自诉口服中药治疗，症状未缓解，今为求进一步诊治就诊于我科门诊，门诊以“左上肺肺腺癌”收入我科住院治疗。 | 282 | [
{
"anatomy_list": [
"左侧胸腔"
],
"character": [
"少量"
],
"core_name": "积液",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"明显增大"
],
"core_name": "病灶",
"tendency": ""
},
{
"anatomy_list": [
"左上肺"
],
"character": [],
"core_name": "腺癌",
"tendency": ""
}
] |
目前间断咳嗽，咳少量白色粘痰，偶尔有少量黄痰，无全身乏力、肌肉酸疼，无发热、盗汗，无胸痛、咯血等不适。 | 997 | [
{
"anatomy_list": [],
"character": [
"间断"
],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"少量",
"白色",
"粘"
],
"core_name": "咳痰",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"少量",
"黄色",
"偶尔"
],
"core_name": "咳痰",
"tendency": ""
},
{
"anatomy_list": [
"全身"
],
"character": [],
"core_name": "乏力",
"tendency": "否定"
},
{
"anatomy_list": [
"肌肉"
],
"character": [
"酸痛"
],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "发热",
"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"
}
] |
排除放化疗禁忌后于2020-8-3至2020-9-11予以宫颈癌调强放疗，放疗计划：ptv50.40G/28f，放疗期间分别于2020-8-5、8-12、8-19、8-26、9-2予以“顺铂40mg”同步化疗，并于2020-9-4、9-9、9-15、9-18、9-22、9-25予以6次后装治疗。 | 1,615 | [
{
"anatomy_list": [
"宫颈"
],
"character": [],
"core_name": "癌",
"tendency": ""
}
] |
患者自发病以来， 精神稍差 ， 食欲稍差 ， 睡眠欠佳 ， 造瘘口排便稍困难 ， 小便如常 ， 体重减轻 。 | 349 | [
{
"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": [
"造瘘口"
],
"character": [
"稍"
],
"core_name": "排便困难",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"如常"
],
"core_name": "小便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "体重减轻",
"tendency": ""
}
] |
患者自诉2月前无明显诱因出现前胸部胸部疼痛，呈隐痛，不伴牵涉放射痛，阵发，否认发热、盗汗、乏力、咯血，否认胸闷气促、痰中带血、进行性消瘦，无心前区疼痛、心慌等不适，当时未就诊，患者因仍疼痛仍存，2天前遂就诊于我院门诊，行胸部平扫ct示“左肺下叶后基底段段结节，考虑高风险结节，肿瘤性病变可能”，患者为手术治疗入住我院。 | 1,485 | [
{
"anatomy_list": [
"前胸部"
],
"character": [
"隐痛",
"不伴牵涉放射痛",
"阵发"
],
"core_name": "疼痛",
"tendency": ""
},
{
"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": "乏力",
"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": [],
"character": [],
"core_name": "气促",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"带血"
],
"core_name": "咳痰",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"进行性"
],
"core_name": "消瘦",
"tendency": "否定"
},
{
"anatomy_list": [
"心前区"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [
"心"
],
"character": [],
"core_name": "心慌",
"tendency": "否定"
},
{
"anatomy_list": [
"前胸部"
],
"character": [],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"左肺下叶后基底段"
],
"character": [
"高风险"
],
"core_name": "结节",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"肿瘤性"
],
"core_name": "病变",
"tendency": "不确定"
}
] |
上述症状逐渐加重，为求进一步系统治疗来我院，门诊以“1.右侧中耳肿物。 | 1,020 | [
{
"anatomy_list": [
"右侧中耳"
],
"character": [],
"core_name": "肿物",
"tendency": ""
}
] |
入院前3+年，患者因“咳嗽咳痰2+年，确诊左下肺肺癌1月”于我院住院治疗，于2016年8月19日在全麻下行胸腔镜中转开胸左下肺癌根治术+胸膜粘连烙断术，手术顺利，术后病理检查（我院，病理号：123456）：<左肺下叶>低分化鳞状细胞癌，支气管切缘未见癌累及。 | 829 | [
{
"anatomy_list": [],
"character": [],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "咳痰",
"tendency": ""
},
{
"anatomy_list": [
"左下肺"
],
"character": [],
"core_name": "癌",
"tendency": ""
},
{
"anatomy_list": [
"左肺下叶"
],
"character": [
"低分化"
],
"core_name": "鳞癌",
"tendency": ""
},
{
"anatomy_list": [
"支气管切缘"
],
"character": [
"累及"
],
"core_name": "癌",
"tendency": "否定"
}
] |
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。 | 286 | [
{
"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"
}
] |
入院前半年，患者无明显诱因出现尿频，夜尿次数增多，每晚3-4次，伴排尿困难，表现为：尿线变细，射程变短。 | 1,095 | [
{
