diff --git "a/CHIP-CDEE_dev.json" "b/CHIP-CDEE_dev.json" new file mode 100644--- /dev/null +++ "b/CHIP-CDEE_dev.json" @@ -0,0 +1,19626 @@ +[ + { + "id": 1744, + "text": "遂就诊于我院门诊行上消化道钡餐检查提示:右肺门结节及右肺上叶大叶性肺炎,胃蠕动减弱,血图分析提示hb 65g/L,今为求进一步诊治遂入我院入我科。", + "event": [ + { + "core_name": "结节", + "tendency": "", + "character": [], + "anatomy_list": [ + "右肺门" + ] + }, + { + "core_name": "肺炎", + "tendency": "", + "character": [ + "大叶性" + ], + "anatomy_list": [ + "右肺上叶" + ] + }, + { + "core_name": "蠕动减弱", + "tendency": "", + "character": [], + "anatomy_list": [ + "胃" + ] + } + ] + }, + { + "id": 11, + "text": "本次发病以来患者精神食欲稍差,大小便如常,睡眠较差,体重无明显下降。", + "event": [ + { + "core_name": "精神", + "tendency": "", + "character": [ + "稍差" + ], + "anatomy_list": [] + }, + { + "core_name": "食欲", + "tendency": "", + "character": [ + "稍差" + ], + "anatomy_list": [] + }, + { + "core_name": "大小便", + "tendency": "", + "character": [ + "正常" + ], + "anatomy_list": [] + }, + { + "core_name": "睡眠", + "tendency": "", + "character": [ + "较差" + ], + "anatomy_list": [] + }, + { + "core_name": "体重下降", + "tendency": "否定", + "character": [ + "明显" + ], + "anatomy_list": [] + } + ] + }, + { + "id": 295, + "text": "患者本次发病以来,食欲正常, 神志清醒,精神尚可,睡眠尚可,大便正常,小便正常,近一年体重减少10kg。", + "event": [ + { + "core_name": "食欲", + "tendency": "", + "character": [ + "正常" + ], + "anatomy_list": [] + }, + { + "core_name": "神志", + "tendency": "", + "character": [ + "清醒" + ], + "anatomy_list": [] + }, + { + "core_name": "精神", + "tendency": "", + "character": [ + "尚可" + ], + "anatomy_list": [] + }, + { + "core_name": "睡眠", + "tendency": "", + "character": [ + "尚可" + ], + "anatomy_list": [] + }, + { + "core_name": "大便", + "tendency": "", + "character": [ + "正常" + ], + "anatomy_list": [] + }, + { + "core_name": "小便", + "tendency": "", + "character": [ + "正常" + ], + "anatomy_list": [] + }, + { + "core_name": "体重减少", + "tendency": "", + "character": [], + "anatomy_list": [] + } + ] + }, + { + "id": 1605, + "text": "2020-7-26于某医院某院区就诊,行电子阴道镜:宫颈癌?妇科彩超提示:宫颈处减弱回声,约7.6×4.0cm;宫腔内积液。", + "event": [ + { + "core_name": "癌", + "tendency": "不确定", + "character": [], + "anatomy_list": [ + "宫颈" + ] + }, + { + "core_name": "回声", + "tendency": "", + "character": [ + "减弱" + ], + "anatomy_list": [ + "宫颈处" + ] + }, + { + "core_name": "积液", + "tendency": "", + "character": [], + "anatomy_list": [ + "宫腔内" + ] + } + ] + }, + { + "id": 1256, + "text": "因患者需期末考试,故予以口服“雷贝拉唑钠肠溶片”治疗,现腹痛情况明显好转。", + "event": [ + { + "core_name": "疼痛", + "tendency": "", + "character": [ + "明显好转" + ], + "anatomy_list": [ + "腹" + ] + } + ] + }, + { + "id": 587, + "text": "4.左膝关节退行性变。", + "event": [ + { + "core_name": "病变", + "tendency": "", + "character": [ + "退行性" + ], + "anatomy_list": [ + "左膝关节" + ] + } + ] + }, + { + "id": 1408, + "text": "院外经口饮食差,消瘦,静脉营养支持好转出院。", + "event": [ + { + "core_name": "饮食", + "tendency": "", + "character": [ + "差" + ], + "anatomy_list": [] + }, + { + "core_name": "消瘦", + "tendency": "", + "character": [], + "anatomy_list": [] + } + ] + }, + { + "id": 1141, + "text": "2016年4月8日患者无明显诱因出现阴道少许流血,每日用少量卫生纸即可,无明显臭味,2+日自净,未重视未处理。", + "event": [ + { + "core_name": "出血", + "tendency": "", + "character": [ + "少许" + ], + "anatomy_list": [ + "阴道" + ] + }, + { + "core_name": "臭味", + "tendency": "否定", + "character": [ + "明显" + ], + "anatomy_list": [] + } + ] + }, + { + "id": 1868, + "text": "现入院行第四次化疗,故门诊以“直肠腺癌术后”收入住院。", + "event": [ + { + "core_name": "腺癌", + "tendency": "", + "character": [ + "术后" + ], + "anatomy_list": [ + "直肠" + ] + } + ] + }, + { + "id": 350, + "text": "患者既往月经规律,初潮年龄15岁,4/2525天,量中,无痛经,13年前自然绝经,绝经后无异常阴道流血及流液,无同房接触性出血,未行妇科检查。", + "event": [ + { + "core_name": "月经", + "tendency": "", + "character": [ + "规律", + "量中" + ], + "anatomy_list": [] + }, + { + "core_name": "痛经", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "出血", + "tendency": "否定", + "character": [ + "异常", + "绝经后" + ], + "anatomy_list": [ + "阴道" + ] + }, + { + "core_name": "流液", + "tendency": "否定", + "character": [ + "异常", + "绝经后" + ], + "anatomy_list": [ + "阴道" + ] + }, + { + "core_name": "出血", + "tendency": "否定", + "character": [ + "同房接触性" + ], + "anatomy_list": [] + } + ] + }, + { + "id": 1257, + "text": "为求进一步治疗,昨日再次就诊于我院门诊,遂以“胃窦包块:间质瘤?”收入我科。", + "event": [ + { + "core_name": "包块", + "tendency": "", + "character": [], + "anatomy_list": [ + "胃窦" + ] + }, + { + "core_name": "间质瘤", + "tendency": "不确定", + "character": [], + "anatomy_list": [ + "胃窦" + ] + } + ] + }, + { + "id": 1077, + "text": "术后行静脉港置管辅助化疗治疗,方案为ec-t(吡柔比星+环磷酰胺序贯紫杉醇),共行5疗程,化疗后产生中度药物骨髓毒性反应,予以对症支持治疗;原始病灶位于右乳外上,簇状钙化灶,临床不能触及。现为继续化疗入院。", + "event": [ + { + "core_name": "毒性反应", + "tendency": "", + "character": [ + "化疗后", + "中度" + ], + "anatomy_list": [ + "骨髓" + ] + }, + { + "core_name": "病灶", + "tendency": "", + "character": [ + "原始" + ], + "anatomy_list": [ + "右乳外上" + ] + }, + { + "core_name": "钙化灶", + "tendency": "", + "character": [ + "簇状", + "不能触及" + ], + "anatomy_list": [ + "右乳外上" + ] + } + ] + }, + { + "id": 324, + "text": "院外患者无乳头溢液,无乳房胀痛等不适。", + "event": [ + { + "core_name": "溢液", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "乳头" + ] + }, + { + "core_name": "疼痛", + "tendency": "否定", + "character": [ + "胀痛" + ], + "anatomy_list": [ + "乳房" + ] + } + ] + }, + { + "id": 1547, + "text": "患者于入院前1+年无明显诱因出现双下肢乏力,活动后伴轻微疼痛,休息后双下肢疼痛可缓解,乏力稍缓解,无胸闷胸痛,无畏寒发热,无咳嗽咳痰,期间乏力程度无明显变化,患者未予重视,期间自服药物(具体不详),上述症状缓解不明显,今为求相应诊治,就诊于我院,门诊以“双下肢乏力待查”收入我科。", + "event": [ + { + "core_name": "乏力", + "tendency": "不确定", + "character": [], + "anatomy_list": [ + "双下肢" + ] + }, + { + "core_name": "疼痛", + "tendency": "", + "character": [ + "活动后", + "轻微" + ], + "anatomy_list": [ + "双下肢" + ] + }, + { + "core_name": "疼痛", + "tendency": "", + "character": [ + "休息后可缓解" + ], + "anatomy_list": [ + "双下肢" + ] + }, + { + "core_name": "乏力", + "tendency": "", + "character": [ + "休息后稍缓解" + ], + "anatomy_list": [ + "双下肢" + ] + }, + { + "core_name": "胸闷", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "胸" + ] + }, + { + "core_name": "疼痛", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "胸" + ] + }, + { + "core_name": "畏寒", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "发热", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "咳嗽", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "咳痰", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "乏力", + "tendency": "", + "character": [ + "1期间程度无明显变化" + ], + "anatomy_list": [] + }, + { + "core_name": "乏力", + "tendency": "不确定", + "character": [], + "anatomy_list": [ + "双下肢" + ] + } + ] + }, + { + "id": 530, + "text": "左室整体收缩功能减低”,予以“呋塞米20mg利尿+西地兰0.2mg强心”处理,以“扩张性心肌病”收入我科。", + "event": [ + { + "core_name": "收缩功能减低", + "tendency": "", + "character": [ + "减低" + ], + "anatomy_list": [ + "左室" + ] + }, + { + "core_name": "心肌病", + "tendency": "", + "character": [ + "扩张性" + ], + "anatomy_list": [] + } + ] + }, + { + "id": 812, + "text": "近3年患者症状加重,痰由白色粘痰转为黄色脓痰,且伴劳力性胸闷、心悸、气促,约持续半分钟左右,活动后尤甚,休息后可逐渐缓解,偶伴双下肢凹陷性水肿,伴端坐呼吸,无夜间阵发性呼吸困难,既往在我科及呼吸科住院,被诊断为“1.慢性阻塞性肺疾病 慢性肺源性心脏病 心力衰竭;2.冠状动脉粥样硬化性心脏病 心房纤颤”患者院外一直口服“阿司匹林肠溶片、泰嘉、欣康、麝香保心丸、胺碘酮”等药物治疗(具体剂量不详)。", + "event": [ + { + "core_name": "咳痰", + "tendency": "", + "character": [ + "白色粘痰转为黄色脓痰" + ], + "anatomy_list": [] + }, + { + "core_name": "胸闷", + "tendency": "", + "character": [ + "劳力性", + "活动后加重", + "休息后可逐渐缓解" + ], + "anatomy_list": [ + "胸" + ] + }, + { + "core_name": "心悸", + "tendency": "", + "character": [ + "活动后加重", + "休息后可逐渐缓解" + ], + "anatomy_list": [ + "心" + ] + }, + { + "core_name": "气促", + "tendency": "", + "character": [ + "活动后加重", + "休息后可逐渐缓解" + ], + "anatomy_list": [] + }, + { + "core_name": "水肿", + "tendency": "", + "character": [ + "凹陷性", + "偶伴" + ], + "anatomy_list": [ + "双下肢" + ] + }, + { + "core_name": "端坐呼吸", + "tendency": "", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "呼吸困难", + "tendency": "否定", + "character": [ + "夜间", + "阵发性" + ], + "anatomy_list": [] + }, + { + "core_name": "肺疾病", + "tendency": "", + "character": [ + "慢性", + "阻塞性" + ], + "anatomy_list": [ + "肺" + ] + }, + { + "core_name": "心脏病", + "tendency": "", + "character": [ + "慢性", + "肺源性" + ], + "anatomy_list": [ + "心脏" + ] + }, + { + "core_name": "心力衰竭", + "tendency": "", + "character": [], + "anatomy_list": [ + "心" + ] + }, + { + "core_name": "心脏病", + "tendency": "", + "character": [ + "冠状动脉粥样硬化性" + ], + "anatomy_list": [ + "心脏" + ] + }, + { + "core_name": "心房纤颤", + "tendency": "", + "character": [], + "anatomy_list": [ + "心房" + ] + } + ] + }, + { + "id": 1217, + "text": "2016年12月患者因阴道大量流血急诊至某医院就诊,考虑“功血”,给予止血药止血治疗(具体治疗经过不详)后未进一步诊治,停药后阴道分泌物继续增多,呈暗红色,伴异味,伴同房后有少量阴道流血,呈鲜红色,量较少,持续两天后消失。", + "event": [ + { + "core_name": "出血", + "tendency": "", + "character": [ + "大量" + ], + "anatomy_list": [ + "阴道" + ] + }, + { + "core_name": "功能失调性子宫出血", + "tendency": "不确定", + "character": [], + "anatomy_list": [ + "子宫" + ] + }, + { + "core_name": "阴道分泌物", + "tendency": "", + "character": [ + "继续增多", + "呈暗红色", + "伴异味" + ], + "anatomy_list": [ + "阴道" + ] + }, + { + "core_name": "出血", + "tendency": "", + "character": [ + "同房后", + "少量", + "呈鲜红色", + "量较少", + "持续两天后消失" + ], + "anatomy_list": [ + "阴道" + ] + } + ] + }, + { + "id": 263, + "text": "患者此次患病以来,精神状态欠佳,小便正常,大便可疑黑便。", + "event": [ + { + "core_name": "精神", + "tendency": "", + "character": [ + "欠佳" + ], + "anatomy_list": [] + }, + { + "core_name": "小便", + "tendency": "", + "character": [ + "正常" + ], + "anatomy_list": [] + }, + { + "core_name": "黑便", + "tendency": "不确定", + "character": [], + "anatomy_list": [] + } + ] + }, + { + "id": 982, + "text": "2月前,患者结核门诊痰检结果示:发现抗酸杆菌(+);结核rna恒温扩增检测:阴性,肺结核(活菌)核酸检测:阴性,结核分枝杆菌耐药性检测:利福平耐药未检出;咳嗽、咳痰较前加重,于我科住院治疗,完善相关检查,考虑诊断为“1.继发型肺结核 双肺 涂阳 培阳 复治 耐多药肺结核 2.肺部感染 3.败血症?4.营养不良 5.慢性乙肝携带者 6.慢性胃炎 7.电解质代谢紊乱 8.低蛋白血症 9.前列腺增生症 10.前列腺病变待查”,给予抗感染、止咳祛痰等治疗,患者症状好转出院。", + "event": [ + { + "core_name": "结核", + "tendency": "", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "咳嗽", + "tendency": "", + "character": [ + "加重" + ], + "anatomy_list": [] + }, + { + "core_name": "咳痰", + "tendency": "", + "character": [ + "加重" + ], + "anatomy_list": [] + }, + { + "core_name": "结核", + "tendency": "不确定", + "character": [ + "继发性" + ], + "anatomy_list": [ + "双肺" + ] + }, + { + "core_name": "结核", + "tendency": "不确定", + "character": [ + "耐多药" + ], + "anatomy_list": [ + "肺" + ] + }, + { + "core_name": "感染", + "tendency": "不确定", + "character": [], + "anatomy_list": [ + "肺部" + ] + }, + { + "core_name": "败血症", + "tendency": "不确定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "营养不良", + "tendency": "不确定", + "character": [], + "anatomy_list": [ + "肺部" + ] + }, + { + "core_name": "乙肝携带者", + "tendency": "不确定", + "character": [ + "慢性", + "乙型" + ], + "anatomy_list": [ + "肝" + ] + }, + { + "core_name": "胃炎", + "tendency": "不确定", + "character": [ + "慢性" + ], + "anatomy_list": [ + "胃" + ] + }, + { + "core_name": "电解质代谢紊乱", + "tendency": "", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "低蛋白血症", + "tendency": "不确定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "增生症", + "tendency": "不确定", + "character": [], + "anatomy_list": [ + "前列腺" + ] + }, + { + "core_name": "病变", + "tendency": "", + "character": [], + "anatomy_list": [ + "前列腺" + ] + } + ] + }, + { + "id": 880, + "text": "10+年前,患者发现血压增高,后多次测血压大于140/90mmHg,最高血压150+/?mmhg,偶服用药物治疗(美托洛尔缓释片、培哚普利),未规律监测血压,血压波动情况不详。", + "event": [ + { + "core_name": "血压", + "tendency": "", + "character": [ + "增高" + ], + "anatomy_list": [] + }, + { + "core_name": "血压", + "tendency": "", + "character": [ + "波动情况不详" + ], + "anatomy_list": [] + } + ] + }, + { + "id": 972, + "text": "12年前,患者无明显诱因出现咳嗽、咳痰,干咳为主,咳少量白色粘痰,痰不易咳出,伴胸闷、气促、呼吸困难,无咯血、胸痛,无腹痛、腹胀,无潮热、盗汗等不适。", + "event": [ + { + "core_name": "咳嗽", + "tendency": "", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "咳痰", + "tendency": "", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "咳嗽", + "tendency": "", + "character": [ + "干性" + ], + "anatomy_list": [] + }, + { + "core_name": "咳痰", + "tendency": "", + "character": [ + "少量", + "白色", + "粘性", + "不易咳出" + ], + "anatomy_list": [] + }, + { + "core_name": "胸闷", + "tendency": "", + "character": [], + "anatomy_list": [ + "胸" + ] + }, + { + "core_name": "气促", + "tendency": "", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "呼吸困难", + "tendency": "", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "咯血", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "疼痛", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "胸" + ] + }, + { + "core_name": "疼痛", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "腹" + ] + }, + { + "core_name": "腹胀", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "腹" + ] + }, + { + "core_name": "潮热", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "盗汗", + "tendency": "否定", + "character": [], + "anatomy_list": [] + } + ] + }, + { + "id": 1270, + "text": "11月前患者于我院诊断为“右肺鳞状细胞癌 ”,分别于2016-07-09日、2016-08-06日、2017-01-05、2017-02-15日行紫杉醇240mg d1+奥沙利铂230mg d2化疗4次,化疗过程中有头晕、头痛、呕吐、轻微腹泻等化疗反应,予以对症治疗后好转出院。", + "event": [ + { + "core_name": "鳞癌", + "tendency": "", + "character": [], + "anatomy_list": [ + "右肺" + ] + }, + { + "core_name": "头晕", + "tendency": "", + "character": [], + "anatomy_list": [ + "头" + ] + }, + { + "core_name": "疼痛", + "tendency": "", + "character": [], + "anatomy_list": [ + "头" + ] + }, + { + "core_name": "呕吐", + "tendency": "", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "腹泻", + "tendency": "", + "character": [ + "轻微" + ], + "anatomy_list": [] + } + ] + }, + { + "id": 112, + "text": "入院半月前,患者无明显诱因出现黑便,成形,量少,次数不详,伴上腹胀、反酸、烧心、呃逆,伴背部放射痛、身黄、尿黄,无厌油、恶心、呕吐、呕血、腹痛、腹泻、便血,无畏寒、发热,无心悸、气促、头晕,无黑曚、晕厥,无眼黄、身黄、尿黄等不适,患者自行购买“斯达舒、铝碳酸镁”服用2+天后未再黑便,上腹胀、反酸、烧心、呃逆有所好转;入院20小时前,患者无明显诱因再次出现黑便,先后解2次较多量成形黑便(具体不详)、2次较少量黑色稀便,伴上腹胀、反酸、烧心、呃逆、背部放射痛、身黄、尿黄,患者未予处理,入院3小时前出现呕咖啡色样物质1次,约500ml,含食物残渣,无鲜血、血凝块,并伴乏力、大汗、心慌、头昏、眼花,无厌油、腹痛、腹泻、便血,无畏寒、发热等不适,遂于我院急诊科就诊,急诊科查:血常规:血红蛋白浓度(hb)122g/L、红细胞计数(rbc)3.66*10^12/L、白细胞计数(wbc) 12.5*10^9/L 、中性粒细胞百分百 75.9%;肝功、电解质、凝血象未见明显异常;予以补液等处理后转入我科。", + "event": [ + { + "core_name": "黑便", + "tendency": "", + "character": [ + "成形", + "量少", + "���数不详" + ], + "anatomy_list": [] + }, + { + "core_name": "腹胀", + "tendency": "", + "character": [], + "anatomy_list": [ + "上腹" + ] + }, + { + "core_name": "反酸", + "tendency": "", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "烧心", + "tendency": "", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "呃逆", + "tendency": "", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "疼痛", + "tendency": "", + "character": [ + "放射性" + ], + "anatomy_list": [ + "背部" + ] + }, + { + "core_name": "黄染", + "tendency": "", + "character": [], + "anatomy_list": [ + "身" + ] + }, + { + "core_name": "尿黄", + "tendency": "", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "厌油", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "恶心", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "呕吐", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "呕血", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "疼痛", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "腹" + ] + }, + { + "core_name": "腹泻", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "腹" + ] + }, + { + "core_name": "便血", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "畏寒", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "发热", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "心悸", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "心" + ] + }, + { + "core_name": "气促", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "头晕", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "头" + ] + }, + { + "core_name": "黒朦", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "晕厥", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "黄染", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "眼" + ] + }, + { + "core_name": "黄染", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "身" + ] + }, + { + "core_name": "尿黄", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "黑便", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "腹胀", + "tendency": "", + "character": [ + "好转" + ], + "anatomy_list": [ + "上腹" + ] + }, + { + "core_name": "反酸", + "tendency": "", + "character": [ + "好转" + ], + "anatomy_list": [] + }, + { + "core_name": "烧心", + "tendency": "", + "character": [ + "好转" + ], + "anatomy_list": [ + "心" + ] + }, + { + "core_name": "呃逆", + "tendency": "", + "character": [ + "好转" + ], + "anatomy_list": [] + }, + { + "core_name": "黑便", + "tendency": "", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "黑便", + "tendency": "", + "character": [ + "较多量", + "成形", + "2次" + ], + "anatomy_list": [] + }, + { + "core_name": "黑便", + "tendency": "", + "character": [ + "少量", + "稀便", + "2次" + ], + "anatomy_list": [] + }, + { + "core_name": "腹胀", + "tendency": "", + "character": [], + "anatomy_list": [ + "上腹" + ] + }, + { + "core_name": "反酸", + "tendency": "", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "烧心", + "tendency": "", + "character": [], + "anatomy_list": [ + "心" + ] + }, + { + "core_name": "呃逆", + "tendency": "", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "疼痛", + "tendency": "", + "character": [ + "放射性" + ], + "anatomy_list": [ + "背部" + ] + }, + { + "core_name": "黄染", + "tendency": "", + "character": [], + "anatomy_list": [ + "身" + ] + }, + { + "core_name": "尿黄", + "tendency": "", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "呕吐", + "tendency": "", + "character": [ + "咖啡色样", + "含食物残渣", + "无鲜血", + "无血凝块" + ], + "anatomy_list": [] + }, + { + "core_name": "乏力", + "tendency": "", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "出汗", + "tendency": "", + "character": [ + "增多" + ], + "anatomy_list": [] + }, + { + "core_name": "心慌", + "tendency": "", + "character": [], + "anatomy_list": [ + "心" + ] + }, + { + "core_name": "头昏", + "tendency": "", + "character": [], + "anatomy_list": [ + "头" + ] + }, + { + "core_name": "眼花", + "tendency": "", + "character": [], + "anatomy_list": [ + "眼" + ] + }, + { + "core_name": "厌油", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "疼痛", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "腹" + ] + }, + { + "core_name": "腹泻", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "腹部" + ] + }, + { + "core_name": "便血", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "畏寒", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "发热", + "tendency": "否定", + "character": [], + "anatomy_list": [] + } + ] + }, + { + "id": 1822, + "text": "入院1+年前患者无明显诱因出现阴道不规律出血,为鲜红色,每次量少,伴血凝块,伴下腹隐痛,持续时间短,能忍受,无放射痛,无阴道阴道坠胀,无尿频、尿急、尿痛、血尿,无呕血、黑便,无头痛、头昏、乏力,无畏寒、发热,无明显体重下降,于我院行宫颈脱落细胞检查:鳞状细胞癌。", + "event": [ + { + "core_name": "出血", + "tendency": "", + "character": [ + "不规律", + "鲜红色", + "每次量少", + "血凝块" + ], + "anatomy_list": [ + "阴道" + ] + }, + { + "core_name": "疼痛", + "tendency": "", + "character": [ + "隐痛", + "持续时间短", + "能忍受" + ], + "anatomy_list": [ + "下腹" + ] + }, + { + "core_name": "疼痛", + "tendency": "否定", + "character": [ + "放射性" + ], + "anatomy_list": [] + }, + { + "core_name": "坠胀", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "阴道" + ] + }, + { + "core_name": "尿频", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "尿急", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "尿痛", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "血尿", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "呕血", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "黑便", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "疼痛", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "头" + ] + }, + { + "core_name": "头昏", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "头" + ] + }, + { + "core_name": "乏力", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "畏寒", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "发热", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "体重下降", + "tendency": "否定", + "character": [ + "明显" + ], + "anatomy_list": [] + }, + { + "core_name": "鳞癌", + "tendency": "", + "character": [], + "anatomy_list": [ + "宫颈" + ] + } + ] + }, + { + "id": 339, + "text": "患者 1+月 前无明显诱因下开始出现大便次数增多,由 1 次/天增加至 3-4 次/天, 伴便血 , 便血与粪便混合 。", + "event": [ + { + "core_name": "大便", + "tendency": "", + "character": [ + "次数增多", + "由 1 次/天增加至 3-4 次/天" + ], + "anatomy_list": [] + }, + { + "core_name": "便血", + "tendency": "", + "character": [ + "便血与粪便混合" + ], + "anatomy_list": [] + } + ] + }, + { + "id": 1268, + "text": "建议住院治疗,患者遂于今日入我院,门诊以“左肺门肿块待查”收入我科住院治疗。", + "event": [ + { + "core_name": "肿块", + "tendency": "不确定", + "character": [], + "anatomy_list": [ + "左肺门" + ] + } + ] + }, + { + "id": 303, + "text": "考虑患者肺癌术后复发,遂于2011-10-28在我科行左侧胸腔奈达铂100mg局部灌注化疗术+多西他赛100mg全身静脉化疗,于2011-11-22行多西他赛100mg全身静脉化疗,于2011-11-23行胸腔穿刺抽液术+奈达铂100mg灌注术,2011-12-15行奈达铂100mg+多西他赛80mg全身静脉化疗,2012-01-06行多西他赛100mg+奈达铂80mg全身静脉化疗,好转出院,此后患者多次复查未见明显转移病灶。", + "event": [ + { + "core_name": "癌", + "tendency": "不确定", + "character": [ + "术后复发" + ], + "anatomy_list": [ + "肺" + ] + }, + { + "core_name": "病灶", + "tendency": "否定", + "character": [ + "明显", + "转移" + ], + "anatomy_list": [] + } + ] + }, + { + "id": 746, + "text": "病程中患者精神、饮食欠佳,小便正常,大便如上述,体重无明显下降。", + "event": [ + { + "core_name": "精神", + "tendency": "", + "character": [ + "欠佳" + ], + "anatomy_list": [] + }, + { + "core_name": "进食", + "tendency": "", + "character": [ + "欠佳" + ], + "anatomy_list": [] + }, + { + "core_name": "小便", + "tendency": "", + "character": [ + "正常" + ], + "anatomy_list": [] + }, + { + "core_name": "大便", + "tendency": "", + "character": [ + "正常" + ], + "anatomy_list": [] + }, + { + "core_name": "体重下降", + "tendency": "否定", + "character": [ + "明显" + ], + "anatomy_list": [] + } + ] + }, + { + "id": 1719, + "text": "4天前到我院就诊行胸部ct检查提示“右肺下叶片块影并周围炎症改变”,今为明确诊治入院。", + "event": [ + { + "core_name": "片块影", + "tendency": "", + "character": [], + "anatomy_list": [ + "右肺下" + ] + }, + { + "core_name": "炎症改变", + "tendency": "", + "character": [], + "anatomy_list": [ + "右肺下周围" + ] + } + ] + }, + { + "id": 770, + "text": "患者未予重视,未作相关处理,遂到到我院门诊就诊,查血常规:血红蛋白50g/L;红细胞压积16.4%;上腹部彩超提示胆囊壁毛糙,胆囊息肉样变。", + "event": [ + { + "core_name": "毛糙", + "tendency": "", + "character": [], + "anatomy_list": [ + "胆囊壁" + ] + }, + { + "core_name": "息肉样变", + "tendency": "", + "character": [], + "anatomy_list": [ + "胆囊" + ] + } + ] + }, + { + "id": 493, + "text": "现患者无腹胀、呕吐,无发热、咳嗽、咳痰等不适,为行第1次曲妥珠单抗靶向化疗入院,门诊以“左乳癌术后第6次化疗后”收入我科。", + "event": [ + { + "core_name": "腹胀", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "腹" + ] + }, + { + "core_name": "呕吐", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "发热", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "咳嗽", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "咳痰", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "癌", + "tendency": "", + "character": [ + "术后", + "第6次化疗后" + ], + "anatomy_list": [ + "左乳" + ] + } + ] + }, + { + "id": 1778, + "text": "为求进一步诊治,于我院就诊,门诊以“黄疸原因待查”收治入科。", + "event": [ + { + "core_name": "黄疸", + "tendency": "不确定", + "character": [], + "anatomy_list": [] + } + ] + }, + { + "id": 1122, + "text": "随即分别于术后8天、术后1月、术后3月先后三次给予卡铂800mg腹腔灌注+紫杉醇210mg静脉滴注化疗,化疗过程中有恶心、呕吐等不适,复查示ii度骨髓抑制,予以升白细胞、止吐等对症处理后好转出院。", + "event": [ + { + "core_name": "恶心", + "tendency": "", + "character": [ + "化疗过程中" + ], + "anatomy_list": [] + }, + { + "core_name": "呕吐", + "tendency": "", + "character": [ + "化疗过程中" + ], + "anatomy_list": [] + }, + { + "core_name": "骨髓抑制", + "tendency": "", + "character": [ + "II度" + ], + "anatomy_list": [ + "骨髓" + ] + } + ] + }, + { + "id": 2003, + "text": "本次入院记录 患者于2月余前于某医院复查甲胎蛋白示:39.2ng/ml,无纳差、乏力、厌油,无眼黄、身黄,无反酸、嗳气等不适,未特殊治疗;1月前随访甲胎蛋白示:64.9ng/ml,3天前随访甲胎蛋白示:76.0ng/ml,遂于我院就诊,门诊以“原发性肝癌介入术后”收入我科。", + "event": [ + { + "core_name": "纳差", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "乏力", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "厌油", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "黄染", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "眼" + ] + }, + { + "core_name": "黄染", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "身" + ] + }, + { + "core_name": "反酸", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "嗳气", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "癌", + "tendency": "", + "character": [ + "介入术后", + "原发性" + ], + "anatomy_list": [ + "肝" + ] + } + ] + }, + { + "id": 717, + "text": "门诊以“直肠癌术后”收治入院。", + "event": [ + { + "core_name": "癌", + "tendency": "", + "character": [ + "术后" + ], + "anatomy_list": [ + "直肠" + ] + } + ] + }, + { + "id": 1002, + "text": "进一步行腹部ct检查提示肝右叶前段稍低密度结节低密度结节影,大小约1.8×2.2cm,包膜完整,增强后明显强化,考虑肿瘤性病变,原发性小肝癌可能性大。", + "event": [ + { + "core_name": "结节影", + "tendency": "", + "character": [ + "稍低密度", + "包膜完整", + "增强后明显强化" + ], + "anatomy_list": [ + "肝右叶前段" + ] + }, + { + "core_name": "病变", + "tendency": "不确定", + "character": [ + "肿瘤性" + ], + "anatomy_list": [] + }, + { + "core_name": "癌", + "tendency": "不确定", + "character": [ + "原发性", + "小" + ], + "anatomy_list": [ + "肝" + ] + } + ] + }, + { + "id": 1973, + "text": "患者本次发病以来,食欲正常神志清醒,精神欠佳,睡眠欠佳,大便如上述,小便正常,体重无明显变化。", + "event": [ + { + "core_name": "食欲", + "tendency": "", + "character": [ + "正常" + ], + "anatomy_list": [] + }, + { + "core_name": "神志", + "tendency": "", + "character": [ + "清醒" + ], + "anatomy_list": [] + }, + { + "core_name": "精神", + "tendency": "", + "character": [ + "欠佳" + ], + "anatomy_list": [] + }, + { + "core_name": "睡眠", + "tendency": "", + "character": [ + "欠佳" + ], + "anatomy_list": [] + }, + { + "core_name": "大便", + "tendency": "", + "character": [ + "正常" + ], + "anatomy_list": [] + }, + { + "core_name": "小便", + "tendency": "", + "character": [ + "正常" + ], + "anatomy_list": [] + }, + { + "core_name": "体重改变", + "tendency": "否定", + "character": [ + "明显" + ], + "anatomy_list": [] + } + ] + }, + { + "id": 1065, + "text": "患者本次发病以来,食欲正常,神志清醒,精神尚可,睡眠尚可,大便如上诉,小便正常,体重无明显变化。", + "event": [ + { + "core_name": "食欲", + "tendency": "", + "character": [ + "正常" + ], + "anatomy_list": [] + }, + { + "core_name": "神志", + "tendency": "", + "character": [ + "清醒" + ], + "anatomy_list": [] + }, + { + "core_name": "精神", + "tendency": "", + "character": [ + "尚可" + ], + "anatomy_list": [] + }, + { + "core_name": "睡眠", + "tendency": "", + "character": [ + "尚可" + ], + "anatomy_list": [] + }, + { + "core_name": "小便", + "tendency": "", + "character": [ + "正常" + ], + "anatomy_list": [] + }, + { + "core_name": "体重改变", + "tendency": "否定", + "character": [ + "明显" + ], + "anatomy_list": [] + } + ] + }, + { + "id": 1700, + "text": "入院前2年,患者无明显诱因下出现阵发性咳嗽,咳大量白色粘稠痰,痰易咳出,伴口干、冷汗,活动后感心累,症状于夜间加重,无发热、畏寒,无胸痛、咯血,遂就诊于我院,“胸部ct示:右肺上叶楔形致密影,右上肺不张;纤支镜示:右上叶开口被一菜花样新生物完全阻塞;病理诊断:右上叶开口小细胞性恶性肿瘤,倾向于低分化鳞癌”。", + "event": [ + { + "core_name": "咳嗽", + "tendency": "", + "character": [ + "阵发性" + ], + "anatomy_list": [] + }, + { + "core_name": "咳痰", + "tendency": "", + "character": [ + "大量", + "白色", + "粘稠" + ], + "anatomy_list": [] + }, + { + "core_name": "咳痰", + "tendency": "", + "character": [ + "易咳出" + ], + "anatomy_list": [] + }, + { + "core_name": "口干", + "tendency": "", + "character": [], + "anatomy_list": [ + "口" + ] + }, + { + "core_name": "冷汗", + "tendency": "", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "心累", + "tendency": "", + "character": [ + "活动后" + ], + "anatomy_list": [ + "心" + ] + }, + { + "core_name": "发热", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "畏寒", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "疼痛", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "胸" + ] + }, + { + "core_name": "咯血", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "致密影", + "tendency": "", + "character": [ + "楔形" + ], + "anatomy_list": [ + "右肺上叶" + ] + }, + { + "core_name": "肺不张", + "tendency": "", + "character": [], + "anatomy_list": [ + "右上肺" + ] + }, + { + "core_name": "新生物", + "tendency": "", + "character": [ + "菜花样" + ], + "anatomy_list": [ + "右上肺右上叶开口" + ] + }, + { + "core_name": "阻塞", + "tendency": "", + "character": [ + "完全", + "被新生物" + ], + "anatomy_list": [ + "右上肺右上叶开��" + ] + }, + { + "core_name": "肿瘤", + "tendency": "", + "character": [ + "小细胞性", + "恶性" + ], + "anatomy_list": [ + "右上肺右上叶开口" + ] + }, + { + "core_name": "鳞癌", + "tendency": "不确定", + "character": [ + "低分化" + ], + "anatomy_list": [ + "右上肺右上叶开口" + ] + } + ] + }, + { + "id": 1135, + "text": "4、腹腔少量积液。", + "event": [ + { + "core_name": "积液", + "tendency": "", + "character": [ + "少量" + ], + "anatomy_list": [ + "腹腔" + ] + } + ] + }, + { + "id": 909, + "text": "患者于4+年前体检时行腹部彩超发现胆囊结石,未见报告,具体不详,患者自诉无腹痛、腹胀、腹泻等不适,故未予重视与治疗。", + "event": [ + { + "core_name": "结石", + "tendency": "", + "character": [], + "anatomy_list": [ + "胆囊" + ] + }, + { + "core_name": "疼痛", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "腹" + ] + }, + { + "core_name": "腹胀", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "腹" + ] + }, + { + "core_name": "腹泻", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "腹" + ] + } + ] + }, + { + "id": 81, + "text": "遂来我院就诊,行麦默通穿刺活检后确诊为左乳浸润性癌。", + "event": [ + { + "core_name": "癌", + "tendency": "", + "character": [ + "浸润性" + ], + "anatomy_list": [ + "左乳" + ] + } + ] + }, + { + "id": 327, + "text": "患者1月前无明显诱因出现胀痛,表现为脐周阵发性胀痛,偶为窜气样疼痛,疼痛较重,不伴腰背部及肩部放射性疼痛,排气排便后稍缓解。", + "event": [ + { + "core_name": "疼痛", + "tendency": "", + "character": [ + "胀痛" + ], + "anatomy_list": [] + }, + { + "core_name": "疼痛", + "tendency": "", + "character": [ + "胀痛", + "阵发性", + "偶为窜气样疼痛", + "疼痛较重", + "排气排便后稍缓解" + ], + "anatomy_list": [ + "脐周" + ] + }, + { + "core_name": "疼痛", + "tendency": "否定", + "character": [ + "放射性" + ], + "anatomy_list": [ + "腰背部", + "肩部" + ] + } + ] + }, + { + "id": 1232, + "text": "患者遂来我院急诊科查全腹ct:1、胃窦、十二指肠区条状高密度影,考虑术后改变可能。请结合临床。", + "event": [ + { + "core_name": "密度影", + "tendency": "", + "character": [ + "高", + "条状" + ], + "anatomy_list": [ + "胃窦", + "十二指肠区" + ] + }, + { + "core_name": "术后改变", + "tendency": "不确定", + "character": [], + "anatomy_list": [] + } + ] + }, + { + "id": 1214, + "text": "入院前3天,患者因剑突下隐痛及喉部梗阻感,就诊于某医院,于该院行“冠脉造影及右冠球囊扩张术”冠脉造影示:lm分叉处斑块,lad近段原支架内血流通畅,中段分叉后狭窄70%,中远段狭窄80%,lcx弥漫斑块,中段狭窄60%-70%,可见溃疡和瘤样扩张,远段细小,狭窄70%-80%,om远段狭窄80%,rca近段见原支架内再狭窄85%,中段原支架内血流通畅,中远段支架内可见内皮增生狭窄50%,于rca支架近段狭窄处行球囊扩张后,rac支架内血流通畅,timi血流3级。", + "event": [ + { + "core_name": "疼痛", + "tendency": "", + "character": [ + "隐痛" + ], + "anatomy_list": [ + "剑突下" + ] + }, + { + "core_name": "梗阻感", + "tendency": "", + "character": [], + "anatomy_list": [ + "喉部" + ] + }, + { + "core_name": "斑块", + "tendency": "", + "character": [], + "anatomy_list": [ + "冠脉lm分叉处" + ] + }, + { + "core_name": "血流通畅", + "tendency": "", + "character": [ + "原支架内" + ], + "anatomy_list": [ + "冠脉lad近段" + ] + }, + { + "core_name": "狭窄", + "tendency": "", + "character": [ + "70%" + ], + "anatomy_list": [ + "冠脉lad中段分叉后" + ] + }, + { + "core_name": "狭窄", + "tendency": "", + "character": [ + "80%" + ], + "anatomy_list": [ + "冠脉lad中远段" + ] + }, + { + "core_name": "斑块", + "tendency": "", + "character": [ + "弥漫" + ], + "anatomy_list": [ + "冠脉lcx" + ] + }, + { + "core_name": "狭窄", + "tendency": "", + "character": [ + "60%-70%" + ], + "anatomy_list": [ + "冠脉lcx中段" + ] + }, + { + "core_name": "溃疡", + "tendency": "", + "character": [], + "anatomy_list": [ + "冠脉lcx中段" + ] + }, + { + "core_name": "扩张", + "tendency": "", + "character": [ + "瘤样" + ], + "anatomy_list": [ + "冠脉lcx中段" + ] + }, + { + "core_name": "狭窄", + "tendency": "", + "character": [ + "70%-80%" + ], + "anatomy_list": [ + "冠脉lcx远段" + ] + }, + { + "core_name": "细小", + "tendency": "", + "character": [], + "anatomy_list": [ + "冠脉lcx远段" + ] + }, + { + "core_name": "狭窄", + "tendency": "", + "character": [ + "80%" + ], + "anatomy_list": [ + "冠脉om远段" + ] + }, + { + "core_name": "再狭窄", + "tendency": "", + "character": [ + "原支架内", + "85%" + ], + "anatomy_list": [ + "rca近段" + ] + }, + { + "core_name": "血流通畅", + "tendency": "", + "character": [ + "原支架内" + ], + "anatomy_list": [ + "rca中段" + ] + }, + { + "core_name": "增生狭窄", + "tendency": "", + "character": [ + "支架内", + "50%" + ], + "anatomy_list": [ + "rca中远段内皮" + ] + }, + { + "core_name": "血流通畅", + "tendency": "", + "character": [ + "支架内" + ], + "anatomy_list": [ + "rca" + ] + }, + { + "core_name": "timi血流", + "tendency": "", + "character": [ + "3级" + ], + "anatomy_list": [] + } + ] + }, + { + "id": 1170, + "text": "患者为求进一步诊治,遂来我科,以“胆囊结石、胆囊炎”收入我科。", + "event": [ + { + "core_name": "结石", + "tendency": "", + "character": [], + "anatomy_list": [ + "胆囊" + ] + }, + { + "core_name": "胆囊炎", + "tendency": "", + "character": [], + "anatomy_list": [ + "胆囊" + ] + } + ] + }, + { + "id": 2051, + "text": "于2011-09-13行超声胃镜检查并取活检术,术后病检提示:1、(十二指肠球部)送检粘膜下方见少许异型细胞团,恶性肿瘤可能;2、(胃体)息肉。", + "event": [ + { + "core_name": "异形细胞团", + "tendency": "", + "character": [ + "少许" + ], + "anatomy_list": [ + "十二指肠球粘膜下方" + ] + }, + { + "core_name": "肿瘤", + "tendency": "不确定", + "character": [ + "恶性" + ], + "anatomy_list": [ + "十二指肠球粘膜下方" + ] + }, + { + "core_name": "息肉", + "tendency": "", + "character": [], + "anatomy_list": [ + "胃体" + ] + } + ] + }, + { + "id": 1161, + "text": "三天前突然咳出10ml鲜血。", + "event": [ + { + "core_name": "咳血", + "tendency": "", + "character": [ + "突然", + "10ml", + "鲜血" + ], + "anatomy_list": [] + } + ] + }, + { + "id": 1226, + "text": "诊断为“宫颈神经内分泌癌iib期”,因病灶大,建议先行新辅助化疗,排除化疗禁忌症后于2017年06月16日、2017年7月8日行tp(紫杉醇240mg+奈达铂140mg)静脉化疗2周期,化疗过程顺利。", + "event": [ + { + "core_name": "癌", + "tendency": "", + "character": [ + "神经内分泌", + "iib期" + ], + "anatomy_list": [ + "宫颈" + ] + }, + { + "core_name": "病灶", + "tendency": "", + "character": [ + "大" + ], + "anatomy_list": [] + } + ] + }, + { + "id": 575, + "text": "术后于某医院进一步检查,会诊某医院病理切片123456提示:(右卵巢)恶性肿瘤,根据免疫组化考虑恶性混合性生殖细胞瘤(无性细胞瘤合并卵黄囊瘤)。", + "event": [ + { + "core_name": "肿瘤", + "tendency": "", + "character": [ + "恶性" + ], + "anatomy_list": [ + "右卵巢" + ] + }, + { + "core_name": "瘤", + "tendency": "不确定", + "character": [ + "恶性", + "混合性" + ], + "anatomy_list": [ + "右卵巢", + "生殖细胞" + ] + }, + { + "core_name": "瘤", + "tendency": "不确定", + "character": [ + "无恶性细胞" + ], + "anatomy_list": [ + "右卵巢" + ] + }, + { + "core_name": "瘤", + "tendency": "不确定", + "character": [ + "卵黄囊" + ], + "anatomy_list": [ + "右卵巢" + ] + } + ] + }, + { + "id": 1169, + "text": "患者于当地医院就诊,行腹部彩超、ct等检查,患者家属自诉检查结果提示胆囊结石(未见报告单),予以输液治疗(具体不详),治疗后症状稍缓解。", + "event": [ + { + "core_name": "结石", + "tendency": "", + "character": [], + "anatomy_list": [ + "胆囊" + ] + } + ] + }, + { + "id": 1448, + "text": "2010年11月患者复查腹部ct见肝右前叶动脉期小结节灶,0.4cm,有强化,考虑肝癌,建议患者手术治疗。", + "event": [ + { + "core_name": "结节灶", + "tendency": "", + "character": [ + "小", + "有强化", + "动脉期" + ], + "anatomy_list": [ + "肝右前叶" + ] + }, + { + "core_name": "癌", + "tendency": "不确定", + "character": [], + "anatomy_list": [ + "肝" + ] + } + ] + }, + { + "id": 1094, + "text": "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,体重减少5Kg。", + "event": [ + { + "core_name": "食欲", + "tendency": "", + "character": [ + "减退" + ], + "anatomy_list": [] + }, + { + "core_name": "神志", + "tendency": "", + "character": [ + "清醒" + ], + "anatomy_list": [] + }, + { + "core_name": "精神", + "tendency": "", + "character": [ + "尚可" + ], + "anatomy_list": [] + }, + { + "core_name": "睡眠", + "tendency": "", + "character": [ + "尚可" + ], + "anatomy_list": [] + }, + { + "core_name": "大便", + "tendency": "", + "character": [ + "正常" + ], + "anatomy_list": [] + }, + { + "core_name": "小便", + "tendency": "", + "character": [ + "正常" + ], + "anatomy_list": [] + }, + { + "core_name": "体重减轻", + "tendency": "", + "character": [], + "anatomy_list": [] + } + ] + }, + { + "id": 272, + "text": "现患者为求进一步治疗就诊于我院,以“双下肢乏力”收入我科住院治疗。", + "event": [ + { + "core_name": "乏力", + "tendency": "", + "character": [], + "anatomy_list": [ + "双下肢" + ] + } + ] + }, + { + "id": 1679, + "text": "9天前,患者受凉后再次出现咳嗽咳痰症状加重,咳白色粘痰,易咯出,量不多;伴发热,有畏寒,无明显寒战,在外测得体温最高达39℃;伴呕吐,呕吐物为胃内容物,无咖啡色样物质;无反酸嗳气,无咯血胸痛,无左侧胸前区压榨感及左肩及左手臂内侧放射性疼痛等不适。", + "event": [ + { + "core_name": "咳嗽", + "tendency": "", + "character": [ + "受凉后加重" + ], + "anatomy_list": [] + }, + { + "core_name": "咳痰", + "tendency": "", + "character": [ + "受凉后加重" + ], + "anatomy_list": [] + }, + { + "core_name": "咳痰", + "tendency": "", + "character": [ + "白色", + "粘", + "易咯出", + "量不多" + ], + "anatomy_list": [] + }, + { + "core_name": "发热", + "tendency": "", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "畏寒", + "tendency": "", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "寒战", + "tendency": "否定", + "character": [ + "明显" + ], + "anatomy_list": [] + }, + { + "core_name": "体温", + "tendency": "", + "character": [ + "升高" + ], + "anatomy_list": [] + }, + { + "core_name": "呕吐", + "tendency": "", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "呕吐", + "tendency": "", + "character": [ + "呕吐物为胃内容物", + "无咖啡色样物质" + ], + "anatomy_list": [] + }, + { + "core_name": "返酸", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "嗳气", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "咯血", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "疼痛", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "胸" + ] + }, + { + "core_name": "压榨感", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "左侧胸前区" + ] + }, + { + "core_name": "疼痛", + "tendency": "否定", + "character": [ + "放射性" + ], + "anatomy_list": [ + "左肩", + "左手臂内侧" + ] + } + ] + }, + { + "id": 336, + "text": "患病以来,患者精神、食欲、睡眠欠佳,大小便正常,近期体重无明显变化。", + "event": [ + { + "core_name": "精神", + "tendency": "", + "character": [ + "欠佳" + ], + "anatomy_list": [] + }, + { + "core_name": "食欲", + "tendency": "", + "character": [ + "欠佳" + ], + "anatomy_list": [] + }, + { + "core_name": "睡眠", + "tendency": "", + "character": [ + "欠佳" + ], + "anatomy_list": [] + }, + { + "core_name": "大小便", + "tendency": "", + "character": [ + "正常" + ], + "anatomy_list": [] + }, + { + "core_name": "体重变化", + "tendency": "否定", + "character": [ + "明显" + ], + "anatomy_list": [] + } + ] + }, + { + "id": 611, + "text": "患者自起病以来,精神可,胃纳可,大便如常,小便如上述,体重未见明显下降。", + "event": [ + { + "core_name": "精神", + "tendency": "", + "character": [ + "可" + ], + "anatomy_list": [] + }, + { + "core_name": "胃纳", + "tendency": "", + "character": [ + "可" + ], + "anatomy_list": [ + "胃" + ] + }, + { + "core_name": "大便", + "tendency": "", + "character": [ + "如常" + ], + "anatomy_list": [] + }, + { + "core_name": "小便", + "tendency": "", + "character": [ + "如常" + ], + "anatomy_list": [] + }, + { + "core_name": "体重下降", + "tendency": "否定", + "character": [ + "明显" + ], + "anatomy_list": [] + } + ] + }, + { + "id": 260, + "text": "无痛胃镜:1.十二指肠球部多发性溃疡多发性溃疡伴出血(a1期,forrestib)2.糜烂性胃炎(3级)3.食管隆起:组织外压?其他?可进一步超声胃镜检查。", + "event": [ + { + "core_name": "溃疡", + "tendency": "", + "character": [ + "多发性", + "1期", + "forrestib" + ], + "anatomy_list": [ + "十二指肠球部" + ] + }, + { + "core_name": "出血", + "tendency": "", + "character": [], + "anatomy_list": [ + "十二指肠球部" + ] + }, + { + "core_name": "胃炎", + "tendency": "", + "character": [ + "糜烂性", + "3级" + ], + "anatomy_list": [ + "胃" + ] + }, + { + "core_name": "隆起", + "tendency": "", + "character": [], + "anatomy_list": [ + "食管" + ] + } + ] + }, + { + "id": 458, + "text": "4.双肾肾周少许絮状渗出,双肾多发小囊肿。", + "event": [ + { + "core_name": "渗出", + "tendency": "", + "character": [ + "少许", + "絮状" + ], + "anatomy_list": [ + "双肾周" + ] + }, + { + "core_name": "囊肿", + "tendency": "", + "character": [ + "多发", + "小" + ], + "anatomy_list": [ + "双肾" + ] + } + ] + }, + { + "id": 1869, + "text": "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。", + "event": [ + { + "core_name": "精神", + "tendency": "", + "character": [ + "稍差" + ], + "anatomy_list": [] + }, + { + "core_name": "食欲", + "tendency": "", + "character": [ + "稍差" + ], + "anatomy_list": [] + }, + { + "core_name": "睡眠", + "tendency": "", + "character": [ + "欠佳" + ], + "anatomy_list": [] + }, + { + "core_name": "大便", + "tendency": "", + "character": [ + "正常" + ], + "anatomy_list": [] + }, + { + "core_name": "小便", + "tendency": "", + "character": [ + "如常" + ], + "anatomy_list": [] + }, + { + "core_name": "体重改变", + "tendency": "否定", + "character": [ + "明显" + ], + "anatomy_list": [] + } + ] + }, + { + "id": 841, + "text": "2月前前患者于我院体检查甲状腺彩超提示“甲状腺右叶异常回声,ti-rads4a类,建议穿刺活检”,甲功及甲功抗体未见异常。", + "event": [ + { + "core_name": "异常回声", + "tendency": "", + "character": [ + "ti-rads4a类" + ], + "anatomy_list": [ + "甲状腺右叶" + ] + }, + { + "core_name": "甲状腺功能异常", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "甲状腺" + ] + }, + { + "core_name": "甲状腺功能抗体异常", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "甲状腺" + ] + } + ] + }, + { + "id": 1963, + "text": "2015年因“直肠癌”于“某医院”手术治疗,术中输血(具体血型及量不详),无输血反应,术后正规化疗,目前大便正常。", + "event": [ + { + "core_name": "癌", + "tendency": "", + "character": [], + "anatomy_list": [ + "直肠" + ] + }, + { + "core_name": "输血反应", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "大便", + "tendency": "", + "character": [ + "正常" + ], + "anatomy_list": [] + } + ] + }, + { + "id": 1148, + "text": "无畏寒发热、无头痛头晕、无恶心、无腹胀腹痛、无呼吸困难、无咳嗽咳痰、无声音嘶哑。", + "event": [ + { + "core_name": "畏寒", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "发热", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "疼痛", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "头" + ] + }, + { + "core_name": "头晕", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "头" + ] + }, + { + "core_name": "恶心", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "腹胀", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "腹" + ] + }, + { + "core_name": "疼痛", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "腹" + ] + }, + { + "core_name": "呼吸困难", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "咳嗽", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "咳痰", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "声音嘶哑", + "tendency": "否定", + "character": [], + "anatomy_list": [] + } + ] + }, + { + "id": 1238, + "text": "入院前1月,患者无明显诱因开始出现腹胀,呈持续性,与进食及体位无关,伴剑突下隐痛,尚可忍受,伴四肢乏力(能坚持日常工作),大便次数增多,约6-7次/天,为黄色稀糊状便,无身黄、尿黄等不适。", + "event": [ + { + "core_name": "腹胀", + "tendency": "", + "character": [ + "持续性", + "与进食及体位无关" + ], + "anatomy_list": [ + "腹" + ] + }, + { + "core_name": "疼痛", + "tendency": "", + "character": [ + "隐痛", + "尚可忍受" + ], + "anatomy_list": [ + "剑突下" + ] + }, + { + "core_name": "乏力", + "tendency": "", + "character": [ + "能坚持日常工作" + ], + "anatomy_list": [ + "四肢" + ] + }, + { + "core_name": "大便", + "tendency": "", + "character": [ + "次数增多", + "约6-7次/天", + "黄色稀糊状" + ], + "anatomy_list": [] + }, + { + "core_name": "黄染", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "身" + ] + }, + { + "core_name": "尿黄", + "tendency": "否定", + "character": [], + "anatomy_list": [] + } + ] + }, + { + "id": 1685, + "text": "患者患病以来,精神、食欲、睡眠可,大小便正常,体重无明显下降。", + "event": [ + { + "core_name": "精神", + "tendency": "", + "character": [ + "可" + ], + "anatomy_list": [] + }, + { + "core_name": "食欲", + "tendency": "", + "character": [ + "可" + ], + "anatomy_list": [] + }, + { + "core_name": "睡眠", + "tendency": "", + "character": [ + "可" + ], + "anatomy_list": [] + }, + { + "core_name": "大小便", + "tendency": "", + "character": [ + "正常" + ], + "anatomy_list": [] + }, + { + "core_name": "体重下降", + "tendency": "否定", + "character": [ + "明显" + ], + "anatomy_list": [] + } + ] + }, + { + "id": 586, + "text": "3.左腓骨上段骨折。", + "event": [ + { + "core_name": "骨折", + "tendency": "", + "character": [], + "anatomy_list": [ + "左腓骨上段" + ] + } + ] + }, + { + "id": 1945, + "text": "患者遂于某医院就诊,行胸部ct检查提示双肺炎症,考虑肺部感染,予以抗炎等对症支持治疗后复查ct提示脊柱阴影,后行胸椎mri:所示多个胸椎椎体及椎弓多发异常信号伴椎体周围多软组织影及胸10椎体压缩性骨折,考虑:1)转移瘤?2)多发性骨髓瘤?,后患者就诊于某医院行免疫球蛋白八项:免疫球蛋白轻链lambda 9460.00mg/dl,免疫球蛋白g 101.00g/L。", + "event": [ + { + "core_name": "炎症", + "tendency": "", + "character": [], + "anatomy_list": [ + "双肺" + ] + }, + { + "core_name": "感染", + "tendency": "不确定", + "character": [], + "anatomy_list": [ + "肺部" + ] + }, + { + "core_name": "阴影", + "tendency": "", + "character": [], + "anatomy_list": [ + "脊柱" + ] + }, + { + "core_name": "异常信号", + "tendency": "", + "character": [ + "多个", + "多发" + ], + "anatomy_list": [ + "胸椎椎体", + "椎弓" + ] + }, + { + "core_name": "软组织影", + "tendency": "", + "character": [ + "多" + ], + "anatomy_list": [ + "胸椎体周围" + ] + }, + { + "core_name": "骨折", + "tendency": "", + "character": [ + "压缩性" + ], + "anatomy_list": [ + "胸椎T10椎体" + ] + }, + { + "core_name": "瘤", + "tendency": "不确定", + "character": [ + "转移" + ], + "anatomy_list": [] + }, + { + "core_name": "瘤", + "tendency": "不确定", + "character": [ + "多发性" + ], + "anatomy_list": [ + "骨髓" + ] + } + ] + }, + { + "id": 475, + "text": "现为求进一步诊治,前来我院,门诊以“高血压、心功能不全”收住院。", + "event": [ + { + "core_name": "高血压", + "tendency": "", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "心功能不全", + "tendency": "", + "character": [], + "anatomy_list": [ + "心" + ] + } + ] + }, + { + "id": 1163, + "text": "入院前3月,患者无明显诱因出现心悸、胸闷,活动后或夜间加重,每次持续时间约20-30秒,休息后可自行缓解,伴头昏、胸背部背部隐痛不适,无左肩及左上肢放射痛,无夜间阵发性呼吸困难及端坐呼吸,无浮肿、少尿,无畏寒、发热、头痛,无恶心、呕吐,无腹痛、腹泻。", + "event": [ + { + "core_name": "心悸", + "tendency": "", + "character": [ + "活动后或夜间加重", + "每次持续时间约20-29秒", + "休息后可自行缓解" + ], + "anatomy_list": [ + "心" + ] + }, + { + "core_name": "胸闷", + "tendency": "", + "character": [ + "活动后或夜间加重", + "每次持续时间约20-30秒", + "休息后可自行缓解" + ], + "anatomy_list": [ + "胸" + ] + }, + { + "core_name": "头昏", + "tendency": "", + "character": [], + "anatomy_list": [ + "头" + ] + }, + { + "core_name": "疼痛", + "tendency": "", + "character": [ + "隐痛" + ], + "anatomy_list": [ + "胸部", + "背部" + ] + }, + { + "core_name": "胸背部不适", + "tendency": "", + "character": [], + "anatomy_list": [ + "胸部", + "背部" + ] + }, + { + "core_name": "疼痛", + "tendency": "否定", + "character": [ + "放射性" + ], + "anatomy_list": [ + "左肩", + "左上肢" + ] + }, + { + "core_name": "呼吸困难", + "tendency": "否定", + "character": [ + "夜间", + "阵发性" + ], + "anatomy_list": [] + }, + { + "core_name": "端坐呼吸", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "浮肿", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "少尿", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "左肩", + "左上肢" + ] + }, + { + "core_name": "畏寒", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "发热", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "疼痛", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "头" + ] + }, + { + "core_name": "恶心", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "呕吐", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "疼痛", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "腹" + ] + }, + { + "core_name": "腹泻", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "腹" + ] + } + ] + }, + { + "id": 1083, + "text": "患者本次发病以来,食欲一般,神志清醒,精神尚可,睡眠尚可,大便如常,小便如上述,体重无明显变化。", + "event": [ + { + "core_name": "食欲", + "tendency": "", + "character": [ + "一般" + ], + "anatomy_list": [] + }, + { + "core_name": "神志", + "tendency": "", + "character": [ + "清醒" + ], + "anatomy_list": [] + }, + { + "core_name": "精神", + "tendency": "", + "character": [ + "尚可" + ], + "anatomy_list": [] + }, + { + "core_name": "睡眠", + "tendency": "", + "character": [ + "尚可" + ], + "anatomy_list": [] + }, + { + "core_name": "大便", + "tendency": "", + "character": [ + "如常" + ], + "anatomy_list": [] + }, + { + "core_name": "小便", + "tendency": "", + "character": [ + "如常" + ], + "anatomy_list": [] + }, + { + "core_name": "体重改变", + "tendency": "否定", + "character": [ + "明显" + ], + "anatomy_list": [] + } + ] + }, + { + "id": 645, + "text": "第五次化疗妇科彩超提示:子宫肌层不均质,以右前壁为着,内见27*28*30mm的混合回声区,边界欠清楚,其内大部分为无回声,少部分为中低回声,cdfi:无回声区区内见丰富血流信号,ri:0.44。", + "event": [ + { + "core_name": "不均质", + "tendency": "", + "character": [ + "肌层" + ], + "anatomy_list": [ + "子宫", + "子宫右前壁" + ] + }, + { + "core_name": "混合回声区", + "tendency": "", + "character": [ + "混合", + "边界欠清楚", + "其内大部分为无回声", + "少部分为中低回声" + ], + "anatomy_list": [ + "子宫" + ] + }, + { + "core_name": "血流信号", + "tendency": "", + "character": [ + "丰富", + "无回声区内" + ], + "anatomy_list": [ + "子宫" + ] + } + ] + }, + { + "id": 698, + "text": "患者同时行取环术,给予妇乐片独一味胶囊治疗,患者阴道流液症状好转,今患者为进一步治疗入我院,门诊以“子宫内膜癌”收入我科住院治疗。", + "event": [ + { + "core_name": "流液", + "tendency": "", + "character": [ + "好转" + ], + "anatomy_list": [ + "阴道" + ] + }, + { + "core_name": "癌", + "tendency": "", + "character": [], + "anatomy_list": [ + "子宫内膜" + ] + } + ] + }, + { + "id": 1772, + "text": "术中见:肿块大小约1.8x1.5cm,术后病理检查回报:):(左乳)浸润性癌,非特殊类型,iii级8分。", + "event": [ + { + "core_name": "肿块", + "tendency": "", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "癌", + "tendency": "", + "character": [ + "浸润性", + "非特殊类型", + "iii级8分" + ], + "anatomy_list": [ + "左乳" + ] + } + ] + }, + { + "id": 939, + "text": "于2018-6-11行颅内占位病变切除术,术后病检示:(左侧顶叶占位)转移性腺癌,结合免疫组化,考虑肺部来源,免疫组化:ck7+、p40-、p63-、ttf-1+、napsin-a+、ki67约40%、ck20-、ck+、cga-、syn-、cd56-。未进一步治疗。", + "event": [ + { + "core_name": "占位", + "tendency": "", + "character": [], + "anatomy_list": [ + "左侧顶叶" + ] + }, + { + "core_name": "腺癌", + "tendency": "", + "character": [ + "转移性" + ], + "anatomy_list": [ + "左侧顶叶" + ] + } + ] + }, + { + "id": 1661, + "text": "于2017-03-14行第四次化疗,予以吡柔比星 110mg ivgtt qd d1-3+维a酸 10mg po tid d1-14+亚砷酸10mg ivgtt qd d1-14进行化疗,辅以碱化尿液、水化、增强免疫力、减轻胃肠道反应、升白细胞、血小板等对症治疗后,好转出院;2017-4-17行第五次化疗,予以亚砷酸 10mg 维持治疗,并先后两次予以阿糖胞苷50mg+地塞米松磷酸钠10mg+甲氨蝶呤15mg鞘内注射化疗,化疗期间及化疗后未诉特殊不适。患者现拟行第6次维持巩固化疗入院。", + "event": [ + { + "core_name": "胃肠反应", + "tendency": "", + "character": [ + "减轻" + ], + "anatomy_list": [ + "胃", + "肠" + ] + } + ] + }, + { + "id": 1739, + "text": "6月23日复查骨髓细胞形态学“一、骨髓象原始粒细胞3%;二、外周血涂片淋巴细胞及单核细胞比例略增高,偶见幼粒,成熟红细胞大小不等,血小板成簇、散在少见,可见巨大血小板三、细胞化学染色mpo:正常,细胞外铁:++++细胞内铁:72%,环铁占36%;意见:1.粒、红二系可见轻度病态造血2.