"anatomy_list": [],
"character": [],
"core_name": "尿频",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"次数增多",
"每晚3-4次"
],
"core_name": "夜尿",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "排尿困难",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "尿线变细",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "射程变短",
"tendency": ""
}
] |
2.右肺中叶内侧段及左肺上叶下舌段纤维灶；双肺散在钙化灶。 | 1,610 | [
{
"anatomy_list": [
"右肺中叶内侧段及左肺上叶下舌段"
],
"character": [],
"core_name": "纤维灶",
"tendency": ""
},
{
"anatomy_list": [
"双肺"
],
"character": [
"散在"
],
"core_name": "钙化灶",
"tendency": ""
}
] |
近1-月以来，患者出现进行性呼吸困难，伴胸闷，伴四肢乏力，伴头晕，伴双下肢水肿，偶有心悸，突发突止，不伴黒朦，不伴意识障碍，不伴发热畏寒，不伴胸痛，不伴放射痛，不伴恶心呕吐，患者就诊于某卫生院，完善胸片检查提示左肺胸腔积液可能，建议患者转上级医院继续治疗，患者遂就诊于我院门诊，门诊以“肺恶性肿瘤”收治我科。 | 1,495 | [
{
"anatomy_list": [],
"character": [
"进行性"
],
"core_name": "呼吸困难",
"tendency": ""
},
{
"anatomy_list": [
"胸"
],
"character": [],
"core_name": "胸闷",
"tendency": ""
},
{
"anatomy_list": [
"四肢"
],
"character": [],
"core_name": "乏力",
"tendency": ""
},
{
"anatomy_list": [
"头"
],
"character": [],
"core_name": "头晕",
"tendency": ""
},
{
"anatomy_list": [
"双下肢"
],
"character": [],
"core_name": "水肿",
"tendency": ""
},
{
"anatomy_list": [
"心"
],
"character": [
"突发突止"
],
"core_name": "心悸",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "黒朦",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "意识障碍",
"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": [
"胸"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [],
"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": [
"左肺",
"胸腔"
],
"character": [],
"core_name": "积液",
"tendency": "不确定"
},
{
"anatomy_list": [
"肺"
],
"character": [
"恶性"
],
"core_name": "肿瘤",
"tendency": ""
}
] |
患者自起病以来，精神略差，胃纳略差，大便次数增多，小便如常，患病期间体重下降约5kg。 | 211 | [
{
"anatomy_list": [],
"character": [
"略差"
],
"core_name": "精神",
"tendency": ""
},
{
"anatomy_list": [
"胃"
],
"character": [
"略差"
],
"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": ""
}
] |
患者53岁绝经，绝经前平素月经规则，初潮12岁，周期26-30天，经期3-5天，量中等，无血凝块，偶有痛经，既往白带正常，无异味。 | 694 | [
{
"anatomy_list": [],
"character": [],
"core_name": "绝经",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"绝经前",
"规则"
],
"core_name": "月经",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"量中等",
"无血凝块"
],
"core_name": "月经",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"偶尔"
],
"core_name": "痛经",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"正常",
"无异味"
],
"core_name": "白带",
"tendency": ""
}
] |
1周前患者于我院门诊复查，完善上腹部腹部ct检查提示肝癌介入术后改变于前片（2014.12.29）比较变化不大，肝左叶外侧段包膜下小结节大小较前无明显改变，肝硬化硬化结节可，甲胎蛋白较前明显升高（未见报告），患者无明显肝区疼痛、乏力、纳差等不适，为求进一步治疗，遂入我院就诊，门诊以“肝细胞癌”收治入院。 | 63 | [
{
"anatomy_list": [
"肝"
],
"character": [],
"core_name": "癌",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"介入术后",
"与前片比较变化不大"
],
"core_name": "术后改变",
"tendency": ""
},
{
"anatomy_list": [
"肝左叶外侧段包膜下"
],
"character": [
"小",
"大小较前无明显改变"
],
"core_name": "结节",
"tendency": ""
},
{
"anatomy_list": [
"肝"
],
"character": [],
"core_name": "硬化",
"tendency": ""
},
{
"anatomy_list": [
"肝"
],
"character": [
"硬化"
],
"core_name": "结节",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"较前明显升高"
],
"core_name": "甲胎蛋白",
"tendency": ""
},
{
"anatomy_list": [
"肝区"
],
"character": [
"明显"
],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "乏力",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "纳差",
"tendency": "否定"
},
{
"anatomy_list": [