细胞外铁:++++,细胞内铁占72%,其中环铁占36%”,免疫分型“可见粒系前体细胞发育发育异常”,血常规“白细胞数目1.09*10^9/L↓,血红蛋白55g/l↓,血小板数目22*10^9/L↓,中性粒细胞数目0.61*10^9/L↓”。", + "event": [ + { + "core_name": "淋巴细胞及单核细胞增高", + "tendency": "", + "character": [ + "增高" + ], + "anatomy_list": [ + "淋巴细胞", + "单核细胞" + ] + }, + { + "core_name": "大小不等", + "tendency": "", + "character": [ + "幼粒", + "成熟红细胞", + "偶见" + ], + "anatomy_list": [] + }, + { + "core_name": "血小板", + "tendency": "", + "character": [ + "成簇", + "散在少见" + ], + "anatomy_list": [] + }, + { + "core_name": "病态造血", + "tendency": "", + "character": [ + "粒、红二系" + ], + "anatomy_list": [] + }, + { + "core_name": "发育异常", + "tendency": "", + "character": [ + "" + ], + "anatomy_list": [] + } + ] + }, + { + "id": 836, + "text": "患者6月前因“发现左乳包块伴点状钙化3小时”入院,入院后完善相关检查后行左乳包块麦默通活检术+术中冰冻,术后病理示:(左乳)浸润性癌。", + "event": [ + { + "core_name": "包块", + "tendency": "", + "character": [], + "anatomy_list": [ + "左乳" + ] + }, + { + "core_name": "钙化", + "tendency": "", + "character": [ + "点状" + ], + "anatomy_list": [ + "左乳" + ] + }, + { + "core_name": "癌", + "tendency": "", + "character": [ + "浸润性" + ], + "anatomy_list": [ + "左乳" + ] + } + ] + }, + { + "id": 1912, + "text": "入院前1+年,患者受凉后出现咳嗽、咳痰,咳白色泡沫样痰,无咯血、喘息及呼吸困难,偶有上腹部不适,反酸、嗳气等症状,遂到我院就诊,胸部ct提示:左肺下叶肿块伴远端阻塞性炎症、支气管阻塞性痰栓形成,多系肿瘤,建议纤维支气管镜活检;双肺尘肺。", + "event": [ + { + "core_name": "咳嗽", + "tendency": "", + "character": [ + "受凉后" + ], + "anatomy_list": [] + }, + { + "core_name": "咳痰", + "tendency": "", + "character": [ + "受凉后" + ], + "anatomy_list": [] + }, + { + "core_name": "咳痰", + "tendency": "", + "character": [ + "白色", + "泡沫样" + ], + "anatomy_list": [] + }, + { + "core_name": "咯血", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "气喘", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "呼吸困难", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "上腹部不适", + "tendency": "", + "character": [ + "偶有" + ], + "anatomy_list": [ + "上腹部" + ] + }, + { + "core_name": "反酸", + "tendency": "", + "character": [ + "偶有" + ], + "anatomy_list": [] + }, + { + "core_name": "嗳气", + "tendency": "", + "character": [ + "偶有" + ], + "anatomy_list": [] + }, + { + "core_name": "肿块", + "tendency": "", + "character": [], + "anatomy_list": [ + "左肺下叶" + ] + }, + { + "core_name": "炎症", + "tendency": "", + "character": [ + "阻塞性" + ], + "anatomy_list": [ + "左肺下叶远端" + ] + }, + { + "core_name": "痰栓", + "tendency": "", + "character": [ + "阻塞性" + ], + "anatomy_list": [ + "支气管" + ] + }, + { + "core_name": "肿瘤", + "tendency": "", + "character": [], + "anatomy_list": [ + "支气管" + ] + }, + { + "core_name": "尘肺", + "tendency": "", + "character": [], + "anatomy_list": [ + "双肺" + ] + } + ] + }, + { + "id": 1841, + "text": "患者于2天前无明显诱因感右侧胸痛加重,为诊治,于今日来我院门诊就诊,门诊医师以“咳嗽、胸痛”收入院治疗。", + "event": [ + { + "core_name": "疼痛", + "tendency": "", + "character": [ + "加重" + ], + "anatomy_list": [ + "右侧胸" + ] + }, + { + "core_name": "咳嗽", + "tendency": "", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "疼痛", + "tendency": "", + "character": [], + "anatomy_list": [ + "胸" + ] + } + ] + }, + { + "id": 1521, + "text": "出院后间断有咳嗽、咳痰,为白色泡沫痰,偶晨起有痰中少量血丝,否认潮热、盗汗。", + "event": [ + { + "core_name": "咳嗽", + "tendency": "", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "咳痰", + "tendency": "", + "character": [ + "白色", + "泡沫痰" + ], + "anatomy_list": [] + }, + { + "core_name": "咳痰", + "tendency": "", + "character": [ + "偶晨起", + "少量", + "血丝" + ], + "anatomy_list": [] + }, + { + "core_name": "潮热", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "盗汗", + "tendency": "否定", + "character": [], + "anatomy_list": [] + } + ] + }, + { + "id": 1104, + "text": "术后患者于肝胆胸外科化疗,分别于2017-01-06起给予tp方案(药物方案:紫杉醇180mg d1,顺铂100mg2)化疗3周期,于2017-04-18起给予tp方案化疗2周期(药物:紫杉醇150mg d1,顺铂100mg2),2017-5-23给予tp(化疗药物:紫杉醇180mg d1,顺铂100mg2)方案化疗1周期,共计6周期,患者无明显化疗毒副反应及骨髓抑制。", + "event": [ + { + "core_name": "化疗毒副反应", + "tendency": "否定", + "character": [ + "��显" + ], + "anatomy_list": [] + }, + { + "core_name": "骨髓抑制", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "骨髓" + ] + } + ] + }, + { + "id": 671, + "text": "于全麻下行“右侧乳腺癌改良根治术”,术后病检示:浸润性导管癌,腋窝有5个淋巴结转移。", + "event": [ + { + "core_name": "导管癌", + "tendency": "", + "character": [ + "浸润性" + ], + "anatomy_list": [] + }, + { + "core_name": "癌", + "tendency": "", + "character": [ + "转移" + ], + "anatomy_list": [ + "腋窝淋巴结" + ] + } + ] + }, + { + "id": 1654, + "text": "后患者反复发热不适(体温不详),伴畏寒,无寒战,伴咳嗽、咳痰,咳少量白色粘液痰,咽喉部疼痛、全身肌肉酸痛不适,伴乏力、活动后心累气促不适,遂于我科住院治疗。", + "event": [ + { + "core_name": "发热", + "tendency": "", + "character": [ + "反复", + "体温不详" + ], + "anatomy_list": [] + }, + { + "core_name": "畏寒", + "tendency": "", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "寒颤", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "咳嗽", + "tendency": "", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "咳痰", + "tendency": "", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "咳痰", + "tendency": "", + "character": [ + "少量", + "白色", + "粘液" + ], + "anatomy_list": [] + }, + { + "core_name": "疼痛", + "tendency": "", + "character": [], + "anatomy_list": [ + "咽喉部" + ] + }, + { + "core_name": "疼痛", + "tendency": "", + "character": [ + "酸痛" + ], + "anatomy_list": [ + "全身肌肉" + ] + }, + { + "core_name": "全身肌肉不适", + "tendency": "", + "character": [], + "anatomy_list": [ + "全身肌肉" + ] + }, + { + "core_name": "乏力", + "tendency": "", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "心累", + "tendency": "", + "character": [ + "活动后" + ], + "anatomy_list": [ + "心" + ] + }, + { + "core_name": "气促", + "tendency": "", + "character": [ + "活动后" + ], + "anatomy_list": [] + } + ] + }, + { + "id": 122, + "text": "患者目前无咳嗽,无肝区疼痛,有胸壁疼痛。", + "event": [ + { + "core_name": "咳嗽", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "疼痛", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "肝区" + ] + }, + { + "core_name": "疼痛", + "tendency": "", + "character": [], + "anatomy_list": [ + "胸壁" + ] + } + ] + }, + { + "id": 1625, + "text": "考虑肿瘤残存可能,因患者宫腔节育环取出困难无法行盆腔mri检查,建议行活检进一步明确,根据病理结果评估后续化疗或手术治疗方案。", + "event": [ + { + "core_name": "肿瘤", + "tendency": "不确定", + "character": [ + "残存" + ], + "anatomy_list": [] + } + ] + }, + { + "id": 95, + "text": "8月初,患者于当地诊所就诊,给予药物治疗(具体不详),阴道流血量稍有减少,后再次出现阴道流血量多。", + "event": [ + { + "core_name": "出血", + "tendency": "", + "character": [ + "量稍有减少" + ], + "anatomy_list": [ + "阴道" + ] + }, + { + "core_name": "出血", + "tendency": "", + "character": [ + "再次出现", + "量多" + ], + "anatomy_list": [ + "阴道" + ] + } + ] + }, + { + "id": 331, + "text": "腹部立卧位片示:1、考虑肠梗阻2、右侧尿路双j管置入术后表现。", + "event": [ + { + "core_name": "梗阻", + "tendency": "不确定", + "character": [], + "anatomy_list": [ + "肠" + ] + } + ] + }, + { + "id": 1989, + "text": "至某医院就诊,查:“血常规:血红蛋白偏低”(具体不详),予输液(具体��详)后仍有解暗红血便2次,量共约100g。", + "event": [ + { + "core_name": "血便", + "tendency": "", + "character": [ + "暗红色" + ], + "anatomy_list": [] + }, + { + "core_name": "血红蛋白", + "tendency": "", + "character": [ + "偏低" + ], + "anatomy_list": [] + } + ] + }, + { + "id": 1328, + "text": "曾连续数年以上发作,每次发作均在 3月 以上,诊断为”慢性支气管炎”。", + "event": [ + { + "core_name": "支气管炎", + "tendency": "", + "character": [ + "慢性" + ], + "anatomy_list": [ + "支气管" + ] + } + ] + }, + { + "id": 1290, + "text": "于2018-02-06行左侧髂骨放射治疗,放疗剂量ptv(30G,10f),放疗期间患者诉左髂骨疼痛不适,期间予以抗溶骨治疗及止痛药物治疗后好转出院。", + "event": [ + { + "core_name": "疼痛", + "tendency": "", + "character": [ + "放疗期间" + ], + "anatomy_list": [ + "左髂骨" + ] + } + ] + }, + { + "id": 1349, + "text": "2天前,患者ptcd管无引流液,无明显腹痛、腹胀,无恶心、呕吐,无反酸、嗳气,无畏寒、发热,无胸闷、胸痛等特殊不适,予以生理盐水冲洗ptcd管后仍无明显引流液流出,现患者为求进一步诊治于我院就诊,门诊以“胆管癌术后复发,第一次免疫治疗后”收住我科。", + "event": [ + { + "core_name": "引流液", + "tendency": "否定", + "character": [ + "ptcd管" + ], + "anatomy_list": [] + }, + { + "core_name": "疼痛", + "tendency": "否定", + "character": [ + "明显" + ], + "anatomy_list": [ + "腹" + ] + }, + { + "core_name": "腹胀", + "tendency": "否定", + "character": [ + "明显" + ], + "anatomy_list": [ + "腹" + ] + }, + { + "core_name": "恶心", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "呕吐", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "反酸", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "嗳气", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "畏寒", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "发热", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "胸闷", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "胸" + ] + }, + { + "core_name": "疼痛", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "胸" + ] + }, + { + "core_name": "引流液", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "癌", + "tendency": "", + "character": [ + "术后", + "复发" + ], + "anatomy_list": [ + "胆管" + ] + } + ] + }, + { + "id": 1950, + "text": "mri提示前列腺侵犯膀胱,于2018年12月3日在局麻下行经直肠前列腺穿刺活检术,术后病检提示:前列腺腺癌gleason评分最高为4+5=9分,骨扫描提示为l5存在放射性浓聚,考虑肿瘤转移可能。", + "event": [ + { + "core_name": "癌", + "tendency": "", + "character": [ + "侵犯膀胱" + ], + "anatomy_list": [ + "前列腺" + ] + }, + { + "core_name": "腺癌", + "tendency": "", + "character": [ + "gleason评分最高为4+5=9分" + ], + "anatomy_list": [ + "前列腺" + ] + }, + { + "core_name": "浓聚", + "tendency": "不确定", + "character": [ + "放射性" + ], + "anatomy_list": [ + "骨" + ] + }, + { + "core_name": "肿瘤", + "tendency": "不确定", + "character": [ + "转移" + ], + "anatomy_list": [] + } + ] + }, + { + "id": 1024, + "text": "入院前9+月,患者无明显诱因出现阴道不规则出血,为淡红色,每次量少,遂于我院妇科门诊行上腹部+妇科超声提示肿瘤复发转移,2017.12.01-2018.01.15给予宫颈癌复发病灶放射治疗(预防区50G/25f/5w,病灶区60G/30f/6w),放疗过程顺利���院外无特殊不适。", + "event": [ + { + "core_name": "出血", + "tendency": "", + "character": [ + "不规则", + "淡红色", + "每次量少" + ], + "anatomy_list": [ + "阴道" + ] + }, + { + "core_name": "肿瘤", + "tendency": "", + "character": [ + "复发", + "转移" + ], + "anatomy_list": [] + } + ] + }, + { + "id": 75, + "text": "现仍偶诉左髋关节疼痛,活动时明显,轻压痛,行走时可见轻微跛行,无红肿,无进行性加重,其他关节未见明显异常及畸形,偶有咳嗽,无咳痰、流涕,无发热,无头痛、呕吐,无腹痛、腹胀,无胸闷、胸痛,活动量未见明显减少。", + "event": [ + { + "core_name": "疼痛", + "tendency": "", + "character": [ + "活动时明显", + "轻压痛", + "无进行性加重" + ], + "anatomy_list": [ + "左髋关节" + ] + }, + { + "core_name": "跛行", + "tendency": "", + "character": [ + "行走时可见", + "轻微" + ], + "anatomy_list": [] + }, + { + "core_name": "红肿", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "畸形", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "其他关节" + ] + }, + { + "core_name": "咳嗽", + "tendency": "", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "咳痰", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "流涕", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "发热", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "疼痛", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "头" + ] + }, + { + "core_name": "呕吐", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "疼痛", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "腹" + ] + }, + { + "core_name": "腹胀", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "腹" + ] + }, + { + "core_name": "胸闷", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "胸" + ] + }, + { + "core_name": "疼痛", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "胸" + ] + }, + { + "core_name": "活动量减少", + "tendency": "否定", + "character": [ + "明显" + ], + "anatomy_list": [] + } + ] + }, + { + "id": 1211, + "text": "8.腹膜后淋巴结显示。", + "event": [ + { + "core_name": "显示", + "tendency": "", + "character": [], + "anatomy_list": [ + "腹膜后淋巴结" + ] + } + ] + }, + { + "id": 1683, + "text": "患者恢复顺利,无特殊不适,切口甲级愈合,治愈拆线出院。", + "event": [ + { + "core_name": "切口", + "tendency": "", + "character": [ + "甲级愈合" + ], + "anatomy_list": [] + } + ] + }, + { + "id": 1826, + "text": "5天前患者无明显诱因出现每次进食后恶心、呕吐,呕吐物为胃内容物,非喷射性,伴反酸、嗳气、腹胀、腹痛,伴少尿,无肛门停止排气,无腹痛、腹泻,无胸闷、心前区压榨感,无胸痛、咯血,为进一步治疗入院,呼120入我院,以\"呕吐原因待查:肠梗阻?肾功能不全?宫颈鳞癌放化疗后伴腹腔广泛转移(iv期)\"收入我科。", + "event": [ + { + "core_name": "恶心", + "tendency": "", + "character": [ + "进食后" + ], + "anatomy_list": [] + }, + { + "core_name": "呕吐", + "tendency": "", + "character": [ + "进食后" + ], + "anatomy_list": [] + }, + { + "core_name": "呕吐", + "tendency": "", + "character": [ + "非喷射性", + "呕吐物为胃内容物" + ], + "anatomy_list": [] + }, + { + "core_name": "反酸", + "tendency": "", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "嗳气", + "tendency": "", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "腹胀", + "tendency": "", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "疼痛", + "tendency": "", + "character": [], + "anatomy_list": [ + "腹" + ] + }, + { + "core_name": "少尿", + "tendency": "", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "排气", + "tendency": "否定", + "character": [ + "停止" + ], + "anatomy_list": [ + "肛门" + ] + }, + { + "core_name": "疼痛", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "腹" + ] + }, + { + "core_name": "腹泻", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "腹" + ] + }, + { + "core_name": "胸闷", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "胸" + ] + }, + { + "core_name": "压榨感", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "心前区" + ] + }, + { + "core_name": "疼痛", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "胸" + ] + }, + { + "core_name": "咯血", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "呕吐", + "tendency": "不确定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "梗阻", + "tendency": "不确定", + "character": [], + "anatomy_list": [ + "肠" + ] + }, + { + "core_name": "肾功能不全", + "tendency": "不确定", + "character": [], + "anatomy_list": [ + "肾" + ] + }, + { + "core_name": "鳞癌", + "tendency": "不确定", + "character": [ + "放化疗后", + "iv期" + ], + "anatomy_list": [ + "宫颈" + ] + }, + { + "core_name": "鳞癌", + "tendency": "不确定", + "character": [ + "iv期", + "广泛转移" + ], + "anatomy_list": [ + "腹腔" + ] + } + ] + }, + { + "id": 1804, + "text": "伤后他人送患者到“某医院”住院治疗3天,行头颅ct提示左颞骨及颧弓骨折、左小腿x片提示左腓骨中段骨折(未见报告),予以左小腿石膏托制动、甘露醇脱水降颅压、奥拉西坦营养神经、奥美拉唑抑酸护胃及补液对症等治疗,患者自觉头晕头痛症状好转不明显,近两日出现阵时恶心伴视物旋转,伴返酸,无呕吐。", + "event": [ + { + "core_name": "骨折", + "tendency": "", + "character": [], + "anatomy_list": [ + "左颞骨", + "左颧弓" + ] + }, + { + "core_name": "骨折", + "tendency": "", + "character": [], + "anatomy_list": [ + "左腓骨中段" + ] + }, + { + "core_name": "头晕", + "tendency": "", + "character": [ + "好转不明显" + ], + "anatomy_list": [ + "头" + ] + }, + { + "core_name": "疼痛", + "tendency": "", + "character": [ + "好转不明显" + ], + "anatomy_list": [ + "头" + ] + }, + { + "core_name": "恶心", + "tendency": "", + "character": [ + "阵时" + ], + "anatomy_list": [] + }, + { + "core_name": "视物旋转", + "tendency": "", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "返酸", + "tendency": "", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "呕吐", + "tendency": "否定", + "character": [], + "anatomy_list": [] + } + ] + }, + { + "id": 271, + "text": "无潮热、盗汗,无咳嗽、咳痰,无胸闷、气促,无呼吸困难,无大小便失禁等。", + "event": [ + { + "core_name": "潮热", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "盗汗", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "咳嗽", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "咳痰", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "胸闷", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "胸" + ] + }, + { + "core_name": "气促", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "呼吸困难", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "大小便", + "tendency": "否定", + "character": [ + "失禁" + ], + "anatomy_list": [] + } + ] + }, + { + "id": 102, + "text": "患者目前未诉头昏、头痛、咳嗽、咳痰、发热、畏寒、恶心、呕吐等不适,门诊以“残胃癌术后第3次化疗”收入我科。", + "event": [ + { + "core_name": "头昏", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "头" + ] + }, + { + "core_name": "疼痛", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "头" + ] + }, + { + "core_name": "咳嗽", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "咳痰", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "发热", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "畏寒", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "恶心", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "呕吐", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "癌", + "tendency": "", + "character": [ + "残胃", + "术后" + ], + "anatomy_list": [ + "胃" + ] + } + ] + }, + { + "id": 559, + "text": "无头晕、心慌。", + "event": [ + { + "core_name": "头晕", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "头" + ] + }, + { + "core_name": "心慌", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "心" + ] + } + ] + }, + { + "id": 1829, + "text": "入院前2月,患者上述症状加重,稍运动后就感到下腹部刺痛,伴尿痛,仍无其他特殊症状。", + "event": [ + { + "core_name": "疼痛", + "tendency": "", + "character": [ + "稍运动后", + "刺痛" + ], + "anatomy_list": [ + "下腹部" + ] + }, + { + "core_name": "尿痛", + "tendency": "", + "character": [], + "anatomy_list": [] + } + ] + }, + { + "id": 177, + "text": "2019-2开始吃艾坦,2019-4开始口服奥拉帕尼(盗版的),2019-10开始腰背部疼痛(未予重视)。", + "event": [ + { + "core_name": "疼痛", + "tendency": "", + "character": [], + "anatomy_list": [ + "腰背部" + ] + } + ] + }, + { + "id": 1017, + "text": "20余年前患者无明显诱因出现右耳流脓,伴听觉减退,约数年发作一次,无眩晕、耳鸣,无头晕、头痛、无恶心、呕吐,无咳嗽、咳痰。", + "event": [ + { + "core_name": "流脓", + "tendency": "", + "character": [], + "anatomy_list": [ + "右耳" + ] + }, + { + "core_name": "听觉减退", + "tendency": "", + "character": [ + "约数年发作一次" + ], + "anatomy_list": [] + }, + { + "core_name": "眩晕", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "耳鸣", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "耳" + ] + }, + { + "core_name": "头晕", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "头" + ] + }, + { + "core_name": "疼痛", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "头" + ] + }, + { + "core_name": "恶心", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "呕吐", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "咳嗽", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "咳痰", + "tendency": "否定", + "character": [], + "anatomy_list": [] + } + ] + }, + { + "id": 990, + "text": "3天前患者无明显诱因出现喘累、胸闷,常于活动后出现,伴咳嗽、咳痰,咳白色泡沫痰,伴恶心、干呕,伴声嘶,伴乏力,无头晕、头痛,无胸痛,无腹胀、腹泻,无寒战、发热等不适,遂就诊于我院,门诊以“肺ca”收入我科。", + "event": [ + { + "core_name": "喘累", + "tendency": "", + "character": [ + "常于活动后出现" + ], + "anatomy_list": [] + }, + { + "core_name": "胸闷", + "tendency": "", + "character": [ + "常于活动后出现" + ], + "anatomy_list": [ + "胸" + ] + }, + { + "core_name": "咳嗽", + "tendency": "", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "咳痰", + "tendency": "", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "咳痰", + "tendency": "", + "character": [ + "白色", + "泡沫痰" + ], + "anatomy_list": [] + }, + { + "core_name": "恶心", + "tendency": "", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "干呕", + "tendency": "", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "声嘶", + "tendency": "", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "乏力", + "tendency": "", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "头晕", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "头" + ] + }, + { + "core_name": "疼痛", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "头" + ] + }, + { + "core_name": "疼痛", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "胸" + ] + }, + { + "core_name": "腹胀", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "腹" + ] + }, + { + "core_name": "腹泻", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "腹" + ] + }, + { + "core_name": "寒颤", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "发热", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "癌", + "tendency": "", + "character": [], + "anatomy_list": [ + "肺" + ] + } + ] + }, + { + "id": 1873, + "text": "考虑“肠梗阻”,现为求进一步治疗来我院收入我科。", + "event": [ + { + "core_name": "梗阻", + "tendency": "不确定", + "character": [], + "anatomy_list": [ + "肠" + ] + } + ] + }, + { + "id": 739, + "text": "9月前患者再次于打麻将过程中突发意识丧失,家属诉患者发病过程有双目凝视、四肢抽搐、小便失禁,持续约1分1分钟左右,意识恢复后出现恶心、呕吐,呕出淡黄色胃内容物,休息后逐渐缓解。", + "event": [ + { + "core_name": "意识丧失", + "tendency": "", + "character": [ + "打麻将过程中", + "突发" + ], + "anatomy_list": [] + }, + { + "core_name": "凝视", + "tendency": "", + "character": [], + "anatomy_list": [ + "双目" + ] + }, + { + "core_name": "抽搐", + "tendency": "", + "character": [], + "anatomy_list": [ + "四肢" + ] + }, + { + "core_name": "小便", + "tendency": "", + "character": [ + "失禁" + ], + "anatomy_list": [] + }, + { + "core_name": "恶心", + "tendency": "", + "character": [ + "意识恢复后" + ], + "anatomy_list": [] + }, + { + "core_name": "呕吐", + "tendency": "", + "character": [ + "意识恢复后", + "呕出淡黄色胃内容物", + "休息后逐渐缓解" + ], + "anatomy_list": [] + } + ] + }, + { + "id": 1767, + "text": "术后病检示:右乳外上象限非特殊性浸润性癌,中分化。", + "event": [ + { + "core_name": "癌", + "tendency": "", + "character": [ + "非特殊性", + "中分化", + "浸润性" + ], + "anatomy_list": [ + "右乳外上象限" + ] + } + ] + }, + { + "id": 1694, + "text": "患者入院前1周无明显诱因出现尿频,日间约10次,夜间约4次,每次尿量中等,伴尿痛及双侧腰痛,伴排尿费力,多需用力咳嗽后排尿。", + "event": [ + { + "core_name": "尿频", + "tendency": "", + "character": [ + "尿量中等" + ], + "anatomy_list": [] + }, + { + "core_name": "尿痛", + "tendency": "", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "疼痛", + "tendency": "", + "character": [], + "anatomy_list": [ + "双侧腰部" + ] + }, + { + "core_name": "排尿费力", + "tendency": "", + "character": [ + "多需用力咳嗽" + ], + "anatomy_list": [] + } + ] + }, + { + "id": 1439, + "text": "于2018-06-13行ct引导下经皮肺穿刺活检,冰冻病理提示(123456):(右上)肺穿刺组织考虑鳞癌。", + "event": [ + { + "core_name": "鳞癌", + "tendency": "不确定", + "character": [], + "anatomy_list": [ + "右上肺" + ] + } + ] + }, + { + "id": 1880, + "text": "2+年前,患者无明显诱因出现四肢肢端麻木,偶有头昏,伴烦渴、多饮、多尿,无胸闷、心累、气促,无腹泻、腹痛,无间歇性跛行,无静息痛,无下肢皮温改变,无下肢水肿,无关节活动障碍,患者于某医院就诊,予以调整降糖方案为门冬胰岛素30早餐前24u,晚餐前24u腹部皮下注射控制血糖,平素监测空腹指血糖波动在11-12mm12mmol/L,患者未重视,未进一步治疗,患者感口干、多饮症状加重时自行调整胰岛素剂量。", + "event": [ + { + "core_name": "麻木", + "tendency": "", + "character": [], + "anatomy_list": [ + "四肢肢端" + ] + }, + { + "core_name": "头昏", + "tendency": "", + "character": [ + "偶有" + ], + "anatomy_list": [ + "头" + ] + }, + { + "core_name": "烦渴", + "tendency": "", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "多饮", + "tendency": "", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "多尿", + "tendency": "", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "胸闷", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "胸" + ] + }, + { + "core_name": "心累", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "心" + ] + }, + { + "core_name": "气促", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "腹泻", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "腹" + ] + }, + { + "core_name": "疼痛", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "腹" + ] + }, + { + "core_name": "跛行", + "tendency": "否定", + "character": [ + "间歇性" + ], + "anatomy_list": [] + }, + { + "core_name": "静息痛", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "皮温改变", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "下肢" + ] + }, + { + "core_name": "水肿", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "下肢" + ] + }, + { + "core_name": "活动障碍", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "关节" + ] + }, + { + "core_name": "口干", + "tendency": "", + "character": [ + "加重" + ], + "anatomy_list": [ + "口" + ] + }, + { + "core_name": "多饮", + "tendency": "", + "character": [ + "加重" + ], + "anatomy_list": [] + } + ] + }, + { + "id": 2054, + "text": "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,体重减少约10Kg。", + "event": [ + { + "core_name": "食欲", + "tendency": "", + "character": [ + "减退" + ], + "anatomy_list": [] + }, + { + "core_name": "神志", + "tendency": "", + "character": [ + "清醒" + ], + "anatomy_list": [] + }, + { + "core_name": "精神", + "tendency": "", + "character": [ + "尚可" + ], + "anatomy_list": [] + }, + { + "core_name": "睡眠", + "tendency": "", + "character": [ + "尚可" + ], + "anatomy_list": [] + }, + { + "core_name": "大便", + "tendency": "", + "character": [ + "正常" + ], + "anatomy_list": [] + }, + { + "core_name": "小便", + "tendency": "", + "character": [ + "正常" + ], + "anatomy_list": [] + }, + { + "core_name": "体重减少", + "tendency": "", + "character": [], + "anatomy_list": [] + } + ] + }, + { + "id": 310, + "text": "患者15天前,患者因\"尿频、尿急、尿痛及排尿困难1+年,加重伴腰背部胀痛不适1月 \"到某医院就诊,行泌尿系彩超提示:“1.左输尿管上段扩张伴腔内低回声:肿瘤?2.前列腺增大、回声粗细不均,血供丰富;3.左肾积水;4.膀胱壁增厚、粗糙。", + "event": [ + { + "core_name": "尿频", + "tendency": "", + "character": [ + "加重" + ], + "anatomy_list": [] + }, + { + "core_name": "尿急", + "tendency": "", + "character": [ + "加重" + ], + "anatomy_list": [] + }, + { + "core_name": "尿痛", + "tendency": "", + "character": [ + "加重" + ], + "anatomy_list": [] + }, + { + "core_name": "排尿困难", + "tendency": "", + "character": [ + "加重" + ], + "anatomy_list": [] + }, + { + "core_name": "疼痛", + "tendency": "", + "character": [ + "胀痛" + ], + "anatomy_list": [ + "腰背部" + ] + }, + { + "core_name": "扩张", + "tendency": "", + "character": [], + "anatomy_list": [ + "左输尿管上段" + ] + }, + { + "core_name": "回声", + "tendency": "", + "character": [ + "低" + ], + "anatomy_list": [ + "左输尿管上段腔内" + ] + }, + { + "core_name": "肿瘤", + "tendency": "不确定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "增大", + "tendency": "", + "character": [], + "anatomy_list": [ + "前列腺" + ] + }, + { + "core_name": "回声", + "tendency": "", + "character": [ + "粗细不均" + ], + "anatomy_list": [ + "前列腺" + ] + }, + { + "core_name": "血供丰富", + "tendency": "", + "character": [], + "anatomy_list": [ + "前列腺" + ] + }, + { + "core_name": "积水", + "tendency": "", + "character": [], + "anatomy_list": [ + "左肾" + ] + }, + { + "core_name": "增厚", + "tendency": "", + "character": [], + "anatomy_list": [ + "膀胱壁" + ] + }, + { + "core_name": "粗糙", + "tendency": "", + "character": [], + "anatomy_list": [ + "膀胱壁" + ] + } + ] + }, + { + "id": 1489, + "text": "患者本次发病以来,食欲减退, 神志清醒,精神欠佳,睡眠欠佳,大便正常,小便正常,体重减少(具体不详)。", + "event": [ + { + "core_name": "食欲", + "tendency": "", + "character": [ + "减退" + ], + "anatomy_list": [] + }, + { + "core_name": "神志", + "tendency": "", + "character": [ + "清醒" + ], + "anatomy_list": [] + }, + { + "core_name": "精神", + "tendency": "", + "character": [ + "欠佳" + ], + "anatomy_list": [] + }, + { + "core_name": "睡眠", + "tendency": "", + "character": [ + "欠佳" + ], + "anatomy_list": [] + }, + { + "core_name": "大便", + "tendency": "", + "character": [ + "正常" + ], + "anatomy_list": [] + }, + { + "core_name": "小便", + "tendency": "", + "character": [ + "正常" + ], + "anatomy_list": [] + }, + { + "core_name": "体重减轻", + "tendency": "", + "character": [], + "anatomy_list": [] + } + ] + }, + { + "id": 733, + "text": "5天前,患者无明显诱因再次出现头昏、乏力,伴活动后气促,休息数分钟后能缓解,今日到我院门诊复查血常规:血红蛋白51g/l,要求输血纠正贫血来院,我科以“重度贫血、白血病”收住入院。", + "event": [ + { + "core_name": "头昏", + "tendency": "", + "character": [], + "anatomy_list": [ + "头" + ] + }, + { + "core_name": "乏力", + "tendency": "", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "气促", + "tendency": "", + "character": [ + "活动后", + "休息数分钟后能缓解" + ], + "anatomy_list": [] + }, + { + "core_name": "贫血", + "tendency": "", + "character": [ + "重度" + ], + "anatomy_list": [] + }, + { + "core_name": "白血病", + "tendency": "", + "character": [], + "anatomy_list": [] + } + ] + }, + { + "id": 1014, + "text": "我院急诊全麻下行“腹腔镜探查术+脾部分切除术+左侧黄体囊肿剥除术”,手术顺利,术后予抗生素抗感染、抑酸护胃、护肝、止痛、止吐、解痉、消肿、雾化等治疗,术后病理提示(123456):左侧卵巢黄体囊肿符合出血、囊性变。", + "event": [ + { + "core_name": "囊肿", + "tendency": "", + "character": [ + "出血" + ], + "anatomy_list": [ + "左侧卵巢黄体" + ] + }, + { + "core_name": "囊肿", + "tendency": "", + "character": [ + "囊性变" + ], + "anatomy_list": [ + "左侧卵巢黄体" + ] + } + ] + }, + { + "id": 738, + "text": "4年前于“某医院”就诊,家属诉考虑“脑供血不足”(未见报告及病历),具体治疗不详,出院后症状无明显改善。", + "event": [ + { + "core_name": "供血不足", + "tendency": "不确定", + "character": [], + "anatomy_list": [ + "脑" + ] + } + ] + }, + { + "id": 796, + "text": "患者于入院前2月余因“反复畏寒、寒战半年,再发伴肝功异常10余天”入我院,于2012-3-27在局麻下行ercp,见乳头肿大,尖端周围明显新生物,触之易出血,并取活检5块,送病检提示:十二指肠乳头管状绒毛状腺瘤,局灶腺体轻度不典型增生。", + "event": [ + { + "core_name": "畏寒", + "tendency": "", + "character": [ + "反复" + ], + "anatomy_list": [] + }, + { + "core_name": "寒颤", + "tendency": "", + "character": [ + "反复" + ], + "anatomy_list": [] + }, + { + "core_name": "肝功能异常", + "tendency": "", + "character": [], + "anatomy_list": [ + "肝" + ] + }, + { + "core_name": "肿大", + "tendency": "", + "character": [], + "anatomy_list": [ + "乳头" + ] + }, + { + "core_name": "新生物", + "tendency": "", + "character": [ + "明显", + "触之易出血" + ], + "anatomy_list": [ + "乳头周围" + ] + }, + { + "core_name": "腺瘤", + "tendency": "", + "character": [ + "管状", + "绒毛状" + ], + "anatomy_list": [ + "十二指肠乳头" + ] + }, + { + "core_name": "增生", + "tendency": "", + "character": [ + "局灶", + "非典型性", + "轻度" + ], + "anatomy_list": [ + "腺体" + ] + } + ] + }, + { + "id": 844, + "text": "未规律监测血糖,现自服“二甲双胍缓释片500mg早上、1000mg中午、晚上”控制血糖,血糖控制情况不详。", + "event": [ + { + "core_name": "血糖", + "tendency": "", + "character": [ + "控制情况不详" + ], + "anatomy_list": [] + } + ] + }, + { + "id": 805, + "text": "2、胸12、腰1椎体新近压缩性骨折。", + "event": [ + { + "core_name": "骨折", + "tendency": "", + "character": [ + "新近", + "压缩性" + ], + "anatomy_list": [ + "胸12、腰1椎体" + ] + } + ] + }, + { + "id": 1763, + "text": "(左腋窝)淋巴结见癌转移(2/39)。", + "event": [ + { + "core_name": "癌", + "tendency": "", + "character": [ + "转移" + ], + "anatomy_list": [ + "左腋窝淋巴结" + ] + } + ] + }, + { + "id": 1167, + "text": "院外未进行特殊治疗,患者为防止病情进一步加重,遂于今日来我院就诊,门诊以“冠心病”收住入院。", + "event": [ + { + "core_name": "心脏病", + "tendency": "", + "character": [ + "硬化性", + "粥样" + ], + "anatomy_list": [ + "冠状动���", + "心脏" + ] + } + ] + }, + { + "id": 1146, + "text": "入院前24天完成肿瘤术后第3次化疗,出院后无特殊不适,现按疗程入院行下一疗程化疗,门诊以“肿瘤化疗”收入院,现患儿精神反应可,无发热、咳嗽,进食可。", + "event": [ + { + "core_name": "精神反应", + "tendency": "", + "character": [ + "可" + ], + "anatomy_list": [] + }, + { + "core_name": "发热", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "咳嗽", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "进食", + "tendency": "", + "character": [ + "可" + ], + "anatomy_list": [] + } + ] + }, + { + "id": 759, + "text": "2018-2-15患者因“发热3天”入院,完善胸部ct提示:与2018年2月2日胸部ct比较:1.右下肺肺门占位,考虑肿瘤伴阻塞性肺炎,肿块较前变化不大。", + "event": [ + { + "core_name": "发热", + "tendency": "", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "占位", + "tendency": "", + "character": [], + "anatomy_list": [ + "右下肺门" + ] + }, + { + "core_name": "肿瘤", + "tendency": "不确定", + "character": [], + "anatomy_list": [ + "右下肺门" + ] + }, + { + "core_name": "肺炎", + "tendency": "不确定", + "character": [ + "阻塞性" + ], + "anatomy_list": [ + "肺" + ] + }, + { + "core_name": "肿块", + "tendency": "", + "character": [ + "较前变化不大" + ], + "anatomy_list": [ + "右下肺门" + ] + } + ] + }, + { + "id": 860, + "text": "入院前半天解1次黑色糊状便,诉量较多,具体不详,伴恶心,感中上腹上腹部不适,伴心悸、乏力表现,在外口服1粒云南白药胶囊治疗无缓解。", + "event": [ + { + "core_name": "大便", + "tendency": "", + "character": [ + "黑色", + "糊状", + "量较多" + ], + "anatomy_list": [] + }, + { + "core_name": "恶心", + "tendency": "", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "不适", + "tendency": "", + "character": [], + "anatomy_list": [ + "中上腹部" + ] + }, + { + "core_name": "心悸", + "tendency": "", + "character": [], + "anatomy_list": [ + "心" + ] + }, + { + "core_name": "乏力", + "tendency": "", + "character": [], + "anatomy_list": [] + } + ] + }, + { + "id": 837, + "text": "遂于术后行1次新辅助化疗,并于2017-06-02在全麻下行左腋窝前哨淋巴结活检术+术中冰冻+左乳癌改良根治术,术后病理示:(左乳)浸润性导管癌(Ⅱ级,7分)病检术后之乳腺根治标本(原病变参见17-8223号),残腔内见少许癌残留,皮肤、基底、乳头未见癌累及。", + "event": [ + { + "core_name": "导管癌", + "tendency": "", + "character": [ + "浸润性", + "Ⅱ级", + "7分" + ], + "anatomy_list": [ + "左乳" + ] + }, + { + "core_name": "癌", + "tendency": "", + "character": [ + "残腔内", + "少许", + "残留" + ], + "anatomy_list": [] + }, + { + "core_name": "癌", + "tendency": "否定", + "character": [ + "累及" + ], + "anatomy_list": [ + "乳头" + ] + }, + { + "core_name": "癌", + "tendency": "否定", + "character": [ + "累及" + ], + "anatomy_list": [ + "乳房皮肤" + ] + }, + { + "core_name": "癌", + "tendency": "否定", + "character": [ + "累及" + ], + "anatomy_list": [ + "乳房基底" + ] + } + ] + }, + { + "id": 1520, + "text": "近2年前患者咳嗽时痰中带血丝,为鲜红色血丝,病情加重时咯鲜红色血痰,伴喘累、心悸,多次我院住院诊断为“慢阻肺急性发作 冠心病 快速心房纤颤 支气管扩张”,给予抗感染、解痉、控制心室率等内科治疗好转出院。", + "event": [ + { + "core_name": "咳嗽", + "tendency": "", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "咳痰", + "tendency": "", + "character": [ + "鲜红色血丝" + ], + "anatomy_list": [] + }, + { + "core_name": "咳痰", + "tendency": "", + "character": [ + "病情加重时", + "鲜红色", + "血痰" + ], + "anatomy_list": [] + }, + { + "core_name": "喘累", + "tendency": "", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "心悸", + "tendency": "", + "character": [], + "anatomy_list": [ + "心" + ] + }, + { + "core_name": "肺疾病", + "tendency": "", + "character": [ + "急性发作", + "慢性", + "阻塞性" + ], + "anatomy_list": [ + "肺" + ] + }, + { + "core_name": "冠心病", + "tendency": "", + "character": [], + "anatomy_list": [ + "心" + ] + }, + { + "core_name": "心房纤颤", + "tendency": "", + "character": [ + "快速" + ], + "anatomy_list": [ + "心房" + ] + }, + { + "core_name": "扩张", + "tendency": "", + "character": [], + "anatomy_list": [ + "支气管" + ] + } + ] + }, + { + "id": 1638, + "text": "患者发病以来,神志 清晰,精神可,胃纳可,大便如常,小便如常,体重未见明显下降。", + "event": [ + { + "core_name": "神志", + "tendency": "", + "character": [ + "清" + ], + "anatomy_list": [] + }, + { + "core_name": "精神", + "tendency": "", + "character": [ + "可" + ], + "anatomy_list": [] + }, + { + "core_name": "胃纳", + "tendency": "", + "character": [ + "可" + ], + "anatomy_list": [ + "胃" + ] + }, + { + "core_name": "大便", + "tendency": "", + "character": [ + "如常" + ], + "anatomy_list": [] + }, + { + "core_name": "排尿", + "tendency": "", + "character": [ + "如常" + ], + "anatomy_list": [] + }, + { + "core_name": "体重下降", + "tendency": "否定", + "character": [ + "明显" + ], + "anatomy_list": [] + } + ] + }, + { + "id": 975, + "text": "患者遂至“某医院”就诊,自诉完善检查后诊断:继发性肺结核 涂(+)初治、结核性胸膜炎,予以抗结核治疗(具体不详)后好转出院,院外继续口服结核药物1+年,自觉症状好转,复查痰抗酸杆菌阴性,遂自行停用抗结核药物。", + "event": [ + { + "core_name": "结核", + "tendency": "", + "character": [ + "继发性", + "初治" + ], + "anatomy_list": [ + "肺" + ] + }, + { + "core_name": "胸膜炎", + "tendency": "", + "character": [ + "结核性" + ], + "anatomy_list": [ + "胸膜" + ] + } + ] + }, + { + "id": 1569, + "text": "患者起病以来,精神尚可,食欲较差,大便稀黄,3-5次/天,小便量如常,体重无明显变化。", + "event": [ + { + "core_name": "精神", + "tendency": "", + "character": [ + "尚可" + ], + "anatomy_list": [] + }, + { + "core_name": "食欲", + "tendency": "", + "character": [ + "较差" + ], + "anatomy_list": [] + }, + { + "core_name": "大便", + "tendency": "", + "character": [ + "稀黄" + ], + "anatomy_list": [] + }, + { + "core_name": "小便", + "tendency": "", + "character": [ + "量如常" + ], + "anatomy_list": [] + }, + { + "core_name": "体重改变", + "tendency": "否定", + "character": [ + "明显" + ], + "anatomy_list": [] + } + ] + }, + { + "id": 2011, + "text": "5年前开始到“某医院”就诊,诊断为“慢性阻塞性肺病”,予以“舒利迭50/500ug、噻托溴铵”吸入治疗,患者坚持用药,平时症状控制可。", + "event": [ + { + "core_name": "肺病", + "tendency": "", + "character": [ + "慢性", + "阻塞性" + ], + "anatomy_list": [ + "肺" + ] + } + ] + }, + { + "id": 935, + "text": "患者病程中反复眼红、近7年来患者视力明显下降,反复腮腺炎,近1年来发作频率增加,脱发较明显,有鼻干,双下肢远端内侧反复出现皮下结节30余年,无光过敏,无晨僵、无眼干、无耳痛、耳鸣,无反复口腔溃疡,无牙齿片状脱落,无��獗齿,无咀嚼疼痛、乏力,无关节疼痛,无手指遇冷后变白变紫又变红现象等。", + "event": [ + { + "core_name": "眼红", + "tendency": "", + "character": [ + "反复" + ], + "anatomy_list": [ + "眼" + ] + }, + { + "core_name": "视力下降", + "tendency": "", + "character": [ + "明显" + ], + "anatomy_list": [] + }, + { + "core_name": "腮腺炎", + "tendency": "", + "character": [ + "反复" + ], + "anatomy_list": [ + "腮腺" + ] + }, + { + "core_name": "脱发", + "tendency": "", + "character": [ + "较明显" + ], + "anatomy_list": [] + }, + { + "core_name": "鼻干", + "tendency": "", + "character": [], + "anatomy_list": [ + "鼻" + ] + }, + { + "core_name": "结节", + "tendency": "", + "character": [ + "反复", + "皮下" + ], + "anatomy_list": [ + "双下肢远端内侧" + ] + }, + { + "core_name": "过敏", + "tendency": "否定", + "character": [ + "光" + ], + "anatomy_list": [] + }, + { + "core_name": "晨僵", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "眼干", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "眼" + ] + }, + { + "core_name": "疼痛", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "耳" + ] + }, + { + "core_name": "耳鸣", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "耳" + ] + }, + { + "core_name": "溃疡", + "tendency": "否定", + "character": [ + "反复" + ], + "anatomy_list": [ + "口腔" + ] + }, + { + "core_name": "脱落", + "tendency": "否定", + "character": [ + "片状" + ], + "anatomy_list": [ + "牙齿" + ] + }, + { + "core_name": "猖獗齿", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "疼痛", + "tendency": "否定", + "character": [ + "咀嚼" + ], + "anatomy_list": [] + }, + { + "core_name": "乏力", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "疼痛", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "关节" + ] + }, + { + "core_name": "变白", + "tendency": "否定", + "character": [ + "遇冷后" + ], + "anatomy_list": [ + "手指" + ] + }, + { + "core_name": "变紫", + "tendency": "否定", + "character": [ + "遇冷后" + ], + "anatomy_list": [ + "手指" + ] + }, + { + "core_name": "变红", + "tendency": "否定", + "character": [ + "遇冷后" + ], + "anatomy_list": [ + "手指" + ] + } + ] + }, + { + "id": 1749, + "text": "患者2月余前因乏力、纳差于我我院就诊,行腹部mr发现肝占位性病变,遂于2016-10-11于我院行“胆囊切除术+中肝癌切除术”,术后予以抑酸,保肝,止血,抗感染,止吐,营养支持,改善微循环等治疗,术后病理示:1、(肝中叶)癌,低分化胆管细胞癌。", + "event": [ + { + "core_name": "乏力", + "tendency": "", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "纳差", + "tendency": "", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "病变", + "tendency": "", + "character": [ + "占位性" + ], + "anatomy_list": [ + "肝" + ] + }, + { + "core_name": "癌", + "tendency": "", + "character": [], + "anatomy_list": [ + "肝中叶" + ] + }, + { + "core_name": "癌", + "tendency": "", + "character": [ + "低分化" + ], + "anatomy_list": [ + "胆管细胞" + ] + } + ] + }, + { + "id": 1958, + "text": "入院前7天患者无明显诱因出现鼻出血,成滴流出,出血量较多(具体不详),自诉血液由前鼻孔和口腔内流出,自行指压鼻部缓解,期间无晕厥、咳嗽、呕血、黑便,无恶性、呕吐,无头昏、头痛、眩晕等症状,无鼻阻、发热、咳嗽、咳痰、听力下降,无咯血、胸痛,无潮热、盗汗、全身乏力、食欲减退等。未因重视而就医。", + "event": [ + { + "core_name": "出血", + "tendency": "", + "character": [ + "成滴流出", + "量较" + ], + "anatomy_list": [ + "鼻" + ] + }, + { + "core_name": "血液流出", + "tendency": "", + "character": [], + "anatomy_list": [ + "前鼻孔", + "口腔" + ] + }, + { + "core_name": "晕厥", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "咳嗽", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "呕血", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "黑便", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "恶心", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "呕吐", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "头昏", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "头" + ] + }, + { + "core_name": "疼痛", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "头" + ] + }, + { + "core_name": "眩晕", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "鼻塞", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "鼻" + ] + }, + { + "core_name": "发热", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "咳嗽", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "咳痰", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "听力下降", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "咯血", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "疼痛", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "胸" + ] + }, + { + "core_name": "潮热", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "盗汗", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "乏力", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "全身" + ] + }, + { + "core_name": "食欲减退", + "tendency": "否定", + "character": [], + "anatomy_list": [] + } + ] + }, + { + "id": 2004, + "text": "入院前2月,患者体检时发现右乳无痛性包块,约拇指指头大小,质韧,边界欠清,活动度尚可,无压痛,局部皮肤无红肿;乳头无溢血、溢液等;为求进一步治疗,就诊于我科,完善相关辅助检查,于2016-11-18日在全麻下行右乳包块切除+术中冰冻术,术中冰冻提示提示为恶性,遂行右乳癌改良根治术,术后病理诊断(123456):1.(右乳)癌,70%为浸润性癌,非特殊类型,Ⅰ级5分(导管内癌成份占30%);30%为粘液癌成份。", + "event": [ + { + "core_name": "包块", + "tendency": "", + "character": [ + "无痛性", + "约拇指指头大小", + "质韧", + "边界欠清", + "活动度尚可", + "无压痛" + ], + "anatomy_list": [ + "右乳" + ] + }, + { + "core_name": "红肿", + "tendency": "否定", + "character": [ + "局部" + ], + "anatomy_list": [ + "皮肤" + ] + }, + { + "core_name": "溢血", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "乳头" + ] + }, + { + "core_name": "溢液", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "乳头" + ] + }, + { + "core_name": "包块", + "tendency": "", + "character": [ + "恶性" + ], + "anatomy_list": [] + }, + { + "core_name": "癌", + "tendency": "", + "character": [], + "anatomy_list": [ + "右乳" + ] + }, + { + "core_name": "癌", + "tendency": "", + "character": [ + "浸润性", + "非特殊类型", + "Ⅰ级5分" + ], + "anatomy_list": [ + "右乳" + ] + }, + { + "core_name": "癌", + "tendency": "", + "character": [ + "导管内" + ], + "anatomy_list": [ + "右乳" + ] + }, + { + "core_name": "癌", + "tendency": "", + "character": [ + "粘液" + ], + "anatomy_list": [ + "右乳" + ] + } + ] + }, + { + "id": 593, + "text": "2周前患者复查胃镜:食管至胃底胃体ca化疗后、慢性萎缩性胃炎。", + "event": [ + { + "core_name": "癌", + "tendency": "", + "character": [ + "化疗后" + ], + "anatomy_list": [ + "食管至胃底胃体" + ] + }, + { + "core_name": "胃炎", + "tendency": "", + "character": [ + "慢性", + "萎缩性" + ], + "anatomy_list": [ + "胃" + ] + } + ] + }, + { + "id": 314, + "text": "1+月前,患者无明显诱因出现阴道少许血性分泌物,无阴道阴道流液,伴尿频、尿痛、下腹部及腰骶部坠胀,无尿急、尿血及排尿困难,无腹痛腹泻,自行于某医院就诊,给予输液治疗(具体不详),尿频尿痛好转,阴道流血持续5天自行停止。", + "event": [ + { + "core_name": "分泌物", + "tendency": "", + "character": [ + "血性", + "少许" + ], + "anatomy_list": [ + "阴道" + ] + }, + { + "core_name": "流液", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "阴道" + ] + }, + { + "core_name": "尿频", + "tendency": "", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "尿痛", + "tendency": "", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "坠胀", + "tendency": "", + "character": [], + "anatomy_list": [ + "下腹部", + "腰骶部" + ] + }, + { + "core_name": "尿急", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "尿血", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "排尿困难", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "疼痛", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "腹" + ] + }, + { + "core_name": "腹泻", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "腹" + ] + }, + { + "core_name": "尿频", + "tendency": "", + "character": [ + "好转" + ], + "anatomy_list": [] + }, + { + "core_name": "尿痛", + "tendency": "", + "character": [ + "好转" + ], + "anatomy_list": [] + }, + { + "core_name": "出血", + "tendency": "", + "character": [ + "持续5天自行停止" + ], + "anatomy_list": [ + "阴道" + ] + } + ] + }, + { + "id": 696, + "text": "患者为求进一步治疗,遂于2016-5-16入我院就诊,电子阴道镜检查示:宫颈i度糜烂,薄的醋酸白色上皮;tct:轻度炎症,未见上皮内病变或恶性细胞,妇科彩超示:1.宫腔内偏强回声,子宫内膜ca待排,建议进一步检查。", + "event": [ + { + "core_name": "糜烂", + "tendency": "", + "character": [ + "i度" + ], + "anatomy_list": [ + "宫颈" + ] + }, + { + "core_name": "醋酸白色上皮", + "tendency": "", + "character": [ + "薄的" + ], + "anatomy_list": [] + }, + { + "core_name": "炎症", + "tendency": "", + "character": [ + "轻度" + ], + "anatomy_list": [ + "宫颈" + ] + }, + { + "core_name": "病变", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "上皮内", + "恶性细胞" + ] + }, + { + "core_name": "回声", + "tendency": "", + "character": [ + "偏强" + ], + "anatomy_list": [ + "宫腔内" + ] + }, + { + "core_name": "癌", + "tendency": "不确定", + "character": [], + "anatomy_list": [ + "子宫内膜" + ] + } + ] + }, + { + "id": 2045, + "text": "患者自发病以来,精神差,食欲差,睡眠可,大便如常,小便如常,体重无明显变化。", + "event": [ + { + "core_name": "精神", + "tendency": "", + "character": [ + "差" + ], + "anatomy_list": [] + }, + { + "core_name": "食欲", + "tendency": "", + "character": [ + "差" + ], + "anatomy_list": [] + }, + { + "core_name": "睡眠", + "tendency": "", + "character": [ + "可 " + ], + "anatomy_list": [] + }, + { + "core_name": "大便", + "tendency": "", + "character": [ + "如常" + ], + "anatomy_list": [] + }, + { + "core_name": "小便", + "tendency": "", + "character": [ + "如常" + ], + "anatomy_list": [] + }, + { + "core_name": "体重改变", + "tendency": "否定", + "character": [ + "明显" + ], + "anatomy_list": [] + } + ] + }, + { + "id": 1994, + "text": "子宫平滑肌瘤伴玻变。", + "event": [ + { + "core_name": "肌瘤", + "tendency": "", + "character": [], + "anatomy_list": [ + "子宫平滑肌" + ] + }, + { + "core_name": "玻变", + "tendency": "", + "character": [], + "anatomy_list": [ + "子宫平滑肌" + ] + } + ] + }, + { + "id": 621, + "text": "入院前6+月,患者无明显诱因出现性生活后阴道流血,量少,色鲜红,不伴疼痛,可自行停止,患者未引起重视,未正规检查及诊治。", + "event": [ + { + "core_name": "出血", + "tendency": "", + "character": [ + "性生活后", + "量少", + "色鲜红", + "不伴疼痛", + "可自行停止" + ], + "anatomy_list": [ + "阴道" + ] + } + ] + }, + { + "id": 1320, + "text": "后口服依西美坦至2018年5月,患者无明显诱因出现咳嗽,我院门诊查胸部ct提示:肺内、右肺门、肝脏多发转移可能。", + "event": [ + { + "core_name": "咳嗽", + "tendency": "", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "癌", + "tendency": "不确定", + "character": [ + "多发", + "转移" + ], + "anatomy_list": [ + "肺内", + "右肺门", + "肝脏" + ] + } + ] + }, + { + "id": 1953, + "text": "半月前,患者家属发现患者皮肤黄染,尿色加深,无厌油,无恶心、呕吐,无纳差,诉双下肢乏力,无腹胀、腹痛、腹泻,无反酸、嗳气,无呕血、黑便,无牙龈出血,无畏寒及发热,无咳嗽、咳痰,无头昏、头痛,无酱油色尿,无皮肤瘙痒,自诉大便颜色变浅,黄白色,患者及家属为求进一步诊治就诊于我院,急诊以“黄疸待查”收治入院。", + "event": [ + { + "core_name": "黄染", + "tendency": "", + "character": [], + "anatomy_list": [ + "皮肤" + ] + }, + { + "core_name": "小便", + "tendency": "", + "character": [ + "色加深" + ], + "anatomy_list": [] + }, + { + "core_name": "厌油", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "恶心", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "呕吐", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "纳差", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "乏力", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "双下肢" + ] + }, + { + "core_name": "腹胀", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "腹" + ] + }, + { + "core_name": "疼痛", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "腹" + ] + }, + { + "core_name": "腹泻", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "腹" + ] + }, + { + "core_name": "返酸", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "嗳气", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "呕血", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "黑便", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "出血", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "牙龈" + ] + }, + { + "core_name": "畏寒", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "发热", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "咳嗽", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "咳痰", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "头昏", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "头" + ] + }, + { + "core_name": "疼痛", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "头" + ] + }, + { + "core_name": "小便", + "tendency": "否定", + "character": [ + "酱油色" + ], + "anatomy_list": [] + }, + { + "core_name": "瘙痒", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "皮肤" + ] + }, + { + "core_name": "大便", + "tendency": "", + "character": [ + "颜色变浅", + "黄白色" + ], + "anatomy_list": [] + }, + { + "core_name": "黄疸", + "tendency": "", + "character": [], + "anatomy_list": [] + } + ] + }, + { + "id": 248, + "text": "腹部彩超示:肝脏实性占位:ca? 。", + "event": [ + { + "core_name": "占位", + "tendency": "", + "character": [ + "实性" + ], + "anatomy_list": [ + "肝脏" + ] + }, + { + "core_name": "癌", + "tendency": "不确定", + "character": [], + "anatomy_list": [ + "肝" + ] + } + ] + }, + { + "id": 1338, + "text": "于2019年3月11日在全麻下行“右半肝切除+门静脉切开取栓+胆囊切除术+肝内胆管空肠吻合+t管引流术”,术后病理检查提示为“病检结果已回<肝脏>低分化癌,结合形态及免疫组化,符合低分化胆管细胞癌。<胆管下端冰冻>送检组织中见个别不典型细胞。", + "event": [ + { + "core_name": "癌", + "tendency": "", + "character": [ + "低分化" + ], + "anatomy_list": [ + "肝脏" + ] + }, + { + "core_name": "癌", + "tendency": "", + "character": [ + "低分化" + ], + "anatomy_list": [ + "胆管", + "细胞" + ] + } + ] + }, + { + "id": 1008, + "text": "免疫结果为右半结肠非霍奇金氏淋巴瘤(弥漫大b细胞型)。", + "event": [ + { + "core_name": "瘤", + "tendency": "", + "character": [ + "弥漫性", + "大B细胞" + ], + "anatomy_list": [ + "右半结肠", + "淋巴" + ] + }, + { + "core_name": "瘤", + "tendency": "", + "character": [ + "非霍奇金氏" + ], + "anatomy_list": [ + "右半结肠", + "淋巴" + ] + } + ] + }, + { + "id": 1462, + "text": "病程中患者存在飞蚊症,视近物模糊,但无烦渴多饮,无肢端发麻等不适。", + "event": [ + { + "core_name": "飞蚊症", + "tendency": "", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "视物模糊", + "tendency": "", + "character": [ + "近物" + ], + "anatomy_list": [] + }, + { + "core_name": "烦渴", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "多饮", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "发麻", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "肢端" + ] + } + ] + }, + { + "id": 710, + "text": "术后每月定期复查,血清ca125持续升高,he4、ca153、ca199、cea均未见异常,2017-9-13(某医院)pet-ct:卵巢癌术后,腹膜后及右侧髂血管血管旁多发淋巴结转移,右肺上叶转移,左髂骨髂���骨骨转移,后出现左侧腰骶部持续性胀痛,2017-9-15ca-125785u/ml,考虑“卵巢癌术后化疗后复发”,于2017-9-16开始予以“tc方案”(紫杉醇+卡铂)静脉化疗,治疗期间ca125缓慢下降,2018-1-8第6次化疗前复查ca-12568.1u/ml,更改为“奥沙利铂+多西他赛”静脉化疗1次,2018-1-30复查ca-12560.8u/ml,第二周期化疗结束后ca125仍未降至正常,后逐渐升高,2018-8-8ca-1251129u/ml,后拒绝检查,失访4月。", + "event": [ + { + "core_name": "血清ca125", + "tendency": "", + "character": [ + "持续升高" + ], + "anatomy_list": [] + }, + { + "core_name": "he4", + "tendency": "否定", + "character": [ + "异常" + ], + "anatomy_list": [] + }, + { + "core_name": "ca153", + "tendency": "否定", + "character": [ + "异常" + ], + "anatomy_list": [] + }, + { + "core_name": "ca199", + "tendency": "否定", + "character": [ + "异常" + ], + "anatomy_list": [] + }, + { + "core_name": "cea", + "tendency": "否定", + "character": [ + "异常" + ], + "anatomy_list": [] + }, + { + "core_name": "癌", + "tendency": "", + "character": [ + "术后" + ], + "anatomy_list": [ + "卵巢" + ] + }, + { + "core_name": "转移", + "tendency": "", + "character": [ + "多发性" + ], + "anatomy_list": [ + "腹膜后淋巴结", + "右侧髂血管旁淋巴结" + ] + }, + { + "core_name": "转移", + "tendency": "", + "character": [], + "anatomy_list": [ + "右肺上叶" + ] + }, + { + "core_name": "转移", + "tendency": "", + "character": [], + "anatomy_list": [ + "左髂骨" + ] + }, + { + "core_name": "疼痛", + "tendency": "", + "character": [ + "持续性", + "胀痛" + ], + "anatomy_list": [ + "左侧腰骶部" + ] + }, + { + "core_name": "癌", + "tendency": "不确定", + "character": [], + "anatomy_list": [ + "卵巢" + ] + }, + { + "core_name": "ca125", + "tendency": "", + "character": [ + "治疗期间", + "缓慢下降" + ], + "anatomy_list": [] + }, + { + "core_name": "ca125", + "tendency": "否定", + "character": [ + "第二周期化疗结束后", + "降至正常" + ], + "anatomy_list": [] + } + ] + }, + { + "id": 397, + "text": "伴腹胀 , 伴恶心、呕吐,呕吐物为胃内容物 , 发病 以来肛门未排气排便。", + "event": [ + { + "core_name": "腹胀", + "tendency": "", + "character": [], + "anatomy_list": [ + "腹" + ] + }, + { + "core_name": "恶心", + "tendency": "", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "呕吐", + "tendency": "", + "character": [ + "呕吐物为胃内容物" + ], + "anatomy_list": [] + }, + { + "core_name": "排气", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "肛门" + ] + }, + { + "core_name": "排便", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "肛门" + ] + } + ] + }, + { + "id": 1690, + "text": "入院前1年余,患者无明显诱因出现双眼视力逐渐下降,偶感眼痒、流泪,无眼痛、眼胀、眼卡,无畏光、分泌物增多,无视物遮挡、变形、黑影漂浮,无头痛、恶心等不适,患者未予重视及特殊治疗。", + "event": [ + { + "core_name": "视力下降", + "tendency": "", + "character": [ + "逐渐" + ], + "anatomy_list": [ + "双眼" + ] + }, + { + "core_name": "眼痒", + "tendency": "", + "character": [ + "偶感" + ], + "anatomy_list": [ + "眼" + ] + }, + { + "core_name": "流泪", + "tendency": "", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "眼痛", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "眼" + ] + }, + { + "core_name": "眼胀", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "眼" + ] + }, + { + "core_name": "眼卡", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "眼" + ] + }, + { + "core_name": "畏光", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "分泌物", + "tendency": "否定", + "character": [ + "增多" + ], + "anatomy_list": [] + }, + { + "core_name": "视物遮挡", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "视物变形", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "黑影漂浮", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "头痛", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "头" + ] + }, + { + "core_name": "恶心", + "tendency": "否定", + "character": [], + "anatomy_list": [] + } + ] + }, + { + "id": 