"肝细胞"
],
"character": [],
"core_name": "癌",
"tendency": ""
}
] |
出院后患者咳嗽、咳痰逐渐好转，未再出现痰中带血，出现脱发，无发热、畏寒，无胸闷、胸痛，无咯血，无头晕、头痛等不适，规律复查血常规，现患者为行第四周期化疗至我院门诊，门诊以“肺恶性肿瘤”收入我科。 | 573 | [
{
"anatomy_list": [],
"character": [
"逐渐好转"
],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"逐渐好转"
],
"core_name": "咳痰",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"带血"
],
"core_name": "咳痰",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "脱发",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "发热",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "畏寒",
"tendency": "否定"
},
{
"anatomy_list": [
"胸"
],
"character": [],
"core_name": "胸闷",
"tendency": "否定"
},
{
"anatomy_list": [
"胸部"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "咯血",
"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": [
"恶性"
],
"core_name": "肿瘤",
"tendency": ""
}
] |
患者于入院前1月无明显诱因出现腹痛，为上腹部持续性钝痛，伴阵发性绞痛，偶有恶心、呕吐，无反酸、嗳气，无肩背部放射痛，无心前区压榨感，时有咳嗽，咳中量白色泡沫痰，无鼻塞、流涕，无畏寒、发热，偶有头痛，为前额部胀痛，无畏光、畏声，感全身骨骨痛，四肢乏力，双下肢麻木，不能行走，无关节红肿，无皮肤瘙痒，患者为求进一步诊治，遂于我科就诊。 | 542 | [
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"上腹部"
],
"character": [
"持续性",
"钝痛",
"阵发性",
"绞痛"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"偶有"
],
"core_name": "恶心",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"偶有"
],
"core_name": "呕吐",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "反酸",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "嗳气",
"tendency": "否定"
},
{
"anatomy_list": [
"肩",
"背部"
],
"character": [
"放射性"
],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [
"心前区"
],
"character": [],
"core_name": "压榨感",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"时有"
],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"中量",
"白色",
"泡沫痰"
],
"core_name": "咳痰",
"tendency": ""
},
{
"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": "发热",
"tendency": "否定"
},
{
"anatomy_list": [
"头"
],
"character": [
"偶有"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"前额部"
],
"character": [
"胀痛"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "畏光",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "畏声",
"tendency": "否定"
},
{
"anatomy_list": [
"骨",
"全身"
],
"character": [],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"四肢"
],
"character": [],
"core_name": "乏力",
"tendency": ""
},
{
"anatomy_list": [
"双下肢"
],
"character": [],
"core_name": "麻木",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"不能"
],
"core_name": "行走",
"tendency": ""
},
{
"anatomy_list": [
"关节"
],
"character": [],
"core_name": "红肿",
"tendency": "否定"
},
{
"anatomy_list": [
"皮肤"
],
"character": [],
"core_name": "瘙痒",
"tendency": "否定"
}
] |
患者于当地医院就诊考虑“支气管炎”,给予输液治疗后上述症状能缓解。 | 36 | [
{
"anatomy_list": [
"支气管"
],
"character": [],
"core_name": "支气管炎",
"tendency": "不确定"
}
] |
术后分期为：PT3n0M0 iia期；术后给予补充白蛋白、营养支持等治疗；术后患者分别于2019-09-26、2019-11-1按folfox方案化疗2周期（药物总量：奥沙利铂甘露醇：0.14g，奥沙利铂140mg，氟尿嘧啶8.4g）；化疗期间无明显恶心、呕吐、腹胀、腹痛，无骨髓抑制等化疗副反应。患者因个人原因到某地工作，未按时化疗。 | 1,572 | [
{
"anatomy_list": [],
"character": [
"明显"
],
"core_name": "恶心",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"明显"
],
"core_name": "呕吐",
"tendency": "否定"
},
{
"anatomy_list": [
"腹"
],
"character": [
"明显"
],
"core_name": "腹胀",
"tendency": "否定"
},
{
"anatomy_list": [
"腹"
],
"character": [
"明显"
],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [
"骨髓"
],
"character": [],
"core_name": "骨髓抑制",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "化疗副反应",