1493, + "text": "入院前6月,患者无明显诱因出现咯血,表现为痰中带血,伴咳嗽、咳白痰,偶伴头晕,无畏寒、发热,无恶心、呕吐,无头痛,无意识不清,无呼吸困难,无胸闷、心悸,无心前区压榨感,无腹痛、腹泻。", + "event": [ + { + "core_name": "咯血", + "tendency": "", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "咳痰", + "tendency": "", + "character": [ + "带血" + ], + "anatomy_list": [] + }, + { + "core_name": "咳嗽", + "tendency": "", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "咳痰", + "tendency": "", + "character": [ + "白色" + ], + "anatomy_list": [] + }, + { + "core_name": "头晕", + "tendency": "", + "character": [], + "anatomy_list": [ + "头" + ] + }, + { + "core_name": "畏寒", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "发热", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "恶心", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "呕吐", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "疼痛", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "头" + ] + }, + { + "core_name": "意识不清", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "呼吸困难", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "胸闷", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "胸" + ] + }, + { + "core_name": "心悸", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "心" + ] + }, + { + "core_name": "压榨感", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "心前区" + ] + }, + { + "core_name": "疼痛", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "腹" + ] + }, + { + "core_name": "腹泻", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "腹" + ] + } + ] + }, + { + "id": 1293, + "text": "入院前3天,患者肛门少量排气排便,伴腹痛腹胀,呈持续性胀痛不适,阵发性加重,无放射痛及牵涉痛,伴恶心,无呕吐,无畏寒发热,无便血、腹泻,无头昏、头痛;无心慌、胸闷;无嗳气、呃逆等不适,患者自觉腹痛不缓解,为求进一步诊治,遂到我院就医,门诊以“不完全性肠梗阻”收入我科进一步治疗。", + "event": [ + { + "core_name": "排气", + "tendency": "", + "character": [ + "少量" + ], + "anatomy_list": [ + "肛门" + ] + }, + { + "core_name": "排便", + "tendency": "", + "character": [ + "少量" + ], + "anatomy_list": [ + "肛门" + ] + }, + { + "core_name": "疼痛", + "tendency": "", + "character": [], + "anatomy_list": [ + "腹" + ] + }, + { + "core_name": "腹胀", + "tendency": "", + "character": [], + "anatomy_list": [ + "腹" + ] + }, + { + "core_name": "疼痛", + "tendency": "", + "character": [ + "胀痛", + "持续性", + "阵发性加重", + "无放射痛及牵涉痛" + ], + "anatomy_list": [ + "腹" + ] + }, + { + "core_name": "恶心", + "tendency": "", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "呕吐", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "畏寒", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "发热", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "便血", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "腹泻", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "腹" + ] + }, + { + "core_name": "头昏", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "头" + ] + }, + { + "core_name": "疼痛", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "头" + ] + }, + { + "core_name": "心慌", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "心" + ] + }, + { + "core_name": "胸闷", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "胸" + ] + }, + { + "core_name": "嗳气", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "呃逆", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "疼痛", + "tendency": "否定", + "character": [ + "缓解" + ], + "anatomy_list": [ + "腹" + ] + }, + { + "core_name": "梗阻", + "tendency": "", + "character": [ + "不完全性" + ], + "anatomy_list": [ + "肠" + ] + } + ] + }, + { + "id": 781, + "text": "入院2+小时 前 ,患者无明显诱因出现头晕,伴视物旋转,平卧时缓解,坐起时加重,伴恶心、呕吐胃内容物,量及次数具体不详,无咖啡色样物质,无喷射性呕吐;伴耳鸣,无耳胀、听力下降;无外耳道疱疹,无鼻唇沟变浅,无饮水呛咳、吞咽困难、肢体麻木、肢体无力;无发热、畏寒、寒战等不适。", + "event": [ + { + "core_name": "头晕", + "tendency": "", + "character": [ + "坐起时加重", + "平卧时缓解" + ], + "anatomy_list": [ + "头" + ] + }, + { + "core_name": "视物旋转", + "tendency": "", + "character": [ + "坐起时加重", + "平卧时缓解" + ], + "anatomy_list": [] + }, + { + "core_name": "恶心", + "tendency": "", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "呕吐", + "tendency": "", + "character": [ + "胃内容物", + "量及次数具体不详", + "无咖啡色样物质" + ], + "anatomy_list": [] + }, + { + "core_name": "呕吐", + "tendency": "否定", + "character": [ + "喷射性" + ], + "anatomy_list": [] + }, + { + "core_name": "耳鸣", + "tendency": "", + "character": [], + "anatomy_list": [ + "耳" + ] + }, + { + "core_name": "耳胀", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "耳" + ] + }, + { + "core_name": "听力下降", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "疱疹", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "外耳道" + ] + }, + { + "core_name": "变浅", + "tendency": "否定", + "character": [ + "变浅" + ], + "anatomy_list": [ + "鼻唇沟" + ] + }, + { + "core_name": "呛咳", + "tendency": "否定", + "character": [ + "饮水" + ], + "anatomy_list": [] + }, + { + "core_name": "吞咽困难", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "麻木", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "肢体" + ] + }, + { + "core_name": "无力", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "肢体" + ] + }, + { + "core_name": "发热", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "畏寒", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "寒颤", + "tendency": "否定", + "character": [], + "anatomy_list": [] + } + ] + }, + { + "id": 656, + "text": "患者遂致某医院就诊,门诊行乳腺彩超检查,提示:双乳多发囊肿,部分囊内透声较差,考虑出血可能性大。", + "event": [ + { + "core_name": "囊肿", + "tendency": "", + "character": [ + "多发", + "部分囊内透声较差" + ], + "anatomy_list": [ + "双乳" + ] + }, + { + "core_name": "出血", + "tendency": "不确定", + "character": [], + "anatomy_list": [ + "双乳囊内" + ] + } + ] + }, + { + "id": 712, + "text": "2020-4-23ca-1254247u/ml,全腹ct提示:右肺多发结节影,腹腔及腹膜后多发淋巴结多发淋巴结转移,双侧骶翼骨考转移,脊柱mr提示:腰1椎体、腰55椎体骶棘、所示骶骨及左侧髂骨异常信号,考虑转移改变,腹腔后增多软组织影,肿大淋巴结,建议联合靶向治疗,患者拒绝,2020-4-26予以“卡培他滨”治疗,2020-5-16ca-1253697u/ml,2020-5-18予以“伊立替康+卡培他滨”治疗,2020-6-10ca-1253967u/ml。", + "event": [ + { + "core_name": "结节影", + "tendency": "", + "character": [ + "多发" + ], + "anatomy_list": [ + "右肺" + ] + }, + { + "core_name": "转移", + "tendency": "", + "character": [ + "多发" + ], + "anatomy_list": [ + "腹腔淋巴结", + "腹腔后淋巴结" + ] + }, + { + "core_name": "转移", + "tendency": "不确定", + "character": [], + "anatomy_list": [ + "双侧骶翼骨" + ] + }, + { + "core_name": "异常信号", + "tendency": "", + "character": [], + "anatomy_list": [ + "腰1椎体", + "腰5椎体骶棘", + "骶骨", + "左侧髂骨" + ] + }, + { + "core_name": "转移改变", + "tendency": "不确定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "软组织影", + "tendency": "", + "character": [ + "增多" + ], + "anatomy_list": [ + "腹腔后" + ] + }, + { + "core_name": "肿大", + "tendency": "", + "character": [], + "anatomy_list": [ + "腹腔后淋巴结" + ] + } + ] + }, + { + "id": 913, + "text": "25年前,患者在玩耍时右侧腕部及手指不慎被化学物质(具体化学物质名称不详)烧伤(腕部及手部变现不详),当即患者疼痛难忍,哭闹不止,神志清楚,患者家属自行未做任何处理,立即将患者送到某一诊所进行治疗,予以换药、补液、抗感染等常规治疗,伤口愈合后皮肤覆盖创面,但疤痕形成,严重影响腕部及手指功能,在医生建议下行腕部及手指功能康复锻炼(具体治疗过程不详)后,右手小指瘢痕挛缩明显,功能受到影响,其余四指恢复良好,腕部活动有轻微受限,疤痕明显。", + "event": [ + { + "core_name": "烧伤", + "tendency": "", + "character": [ + "化学物质" + ], + "anatomy_list": [ + "右侧腕部" + ] + }, + { + "core_name": "烧伤", + "tendency": "", + "character": [ + "化学物质" + ], + "anatomy_list": [ + "手指" + ] + }, + { + "core_name": "疼痛", + "tendency": "", + "character": [ + "难忍" + ], + "anatomy_list": [ + "右侧腕部" + ] + }, + { + "core_name": "疼痛", + "tendency": "", + "character": [ + "难忍" + ], + "anatomy_list": [ + "手指" + ] + }, + { + "core_name": "哭闹不止", + "tendency": "", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "神志", + "tendency": "", + "character": [ + "清楚" + ], + "anatomy_list": [] + }, + { + "core_name": "疤痕形成", + "tendency": "", + "character": [ + "严重影响腕部及手指功能" + ], + "anatomy_list": [] + }, + { + "core_name": "瘢痕", + "tendency": "", + "character": [ + "挛缩明显" + ], + "anatomy_list": [ + "右手小指" + ] + }, + { + "core_name": "功能受到影响", + "tendency": "", + "character": [], + "anatomy_list": [ + "右手小指" + ] + }, + { + "core_name": "活动受限", + "tendency": "", + "character": [ + "轻微" + ], + "anatomy_list": [ + "腕部" + ] + }, + { + "core_name": "疤痕", + "tendency": "", + "character": [ + "明显" + ], + "anatomy_list": [] + } + ] + }, + { + "id": 1864, + "text": "患者本次发病以来,食欲正常,神志清醒,精神尚可,睡眠可,大便正常,小便正常,体重无明显变化。", + "event": [ + { + "core_name": "食欲", + "tendency": "", + "character": [ + "正常" + ], + "anatomy_list": [] + }, + { + "core_name": "神志", + "tendency": "", + "character": [ + "清醒" + ], + "anatomy_list": [] + }, + { + "core_name": "精神", + "tendency": "", + "character": [ + "尚可" + ], + "anatomy_list": [] + }, + { + "core_name": "睡眠", + "tendency": "", + "character": [ + "可" + ], + "anatomy_list": [] + }, + { + "core_name": "大便", + "tendency": "", + "character": [ + "正常" + ], + "anatomy_list": [] + }, + { + "core_name": "小便", + "tendency": "", + "character": [ + "正常" + ], + "anatomy_list": [] + }, + { + "core_name": "体重改变", + "tendency": "否定", + "character": [ + "明显" + ], + "anatomy_list": [] + } + ] + }, + { + "id": 94, + "text": "月经结束4天后,阴道再次出现流血,持续至今,量多。", + "event": [ + { + "core_name": "出血", + "tendency": "", + "character": [ + "再次", + "持续至今", + "量多" + ], + "anatomy_list": [ + "阴道" + ] + } + ] + }, + { + "id": 468, + "text": "故急诊以“腹痛待查:卵巢黄体囊肿破裂?异位妊娠?”收入我科。", + "event": [ + { + "core_name": "疼痛", + "tendency": "不确定", + "character": [], + "anatomy_list": [ + "腹" + ] + }, + { + "core_name": "囊肿破裂", + "tendency": "不确定", + "character": [], + "anatomy_list": [ + "卵巢黄体" + ] + }, + { + "core_name": "异位妊娠", + "tendency": "不确定", + "character": [], + "anatomy_list": [ + "卵巢黄体" + ] + } + ] + }, + { + "id": 142, + "text": "患者长期排尿困难,夜尿增多,3+月前于i某医院行前列腺穿刺活检,病检结果回示:前列腺腺癌,患者未予特殊处理。", + "event": [ + { + "core_name": "排尿困难", + "tendency": "", + "character": [ + "长期" + ], + "anatomy_list": [] + }, + { + "core_name": "夜尿增多", + "tendency": "", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "腺癌", + "tendency": "", + "character": [], + "anatomy_list": [ + "前列腺" + ] + } + ] + }, + { + "id": 434, + "text": "现患者无肝区疼痛、骨关节关节疼痛等,今为行第8疗程化疗入院。", + "event": [ + { + "core_name": "疼痛", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "肝区" + ] + }, + { + "core_name": "疼痛", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "骨关节" + ] + } + ] + }, + { + "id": 1774, + "text": "患病以来,精神、睡眠、食欲可,二便正常,体重无明显减轻", + "event": [ + { + "core_name": "精神", + "tendency": "", + "character": [ + "可" + ], + "anatomy_list": [] + }, + { + "core_name": "睡眠", + "tendency": "", + "character": [ + "可" + ], + "anatomy_list": [] + }, + { + "core_name": "食欲", + "tendency": "", + "character": [ + "可" + ], + "anatomy_list": [] + }, + { + "core_name": "大小便", + "tendency": "", + "character": [ + "正常" + ], + "anatomy_list": [] + }, + { + "core_name": "体重减轻", + "tendency": "否定", + "character": [ + "明显" + ], + "anatomy_list": [] + } + ] + }, + { + "id": 1634, + "text": "”诊断为降结肠癌,于2013.8.23日行腹腔镜辅助下左结肠切除术+放射性粒子植入术,术后恢复好,病理类型(左半结肠)溃疡型中分化管状乳头状腺癌,浸及肠壁全层,脉管、神经未见癌侵犯,两切端未见癌累及,淋巴结见癌转移(7/12)),分期t3、n2、m0。", + "event": [ + { + "core_name": "癌", + "tendency": "", + "character": [], + "anatomy_list": [ + "降结肠" + ] + }, + { + "core_name": "腺癌", + "tendency": "", + "character": [ + "溃疡型", + "中分化", + "管状", + "乳头状" + ], + "anatomy_list": [ + "左半结肠" + ] + }, + { + "core_name": "癌", + "tendency": "否定", + "character": [ + "侵犯" + ], + "anatomy_list": [ + "脉管", + "神经" + ] + }, + { + "core_name": "癌", + "tendency": "", + "character": [ + "浸及" + ], + "anatomy_list": [ + "肠壁全层" + ] + }, + { + "core_name": "癌", + "tendency": "否定", + "character": [ + "累及" + ], + "anatomy_list": [ + "两切端" + ] + }, + { + "core_name": "癌", + "tendency": "", + "character": [ + "转移", + "分期t3、n2、m0" + ], + "anatomy_list": [ + "淋巴结" + ] + } + ] + }, + { + "id": 1115, + "text": "患者自起病以来,精神可,胃纳可,大便次数增多,尿频,体重未见明显下降。", + "event": [ + { + "core_name": "精神", + "tendency": "", + "character": [ + "可" + ], + "anatomy_list": [] + }, + { + "core_name": "胃纳", + "tendency": "", + "character": [ + "可" + ], + "anatomy_list": [ + "胃" + ] + }, + { + "core_name": "大便", + "tendency": "", + "character": [ + "次数增多" + ], + "anatomy_list": [] + }, + { + "core_name": "尿频", + "tendency": "", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "体重", + "tendency": "", + "character": [ + "无明显下降" + ], + "anatomy_list": [] + } + ] + }, + { + "id": 45, + "text": "今日患者为求进一步治疗来我院就诊,门诊以“盆腔包块待查”收治入院。", + "event": [ + { + "core_name": "包块", + "tendency": "不确定", + "character": [], + "anatomy_list": [ + "盆腔" + ] + } + ] + }, + { + "id": 116, + "text": "遂患者为求进一步诊疗于我科住院,我科予以讨论后患者病情后,于2017-06-11、2017-07-04、2017-07-26、2017-08-21、2017-09-25予以5次tac方案化疗,于2017-08-24在全麻下行右乳癌改良根治术,手术顺利,术后标本送常规病检(2017-08-29):<右乳>浸润性癌,非特殊类型,Ⅱ级7分。", + "event": [ + { + "core_name": "癌", + "tendency": "", + "character": [ + "浸润性", + "非特殊类型", + "Ⅱ级7分" + ], + "anatomy_list": [ + "右乳" + ] + } + ] + }, + { + "id": 1209, + "text": "6.子宫腔积液。", + "event": [ + { + "core_name": "积液", + "tendency": "", + "character": [], + "anatomy_list": [ + "子宫腔" + ] + } + ] + }, + { + "id": 1179, + "text": "诊断慢性髓细胞白血病明确,遂予以国产伊马替尼400mg每日一次口服治疗,前期血象控制尚可,2014年9月底开始多次复查血常规提示白细胞逐渐升高,但脾脏逐渐缩小,患者未定期复查骨穿及调整药物。", + "event": [ + { + "core_name": "白血病", + "tendency": "", + "character": [ + "慢性" + ], + "anatomy_list": [ + "髓细胞" + ] + }, + { + "core_name": "白细胞升高", + "tendency": "", + "character": [ + "逐渐" + ], + "anatomy_list": [ + "白细胞" + ] + }, + { + "core_name": "脾脏缩小", + "tendency": "", + "character": [ + "逐渐" + ], + "anatomy_list": [ + "脾脏" + ] + } + ] + }, + { + "id": 668, + "text": "病程中患者无夜间阵发性呼吸困难,无咯粉红色泡沫痰,无双下肢水肿。", + "event": [ + { + "core_name": "呼吸困难", + "tendency": "否定", + "character": [ + "夜间", + "阵发性" + ], + "anatomy_list": [] + }, + { + "core_name": "咳痰", + "tendency": "否定", + "character": [ + "粉红色", + "泡沫痰" + ], + "anatomy_list": [] + }, + { + "core_name": "水肿", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "双下肢" + ] + } + ] + }, + { + "id": 1942, + "text": "于2018.03.07予以tp方案姑息性化疗;化疗药物(紫杉醇 210mg;顺铂 120mg),胸部ct提示肿瘤处于pd,于2018.05.05更换为dp方案化疗,化疗药物总量(多西他赛 120mg;顺铂120mg),化疗期间无特殊不适,化疗后无骨髓抑制,今为求下周期化疗入院,以\"肺鳞癌伴骨转移\"收入我科。", + "event": [ + { + "core_name": "肿瘤", + "tendency": "", + "character": [ + "处于pd" + ], + "anatomy_list": [] + }, + { + "core_name": "骨髓抑制", + "tendency": "否定", + "character": [ + "化疗后" + ], + "anatomy_list": [ + "骨髓" + ] + }, + { + "core_name": "鳞癌", + "tendency": "", + "character": [], + "anatomy_list": [ + "肺" + ] + }, + { + "core_name": "鳞癌", + "tendency": "", + "character": [ + "转移" + ], + "anatomy_list": [ + "骨" + ] + } + ] + }, + { + "id": 92, + "text": "患者平素月经规则,初潮14岁,周期17天,经期8-9天,量中等,色鲜红,无痛经,血凝块较少,既往白带正常。", + "event": [ + { + "core_name": "月经", + "tendency": "", + "character": [ + "规则" + ], + "anatomy_list": [] + }, + { + "core_name": "痛经", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "经量", + "tendency": "", + "character": [ + "中等" + ], + "anatomy_list": [] + }, + { + "core_name": "月经", + "tendency": "", + "character": [ + "色鲜红" + ], + "anatomy_list": [] + }, + { + "core_name": "血凝块", + "tendency": "", + "character": [ + "较少" + ], + "anatomy_list": [] + }, + { + "core_name": "白带", + "tendency": "", + "character": [ + "正常" + ], + "anatomy_list": [] + } + ] + }, + { + "id": 50, + "text": "予以保肝、增强抵抗力等治疗,于2016-3-2行fc方案化疗;今为行化疗于我院就诊,门诊以“慢性淋巴细胞白血病/小淋巴细胞性淋巴瘤 binet b期”收治入院。", + "event": [ + { + "core_name": "白血病", + "tendency": "", + "character": [ + "慢性" + ], + "anatomy_list": [ + "淋巴细胞" + ] + }, + { + "core_name": "瘤", + "tendency": "", + "character": [ + "小淋巴细胞性", + "binet b期" + ], + "anatomy_list": [ + "淋巴" + ] + } + ] + }, + { + "id": 1102, + "text": "患者偶有咳嗽,无活动后心累、气促,无胸闷、胸痛、咯血、呼吸困难,无潮热、盗汗、疲乏、消瘦,无畏寒、发热。", + "event": [ + { + "core_name": "咳嗽", + "tendency": "", + "character": [ + "偶有" + ], + "anatomy_list": [] + }, + { + "core_name": "气促", + "tendency": "否定", + "character": [ + "活动后" + ], + "anatomy_list": [] + }, + { + "core_name": "心累", + "tendency": "否定", + "character": [ + "活动后" + ], + "anatomy_list": [ + "心" + ] + }, + { + "core_name": "胸闷", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "胸" + ] + }, + { + "core_name": "疼痛", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "胸" + ] + }, + { + "core_name": "咯血", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "呼吸困难", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "潮热", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "盗汗", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "疲乏", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "消瘦", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "畏寒", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "发热", + "tendency": "否定", + "character": [], + "anatomy_list": [] + } + ] + }, + { + "id": 311, + "text": "”遂进一步行前列腺穿刺病检提示:“前列腺癌”全身ect提示:“全身骨显影未见明显异常。", + "event": [ + { + "core_name": "癌", + "tendency": "", + "character": [], + "anatomy_list": [ + "前列腺" + ] + }, + { + "core_name": "骨显影异常", + "tendency": "否定", + "character": [ + "明显" + ], + "anatomy_list": [ + "全身" + ] + } + ] + }, + { + "id": 22, + "text": "患者目前诉术区皮肤麻木及轻微刺痛,诉指端皮肤麻木麻木不适,无头晕、乏力等,今日为行放疗就诊于我科门诊,门诊以“乳腺癌 术后化疗后”收入院。", + "event": [ + { + "core_name": "麻木", + "tendency": "", + "character": [], + "anatomy_list": [ + "术区皮肤" + ] + }, + { + "core_name": "疼痛", + "tendency": "", + "character": [ + "轻微", + "刺痛" + ], + "anatomy_list": [ + "术区皮肤" + ] + }, + { + "core_name": "麻木", + "tendency": "", + "character": [], + "anatomy_list": [ + "指端皮肤" + ] + }, + { + "core_name": "麻木不适", + "tendency": "", + "character": [], + "anatomy_list": [ + "指端皮肤" + ] + }, + { + "core_name": "头晕", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "头" + ] + }, + { + "core_name": "乏力", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "癌", + "tendency": "", + "character": [ + "术后", + "化疗后" + ], + "anatomy_list": [ + "乳腺" + ] + } + ] + }, + { + "id": 31, + "text": "入院2天余,患者于当地医院就诊(具体诊断不详),患者自诉予以“青霉素”治疗后声嘶未见明显好转,后出现阵发性多汗,量多,昼夜无明显变化。", + "event": [ + { + "core_name": "声嘶", + "tendency": "否定", + "character": [ + "明显好转" + ], + "anatomy_list": [] + }, + { + "core_name": "出汗", + "tendency": "", + "character": [ + "阵发性", + "多", + "量多", + "昼夜无明显变化" + ], + "anatomy_list": [] + } + ] + }, + { + "id": 1575, + "text": "今日拟行下一周期化疗来院,遂以“直肠癌术后化疗后”收入住院治疗。", + "event": [ + { + "core_name": "癌", + "tendency": "", + "character": [ + "术后化疗后" + ], + "anatomy_list": [ + "直肠" + ] + } + ] + }, + { + "id": 1140, + "text": "患者绝经17年,既往月经规律,量中,无痛经。", + "event": [ + { + "core_name": "绝经", + "tendency": "", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "月经", + "tendency": "", + "character": [ + "规律", + "量中" + ], + "anatomy_list": [] + }, + { + "core_name": "痛经", + "tendency": "否定", + "character": [], + "anatomy_list": [] + } + ] + }, + { + "id": 1359, + "text": "入院前1+月,患者无明显诱因出现左侧胸痛,为持续性胀痛,以咳嗽及深吸气时明显,伴咳嗽,为刺激性干咳,无咳痰,无胸闷、咯血、呼吸困难,无潮热、盗汗、疲乏、消瘦,无畏寒、发热等不适。", + "event": [ + { + "core_name": "疼痛", + "tendency": "", + "character": [ + "持续性", + "胀痛", + "咳嗽及深吸气时明显" + ], + "anatomy_list": [ + "左侧胸" + ] + }, + { + "core_name": "咳嗽", + "tendency": "", + "character": [ + "刺激性干咳" + ], + "anatomy_list": [] + }, + { + "core_name": "咳痰", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "胸闷", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "胸" + ] + }, + { + "core_name": "咯血", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "呼吸困难", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "潮热", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "盗汗", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "疲乏", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "消瘦", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "畏寒", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "发热", + "tendency": "否定", + "character": [], + "anatomy_list": [] + } + ] + }, + { + "id": 1292, + "text": "患病以来,精神、睡眠欠佳,食欲尚可,大小便正常,否认近期体重明显减轻。", + "event": [ + { + "core_name": "精神", + "tendency": "", + "character": [ + "欠佳" + ], + "anatomy_list": [] + }, + { + "core_name": "睡眠", + "tendency": "", + "character": [ + "欠佳" + ], + "anatomy_list": [] + }, + { + "core_name": "食欲", + "tendency": "", + "character": [ + "尚可" + ], + "anatomy_list": [] + }, + { + "core_name": "大便", + "tendency": "", + "character": [ + "正常" + ], + "anatomy_list": [] + }, + { + "core_name": "小便", + "tendency": "", + "character": [ + "正常" + ], + "anatomy_list": [] + }, + { + "core_name": "体重减轻", + "tendency": "否定", + "character": [ + "明显" + ], + "anatomy_list": [] + } + ] + }, + { + "id": 227, + "text": "患者于1月前无明显原因出现活动后气促,休息后可稍缓解,无发热,无咳嗽、咳痰,无胸痛、咯血、呼吸困难,无心悸、咯粉红色泡沫痰、夜间阵发性呼吸困难,无腹痛腹泻。", + "event": [ + { + "core_name": "气促", + "tendency": "", + "character": [ + "活动后", + "休息后稍缓解" + ], + "anatomy_list": [] + }, + { + "core_name": "发热", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "咳嗽", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "咳痰", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "疼痛", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "胸" + ] + }, + { + "core_name": "咯血", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "呼吸困难", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "心悸", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "心" + ] + }, + { + "core_name": "咳痰", + "tendency": "否定", + "character": [ + "粉红色", + "泡沫" + ], + "anatomy_list": [] + }, + { + "core_name": "呼吸困难", + "tendency": "否定", + "character": [ + "夜间", + "阵发性" + ], + "anatomy_list": [] + }, + { + "core_name": "疼痛", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "腹" + ] + }, + { + "core_name": "腹泻", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "腹" + ] + } + ] + }, + { + "id": 1412, + "text": "患者因“左卵巢鳞状细胞癌”于2016.10.01行了经腹双侧附件切除术+盆腹腔淋巴结清扫术+大网膜切除术+阑尾切除术,术程顺利,术后予以抗炎、对症治疗,病检结果回示:直肠表面结节:低分化鳞状细胞癌;右卵巢有低分化鳞状细胞癌;回盲部肿瘤肿瘤结节:低分化鳞状细胞癌;大网���扪及两个癌结节。", + "event": [ + { + "core_name": "鳞癌", + "tendency": "", + "character": [], + "anatomy_list": [ + "左卵巢" + ] + }, + { + "core_name": "结节", + "tendency": "", + "character": [], + "anatomy_list": [ + "直肠表面" + ] + }, + { + "core_name": "鳞癌", + "tendency": "", + "character": [ + "低分化" + ], + "anatomy_list": [ + "直肠" + ] + }, + { + "core_name": "鳞癌", + "tendency": "", + "character": [ + "低分化" + ], + "anatomy_list": [ + "右卵巢" + ] + }, + { + "core_name": "结节", + "tendency": "", + "character": [ + "肿瘤" + ], + "anatomy_list": [ + "回盲部" + ] + }, + { + "core_name": "鳞癌", + "tendency": "", + "character": [ + "低分化" + ], + "anatomy_list": [ + "回盲部", + "鳞状细胞" + ] + }, + { + "core_name": "结节", + "tendency": "", + "character": [ + "两个", + "癌" + ], + "anatomy_list": [ + "大网膜" + ] + } + ] + }, + { + "id": 1677, + "text": "此后患者病情反复,尤其秋冬季节交替时症状加重,并逐渐出现活动后喘累,无夜间端坐呼吸及咯粉红色泡沫痰。", + "event": [ + { + "core_name": "喘累", + "tendency": "", + "character": [ + "活动后" + ], + "anatomy_list": [] + }, + { + "core_name": "端坐呼吸", + "tendency": "否定", + "character": [ + "夜间" + ], + "anatomy_list": [] + }, + { + "core_name": "咳痰", + "tendency": "否定", + "character": [ + "粉红色", + "泡沫" + ], + "anatomy_list": [] + } + ] + }, + { + "id": 1899, + "text": "2.右侧第四肋骨后支骨骨质破坏,伴周围软组织软组织块块影,建议进一步结合穿刺活检检查。", + "event": [ + { + "core_name": "骨质破坏", + "tendency": "", + "character": [], + "anatomy_list": [ + "右侧第四肋骨后支骨" + ] + }, + { + "core_name": "块影", + "tendency": "", + "character": [], + "anatomy_list": [ + "周围软组织" + ] + } + ] + }, + { + "id": 1337, + "text": "患者9月余前因“身黄、尿黄16日”入院,于我院诊断为:肝门部胆管癌。", + "event": [ + { + "core_name": "黄染", + "tendency": "", + "character": [], + "anatomy_list": [ + "身" + ] + }, + { + "core_name": "尿黄", + "tendency": "", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "癌", + "tendency": "", + "character": [], + "anatomy_list": [ + "肝门", + "胆管" + ] + } + ] + }, + { + "id": 821, + "text": "化疗前予以昂丹司琼止吐,补液等对症治疗,顺利完成前两次化疗,化疗过程中无恶心、呕吐、畏寒、发热、腹泻、黑便等不适。", + "event": [ + { + "core_name": "恶心", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "呕吐", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "畏寒", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "发热", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "腹泻", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "腹" + ] + }, + { + "core_name": "黑便", + "tendency": "否定", + "character": [], + "anatomy_list": [] + } + ] + }, + { + "id": 1361, + "text": "于2016-09-18在某医院完善经彩超引导下左肺实性肿物穿刺活检术,术后病检:(左肺)非小细胞癌,建议做免疫组化进一步分型。", + "event": [ + { + "core_name": "肿物", + "tendency": "", + "character": [ + "实性" + ], + "anatomy_list": [ + "左肺" + ] + }, + { + "core_name": "癌", + "tendency": "", + "character": [], + "anatomy_list": [ + "左肺", + "非小细胞" + ] + } + ] + }, + { + "id": 26, + "text": "患者本次发病以来,食欲正常, 神志清醒,精神尚可,睡眠尚��,大便正常,小便正常,体重无明显变化。", + "event": [ + { + "core_name": "食欲", + "tendency": "", + "character": [ + "正常" + ], + "anatomy_list": [] + }, + { + "core_name": "神志", + "tendency": "", + "character": [ + "清醒" + ], + "anatomy_list": [] + }, + { + "core_name": "精神", + "tendency": "", + "character": [ + "尚可" + ], + "anatomy_list": [] + }, + { + "core_name": "睡眠", + "tendency": "", + "character": [ + "尚可" + ], + "anatomy_list": [] + }, + { + "core_name": "大便", + "tendency": "", + "character": [ + "正常" + ], + "anatomy_list": [] + }, + { + "core_name": "小便", + "tendency": "", + "character": [ + "正常" + ], + "anatomy_list": [] + }, + { + "core_name": "体重变化", + "tendency": "否定", + "character": [ + "明显" + ], + "anatomy_list": [] + } + ] + }, + { + "id": 113, + "text": "7天前,患者无诱因出现腰部疼痛,为持续性胀痛,久卧后加重,坐立可稍缓解,翻身起床时疼痛加重,安静休息部分缓解;无头痛、头晕,无心慌、胸闷,间断性咳嗽,无咯血,无腹痛、腹胀及便血,无双下肢疼痛麻木;到我院就诊,门诊行腰椎mri检查提示:胸腰椎多椎体异常信号改变,考虑骨转移转移性肿瘤,故收治入院。", + "event": [ + { + "core_name": "疼痛", + "tendency": "", + "character": [ + "持续性胀痛", + "久卧后加重", + "坐立可稍缓解", + "翻身起床时疼痛加重", + "安静休息部分缓解" + ], + "anatomy_list": [ + "腰部" + ] + }, + { + "core_name": "疼痛", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "头" + ] + }, + { + "core_name": "头晕", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "头" + ] + }, + { + "core_name": "心慌", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "心" + ] + }, + { + "core_name": "胸闷", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "咳嗽", + "tendency": "否定", + "character": [ + "间断性" + ], + "anatomy_list": [] + }, + { + "core_name": "咯血", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "疼痛", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "腹" + ] + }, + { + "core_name": "腹胀", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "腹" + ] + }, + { + "core_name": "便血", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "疼痛", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "双下肢" + ] + }, + { + "core_name": "麻木", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "双下肢" + ] + }, + { + "core_name": "信号改变", + "tendency": "", + "character": [ + "异常" + ], + "anatomy_list": [ + "胸椎椎体", + "腰椎椎体" + ] + }, + { + "core_name": "肿瘤", + "tendency": "不确定", + "character": [ + "转移性" + ], + "anatomy_list": [ + "骨组织" + ] + } + ] + }, + { + "id": 1858, + "text": "术后予以补液、止血、抗感染、对症支持、伤口换药等处理,病情恢复顺利,无特殊不适,切口愈合良好,好转出院。", + "event": [ + { + "core_name": "切口", + "tendency": "", + "character": [ + "愈合良好" + ], + "anatomy_list": [] + } + ] + }, + { + "id": 1010, + "text": "患者于2020-08-12乘坐公交车突发左下腹部下腹部疼痛疼痛不适,呈持续性胀痛,后逐渐出现头晕、心慌、乏力等不适,面色逐渐苍白,伴晕厥4次,晕厥时无意识,旁人可唤醒,无头痛,无恶心、呕吐等不适,无明显肛门坠胀,无阴道阴道流血、流液,急诊我院行全腹部ct平扫显示:1、肝实质内散在低密度影,建议增强扫描进一步明确。", + "event": [ + { + "core_name": "疼痛", + "tendency": "", + "character": [ + "突发" + ], + "anatomy_list": [ + "左下腹部" + ] + }, + { + "core_name": "疼痛", + "tendency": "", + "character": [ + "持续性", + "胀痛" + ], + "anatomy_list": [ + "左下腹部" + ] + }, + { + "core_name": "头晕", + "tendency": "", + "character": [], + "anatomy_list": [ + "头" + ] + }, + { + "core_name": "心慌", + "tendency": "", + "character": [], + "anatomy_list": [ + "心" + ] + }, + { + "core_name": "疲劳", + "tendency": "", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "苍白", + "tendency": "", + "character": [ + "面色" + ], + "anatomy_list": [] + }, + { + "core_name": "晕厥", + "tendency": "", + "character": [ + "无意识", + "旁人可唤醒", + "4次" + ], + "anatomy_list": [] + }, + { + "core_name": "疼痛", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "头" + ] + }, + { + "core_name": "恶心", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "呕吐", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "坠胀", + "tendency": "否定", + "character": [ + "明显" + ], + "anatomy_list": [ + "肛门" + ] + }, + { + "core_name": "出血", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "阴道" + ] + }, + { + "core_name": "流液", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "阴道" + ] + }, + { + "core_name": "密度影", + "tendency": "", + "character": [ + "散在", + "低" + ], + "anatomy_list": [ + "肝实质内" + ] + } + ] + }, + { + "id": 976, + "text": "5年前,患者无明显诱因再次出现咳嗽、咳痰,干咳为主,无咯血、胸痛,无胸闷、气促等不适,患者至当地疾控中心就诊,完善检查后考虑结核复发,再次予以抗结核治疗(具体药物及疗程不详)。", + "event": [ + { + "core_name": "咳嗽", + "tendency": "", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "咳痰", + "tendency": "", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "咳嗽", + "tendency": "", + "character": [ + "干" + ], + "anatomy_list": [] + }, + { + "core_name": "咯血", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "疼痛", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "胸" + ] + }, + { + "core_name": "胸闷", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "胸" + ] + }, + { + "core_name": "气促", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "结核", + "tendency": "不确定", + "character": [ + "复发" + ], + "anatomy_list": [] + } + ] + }, + { + "id": 776, + "text": "2017-4-7患者因“咯血1月余”到我院门诊就诊,行胸部ct:右肺上叶占位,考虑周围型肺癌,纵膈及右肺门淋巴结肿大。", + "event": [ + { + "core_name": "咯血", + "tendency": "", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "占位", + "tendency": "", + "character": [], + "anatomy_list": [ + "右肺上叶" + ] + }, + { + "core_name": "癌", + "tendency": "不确定", + "character": [ + "周围型" + ], + "anatomy_list": [ + "肺" + ] + }, + { + "core_name": "肿大", + "tendency": "", + "character": [], + "anatomy_list": [ + "纵膈淋巴结", + "右肺门淋巴结" + ] + } + ] + }, + { + "id": 834, + "text": "入院前1月患者无明显诱因再次出现感呼吸困难,咳嗽,痰中带血,于2019年12月6日某医院住院,行ct提示甲状软骨水平-气管分叉水平气管壁不均匀增厚 ,局部呈结节样凸向腔内,部分向腔外突出,管腔不同程度变窄,最窄处位于甲状腺水平,双肺散在散在结节较前增多增大。", + "event": [ + { + "core_name": "呼吸困难", + "tendency": "", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "咳嗽", + "tendency": "", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "咳痰", + "tendency": "", + "character": [ + "带血" + ], + "anatomy_list": [] + }, + { + "core_name": "增厚", + "tendency": "", + "character": [ + "不均匀" + ], + "anatomy_list": [ + "甲状软骨水平气管壁" + ] + }, + { + "core_name": "增厚", + "tendency": "", + "character": [ + "不均匀" + ], + "anatomy_list": [ + "气管分叉水平气管壁" + ] + }, + { + "core_name": "突出", + "tendency": "", + "character": [ + "结节样", + "局部", + "凸向腔内", + "部分向腔外突出" + ], + "anatomy_list": [ + "气管" + ] + }, + { + "core_name": "变窄", + "tendency": "", + "character": [ + "不同程度", + "最窄处位于甲状腺水平" + ], + "anatomy_list": [ + "管腔" + ] + }, + { + "core_name": "结节", + "tendency": "", + "character": [ + "增大", + "增多", + "散在" + ], + "anatomy_list": [ + "双肺" + ] + } + ] + }, + { + "id": 584, + "text": "入院前3小时,驾驶摩托车被其他车辆撞伤,当时受伤时机制不详,伤后即感左小腿膝部疼痛,呈持续性疼痛,伴创面渗血;左足足背拇指开放性伤口,伤口出血,具体出血量不详,伤后无昏迷,可回忆受伤经过,不伴头晕、头痛、心慌、气促、胸闷、胸痛、腹痛、大小便失禁、恶心、呕吐、腹痛、腹胀等,急送入我院就诊,急诊行x线片示:放射检查: 1.左尺桡骨中下段未见异常。", + "event": [ + { + "core_name": "撞伤", + "tendency": "", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "受伤", + "tendency": "", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "疼痛", + "tendency": "", + "character": [ + "持续性" + ], + "anatomy_list": [ + "左小腿", + "膝部" + ] + }, + { + "core_name": "渗血", + "tendency": "", + "character": [], + "anatomy_list": [ + "创面" + ] + }, + { + "core_name": "伤口", + "tendency": "", + "character": [ + "开放性", + "出血", + "具体出血量不详" + ], + "anatomy_list": [ + "左足背", + "拇指" + ] + }, + { + "core_name": "昏迷", + "tendency": "否定", + "character": [ + "伤后" + ], + "anatomy_list": [] + }, + { + "core_name": "受伤", + "tendency": "", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "头晕", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "头" + ] + }, + { + "core_name": "疼痛", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "头" + ] + }, + { + "core_name": "心慌", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "心" + ] + }, + { + "core_name": "气促", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "胸闷", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "胸" + ] + }, + { + "core_name": "疼痛", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "胸" + ] + }, + { + "core_name": "疼痛", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "腹" + ] + }, + { + "core_name": "大小便", + "tendency": "否定", + "character": [ + "失禁" + ], + "anatomy_list": [] + }, + { + "core_name": "恶心", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "呕吐", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "疼痛", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "腹" + ] + }, + { + "core_name": "腹胀", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "腹" + ] + }, + { + "core_name": "异常", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "尺桡骨中段下段" + ] + } + ] + }, + { + "id": 409, + "text": "双肺门肺门及纵隔淋巴结显示,fdg代谢增高,倾向反应性增生。", + "event": [ + { + "core_name": "fdg", + "tendency": "", + "character": [ + "代谢增高" + ], + "anatomy_list": [] + }, + { + "core_name": "增生", + "tendency": "不确定", + "character": [ + "反应性" + ], + "anatomy_list": [ + "双肺门淋巴结", + "纵隔淋巴结" + ] + } + ] + }, + { + "id": 461, + "text": "3.原l4-l5椎体右侧放射性浓聚灶较前无明显变化,考虑良性病变。", + "event": [ + { + "core_name": "浓聚灶", + "tendency": "", + "character": [ + "放射性", + "较前无明显变化" + ], + "anatomy_list": [ + "L4-L5椎体右侧" + ] + }, + { + "core_name": "病变", + "tendency": "不确定", + "character": [ + "良性" + ], + "anatomy_list": [ + "L4-L5椎体右侧" + ] + } + ] + }, + { + "id": 1689, + "text": "患者自患病以来,精神、饮食、睡眠可,大小便未见明显异常,体重无明显增减。", + "event": [ + { + "core_name": "精神", + "tendency": "", + "character": [ + "可" + ], + "anatomy_list": [] + }, + { + "core_name": "进食", + "tendency": "", + "character": [ + "可" + ], + "anatomy_list": [] + }, + { + "core_name": "睡眠", + "tendency": "", + "character": [ + "可" + ], + "anatomy_list": [] + }, + { + "core_name": "大小便异常", + "tendency": "否定", + "character": [ + "明显" + ], + "anatomy_list": [] + }, + { + "core_name": "体重改变", + "tendency": "否定", + "character": [ + "明显" + ], + "anatomy_list": [] + } + ] + }, + { + "id": 39, + "text": "1月前上述症状复发,咳嗽,咳白色泡沫痰,每天痰量约40ml,伴活动后气促、心悸,伴胸痛不适,持续几分钟能自行缓解,无心前区压榨感,无畏寒及寒战,无发热,无咽喉疼痛,无头昏及头痛,无恶心及呕吐,无腹胀及腹痛。", + "event": [ + { + "core_name": "咳嗽", + "tendency": "", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "咳痰", + "tendency": "", + "character": [ + "白色", + "泡沫痰" + ], + "anatomy_list": [] + }, + { + "core_name": "气促", + "tendency": "", + "character": [ + "活动后" + ], + "anatomy_list": [] + }, + { + "core_name": "心悸", + "tendency": "", + "character": [ + "活动后" + ], + "anatomy_list": [ + "心" + ] + }, + { + "core_name": "疼痛", + "tendency": "", + "character": [ + "持续几分钟能自行缓解" + ], + "anatomy_list": [ + "胸部" + ] + }, + { + "core_name": "压榨感", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "心前区" + ] + }, + { + "core_name": "畏寒", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "寒颤", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "发热", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "疼痛", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "咽", + "喉" + ] + }, + { + "core_name": "疼痛", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "头" + ] + }, + { + "core_name": "头昏", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "头" + ] + }, + { + "core_name": "恶心", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "呕吐", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "腹胀", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "腹" + ] + }, + { + "core_name": "疼痛", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "腹" + ] + } + ] + }, + { + "id": 1266, + "text": "入院前1+月,患者无明显诱因再次出现咳嗽、咳痰,为白色泡沫痰,量多,不易咳出,且偶感头晕,感进食梗阻、胸部胀痛,伴背部牵涉痛,食欲明显降低,无发热、畏寒,无头痛,无恶心、呕吐,无胸痛、心前区压榨感,无腹胀、腹痛、腹泻等不适,遂于我院胃肠外科门诊就诊,行上消化道钡餐检查(2018-3-19,我院)示:1.食管中下段外压性改变,考虑左肺门肿块所致,请结合ct检查。", + "event": [ + { + "core_name": "咳嗽", + "tendency": "", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "咳痰", + "tendency": "", + "character": [ + "白色", + "泡沫痰", + "量多", + "不易咳出" + ], + "anatomy_list": [] + }, + { + "core_name": "头晕", + "tendency": "", + "character": [ + "偶感" + ], + "anatomy_list": [ + "头" + ] + }, + { + "core_name": "进食", + "tendency": "", + "character": [ + "梗阻" + ], + "anatomy_list": [] + }, + { + "core_name": "疼痛", + "tendency": "", + "character": [ + "胀痛" + ], + "anatomy_list": [ + "胸部" + ] + }, + { + "core_name": "疼痛", + "tendency": "", + "character": [ + "牵涉痛" + ], + "anatomy_list": [ + "背部" + ] + }, + { + "core_name": "食欲", + "tendency": "", + "character": [ + "明显降低" + ], + "anatomy_list": [] + }, + { + "core_name": "发热", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "畏寒", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "疼痛", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "头" + ] + }, + { + "core_name": "恶心", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "呕吐", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "疼痛", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "胸" + ] + }, + { + "core_name": "压榨感", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "心前区" + ] + }, + { + "core_name": "腹胀", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "腹" + ] + }, + { + "core_name": "疼痛", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "腹" + ] + }, + { + "core_name": "腹泻", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "腹" + ] + }, + { + "core_name": "改变", + "tendency": "", + "character": [ + "外压性" + ], + "anatomy_list": [ + "食管中下段" + ] + }, + { + "core_name": "肿块", + "tendency": "不确定", + "character": [], + "anatomy_list": [ + "左肺门" + ] + } + ] + }, + { + "id": 445, + "text": "为进一步诊治,拟“慢性阻塞性肺疾病急性发作伴肺部感染”收入院", + "event": [ + { + "core_name": "肺疾病", + "tendency": "", + "character": [ + "慢性", + "阻塞性", + "急性发作" + ], + "anatomy_list": [ + "肺部" + ] + }, + { + "core_name": "感染", + "tendency": "", + "character": [], + "anatomy_list": [ + "肺部" + ] + } + ] + }, + { + "id": 1887, + "text": "入院前1+月,患者因右眼红痛3月到我院就诊,诊断为右眼角膜溃疡穿孔,双眼白内障术后,冠心病,并在我科住院治疗,住院后完善相关检查并给予抗炎治疗后,右眼角膜溃疡无明显好转,给予行右眼结膜瓣遮盖术,术后患者眼痛症状明显缓解,后患者因右侧腹股沟疝转入我院普���科治疗,患者出院后自觉右眼渐出现疼痛,并逐渐加重,患者及其家属为求进一步诊治,再次来我院就诊,经检查诊断为右眼角膜溃疡术后,建议住院治疗,遂于今日收住院。", + "event": [ + { + "core_name": "右眼红", + "tendency": "", + "character": [], + "anatomy_list": [ + "右眼" + ] + }, + { + "core_name": "疼痛", + "tendency": "", + "character": [], + "anatomy_list": [ + "右眼" + ] + }, + { + "core_name": "穿孔", + "tendency": "", + "character": [ + "溃疡" + ], + "anatomy_list": [ + "右眼角膜" + ] + }, + { + "core_name": "白内障", + "tendency": "", + "character": [ + "术后" + ], + "anatomy_list": [ + "双眼" + ] + }, + { + "core_name": "冠心病", + "tendency": "", + "character": [], + "anatomy_list": [ + "心" + ] + }, + { + "core_name": "溃疡", + "tendency": "否定", + "character": [ + "明显好转" + ], + "anatomy_list": [ + "右眼角膜" + ] + }, + { + "core_name": "疼痛", + "tendency": "", + "character": [ + "明显缓解" + ], + "anatomy_list": [ + "眼" + ] + }, + { + "core_name": "疝", + "tendency": "", + "character": [], + "anatomy_list": [ + "右侧腹股沟" + ] + }, + { + "core_name": "疼痛", + "tendency": "", + "character": [ + "逐渐加重" + ], + "anatomy_list": [ + "右眼" + ] + }, + { + "core_name": "溃疡", + "tendency": "", + "character": [ + "术后" + ], + "anatomy_list": [ + "右眼角膜" + ] + } + ] + }, + { + "id": 1063, + "text": "发现血糖升高5年,既往诊断“2型糖尿病”明确,现予“格列齐特”控制血糖尚可,具体数值不详。", + "event": [ + { + "core_name": "血糖", + "tendency": "", + "character": [ + "升高" + ], + "anatomy_list": [] + }, + { + "core_name": "糖尿病", + "tendency": "", + "character": [ + "2型" + ], + "anatomy_list": [] + }, + { + "core_name": "血糖", + "tendency": "", + "character": [ + "控制尚可" + ], + "anatomy_list": [] + } + ] + }, + { + "id": 1401, + "text": "病程中患者月经无改变,无痛经,无头晕、心慌,无尿频、尿急、肛门坠胀等不适。", + "event": [ + { + "core_name": "月经", + "tendency": "否定", + "character": [ + "改变" + ], + "anatomy_list": [] + }, + { + "core_name": "痛经", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "头晕", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "头" + ] + }, + { + "core_name": "心慌", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "心" + ] + }, + { + "core_name": "尿频", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "尿急", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "坠胀", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "肛门" + ] + } + ] + }, + { + "id": 160, + "text": "患“高脂血症”1+年,未规范性用药。", + "event": [ + { + "core_name": "高脂血症", + "tendency": "", + "character": [], + "anatomy_list": [] + } + ] + }, + { + "id": 354, + "text": "腋窝淋巴结转移1/12。", + "event": [ + { + "core_name": "转移", + "tendency": "", + "character": [], + "anatomy_list": [ + "腋窝淋巴结" + ] + } + ] + }, + { + "id": 246, + "text": "患者于入院前1月余无明显诱因出现厌油伴食欲下降、恶心,无返酸、嗳气、呕吐、呕血,无腹痛、腹胀、腹泻、黑便,无发热、寒战,无头晕、头痛,患者未予重视,未行任何处理。", + "event": [ + { + "core_name": "厌油", + "tendency": "", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "食欲", + "tendency": "", + "character": [ + "下降" + ], + "anatomy_list": [] + }, + { + "core_name": "恶心", + "tendency": "", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "返酸", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "嗳气", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "呕吐", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "呕血", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "疼痛", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "腹" + ] + }, + { + "core_name": "腹胀", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "腹" + ] + }, + { + "core_name": "腹泻", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "腹" + ] + }, + { + "core_name": "黑便", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "发热", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "寒颤", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "头晕", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "头" + ] + }, + { + "core_name": "疼痛", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "头" + ] + } + ] + }, + { + "id": 649, + "text": "患者自起病以来,精神较萎,胃纳较差,大便如常,小便如常,体重未见明显下降。", + "event": [ + { + "core_name": "精神", + "tendency": "", + "character": [ + "较萎" + ], + "anatomy_list": [] + }, + { + "core_name": "胃纳", + "tendency": "", + "character": [ + "较差" + ], + "anatomy_list": [ + "胃" + ] + }, + { + "core_name": "大便", + "tendency": "", + "character": [ + "如常" + ], + "anatomy_list": [] + }, + { + "core_name": "小便", + "tendency": "", + "character": [ + "如常" + ], + "anatomy_list": [] + }, + { + "core_name": "体重下降", + "tendency": "否定", + "character": [ + "明显" + ], + "anatomy_list": [] + } + ] + }, + { + "id": 1341, + "text": "<癌栓袋>见癌组织。", + "event": [ + { + "core_name": "癌组织", + "tendency": "", + "character": [], + "anatomy_list": [ + "癌栓袋" + ] + } + ] + }, + { + "id": 1302, + "text": "放疗后患者诉偶有咳嗽不适,以夜间平卧时明显,考虑放射性食管炎,给予口服“雷贝拉唑”抑酸护胃治疗后好转出院。", + "event": [ + { + "core_name": "咳嗽", + "tendency": "", + "character": [ + "夜间平卧时明显", + "放疗后", + "偶有" + ], + "anatomy_list": [] + }, + { + "core_name": "食管炎", + "tendency": "不确定", + "character": [ + "放射性" + ], + "anatomy_list": [ + "食管" + ] + } + ] + }, + { + "id": 1050, + "text": "今日门诊以“乳癌术后化疗”收入我科。", + "event": [ + { + "core_name": "癌", + "tendency": "", + "character": [ + "术后化疗" + ], + "anatomy_list": [ + "乳" + ] + } + ] + }, + { + "id": 301, + "text": "其后于我科行卡铂0.45g1+足叶乙甙0.15g1-3方案化疗6周期,化疗过程中患者无明显恶心、呕吐等胃肠道反应,咳嗽等症状明显好转,患者定期在我院复查,均无明显进展。", + "event": [ + { + "core_name": "恶心", + "tendency": "否定", + "character": [ + "明显" + ], + "anatomy_list": [] + }, + { + "core_name": "呕吐", + "tendency": "否定", + "character": [ + "明显" + ], + "anatomy_list": [] + }, + { + "core_name": "胃肠道反应", + "tendency": "否定", + "character": [ + "明显" + ], + "anatomy_list": [ + "胃肠道" + ] + }, + { + "core_name": "咳嗽", + "tendency": "", + "character": [ + "明显好转" + ], + "anatomy_list": [] + } + ] + }, + { + "id": 402, + "text": "术后患者行3疗程辅助化疗,方案为ec-t(表柔比星+环磷酰胺序贯多西他赛),化疗过程顺利,未出现药物骨髓毒性反应,现患者为第四次化疗入院。", + "event": [ + { + "core_name": "毒性反应", + "tendency": "否定", + "character": [ + "药物" + ], + "anatomy_list": [ + "骨髓" + ] + } + ] + }, + { + "id": 846, + "text": "患者6+月前因“阵发性腹痛,伴肛门停止排气、排便2天”入院。", + "event": [ + { + "core_name": "疼痛", + "tendency": "", + "character": [ + "阵发性" + ], + "anatomy_list": [ + "腹" + ] + }, + { + "core_name": "排气", + "tendency": "", + "character": [ + "停止" + ], + "anatomy_list": [ + "肛门" + ] + }, + { + "core_name": "排便", + "tendency": "", + "character": [ + "停止2天" + ], + "anatomy_list": [ + "肛门" + ] + } + ] + }, + { + "id": 2016, + "text": "患者本次发病以来,食欲减退,神志清醒,精神欠佳,睡眠欠佳,大便5日未解,小便正常,体重减少约1kg。", + "event": [ + { + "core_name": "食欲", + "tendency": "", + "character": [ + "减退" + ], + "anatomy_list": [] + }, + { + "core_name": "神志", + "tendency": "", + "character": [ + "清醒" + ], + "anatomy_list": [] + }, + { + "core_name": "精神", + "tendency": "", + "character": [ + "欠佳" + ], + "anatomy_list": [] + }, + { + "core_name": "睡眠", + "tendency": "", + "character": [ + "欠佳" + ], + "anatomy_list": [] + }, + { + "core_name": "大便", + "tendency": "", + "character": [ + "5日未解" + ], + "anatomy_list": [] + }, + { + "core_name": "小便", + "tendency": "", + "character": [ + "正常" + ], + "anatomy_list": [] + }, + { + "core_name": "体重减轻", + "tendency": "", + "character": [], + "anatomy_list": [] + } + ] + }, + { + "id": 1348, + "text": "1月余前患者无明显诱因出现乏力、纳差,无明显腹痛、腹胀,无反酸、嗳气,无心悸、气促,入我院后予以保肝治疗后好转,并于2019年11月26日、2019年12月18日输注信迪利单抗200mg,输注过程顺利,未诉特殊不适。", + "event": [ + { + "core_name": "乏力", + "tendency": "", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "纳差", + "tendency": "", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "疼痛", + "tendency": "否定", + "character": [ + "明显" + ], + "anatomy_list": [ + "腹" + ] + }, + { + "core_name": "腹胀", + "tendency": "否定", + "character": [ + "明显" + ], + "anatomy_list": [ + "腹" + ] + }, + { + "core_name": "反酸", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "嗳气", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "心悸", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "心" + ] + }, + { + "core_name": "气促", + "tendency": "否定", + "character": [], + "anatomy_list": [] + } + ] + }, + { + "id": 86, + "text": "入院前10+月,患者无明显诱因出现活动后心累气促,伴全身乏力,自觉日常活动轻微受限,无头昏、眼花及耳鸣,无畏寒、发热,无咳嗽、咳痰、咯血,无胸闷、心悸及心前区压榨感,无腹痛、呕血及黑便,无皮肤瘀点瘀点及瘀斑,无牙龈出血,无黄染,无肝掌及蜘蛛痣,患者于我院心血管内科住院治疗,查血常规:白细胞数2.46*10^9/L↓红细胞数2.73*10^12/L↓;血红蛋白60g/L↓;血小板数75*10^9/L↓,患者拒绝行骨髓穿刺及输血治疗,给予对症治疗后出院,之后患者上述症状加重,活动后心累气促,日常活动受影响,无咳嗽咳痰,无畏寒发热,无牙龈出血,全身未见瘀斑瘀点,无头晕头痛,无阵发性呼吸困难,查血常规提示:血红蛋白46g/L↓,我院输血等对症治疗后好转出院,患者于某医院就诊,行骨髓穿刺结果考虑mds-raeb2,骨髓活检考虑mds,未治疗;6+月前���患者再次出现活动后心累气促及乏力症状加重,表现为快走时心累气促,休息后缓解,日常活动轻度受限,予以抗感染、输血治疗,并于2018年11月29号给予输注地西他滨25mg1-5全身化疗,化疗后出现iii度骨髓抑制,予以升白、升血小板治疗后纠正。", + "event": [ + { + "core_name": "心累", + "tendency": "", + "character": [ + "活动后" + ], + "anatomy_list": [ + "心" + ] + }, + { + "core_name": "气促", + "tendency": "", + "character": [ + "活动后" + ], + "anatomy_list": [] + }, + { + "core_name": "乏力", + "tendency": "", + "character": [], + "anatomy_list": [ + "全身" + ] + }, + { + "core_name": "活动受限", + "tendency": "", + "character": [ + "轻微", + "日常" + ], + "anatomy_list": [] + }, + { + "core_name": "头昏", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "头" + ] + }, + { + "core_name": "眼花", + "tendency": "否定", + "character": [ + "模糊" + ], + "anatomy_list": [ + "眼" + ] + }, + { + "core_name": "耳鸣", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "耳" + ] + }, + { + "core_name": "畏寒", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "发热", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "咳嗽", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "咳痰", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "咯血", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "胸闷", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "胸" + ] + }, + { + "core_name": "心悸", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "心" + ] + }, + { + "core_name": "压榨感", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "心前区" + ] + }, + { + "core_name": "疼痛", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "腹" + ] + }, + { + "core_name": "呕血", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "黑便", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "瘀点", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "皮肤" + ] + }, + { + "core_name": "瘀斑", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "皮肤" + ] + }, + { + "core_name": "出血", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "牙龈" + ] + }, + { + "core_name": "黄染", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "肝掌", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "掌" + ] + }, + { + "core_name": "蜘蛛痣", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "心累", + "tendency": "", + "character": [ + "活动后" + ], + "anatomy_list": [ + "心" + ] + }, + { + "core_name": "气促", + "tendency": "", + "character": [ + "活动后" + ], + "anatomy_list": [] + }, + { + "core_name": "活动受限", + "tendency": "", + "character": [ + "日常" + ], + "anatomy_list": [] + }, + { + "core_name": "咳嗽", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "咳痰", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "畏寒", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "发热", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "出血", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "牙龈" + ] + }, + { + "core_name": "瘀斑", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "全身" + ] + }, + { + "core_name": "瘀点", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "全身" + ] + }, + { + "core_name": "头晕", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "头" + ] + }, + { + "core_name": "疼痛", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "头" + ] + }, + { + "core_name": "呼吸困难", + "tendency": "否定", + "character": [ + "阵发性" + ], + "anatomy_list": [] + }, + { + "core_name": "mds-raeb2", + "tendency": "不确定", + "character": [], + "anatomy_list": [ + "骨髓" + ] + }, + { + "core_name": "mds", + "tendency": "不确定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "心累", + "tendency": "", + "character": [ + "活动后", + "症状加重" + ], + "anatomy_list": [ + "心" + ] + }, + { + "core_name": "气促", + "tendency": "", + "character": [ + "活动后", + "症状加重" + ], + "anatomy_list": [] + }, + { + "core_name": "乏力", + "tendency": "", + "character": [ + "活动后", + "症状加重" + ], + "anatomy_list": [] + }, + { + "core_name": "心累", + "tendency": "", + "character": [ + "快走时", + "休息后缓解" + ], + "anatomy_list": [ + "心" + ] + }, + { + "core_name": "气促", + "tendency": "", + "character": [ + "快走时", + "休息后缓解" + ], + "anatomy_list": [] + }, + { + "core_name": "活动受限", + "tendency": "", + "character": [ + "日常", + "轻度" + ], + "anatomy_list": [] + }, + { + "core_name": "骨髓抑制", + "tendency": "", + "character": [ + "iii度" + ], + "anatomy_list": [ + "骨髓" + ] + } + ] + }, + { + "id": 1322, + "text": "排除穿刺禁忌后给予胸腔穿刺引流,并在纤维支气管镜下取肺部占位行病理活检示:免疫组化:gcdfp-15(-),gata-3(+),ck(+),ck8(+),her-2(1+),pr小灶(+),er小灶(+)。", + "event": [ + { + "core_name": "病变", + "tendency": "", + "character": [ + "占位" + ], + "anatomy_list": [ + "肺部" + ] + } + ] + }, + { + "id": 384, + "text": "为进一步治疗,今日以\" 肺癌化疗后 \"收入我科。", + "event": [ + { + "core_name": "癌", + "tendency": "", + "character": [ + "化疗后" + ], + "anatomy_list": [ + "肺" + ] + } + ] + }, + { + "id": 115, + "text": "患者因“发现右乳一包快2+月”,于我院门诊行乳腺活检术,术后病理检查结果回报“<右乳>乳腺癌”。", + "event": [ + { + "core_name": "包块", + "tendency": "", + "character": [], + "anatomy_list": [ + "右乳" + ] + }, + { + "core_name": "癌", + "tendency": "", + "character": [], + "anatomy_list": [ + "右乳乳腺" + ] + } + ] + }, + { + "id": 413, + "text": "患者于2012年4月23日我院行左乳房乳癌改良根治术+前哨淋巴结活检术,术后病理提示:前哨淋巴结未见癌转移,已行1次术前辅助化疗,7次术后辅助化疗,化疗方案为吡柔比星+环磷酰胺+多西他赛(ACT)。", + "event": [ + { + "core_name": "癌", + "tendency": "否定", + "character": [ + "转移" + ], + "anatomy_list": [ + "前哨淋巴结" + ] + } + ] + }, + { + "id": 992, + "text": "1年前出现反复腰背痛,尤以t2-4、t7椎体,t8椎体严重,无放射,平卧位稍缓解,疼痛由间断性逐渐发展为持续性。", + "event": [ + { + "core_name": "疼痛", + "tendency": "", + "character": [ + "反复", + "尤以t2-4、t7、t8椎体严重", + "平卧位稍缓解" + ], + "anatomy_list": [ + "腰", + "��" + ] + }, + { + "core_name": "疼痛", + "tendency": "", + "character": [ + "放射性" + ], + "anatomy_list": [] + }, + { + "core_name": "疼痛", + "tendency": "", + "character": [ + "由间断性逐渐发展为持续" + ], + "anatomy_list": [ + "腰", + "背" + ] + } + ] + }, + { + "id": 287, + "text": "2月前患者无明显诱因出现胸痛,为双侧胸部隐痛,呈持续性,程度轻,咳嗽及翻身时加重,休息后缓解,否认与深呼吸、进食、活动有关,偶有咳嗽、咽干、晨起流涕,为白色粘涕,无发热、潮热、盗汗,无咳痰、咯血、咽痛、肌肉酸痛,无胸闷、心悸、喘累,无反酸、烧心、嗳气,无皮肤皮疹、红肿等不适。", + "event": [ + { + "core_name": "疼痛", + "tendency": "", + "character": [], + "anatomy_list": [ + "胸" + ] + }, + { + "core_name": "疼痛", + "tendency": "", + "character": [ + "隐痛", + "呈持续性", + "程度轻", + "咳嗽及翻身时加重", + "休息后缓解", + "否认与深呼吸、进食、活动有关" + ], + "anatomy_list": [ + "双侧胸部" + ] + }, + { + "core_name": "咳嗽", + "tendency": "", + "character": [ + "偶有" + ], + "anatomy_list": [] + }, + { + "core_name": "咽干", + "tendency": "", + "character": [ + "偶有" + ], + "anatomy_list": [] + }, + { + "core_name": "流涕", + "tendency": "", + "character": [ + "晨起", + "白色粘涕" + ], + "anatomy_list": [] + }, + { + "core_name": "发热", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "潮热", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "盗汗", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "咳痰", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "咯血", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "疼痛", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "咽" + ] + }, + { + "core_name": "疼痛", + "tendency": "否定", + "character": [ + "酸痛" + ], + "anatomy_list": [ + "肌肉" + ] + }, + { + "core_name": "胸闷", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "胸" + ] + }, + { + "core_name": "心悸", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "心" + ] + }, + { + "core_name": "喘累", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "反酸", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "烧心", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "嗳气", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "皮疹", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "皮肤" + ] + }, + { + "core_name": "红肿", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "皮肤" + ] + } + ] + }, + { + "id": 230, + "text": "为进一步诊治,遂于我院就诊,门诊拟“胸腔积液原因待查”收入住院。", + "event": [ + { + "core_name": "积液", + "tendency": "不确定", + "character": [], + "anatomy_list": [ + "胸腔" + ] + } + ] + }, + { + "id": 1602, + "text": "入院前半天,患者无明显诱因症状复发加重,伴胸口紧缩感,伴腰部及双下肢游走性疼痛,伴咳嗽咳黑灰色粘液痰(未见到痰液),无恶心呕吐,无头昏头痛,无黑曚晕厥,无胸痛,无腹痛腹胀,无四肢乏力等不适,遂送入我院治疗,门诊以“心力衰竭\"收入我科。", + "event": [ + { + "core_name": "紧缩感", + "tendency": "", + "character": [], + "anatomy_list": [ + "胸口" + ] + }, + { + "core_name": "��痛", + "tendency": "", + "character": [ + "游走性" + ], + "anatomy_list": [ + "腰部", + "双下肢" + ] + }, + { + "core_name": "咳嗽", + "tendency": "", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "咳痰", + "tendency": "", + "character": [ + "粘液", + "黑灰色" + ], + "anatomy_list": [] + }, + { + "core_name": "恶心", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "呕吐", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "头昏", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "头" + ] + }, + { + "core_name": "疼痛", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "头" + ] + }, + { + "core_name": "黒朦", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "晕厥", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "疼痛", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "胸" + ] + }, + { + "core_name": "疼痛", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "腹" + ] + }, + { + "core_name": "腹胀", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "腹" + ] + }, + { + "core_name": "乏力", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "四肢" + ] + }, + { + "core_name": "心力衰竭", + "tendency": "", + "character": [], + "anatomy_list": [ + "心" + ] + } + ] + }, + { + "id": 351, + "text": "6天前患者于我院行妇科彩超发现子宫左前方见大小约156×92mm的异常无回声区,边界清,形态规则,无回声区区内透声好,cdfi:其内部及周边可探及血流信号。", + "event": [ + { + "core_name": "回声区", + "tendency": "", + "character": [ + "异常", + "无", + "边界清", + "形态规则", + "无回声区内透声好" + ], + "anatomy_list": [ + "子宫左前方" + ] + }, + { + "core_name": "血流信号", + "tendency": "", + "character": [], + "anatomy_list": [ + "内部及周边" + ] + } + ] + }, + { + "id": 1934, + "text": "2017-4-12某医院pet-ct示:1、结肠术后改变,未见明确复发征象,吻合口上方、下方右侧腰大肌旁及腹腔第1212、16组多发淋巴结转移。", + "event": [ + { + "core_name": "术后改变", + "tendency": "", + "character": [], + "anatomy_list": [ + "结肠" + ] + }, + { + "core_name": "转移", + "tendency": "", + "character": [ + "多发" + ], + "anatomy_list": [ + "吻合口上方、下方右侧腰大肌旁腹腔1212、16组淋巴结" + ] + } + ] + }, + { + "id": 1267, + "text": "2.胃窦炎征象。", + "event": [ + { + "core_name": "胃窦炎", + "tendency": "", + "character": [], + "anatomy_list": [ + "胃窦" + ] + } + ] + }, + { + "id": 994, + "text": "7月前,患者行相关检查,ct、ect均提示转移性骨肿瘤,并来我院行化疗,上一次化疗时间为2013.5.25,化疗方案为长春瑞滨+洛铂,患者为行相关检查来我院,门诊以“左乳癌术后”收治入院。", + "event": [ + { + "core_name": "肿瘤", + "tendency": "", + "character": [ + "转移性" + ], + "anatomy_list": [ + "骨" + ] + }, + { + "core_name": "癌", + "tendency": "", + "character": [ + "术后" + ], + "anatomy_list": [ + "左乳" + ] + } + ] + }, + { + "id": 954, + "text": "患者现为求进一步诊治,急诊拟“消化道出血”收住入院。", + "event": [ + { + "core_name": "出血", + "tendency": "", + "character": [], + "anatomy_list": [ + "消化道" + ] + } + ] + }, + { + "id": 241, + "text": "1+月前患者症状较前加重,并出现腰背部疼痛伴双下肢大腿后外侧胀痛,平卧位或侧卧位疼痛加重,端坐位或站立位疼痛减轻。", + "event": [ + { + "core_name": "疼痛", + "tendency": "", + "character": [ + "平卧位或侧卧位疼痛加重,端坐位或站立位疼痛减轻" + ], + "anatomy_list": [ + "腰背部" + ] + }, + { + "core_name": "胀痛", + "tendency": "", + "character": [ + "平卧位或侧卧位疼痛加重,端坐位或站立位疼痛减轻" + ], + "anatomy_list": [ + "双下肢大腿后外侧" + ] + } + ] + }, + { + "id": 1578, + "text": "期间每年行常规体检,查宫颈刮片等未见明显异常。", + "event": [ + { + "core_name": "异常", + "tendency": "否定", + "character": [ + "明显" + ], + "anatomy_list": [ + "宫颈" + ] + } + ] + }, + { + "id": 924, + "text": "建议ctu检查,盆腔少量积液。", + "event": [ + { + "core_name": "积液", + "tendency": "", + "character": [ + "少量" + ], + "anatomy_list": [ + "盆腔" + ] + } + ] + }, + { + "id": 1806, + "text": "3天来患者精神食欲及睡眠差,大小便正常,体重无明显减轻。", + "event": [ + { + "core_name": "精神", + "tendency": "", + "character": [ + "差" + ], + "anatomy_list": [] + }, + { + "core_name": "食欲", + "tendency": "", + "character": [ + "差" + ], + "anatomy_list": [] + }, + { + "core_name": "睡眠", + "tendency": "", + "character": [ + "差" + ], + "anatomy_list": [] + }, + { + "core_name": "大小便", + "tendency": "", + "character": [ + "正常" + ], + "anatomy_list": [] + }, + { + "core_name": "体重减轻", + "tendency": "否定", + "character": [ + "明显" + ], + "anatomy_list": [] + } + ] + }, + { + "id": 870, + "text": "入院前8年,患者无明显诱因出现双侧第一跖趾关节关节疼痛,伴发热、发红、关节肿痛,至当地医院就诊,考虑“痛风”,予以“秋水仙碱”口服后关节疼痛疼痛缓解,后未规律服药。", + "event": [ + { + "core_name": "疼痛", + "tendency": "", + "character": [], + "anatomy_list": [ + "双侧第1跖趾关节" + ] + }, + { + "core_name": "发热", + "tendency": "", + "character": [], + "anatomy_list": [ + "双侧第1跖趾关节" + ] + }, + { + "core_name": "发红", + "tendency": "", + "character": [], + "anatomy_list": [ + "双侧第1跖趾关节" + ] + }, + { + "core_name": "肿痛", + "tendency": "", + "character": [], + "anatomy_list": [ + "双侧第1跖趾关节" + ] + }, + { + "core_name": "痛风", + "tendency": "不确定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "疼痛", + "tendency": "", + "character": [ + "缓解" + ], + "anatomy_list": [ + "关节" + ] + } + ] + }, + { + "id": 1825, + "text": "10+天前患者再次出现喘累,活动后气促,伴腹胀,入院后予以胸腔、腹腔穿刺置管引流后稍好转,复查腹部ct见腹腔内肿瘤广泛转移,予以对症治疗后出院。", + "event": [ + { + "core_name": "喘累", + "tendency": "", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "气促", + "tendency": "", + "character": [ + "活动后" + ], + "anatomy_list": [] + }, + { + "core_name": "腹胀", + "tendency": "", + "character": [], + "anatomy_list": [ + "腹" + ] + }, + { + "core_name": "肿瘤", + "tendency": "", + "character": [ + "广泛转移" + ], + "anatomy_list": [ + "腹腔内" + ] + } + ] + }, + { + "id": 630, + "text": "患者平素无同房出血,无异常阴道流血、流液,于8月前于我院行妇科检查宫颈hpv16型阳性,宫颈tct未见上皮内病变及恶性病变,嘱其门诊随访。", + "event": [ + { + "core_name": "出血", + "tendency": "否定", + "character": [ + "同房后" + ], + "anatomy_list": [] + }, + { + "core_name": "出血", + "tendency": "否定", + "character": [ + "异常" + ], + "anatomy_list": [ + "阴道" + ] + }, + { + "core_name": "宫颈hpv16型", + "tendency": "", + "character": [ + "阳性" + ], + "anatomy_list": [] + }, + { + "core_name": "流液", + "tendency": "否定", + "character": [ + "异常" + ], + "anatomy_list": [ + "阴道" + ] + }, + { + "core_name": "病变", + "tendency": "否定", + "character": [ + "上皮内" + ], + "anatomy_list": [ + "宫颈" + ] + }, + { + "core_name": "病变", + "tendency": "否定", + "character": [ + "恶性" + ], + "anatomy_list": [ + "宫颈" + ] + } + ] + }, + { + "id": 1828, + "text": "入院前1+年,患者劳累后出现下腹部刺痛刺痛感,伴尿痛,患者无尿频、尿急,肉眼血尿,无腰部疼痛,无恶心、呕吐,无腹胀、腹泻、便秘等,无头晕、头痛,无胸闷、胸痛、心悸、气促,无寒战、发热等不适,患者未予重视,未予处理。", + "event": [ + { + "core_name": "疼痛", + "tendency": "", + "character": [ + "劳累后", + "刺痛" + ], + "anatomy_list": [ + "下腹部" + ] + }, + { + "core_name": "尿痛", + "tendency": "", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "尿频", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "尿急", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "血尿", + "tendency": "", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "疼痛", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "腰部" + ] + }, + { + "core_name": "恶心", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "呕吐", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "腹胀", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "腹" + ] + }, + { + "core_name": "腹泻", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "腹" + ] + }, + { + "core_name": "便秘", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "头晕", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "头" + ] + }, + { + "core_name": "疼痛", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "头" + ] + }, + { + "core_name": "胸闷", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "胸" + ] + }, + { + "core_name": "疼痛", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "胸" + ] + }, + { + "core_name": "心悸", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "心" + ] + }, + { + "core_name": "气促", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "寒颤", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "发热", + "tendency": "否定", + "character": [], + "anatomy_list": [] + } + ] + }, + { + "id": 1925, + "text": "患者急性腹膜炎经消化疾病中心会诊后建议行手术治疗,患者拒绝并要求保守治疗,经对症保守治疗后病情好转自动出院。", + "event": [ + { + "core_name": "腹膜炎", + "tendency": "", + "character": [ + "急性" + ], + "anatomy_list": [ + "腹膜" + ] + } + ] + }, + { + "id": 1155, + "text": "急诊以“抽搐待查”收入我科住院治疗。", + "event": [ + { + "core_name": "抽搐", + "tendency": "不确定", + "character": [], + "anatomy_list": [] + } + ] + }, + { + "id": 218, + "text": "为求进一步诊治,门诊以“左肺鳞癌”收入我科。", + "event": [ + { + "core_name": "鳞癌", + "tendency": "", + "character": [], + "anatomy_list": [ + "左肺" + ] + } + ] + }, + { + "id": 1759, + "text": "2.肝内钙化灶。", + "event": [ + { + "core_name": "钙化灶", + "tendency": "", + "character": [], + "anatomy_list": [ + "肝内" + ] + } + ] + }, + { + "id": 1386, + "text": "气促���无心慌、心悸等。", + "event": [ + { + "core_name": "气促", + "tendency": "", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "心慌", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "心" + ] + }, + { + "core_name": "心悸", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "心" + ] + } + ] + }, + { + "id": 182, + "text": "双肺散在散在结节,考虑转移瘤可能。", + "event": [ + { + "core_name": "结节", + "tendency": "", + "character": [ + "散在" + ], + "anatomy_list": [ + "双肺" + ] + }, + { + "core_name": "瘤", + "tendency": "不确定", + "character": [ + "转移" + ], + "anatomy_list": [] + } + ] + }, + { + "id": 119, + "text": "于2017-09-02行tac方案化疗治疗,化疗过程中予以抗过敏、护胃、止吐、对症等治疗,今日为行术后第3次化疗,遂来我科就诊,门诊以“右乳癌术后第2次化疗后”收入我科。", + "event": [ + { + "core_name": "癌", + "tendency": "", + "character": [ + "术后", + "第2次化疗后" + ], + "anatomy_list": [ + "右乳" + ] + } + ] + }, + { + "id": 1447, + "text": "78月前(2010年10月),患者因乳腺癌术后放化疗后复查示afp异常升高(85.77IU/ml),腹部彩超未见明显异常占位。", + "event": [ + { + "core_name": "占位", + "tendency": "否定", + "character": [ + "明显异常" + ], + "anatomy_list": [] + } + ] + }, + { + "id": 484, + "text": "患者于2020年10月22日至我院呼吸科就诊,行纤支镜检查活检病理报告:(气管中段)淋巴组织增生性病变,结合临床资料、内镜所见及免疫表型,符合低级别淋巴瘤,倾向黏膜相关淋巴组织结外边缘区淋巴瘤(maltoma)。", + "event": [ + { + "core_name": "病变", + "tendency": "", + "character": [ + "增生性" + ], + "anatomy_list": [ + "气管中段淋巴组织" + ] + }, + { + "core_name": "瘤", + "tendency": "", + "character": [ + "低级别" + ], + "anatomy_list": [ + "淋巴" + ] + }, + { + "core_name": "瘤", + "tendency": "不确定", + "character": [ + "黏膜相关" + ], + "anatomy_list": [ + "淋巴组织结外边缘区", + "淋巴" + ] + } + ] + }, + { + "id": 224, + "text": "给予对症治疗后,患者当日即前往某医院就诊,行肠镜及病检提示:降结肠新生物伴狭窄,管状-绒毛状腺瘤,横结肠及降结肠交界区肠壁不均匀增厚,结肠癌?侵犯胃壁;腹盆腔积液,腹膜网膜肠系膜增厚模糊,转移待排,肝左外叶姐姐,不典型血管瘤?转移?。", + "event": [ + { + "core_name": "新生物", + "tendency": "", + "character": [], + "anatomy_list": [ + "降结肠" + ] + }, + { + "core_name": "狭窄", + "tendency": "", + "character": [], + "anatomy_list": [ + "降结肠" + ] + }, + { + "core_name": "腺瘤", + "tendency": "", + "character": [ + "管状-绒毛状" + ], + "anatomy_list": [] + }, + { + "core_name": "增厚", + "tendency": "", + "character": [ + "不均匀" + ], + "anatomy_list": [ + "横结肠及降结肠交界区肠壁" + ] + }, + { + "core_name": "癌", + "tendency": "不确定", + "character": [], + "anatomy_list": [ + "结肠" + ] + }, + { + "core_name": "侵犯", + "tendency": "", + "character": [], + "anatomy_list": [ + "胃壁" + ] + }, + { + "core_name": "积液", + "tendency": "", + "character": [], + "anatomy_list": [ + "腹", + "盆腔" + ] + }, + { + "core_name": "增厚模糊", + "tendency": "", + "character": [], + "anatomy_list": [ + "腹膜", + "肠系膜", + "网膜" + ] + }, + { + "core_name": "转移", + "tendency": "不确定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "结节", + "tendency": "", + "character": [], + "anatomy_list": [ + "肝左外叶" + ] + }, + { + "core_name": "血管瘤", + "tendency": "不确定", + "character": [ + "不典型" + ], + "anatomy_list": [] + }, + { + "core_name": "转移", + "tendency": "不确定", + "character": [], + "anatomy_list": [] + } + ] + }, + { + "id": 29, + "text": "入院1年前因“发现尿量减少4月,皮肤瘙痒20天”收入我科,考虑“继发性甲状旁腺功能亢进”,予以纠正贫血、降磷补钙、规律透析等治疗后,症状好转出院,出院后于当地医院规律透析治疗,规律透析(周二、周四、周六),未规律监测肌酐,偶查肌酐,值约1000umol/L。", + "event": [ + { + "core_name": "尿量", + "tendency": "", + "character": [ + "减少" + ], + "anatomy_list": [] + }, + { + "core_name": "瘙痒", + "tendency": "", + "character": [], + "anatomy_list": [ + "皮肤" + ] + }, + { + "core_name": "甲状旁腺功能亢进", + "tendency": "不确定", + "character": [ + "继发性" + ], + "anatomy_list": [ + "甲状旁腺" + ] + } + ] + }, + { + "id": 713, + "text": "2020-8-3he4348.90pmol/l↑,ca-1252579.0u/ml↑,于8-4、8-5在我科住院予以免疫细胞治疗(“pd1-t细胞生物制剂”),输注后有轻微恶心、反胃、乏力、食欲减退等不适,停药后症状逐渐消失,现每日口服“盐酸羟考酮缓释片(10mg)”予以镇痛治疗,目前觉左侧腰骶部及左下肢疼痛、麻木较前加重,休息时不能向左侧平躺,无头晕、头痛、心慌、心悸、腹痛、腹胀等不适,小便正常,大便干燥,2~3日1次,此次要求行第二次免疫细胞治疗,门诊以“卵巢高级别浆液性癌iiic期术后化疗后复发伴骨、肺、盆腔、腹腔淋巴结转移”收入我科。", + "event": [ + { + "core_name": "恶心", + "tendency": "", + "character": [ + "输注后", + "轻微" + ], + "anatomy_list": [] + }, + { + "core_name": "反胃", + "tendency": "", + "character": [ + "输注后" + ], + "anatomy_list": [] + }, + { + "core_name": "乏力", + "tendency": "", + "character": [ + "输注后" + ], + "anatomy_list": [] + }, + { + "core_name": "食欲", + "tendency": "", + "character": [ + "输注后", + "减退" + ], + "anatomy_list": [] + }, + { + "core_name": "疼痛", + "tendency": "", + "character": [ + "加重", + "休息时不能向左侧平躺" + ], + "anatomy_list": [ + "左侧腰骶部", + "左下肢" + ] + }, + { + "core_name": "麻木", + "tendency": "", + "character": [ + "加重", + "休息时不能向左侧平躺" + ], + "anatomy_list": [ + "左侧腰骶部", + "左下肢" + ] + }, + { + "core_name": "头晕", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "头" + ] + }, + { + "core_name": "疼痛", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "头" + ] + }, + { + "core_name": "心慌", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "心" + ] + }, + { + "core_name": "心悸", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "心" + ] + }, + { + "core_name": "疼痛", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "腹" + ] + }, + { + "core_name": "腹胀", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "腹" + ] + }, + { + "core_name": "小便", + "tendency": "", + "character": [ + "正常" + ], + "anatomy_list": [] + }, + { + "core_name": "大便", + "tendency": "", + "character": [ + "结干", + "2~3日1次" + ], + "anatomy_list": [] + }, + { + "core_name": "癌", + "tendency": "", + "character": [ + "高级别", + "浆液性", + "术后", + "化疗后", + "复发", + "iiic期" + ], + "anatomy_list": [ + "卵巢" + ] + }, + { + "core_name": "癌", + "tendency": "", + "character": [ + "转移" + ], + "anatomy_list": [ + "骨", + "肺", + "盆腔", + "腹腔淋巴结" + ] + } + ] + }, + { + "id": 507, + "text": "此后,吞咽困难进行性加重,进食半流质、流质饮食仍感梗阻,于2017年10月06日到我院行胃镜提示食管癌,病检:鳞状细胞癌。", + "event": [ + { + "core_name": "吞咽困难", + "tendency": "", + "character": [ + "进行性加重" + ], + "anatomy_list": [] + }, + { + "core_name": "梗阻", + "tendency": "", + "character": [ + "半流质、流质食物" + ], + "anatomy_list": [] + }, + { + "core_name": "癌", + "tendency": "", + "character": [], + "anatomy_list": [ + "食管" + ] + }, + { + "core_name": "鳞癌", + "tendency": "", + "character": [], + "anatomy_list": [] + } + ] + }, + { + "id": 903, + "text": "1天前,患儿出现右下肢疼痛,不能下地行走,不伴咳嗽,无进行性消瘦渐明显,不伴潮热盗汗。", + "event": [ + { + "core_name": "疼痛", + "tendency": "", + "character": [], + "anatomy_list": [ + "右下肢" + ] + }, + { + "core_name": "下地行走", + "tendency": "", + "character": [ + "不能" + ], + "anatomy_list": [] + }, + { + "core_name": "咳嗽", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "消瘦", + "tendency": "否定", + "character": [ + "进行性", + "明显" + ], + "anatomy_list": [] + }, + { + "core_name": "潮热", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "盗汗", + "tendency": "否定", + "character": [], + "anatomy_list": [] + } + ] + }, + { + "id": 1645, + "text": "入院前1年,患者无明显诱因出现上腹胀痛,呈阵发性发作,进食后加重,无恶心、呕吐、反酸、嗳气,无咳嗽、咳痰、气促、胸闷,患者诉服药后好转(具体不详)。患者上腹胀痛反复出现,患者服药后均能控制。", + "event": [ + { + "core_name": "疼痛", + "tendency": "", + "character": [ + "阵发性", + "胀痛", + "进食后加重" + ], + "anatomy_list": [ + "上腹" + ] + }, + { + "core_name": "恶心", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "呕吐", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "返酸", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "嗳气", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "咳嗽", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "咳痰", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "气促", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "胸闷", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "胸" + ] + }, + { + "core_name": "疼痛", + "tendency": "", + "character": [ + "胀痛", + "反复出现" + ], + "anatomy_list": [ + "上腹" + ] + } + ] + }, + { + "id": 1906, + "text": "5.甲状腺密度减低,fdg代谢增高,建议超声检查。", + "event": [ + { + "core_name": "甲状腺密度", + "tendency": "", + "character": [ + "减低" + ], + "anatomy_list": [ + "甲状腺" + ] + }, + { + "core_name": "fdg代谢", + "tendency": "", + "character": [ + "增高" + ], + "anatomy_list": [] + } + ] + }, + { + "id": 512, + "text": "建议1月后返院复查及行放化疗等综合治疗,此次患者为行放化疗来我院,遂以“食管癌术后”收入住院治疗。", + "event": [ + { + "core_name": "癌", + "tendency": "", + "character": [ + "术后" + ], + "anatomy_list": [ + "食管" + ] + } + ] + }, + { + "id": 1929, + "text": "患者本次发病以来,食欲正常,神志清醒,精神尚可,睡眠尚可,大便次数增多,进食油腻食物后解大便频繁,小便正常,体重无明显变化。", + "event": [ + { + "core_name": "食欲", + "tendency": "", + "character": [ + "正常" + ], + "anatomy_list": [] + }, + { + "core_name": "神志", + "tendency": "", + "character": [ + "清醒" + ], + "anatomy_list": [] + }, + { + "core_name": "精神", + "tendency": "", + "character": [ + "尚可" + ], + "anatomy_list": [] + }, + { + "core_name": "睡眠", + "tendency": "", + "character": [ + "尚可" + ], + "anatomy_list": [] + }, + { + "core_name": "大便", + "tendency": "", + "character": [ + "次数增多" + ], + "anatomy_list": [] + }, + { + "core_name": "大便", + "tendency": "", + "character": [ + "频繁", + "进食油腻食物" + ], + "anatomy_list": [] + }, + { + "core_name": "小便", + "tendency": "", + "character": [ + "正常" + ], + "anatomy_list": [] + }, + { + "core_name": "体重改变", + "tendency": "否定", + "character": [ + "明显" + ], + "anatomy_list": [] + } + ] + }, + { + "id": 638, + "text": "(肠周)淋巴结未见癌转移(0/15)。", + "event": [ + { + "core_name": "癌", + "tendency": "否定", + "character": [ + "转移" + ], + "anatomy_list": [ + "肠周淋巴结" + ] + } + ] + }, + { + "id": 1021, + "text": "2.头皮表皮囊肿”收治入院,进一步处理。", + "event": [ + { + "core_name": "囊肿", + "tendency": "", + "character": [ + "表皮" + ], + "anatomy_list": [ + "头皮" + ] + } + ] + }, + { + "id": 1305, + "text": "患者于入院前20+年因受凉后出现咳嗽、咳痰,为少量白色粘液痰,不伴喘息,无咯血,无胸闷、胸痛,无潮热、盗汗等症状,经口服感冒药后症状好转。", + "event": [ + { + "core_name": "咳嗽", + "tendency": "", + "character": [ + "受凉" + ], + "anatomy_list": [] + }, + { + "core_name": "咳痰", + "tendency": "", + "character": [ + "受凉", + "少量", + "白色", + "粘液" + ], + "anatomy_list": [] + }, + { + "core_name": "喘息", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "咯血", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "胸闷", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "胸" + ] + }, + { + "core_name": "疼痛", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "胸" + ] + }, + { + "core_name": "潮热", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "盗汗", + "tendency": "否定", + "character": [], + "anatomy_list": [] + } + ] + }, + { + "id": 1702, + "text": "1天前,患者出现痰中带血,量不多,无发热、畏寒,无胸痛,无声音嘶哑,无吞咽困难,无关节疼痛,为求进一步诊治,收住入院。", + "event": [ + { + "core_name": "咳痰", + "tendency": "", + "character": [ + "带血", + "量不多" + ], + "anatomy_list": [] + }, + { + "core_name": "发热", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "畏寒", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "疼痛", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "胸" + ] + }, + { + "core_name": "声音嘶哑", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "吞咽困难", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "疼痛", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "关节" + ] + } + ] + }, + { + "id": 1081, + "text": "2月前患者因排尿困难,遂到我院就诊,予以膀胱造瘘,术后予以抗感染及对症支持治疗,术后患者恢复可。", + "event": [ + { + "core_name": "排尿困难", + "tendency": "", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "恢复", + "tendency": "", + "character": [ + "可" + ], + "anatomy_list": [] + } + ] + }, + { + "id": 1076, + "text": "患者于入院3个多月前(2016.01.28)因确诊“右乳浸润癌”在全麻下行右乳癌改良根治术;术后病理诊断:右乳浸润性导管癌,腋窝淋巴结转移(0/14);免疫组化:er(+++)60%pr(++)40%cerbb-2(-) ki-6767个细胞(+)。", + "event": [ + { + "core_name": "浸润癌", + "tendency": "", + "character": [], + "anatomy_list": [ + "右乳" + ] + }, + { + "core_name": "导管癌", + "tendency": "", + "character": [ + "浸润性" + ], + "anatomy_list": [ + "右乳" + ] + }, + { + "core_name": "转移", + "tendency": "", + "character": [], + "anatomy_list": [ + "腋窝淋巴结" + ] + } + ] + }, + { + "id": 1630, + "text": "1天前患者头昏明显再发,视物模糊,有轻度头痛,伴双上肢远端麻木,颈部活动障碍,活动时有心累,胸闷症状,无心前区疼痛。", + "event": [ + { + "core_name": "头昏", + "tendency": "", + "character": [ + "明显再发" + ], + "anatomy_list": [ + "头" + ] + }, + { + "core_name": "视物模糊", + "tendency": "", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "疼痛", + "tendency": "", + "character": [ + "轻度" + ], + "anatomy_list": [ + "头" + ] + }, + { + "core_name": "麻木", + "tendency": "", + "character": [], + "anatomy_list": [ + "双上肢远端" + ] + }, + { + "core_name": "活动障碍", + "tendency": "", + "character": [], + "anatomy_list": [ + "颈部" + ] + }, + { + "core_name": "心累", + "tendency": "", + "character": [ + "活动时" + ], + "anatomy_list": [] + }, + { + "core_name": "胸闷", + "tendency": "", + "character": [ + "活动时" + ], + "anatomy_list": [ + "胸" + ] + }, + { + "core_name": "疼痛", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "心前区" + ] + } + ] + }, + { + "id": 793, + "text": "入院前6天,患者再次因受凉后出现喘累较前加重,喜高枕卧位,活动耐量急剧降低,无明显咳嗽、咳痰,伴纳差、全身乏力,无发热、畏寒,无意识障碍、黑朦,无胸痛、咯血,无呕吐、腹痛,双下肢无水肿,在外予对症治疗后病情无明显缓解,随急呼“120”来我院,急诊科予以静滴“多索茶碱”后,以“慢性阻塞性肺病伴急性加重”收入我科住院治疗。", + "event": [ + { + "core_name": "喘累", + "tendency": "", + "character": [ + "受凉后", + "较前加重" + ], + "anatomy_list": [] + }, + { + "core_name": "活动耐量", + "tendency": "", + "character": [ + "急剧降低" + ], + "anatomy_list": [] + }, + { + "core_name": "咳嗽", + "tendency": "否定", + "character": [ + "明显" + ], + "anatomy_list": [] + }, + { + "core_name": "咳痰", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "纳差", + "tendency": "", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "乏力", + "tendency": "", + "character": [], + "anatomy_list": [ + "全身" + ] + }, + { + "core_name": "发热", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "畏寒", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "意识障碍", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "黑朦", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "疼痛", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "胸" + ] + }, + { + "core_name": "咯血", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "呕吐", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "疼痛", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "腹" + ] + }, + { + "core_name": "水肿", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "双下肢" + ] + }, + { + "core_name": "肺病", + "tendency": "", + "character": [ + "慢性", + "阻塞性", + "急性加重" + ], + "anatomy_list": [ + "肺" + ] + } + ] + }, + { + "id": 176, + "text": "2周期化疗后复查腹膜后病变体积稍前减小。", + "event": [ + { + "core_name": "病变", + "tendency": "", + "character": [ + "体积稍前减小" + ], + "anatomy_list": [ + "腹膜后" + ] + } + ] + }, + { + "id": 1710, + "text": "胸部ct见双肺感染、双侧胸腔积液、肩胛骨及骨性胸廓多发低密度影,符合多发性骨髓瘤。", + "event": [ + { + "core_name": "感染", + "tendency": "", + "character": [], + "anatomy_list": [ + "双肺" + ] + }, + { + "core_name": "积液", + "tendency": "", + "character": [], + "anatomy_list": [ + "双侧胸腔" + ] + }, + { + "core_name": "密度影", + "tendency": "", + "character": [ + "多发", + "低" + ], + "anatomy_list": [ + "骨性胸廓", + "肩胛骨" + ] + }, + { + "core_name": "瘤", + "tendency": "", + "character": [ + "多发性" + ], + "anatomy_list": [ + "骨髓" + ] + } + ] + }, + { + "id": 1126, + "text": "2015年1月患者再出现右腹隐痛,无恶心、呕吐,无腹胀、阴道流血,复查ca-125 55.20U/ml ,胸腹部ct提示:1.