"tendency": "否定"
}
] |
无恶心、呕吐，无腹痛、腹泻，无畏寒、发热、黄疸，无转移性右下腹痛，无腹胀，无肛门停止排气排便，无呕血、黑便，无咳嗽、咳痰，无胸闷、呼吸困难。 | 1,251 | [
{
"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": "畏寒",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "发热",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "黄疸",
"tendency": "否定"
},
{
"anatomy_list": [
"右下腹"
],
"character": [
"转移性"
],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "腹胀",
"tendency": "否定"
},
{
"anatomy_list": [
"肛门"
],
"character": [
"停止"
],
"core_name": "排气",
"tendency": "否定"
},
{
"anatomy_list": [
"肛门"
],
"character": [
"停止"
],
"core_name": "排便",
"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": "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": "呼吸困难",
"tendency": "否定"
}
] |
入院前20天，患者行体检肠镜提示“结肠息肉”，平素排便稍费力，大便结燥，无大便不成形，伴大便次数增多，每日2-3次，无大便带血，无腹痛，偶有腹胀，偶有反酸、烧心，无呃逆、嗳气，无厌油、纳差，无进食梗塞感，无饮水呛咳，间断咳嗽、咳痰，无胸闷、胸痛，无头晕、头痛，无畏寒、发热，伴尿频，无尿急、尿痛，无畏寒、发热，无眼黄、身黄等不适，现患者为进一步行息肉切除入院，门诊以“结肠息肉”收入我科继续治疗。 | 888 | [
{
"anatomy_list": [
"结肠"
],
"character": [],
"core_name": "息肉",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"稍"
],
"core_name": "排便费力",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"结燥"
],
"core_name": "大便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"不成形"
],
"core_name": "大便",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"次数增多"
],
"core_name": "大便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"带血"
],
"core_name": "大便",
"tendency": "否定"
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [
"腹"
],
"character": [
"偶有"
],
"core_name": "腹胀",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"偶有"
],
"core_name": "反酸",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"偶有"
],
"core_name": "烧心",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "呃逆",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "嗳气",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "厌油",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "纳差",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"进食"
],
"core_name": "梗塞感",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"饮水"
],
"core_name": "呛咳",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"间断"
],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"间断"
],
"core_name": "咳痰",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "胸闷",
"tendency": "否定"
},
{
"anatomy_list": [
"胸"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [
"头"
],
"character": [],
"core_name": "头晕",
"tendency": "否定"
},
{
"anatomy_list": [
"头"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "畏寒",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "发热",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "尿频",
"tendency": ""
},
{
"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": "畏寒",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "发热",
"tendency": "否定"
},
{
"anatomy_list": [
"眼"
],
"character": [],
"core_name": "黄染",
"tendency": "否定"
},
{
"anatomy_list": [
"身"
],
"character": [],
"core_name": "黄染",
"tendency": ""
},
{
"anatomy_list": [
"结肠"
],
"character": [],
"core_name": "息肉",
"tendency": ""
}
] |
脑mri增强（2014-10-14）提示：未见明显颅内转移，建议完善骨扫描检查，拟行化疗及粒子植入治疗，患者及家属考虑后拒绝，并要求出院。 | 547 | [
{
"anatomy_list": [
"颅内"
],
"character": [
"明显"
],
"core_name": "转移",
"tendency": "否定"
}
] |
于入院前1天,患者无明显诱因出现恶心不适,无呕吐,期间无咳嗽、咳痰,无呛咳,无血尿、泡沫尿,无尿频、尿痛,无光过敏,无口腔溃疡,无脱发,无发热、畏寒等不适。 | 32 | [
{
"anatomy_list": [],
"character": [],
"core_name": "恶心",
"tendency": ""
},
{
"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": "呛咳",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "血尿",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "泡沫尿",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "尿频",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "尿痛",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"光"
],
"core_name": "过敏",
"tendency": "否定"
},
{
"anatomy_list": [
"口腔"
],
"character": [],
"core_name": "溃疡",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "脱发",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "发热",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "畏寒",
"tendency": "否定"
}
] |
患病以来，精神、食欲、睡眠一般，大便正常，排尿频繁，小便量少，排尿困难，近期体重无明显减轻。 | 1,603 | [
{
"anatomy_list": [],
"character": [
"一般"
],
"core_name": "精神",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"一般"
],
"core_name": "食欲",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"一般"
],
"core_name": "睡眠",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"正常"
],
"core_name": "大便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "尿频",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"量少"
],
"core_name": "小便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "排尿困难",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"明显"
],
"core_name": "体重减轻",
"tendency": "否定"
}
] |
遂行支气管支架植入术及冷冻治疗，术后喘累、呼吸困难明显缓解，行化疗3周期，放疗1周期。 | 996 | [
{
"anatomy_list": [],
"character": [
"术后",
"明显缓解"
],
"core_name": "喘累",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"术后",
"明显缓解"
],
"core_name": "呼吸困难",
"tendency": ""
}
] |
后每2-3年左右发作1次，均于打麻将时发生，症状同前，患者否认发作前有胸闷、胸痛、心悸、气促症状，意识恢复后有恶心、呕吐症状。 | 737 | [
{
"anatomy_list": [
"胸"
],
"character": [
"发作前"
],
"core_name": "胸闷",
"tendency": "否定"
},
{
"anatomy_list": [
"胸"
],
"character": [
"发作前"
],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [
"心"
],
"character": [
"发作前"
],
"core_name": "心悸",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"发作前"
],
"core_name": "气促",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"意识恢复后"
],
"core_name": "恶心",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"意识恢复后"
],
"core_name": "呕吐",
"tendency": ""
}
] |
患者本次发病以来，食欲正常，精神尚可，睡眠尚可，大便正常，小便正常，体重无明显变化。 | 1,278 | [
{
"anatomy_list": [],
"character": [
"正常"
],
"core_name": "食欲",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"尚可"
],
"core_name": "精神",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"尚可"
],
"core_name": "睡眠",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"正常"
],
"core_name": "大便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"正常"
],
"core_name": "小便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"明显"
],
"core_name": "体重改变",
"tendency": "否定"
}
] |
入院前40天，患者于某医院体检发现双侧甲状腺结节，建议进一步检查，患者因个人原因未治疗。 | 1,298 | [
{
"anatomy_list": [
"双侧甲状腺"
],
"character": [],
"core_name": "结节",
"tendency": ""
}
] |
患者在当地诊所（具体不详）就诊，症状未见明显改善，患者未予以重视，咳嗽、咳痰较前明显加重，并出现呼吸困难等不适，后转诊至我院，完善气管镜检查，病检回示鳞状细胞癌，标本送常规病检(2019-11-17):（左主气管活检）结合形态学及免疫组化结果，支持鳞状细胞癌。 | 1,494 | [
{
"anatomy_list": [],
"character": [
"较前明显加重"
],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"较前明显加重"
],
"core_name": "咳痰",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "呼吸困难",
"tendency": ""
},
{
"anatomy_list": [
"左主气管"
],
"character": [],
"core_name": "癌",
"tendency": ""
},
{
"anatomy_list": [
"左主气管"
],
"character": [],
"core_name": "鳞癌",
"tendency": ""
}
] |
患者自发病以来， 精神稍差 ， 食欲稍差 ， 睡眠欠佳 ， 大便量少 ， 小便如常 ， 体重无明显变化 。 | 226 | [
{
"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": [
"量少"
],
"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"
}
] |
（右乳4点、7点包块）穿刺活检：浸润性导管癌。 | 672 | [
{
"anatomy_list": [
"右乳4点7点"
],
"character": [],
"core_name": "包块",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"浸润性"
],
"core_name": "导管癌",
"tendency": ""
}
] |
今患者为求复查就诊于我院，以“下段食管癌术后”收入我科。 | 2,053 | [
{
"anatomy_list": [
"下段食管"
],
"character": [
"术后"
],
"core_name": "癌",
"tendency": ""
}
] |
患者家属自行于某医院复查病理切片结果：（卵巢）高级别浆液性腺癌。 | 1,415 | [
{
"anatomy_list": [
"卵巢"
],
"character": [
"高级别",
"浆液性"
],
"core_name": "腺癌",
"tendency": ""
}
] |
8月前，患者无明显诱因出现双侧肋骨肋骨疼痛，遂于2018.07.02在某医院行ct检查：1.双肺未见明显异常。 | 1,898 | [
{
"anatomy_list": [
"双侧肋骨"
],
"character": [],
"core_name": "疼痛",
"tendency": ""
}
] |
不伴大汗淋漓，不伴畏寒、发热，无胸闷、心悸，无腹胀，腹泻，无尿频、尿急、尿痛等症状。 | 1,231 | [
{
"anatomy_list": [],
"character": [
"增多"
],
"core_name": "出汗",
"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": [
"胸"
],
"character": [],
"core_name": "胸闷",
"tendency": "否定"
},
{
"anatomy_list": [
"心"
],
"character": [],
"core_name": "心悸",
"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": "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"
}
] |
半天前，患者无明显诱因再次出现恶心、呕吐、呕鲜红色血液，伴血凝块，约250ml，伴反酸，无腹痛、腹胀、黑便、腹泻，无黑曚、晕厥、意识丧失，无身黄、眼黄、尿黄，无畏寒、发热，现患者为求进一步治疗，门诊以“上消化道出血”收入我科。 | 583 | [
{
"anatomy_list": [],
"character": [],
"core_name": "恶心",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "呕吐",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"鲜红色",
"血凝块"
],
"core_name": "呕血",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "反酸",
"tendency": ""
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "腹胀",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "黑便",
"tendency": "否定"
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "腹泻",
"tendency": "否定"
},
{
"anatomy_list": [
"眼"
],
"character": [],
"core_name": "黒朦",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "晕厥",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "意识丧失",
"tendency": "否定"
},
{
"anatomy_list": [
"全身"
],
"character": [],
"core_name": "黄染",
"tendency": "否定"
},
{
"anatomy_list": [
"眼"
],
"character": [],
"core_name": "黄染",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "尿黄",
"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": [
"上消化道"
],
"character": [],
"core_name": "出血",
"tendency": ""
}
] |
2018.3.27返院复查膀胱镜见膀胱新生物复发，行新生物电切术后病检示：膀胱底后壁送检散碎组织小灶尿路上皮示高级别尿路上皮癌，另见钙盐沉积及异物肉芽肿；膀胱左侧新生物送检组织衬覆少量尿路上皮伴个别炎症细胞浸润；膀胱颈及三角区送检组织示腺性膀胱炎；左侧输尿管旁送检组织示局灶钙盐沉积，血管扩张充血伴少量慢性炎症细胞浸润。 | 1,432 | [
{
"anatomy_list": [
"膀胱"
],
"character": [
"复发"
],
"core_name": "新生物",
"tendency": ""
},
{
"anatomy_list": [
"膀胱底后壁",
"尿路上皮"
],
"character": [
"高级别"
],
"core_name": "癌",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "钙盐沉积",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "异物肉芽肿",
"tendency": ""
},
{
"anatomy_list": [
"膀胱左侧",
"尿路上皮"
],
"character": [
"衬覆少量尿路上皮",
"炎症细胞浸润"
],
"core_name": "新生物",
"tendency": ""
},
{
"anatomy_list": [
"左侧输尿管旁"
],
"character": [],
"core_name": "钙盐沉积",
"tendency": ""
},
{
"anatomy_list": [
"血管"
],
"character": [],
"core_name": "扩张充血",
"tendency": ""
},
{
"anatomy_list": [
"膀胱左侧"
],
"character": [
"炎症细胞",
"少量",
"慢性"
],
"core_name": "浸润",
"tendency": ""
}
] |
10余天前，患者感右上腹胀较前加重，伴双下肢水肿，小便颜色黄。 | 1,130 | [
{
"anatomy_list": [
"右上腹"
],
"character": [
"加重"
],
"core_name": "腹胀",
"tendency": ""
},
{
"anatomy_list": [
"双下肢"
],
"character": [],
"core_name": "水肿",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"颜色黄"
],
"core_name": "小便",
"tendency": ""
}
] |
患者自发病以来， 精神、食欲、睡眠稍差 ， 二便较少 ， 体重无明显变化 。 | 1,367 | [
{
"anatomy_list": [],
"character": [
"稍差"
],
"core_name": "精神",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"稍差"
],
"core_name": "食欲",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"稍差"
],
"core_name": "睡眠",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"较少"
],
"core_name": "大便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"较少"
],
"core_name": "小便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"明显"
],
"core_name": "体重改变",
"tendency": "否定"
}
] |
患者于5+月前无明显诱因出现咳嗽、咳痰，痰为白色粘稠痰，伴痰中带血，呈鲜红色，量少，无寒战、发热、胸痛、心悸、呼吸困难，无头晕、头痛、腹痛、腹泻等不适。 | 212 | [
{
"anatomy_list": [],
"character": [],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"白色",
"粘稠"
],
"core_name": "咳痰",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"带血",
"鲜红色",
"量少"
],
"core_name": "咳痰",
"tendency": ""
},
{
"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": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [
"心"
],
"character": [],
"core_name": "心悸",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "呼吸困难",
"tendency": "否定"
},
{
"anatomy_list": [
"头"
],
"character": [],
"core_name": "头晕",
"tendency": "否定"
},
{
"anatomy_list": [
"头"
],
"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"
}
] |
3.肝内多发囊肿，脾脏小囊肿。 | 457 | [
{
"anatomy_list": [
"肝内"
],
"character": [
"多发"
],
"core_name": "囊肿",
"tendency": ""
},
{
"anatomy_list": [
"脾脏"
],
"character": [
"小"
],
"core_name": "囊肿",
"tendency": ""
}
] |
2.前列腺增生。 | 875 | [
{
"anatomy_list": [
"前列腺"
],
"character": [],
"core_name": "增生",
"tendency": ""
}
] |
无咳嗽、咳痰、喘累等。 | 936 | [
{
"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": "喘累",
"tendency": "否定"
}
] |
完善头部mr、腹部彩超、全身骨显像等检查后诊断“原发性支气管肺癌右上肺肺小细胞癌并肺内、全身多淋巴结、骨转移t4n3Mm1civ期”，于2018.03.17、2018.04.09、2018.05.04行3周期化疗，方案为：依托泊苷+奈达铂，第三周期复查胸部ct病灶明显吸收，化疗后无特殊不适出院。 | 572 | [
{
"anatomy_list": [
"支气管",
"肺"
],
"character": [
"原发性"
],
"core_name": "癌",
"tendency": ""
},
{
"anatomy_list": [
"右上肺",
"小细胞"
],
"character": [],
"core_name": "癌",
"tendency": ""
},
{
"anatomy_list": [
"右上肺"
],
"character": [
"明显吸收"
],
"core_name": "病灶",
"tendency": ""
},
{
"anatomy_list": [
"肺内",
"全身多淋巴结",
"骨"
],
"character": [
"转移",
"t4n3Mm1civ期"
],
"core_name": "癌",
"tendency": ""
}
] |
4.回肠末段肠管骤热变细、系膜条索影，束带粘连压迫可能，继发近端机械性不全性梗阻。 | 1,543 | [
{
"anatomy_list": [
"回肠末端"
],
"character": [
"骤热"
],
"core_name": "变细",
"tendency": ""
},
{
"anatomy_list": [
"系膜"
],
"character": [],
"core_name": "条索影",
"tendency": ""
},
{
"anatomy_list": [
"束带"
],
"character": [],
"core_name": "粘连",
"tendency": "不确定"
},
{
"anatomy_list": [
"束带"
],
"character": [],
"core_name": "压迫",
"tendency": "不确定"
},
{
"anatomy_list": [
"回肠近端"
],
"character": [
"继发",
"机械性",
"不完全性"
],
"core_name": "梗阻",
"tendency": ""
}
] |
患者在办入院前，购买卫生巾时出现阴道较多流血，可见鲜血顺双腿流下，自觉阴道有组织物掉出，遂立即于急诊科就诊，由急诊请我科住院总医师会诊，立即转入我科，急诊行超声引导下清宫术。 | 693 | [
{
"anatomy_list": [
"阴道"
],
"character": [
"较多",
"鲜血顺双腿流下"
],
"core_name": "出血",
"tendency": ""
},
{
"anatomy_list": [
"阴道"
],
"character": [],
"core_name": "组织物掉出",
"tendency": ""
}
] |