卵巢癌术后复查, 腹膜后及肠系膜多发淋巴结显示增大,与2014.4.22对比有所增大、增多;余无明显变化。", + "event": [ + { + "core_name": "疼痛", + "tendency": "", + "character": [ + "隐痛" + ], + "anatomy_list": [ + "右腹" + ] + }, + { + "core_name": "恶心", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "呕吐", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "腹胀", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "腹" + ] + }, + { + "core_name": "出血", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "阴道" + ] + }, + { + "core_name": "癌", + "tendency": "", + "character": [ + "术后" + ], + "anatomy_list": [ + "卵巢" + ] + }, + { + "core_name": "增大", + "tendency": "", + "character": [ + "增多" + ], + "anatomy_list": [ + "腹膜后淋巴结", + "肠系膜淋巴结" + ] + } + ] + }, + { + "id": 505, + "text": "离院后患儿无发热、咳嗽,无进行性面色苍白,无皮肤瘀斑瘀点及鼻衄、牙龈出血;精神食欲一般,睡眠好;大小便正常。", + "event": [ + { + "core_name": "发热", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "咳嗽", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "面色苍白", + "tendency": "否定", + "character": [ + "进行性" + ], + "anatomy_list": [ + "面" + ] + }, + { + "core_name": "瘀斑", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "皮肤" + ] + }, + { + "core_name": "瘀点", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "皮肤" + ] + }, + { + "core_name": "鼻衄", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "鼻" + ] + }, + { + "core_name": "出血", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "牙龈" + ] + }, + { + "core_name": "精神", + "tendency": "", + "character": [ + "一般" + ], + "anatomy_list": [] + }, + { + "core_name": "食欲", + "tendency": "", + "character": [ + "一般" + ], + "anatomy_list": [] + }, + { + "core_name": "睡眠", + "tendency": "", + "character": [ + "好" + ], + "anatomy_list": [] + }, + { + "core_name": "大小便", + "tendency": "", + "character": [ + "正常" + ], + "anatomy_list": [] + } + ] + }, + { + "id": 236, + "text": "今患者为求进一步治疗来我院门诊,门诊以“糖尿病”收治入院。", + "event": [ + { + "core_name": "糖尿病", + "tendency": "", + "character": [], + "anatomy_list": [] + } + ] + }, + { + "id": 622, + "text": "后患者上诉症状反复发作,均为每次同房后阴道无痛性流少量鲜红色血液,性质同前,均不伴畏寒、发热、尿频、尿急、尿痛,无白带异常,无血凝块,无外阴瘙痒等不适,患者自觉病情严重,为求进一步治疗遂于2019-03-26于我院门诊就诊,电子阴道镜检查示:宫颈ca?厚的醋酸白上皮,进一步完善病检提示:(宫颈)鳞状细胞癌。", + "event": [ + { + "core_name": "出血", + "tendency": "", + "character": [ + "无痛性", + "同房后", + "少量", + "鲜红色" + ], + "anatomy_list": [ + "阴道" + ] + }, + { + "core_name": "畏寒", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "发热", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "尿频", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "尿急", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "尿痛", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "白带", + "tendency": "否定", + "character": [ + "异常" + ], + "anatomy_list": [] + }, + { + "core_name": "血凝块", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "瘙痒", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "外阴" + ] + }, + { + "core_name": "癌", + "tendency": "不确定", + "character": [], + "anatomy_list": [ + "宫颈" + ] + }, + { + "core_name": "醋酸白上皮", + "tendency": "", + "character": [ + "厚的" + ], + "anatomy_list": [] + }, + { + "core_name": "鳞癌", + "tendency": "", + "character": [], + "anatomy_list": [ + "宫颈" + ] + } + ] + }, + { + "id": 923, + "text": "完善腹部ct:双肾、双侧输尿管输尿管积水,双侧输尿管上段管壁增厚。", + "event": [ + { + "core_name": "积水", + "tendency": "", + "character": [], + "anatomy_list": [ + "双肾" + ] + }, + { + "core_name": "积水", + "tendency": "", + "character": [], + "anatomy_list": [ + "双侧输尿管" + ] + }, + { + "core_name": "增厚", + "tendency": "", + "character": [ + "管壁" + ], + "anatomy_list": [ + "双侧输尿管上段" + ] + } + ] + }, + { + "id": 1061, + "text": "近5日患者未排大便,自觉腹胀,反酸,嗳气加重,来我院门诊以“肠梗阻”收入我科。", + "event": [ + { + "core_name": "大便", + "tendency": "", + "character": [ + "未排", + "近5日" + ], + "anatomy_list": [] + }, + { + "core_name": "腹胀", + "tendency": "", + "character": [], + "anatomy_list": [ + "腹" + ] + }, + { + "core_name": "反酸", + "tendency": "", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "嗳气", + "tendency": "", + "character": [ + "加重" + ], + "anatomy_list": [] + }, + { + "core_name": "梗阻", + "tendency": "", + "character": [], + "anatomy_list": [ + "肠" + ] + } + ] + }, + { + "id": 1325, + "text": "2019-1-2患者入院复查ct评估提示疾病进展,积极给予胸腔穿刺引流,给于il-2胸腔灌注控制胸水,于2019-1-7、2019-1-28、2019-2-28:贝伐珠单抗300mg1+卡培他滨口服早2片,晚3片d1-14治疗3次,治疗过程顺利,2019-2-26完善胸部+腹部ct:肝肺转移转移灶稍增多,结合患者cea、ca125较前降低,患者呼吸困难等症状较前好转,评估患者病情稳定,可继续按原方案治疗。", + "event": [ + { + "core_name": "胸水", + "tendency": "", + "character": [], + "anatomy_list": [ + "胸" + ] + }, + { + "core_name": "转移灶", + "tendency": "", + "character": [ + "稍增多" + ], + "anatomy_list": [ + "肝", + "肺" + ] + }, + { + "core_name": "呼吸困难", + "tendency": "", + "character": [ + "较前好转" + ], + "anatomy_list": [] + } + ] + }, + { + "id": 1965, + "text": "患者患病以来精神一般,食欲可,长期睡眠差,大小便正常,近期无明显体重减轻。", + "event": [ + { + "core_name": "精神", + "tendency": "", + "character": [ + "一般" + ], + "anatomy_list": [] + }, + { + "core_name": "食欲", + "tendency": "", + "character": [ + "可" + ], + "anatomy_list": [] + }, + { + "core_name": "睡眠", + "tendency": "", + "character": [ + "差" + ], + "anatomy_list": [] + }, + { + "core_name": "大小便", + "tendency": "", + "character": [ + "正常" + ], + "anatomy_list": [] + }, + { + "core_name": "体重减轻", + "tendency": "否定", + "character": [ + "明显" + ], + "anatomy_list": [] + } + ] + }, + { + "id": 1430, + "text": "入院前1年余,患者因血尿外院诊断为“左侧输尿管尿路上皮癌,膀胱高级别乳头状尿路上皮癌”就诊于我院。", + "event": [ + { + "core_name": "血尿", + "tendency": "", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "癌", + "tendency": "", + "character": [], + "anatomy_list": [ + "左侧输尿管", + "尿路上皮" + ] + }, + { + "core_name": "癌", + "tendency": "", + "character": [ + "高级别", + "乳头状" + ], + "anatomy_list": [ + "膀胱", + "尿路上皮" + ] + } + ] + }, + { + "id": 85, + "text": "术后予以tp(多西他赛+洛铂)化疗+赫赛汀靶向治疗,过程顺利,化疗后产生中度药物骨髓反应及胃肠道反应,予以对症处理。", + "event": [ + { + "core_name": "药物骨髓反应", + "tendency": "", + "character": [ + "化疗后", + "中度" + ], + "anatomy_list": [ + "骨髓" + ] + }, + { + "core_name": "胃肠道反应", + "tendency": "", + "character": [ + "化疗后" + ], + "anatomy_list": [ + "胃肠道" + ] + } + ] + }, + { + "id": 1725, + "text": "入院前4+月患儿因“发热、贫血、骨痛”在我院住院治疗,经micm分型诊断为急性前b淋巴细胞淋巴细胞白血病l2型(e2a/pbx1阳性,中危) ,至今已经完成vdlp、cat诱导缓解化疗,第1-4次hd-mtx、间期治疗1-8周第1次静脉化疗。", + "event": [ + { + "core_name": "发热", + "tendency": "", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "贫血", + "tendency": "", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "疼痛", + "tendency": "", + "character": [], + "anatomy_list": [ + "骨" + ] + }, + { + "core_name": "白血病", + "tendency": "", + "character": [ + "急性", + "前B淋巴细胞", + "l2型", + "e2a/pbx1阳性", + "中危" + ], + "anatomy_list": [] + } + ] + }, + { + "id": 1854, + "text": "”于我科住院治疗,完善相关检查,诊断为“1.直肠腺癌(pT2n0M0);2.慢支炎、肺气肿;3.完全性右束支传导阻滞;4.左肾囊肿”,于2016年2月6日在全麻下行腹腔镜下直肠癌根治术(dixon)。", + "event": [ + { + "core_name": "腺癌", + "tendency": "", + "character": [ + "pT2n0M0" + ], + "anatomy_list": [ + "直肠" + ] + }, + { + "core_name": "支气管炎", + "tendency": "", + "character": [ + "慢性" + ], + "anatomy_list": [ + "支气管" + ] + }, + { + "core_name": "肺气肿", + "tendency": "", + "character": [], + "anatomy_list": [ + "肺" + ] + }, + { + "core_name": "传导阻滞", + "tendency": "", + "character": [ + "完全性" + ], + "anatomy_list": [ + "右束支" + ] + }, + { + "core_name": "囊肿", + "tendency": "", + "character": [], + "anatomy_list": [ + "左肾" + ] + } + ] + }, + { + "id": 725, + "text": "2012年12月初在我科复查,脑胸部及骨未见明显转移,腹部ct提示直肠癌术后吻合口肠壁稍增厚。", + "event": [ + { + "core_name": "转移", + "tendency": "否定", + "character": [ + "明显" + ], + "anatomy_list": [ + "脑", + "胸部", + "骨" + ] + }, + { + "core_name": "癌", + "tendency": "", + "character": [ + "术后" + ], + "anatomy_list": [ + "直肠" + ] + }, + { + "core_name": "增厚", + "tendency": "", + "character": [ + "稍" + ], + "anatomy_list": [ + "吻合口肠壁" + ] + } + ] + }, + { + "id": 515, + "text": "不伴发热、畏寒、寒战、头昏、头痛、胸闷、心悸、胸痛、反酸、嗳气、恶心、呕吐、腹痛、腹胀、腹泻、黑便。", + "event": [ + { + "core_name": "发热", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "畏寒", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "寒颤", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "头昏", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "头" + ] + }, + { + "core_name": "疼痛", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "头" + ] + }, + { + "core_name": "胸闷", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "胸" + ] + }, + { + "core_name": "心悸", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "心" + ] + }, + { + "core_name": "疼痛", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "胸" + ] + }, + { + "core_name": "反酸", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "嗳气", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "恶心", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "呕吐", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "疼痛", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "腹" + ] + }, + { + "core_name": "腹胀", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "腹" + ] + }, + { + "core_name": "腹泻", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "腹" + ] + }, + { + "core_name": "黑便", + "tendency": "否定", + "character": [], + "anatomy_list": [] + } + ] + }, + { + "id": 1644, + "text": "术后于2016-10-22、2016-11-23、2016-12-15、2017-01-06行ec方案化疗4次,于2017-01-30、2017-02-23、2017-03-17、2017-04-07行th方案化疗4次,从2017-04-28开始至今连续行13次靶向治疗,每次靶向治疗间隔21天左右,过程顺利,患者未诉特殊不适,无畏寒、发热,偶有咳嗽、咳痰,无头晕、头痛,无恶心、呕吐;患者今日为求第14次靶向治疗,遂入我院,门诊以“左乳癌术后第13次靶向治疗后”收入我科住院治疗。", + "event": [ + { + "core_name": "畏寒", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "发热", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "咳嗽", + "tendency": "", + "character": [ + "偶有" + ], + "anatomy_list": [] + }, + { + "core_name": "咳痰", + "tendency": "", + "character": [ + "偶有" + ], + "anatomy_list": [] + }, + { + "core_name": "头晕", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "头" + ] + }, + { + "core_name": "疼痛", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "头" + ] + }, + { + "core_name": "恶心", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "呕吐", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "癌", + "tendency": "", + "character": [ + "术后", + "第13次靶向治疗后" + ], + "anatomy_list": [ + "左乳" + ] + } + ] + }, + { + "id": 1798, + "text": "来我院就诊,诊断为“冠心病?”,建议患者冠脉造影明确诊断,患者及家属表示拒绝,予以改善循环、对症等治疗好转。", + "event": [ + { + "core_name": "冠心病", + "tendency": "不确定", + "character": [], + "anatomy_list": [ + "心" + ] + } + ] + }, + { + "id": 1545, + "text": "结合患者本次复查及病检:考虑直肠癌局部复发及远处转移。", + "event": [ + { + "core_name": "癌", + "tendency": "不确定", + "character": [ + "局部", + "复发", + "远处转移" + ], + "anatomy_list": [ + "直肠" + ] + } + ] + }, + { + "id": 21, + "text": "化疗期间患者未复查乳腺彩超、胸部影像学及颅脑检查及骨ect,每2周期化疗后均复查腹部彩超,未见肝脏转移等。", + "event": [ + { + "core_name": "转移", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "肝脏" + ] + } + ] + }, + { + "id": 981, + "text": "经治疗后,患者咳嗽稍好转。", + "event": [ + { + "core_name": "咳嗽", + "tendency": "", + "character": [ + "稍好转" + ], + "anatomy_list": [] + } + ] + }, + { + "id": 1528, + "text": "2020-11-3术后病理(123456):右肺上叶前段结节黏液腺癌,癌周肺组织部分腺泡腔萎陷、肺泡隔增宽,间质纤维组织增生,肺切缘无癌,支气管切缘切缘无癌;第1111组组淋巴结可见癌转移(1/1),第10组淋巴结可见癌转移(2/2),第2.4组淋巴结可见癌转移(5/5),第3a组淋巴结可见癌转移(3/3),第1111组组淋巴结未见癌转移(0/5),第77组组淋巴结未见癌转移(0/14),第8.9组淋巴结可见癌转移(1/3);右肺上叶肺组织弥漫出血、肺间质慢性炎,未见癌组织,肺切缘无癌,支气管切缘切缘无癌。", + "event": [ + { + "core_name": "腺癌", + "tendency": "", + "character": [ + "粘液", + "结节" + ], + "anatomy_list": [ + "右肺上叶前段" + ] + }, + { + "core_name": "萎陷", + "tendency": "", + "character": [], + "anatomy_list": [ + "癌周肺组织部分腺泡腔" + ] + }, + { + "core_name": "增宽", + "tendency": "", + "character": [], + "anatomy_list": [ + "肺泡隔" + ] + }, + { + "core_name": "增生", + "tendency": "", + "character": [], + "anatomy_list": [ + "间质纤维组织" + ] + }, + { + "core_name": "癌", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "肺切缘" + ] + }, + { + "core_name": "癌", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "支气管切缘" + ] + }, + { + "core_name": "癌", + "tendency": "", + "character": [ + "转移" + ], + "anatomy_list": [ + "1111组淋巴结" + ] + }, + { + "core_name": "癌", + "tendency": "", + "character": [ + "转移" + ], + "anatomy_list": [ + "2.4组淋巴结" + ] + }, + { + "core_name": "癌", + "tendency": "", + "character": [ + "转移" + ], + "anatomy_list": [ + "3a组淋巴结" + ] + }, + { + "core_name": "癌", + "tendency": "", + "character": [ + "转移" + ], + "anatomy_list": [ + "10组淋巴结" + ] + }, + { + "core_name": "癌", + "tendency": "否定", + "character": [ + "转移" + ], + "anatomy_list": [ + "1111组组淋巴结" + ] + }, + { + "core_name": "癌", + "tendency": "否定", + "character": [ + "转移" + ], + "anatomy_list": [ + "第77组淋巴结" + ] + }, + { + "core_name": "癌", + "tendency": "", + "character": [ + "转移" + ], + "anatomy_list": [ + "第8.9组淋巴结" + ] + }, + { + "core_name": "出血", + "tendency": "", + "character": [ + "弥漫" + ], + "anatomy_list": [ + "右肺上叶", + "肺组织" + ] + }, + { + "core_name": "肺间质炎", + "tendency": "", + "character": [ + "慢性" + ], + "anatomy_list": [ + "肺间质" + ] + }, + { + "core_name": "癌", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "肺切缘" + ] + }, + { + "core_name": "癌", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "支气管切缘" + ] + } + ] + }, + { + "id": 1261, + "text": "2.双肺气肿。", + "event": [ + { + "core_name": "肺气肿", + "tendency": "", + "character": [], + "anatomy_list": [ + "双肺" + ] + } + ] + }, + { + "id": 1810, + "text": "支气管切缘及肺切缘未见癌累及。", + "event": [ + { + "core_name": "癌", + "tendency": "否定", + "character": [ + "累及" + ], + "anatomy_list": [ + "支气管切缘", + "肺切缘" + ] + } + ] + }, + { + "id": 699, + "text": "患病以来,精神、食欲及睡眠可,大小便正常,体重下降约2.5Kg。", + "event": [ + { + "core_name": "精神", + "tendency": "", + "character": [ + "可" + ], + "anatomy_list": [] + }, + { + "core_name": "食欲", + "tendency": "", + "character": [ + "正常" + ], + "anatomy_list": [] + }, + { + "core_name": "睡眠质量", + "tendency": "", + "character": [ + "可" + ], + "anatomy_list": [] + }, + { + "core_name": "大小便", + "tendency": "", + "character": [ + "正常" + ], + "anatomy_list": [] + }, + { + "core_name": "体重下降", + "tendency": "", + "character": [], + "anatomy_list": [] + } + ] + }, + { + "id": 1150, + "text": "患者自患病以来,精神正常,饮食吞咽困难,流质为主,小大便正常,体重无明显变化。", + "event": [ + { + "core_name": "精神", + "tendency": "", + "character": [ + "正常" + ], + "anatomy_list": [] + }, + { + "core_name": "吞咽困难", + "tendency": "", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "小便", + "tendency": "", + "character": [ + "正常" + ], + "anatomy_list": [] + }, + { + "core_name": "大便", + "tendency": "", + "character": [ + "正常" + ], + "anatomy_list": [] + }, + { + "core_name": "体重", + "tendency": "", + "character": [ + "无明显变化" + ], + "anatomy_list": [] + } + ] + }, + { + "id": 626, + "text": "3年前患者上述症状发作后伴活动后喘累。", + "event": [ + { + "core_name": "喘累", + "tendency": "", + "character": [ + "活动后" + ], + "anatomy_list": [] + } + ] + }, + { + "id": 1688, + "text": "今日患者及家属为求进一步治疗就诊于我院,门诊以“腰椎盘突出症;腰55椎血管瘤”收入我科住院治疗。", + "event": [ + { + "core_name": "突出症", + "tendency": "", + "character": [], + "anatomy_list": [ + "腰椎盘" + ] + }, + { + "core_name": "瘤", + "tendency": "", + "character": [ + "血管" + ], + "anatomy_list": [ + "腰5椎" + ] + } + ] + }, + { + "id": 1970, + "text": "拇指伴有针刺感。", + "event": [ + { + "core_name": "针刺感", + "tendency": "", + "character": [], + "anatomy_list": [ + "拇指" + ] + } + ] + }, + { + "id": 1917, + "text": "在我科行两周期“紫杉醇210mg+奈达铂110mg”化疗后,复查ct(256层)(123456):右侧枕叶结节,考虑转移性肿瘤;左下肺门区占位性病变,考虑肺癌伴左肺下叶阻塞性肺不张;左肺门淋巴结肿大;左侧胸腔积液;右肺上叶局部肺气肿(小叶中心型);右肺细小结节,尘肺?;右肺上叶及斜裂结节,转移性肿瘤可能;肝脏右叶结节,考虑转移性肿瘤;肝右叶大片低强化区,考虑脂肪变性;右肾占位性病变,考虑转移性肿瘤可能性大;左肾小结石;左侧肾上腺结节,考虑转移性肿瘤。", + "event": [ + { + "core_name": "结节", + "tendency": "", + "character": [], + "anatomy_list": [ + "右侧枕叶" + ] + }, + { + "core_name": "肿瘤", + "tendency": "不确定", + "character": [ + "转移性" + ], + "anatomy_list": [ + "右侧枕叶" + ] + }, + { + "core_name": "病变", + "tendency": "", + "character": [ + "占位性" + ], + "anatomy_list": [ + "左下肺1区" + ] + }, + { + "core_name": "癌", + "tendency": "", + "character": [], + "anatomy_list": [ + "肺" + ] + }, + { + "core_name": "肺不张", + "tendency": "", + "character": [ + "阻塞性" + ], + "anatomy_list": [ + "左肺下叶" + ] + }, + { + "core_name": "肿大", + "tendency": "", + "character": [], + "anatomy_list": [ + "左肺门淋巴结" + ] + }, + { + "core_name": "积液", + "tendency": "", + "character": [], + "anatomy_list": [ + "左侧胸腔" + ] + }, + { + "core_name": "肺气肿", + "tendency": "", + "character": [ + "小叶中心型", + "局部" + ], + "anatomy_list": [ + "右肺上叶" + ] + }, + { + "core_name": "结节", + "tendency": "", + "character": [ + "细小" + ], + "anatomy_list": [ + "右肺" + ] + }, + { + "core_name": "尘肺", + "tendency": "不确定", + "character": [], + "anatomy_list": [ + "右肺" + ] + }, + { + "core_name": "结节", + "tendency": "", + "character": [], + "anatomy_list": [ + "右肺上叶", + "右肺上叶斜裂" + ] + }, + { + "core_name": "肿瘤", + "tendency": "不确定", + "character": [ + "转移性" + ], + "anatomy_list": [ + "右肺上叶", + "右肺上叶斜裂" + ] + }, + { + "core_name": "结节", + "tendency": "", + "character": [], + "anatomy_list": [ + "肝脏右叶" + ] + }, + { + "core_name": "肿瘤", + "tendency": "不确定", + "character": [ + "转移性" + ], + "anatomy_list": [ + "肝脏右叶" + ] + }, + { + "core_name": "低强化区", + "tendency": "", + "character": [ + "大片" + ], + "anatomy_list": [ + "肝脏右叶" + ] + }, + { + "core_name": "脂肪变性", + "tendency": "", + "character": [], + "anatomy_list": [ + "肝脏右叶" + ] + }, + { + "core_name": "病变", + "tendency": "", + "character": [ + "占位性" + ], + "anatomy_list": [ + "右肾" + ] + }, + { + "core_name": "肿瘤", + "tendency": "不确定", + "character": [ + "转移性" + ], + "anatomy_list": [ + "右肾" + ] + }, + { + "core_name": "结石", + "tendency": "", + "character": [ + "小" + ], + "anatomy_list": [ + "左肾" + ] + }, + { + "core_name": "结节", + "tendency": "", + "character": [], + "anatomy_list": [ + "左侧肾上腺" + ] + }, + { + "core_name": "肿瘤", + "tendency": "不确定", + "character": [ + "转移性" + ], + "anatomy_list": [] + } + ] + }, + { + "id": 1684, + "text": "于2014年7月19日行第1次化疗,方案:奥沙利铂+雷替曲塞,化疗期间无发热咳嗽,无恶心、呕吐,无腹痛腹泻等不适。", + "event": [ + { + "core_name": "发热", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "咳嗽", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "恶心", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "呕吐", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "疼痛", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "腹" + ] + }, + { + "core_name": "腹泻", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "腹" + ] + } + ] + }, + { + "id": 243, + "text": "再次就诊于肛肠外科,行肛门指检(2016-06-22)未发现明显异常,复查盆腔ct(我院,2016-06-22)提示:盆腔未见明显异常。", + "event": [ + { + "core_name": "异常", + "tendency": "否定", + "character": [ + "明显" + ], + "anatomy_list": [] + }, + { + "core_name": "异常", + "tendency": "否定", + "character": [ + "明显" + ], + "anatomy_list": [ + "盆腔" + ] + } + ] + }, + { + "id": 503, + "text": "患者自起病以来,精神略差,胃纳较差,大便如常,小便如常,近2月体重下降6kg。", + "event": [ + { + "core_name": "精神", + "tendency": "", + "character": [ + "略差" + ], + "anatomy_list": [] + }, + { + "core_name": "胃纳", + "tendency": "", + "character": [ + "较差" + ], + "anatomy_list": [ + "胃" + ] + }, + { + "core_name": "大便", + "tendency": "", + "character": [ + "如常" + ], + "anatomy_list": [] + }, + { + "core_name": "小便", + "tendency": "", + "character": [ + "如常" + ], + "anatomy_list": [] + }, + { + "core_name": "体重下降", + "tendency": "", + "character": [], + "anatomy_list": [] + } + ] + }, + { + "id": 1563, + "text": "自发现以来,包块无明显增大,无咳嗽,气急,无全身黄染,无乳头流脓,溢液,无红肿,皮肤无橘皮样改变等。院外未行特殊诊治。", + "event": [ + { + "core_name": "包块", + "tendency": "否定", + "character": [ + "明显增大" + ], + "anatomy_list": [] + }, + { + "core_name": "咳嗽", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "气促", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "黄染", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "全身" + ] + }, + { + "core_name": "流脓", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "乳头" + ] + }, + { + "core_name": "溢液", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "乳头" + ] + }, + { + "core_name": "红肿", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "乳头" + ] + }, + { + "core_name": "改变", + "tendency": "否定", + "character": [ + "橘皮样" + ], + "anatomy_list": [ + "皮肤" + ] + } + ] + }, + { + "id": 2017, + "text": "术后病检回示:病理号2123456:\"直、乙交界\"中分化腺癌,侵及深肌层;两切端未见癌累及;脂肪组织中未发现明显肿大淋巴结。", + "event": [ + { + "core_name": "腺癌", + "tendency": "", + "character": [ + "中分化" + ], + "anatomy_list": [ + "直、乙交界" + ] + }, + { + "core_name": "腺癌", + "tendency": "", + "character": [ + "侵及" + ], + "anatomy_list": [ + "深肌层" + ] + }, + { + "core_name": "癌", + "tendency": "否定", + "character": [ + "累及" + ], + "anatomy_list": [ + "两切端" + ] + }, + { + "core_name": "肿大", + "tendency": "否定", + "character": [ + "明显" + ], + "anatomy_list": [ + "脂肪组织淋巴结" + ] + } + ] + }, + { + "id": 1153, + "text": "入院前4小时,患者无明显诱因突发意识丧失、呼之不应,伴面色苍白、口唇发绀,双目向上凝视、牙关紧闭、口吐白沫、四肢抽搐、小便失禁,持续约5分5分钟后肢体抽搐渐停止,持续约20分20分钟后患者意识逐渐恢复,醒后不能回忆发作时情况,伴头痛,以额部胀痛为主,伴头昏、视物模糊,无视物旋转,无恶心、呕吐,无耳鸣、听力下降,无心慌、心累、心前区不适,无肢体活动障碍。", + "event": [ + { + "core_name": "意识丧失", + "tendency": "", + "character": [ + "突发" + ], + "anatomy_list": [] + }, + { + "core_name": "呼之不应", + "tendency": "", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "面色苍白", + "tendency": "", + "character": [], + "anatomy_list": [ + "面" + ] + }, + { + "core_name": "发绀", + "tendency": "", + "character": [], + "anatomy_list": [ + "口唇" + ] + }, + { + "core_name": "凝视", + "tendency": "", + "character": [ + "向上" + ], + "anatomy_list": [ + "双目" + ] + }, + { + "core_name": "牙关紧闭", + "tendency": "", + "character": [], + "anatomy_list": [ + "牙" + ] + }, + { + "core_name": "口吐白沫", + "tendency": "", + "character": [], + "anatomy_list": [ + "口" + ] + }, + { + "core_name": "抽搐", + "tendency": "", + "character": [], + "anatomy_list": [ + "四肢" + ] + }, + { + "core_name": "小便", + "tendency": "", + "character": [ + "失禁" + ], + "anatomy_list": [] + }, + { + "core_name": "抽搐", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "肢体" + ] + }, + { + "core_name": "意识恢复", + "tendency": "", + "character": [ + "醒后不能回忆发作时情况" + ], + "anatomy_list": [] + }, + { + "core_name": "疼痛", + "tendency": "", + "character": [ + "胀痛为主" + ], + "anatomy_list": [ + "头", + "额部" + ] + }, + { + "core_name": "头昏", + "tendency": "", + "character": [], + "anatomy_list": [ + "头" + ] + }, + { + "core_name": "视物模糊", + "tendency": "", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "视物旋转", + "tendency": "", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "恶心", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "呕吐", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "耳鸣", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "耳" + ] + }, + { + "core_name": "听力下降", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "耳" + ] + }, + { + "core_name": "心悸", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "心" + ] + }, + { + "core_name": "心前区不适", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "心前区" + ] + }, + { + "core_name": "心累", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "心" + ] + }, + { + "core_name": "活动障碍", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "肢体" + ] + } + ] + }, + { + "id": 1134, + "text": "3、双肾多发囊肿。", + "event": [ + { + "core_name": "囊肿", + "tendency": "", + "character": [ + "多发" + ], + "anatomy_list": [ + "双肾" + ] + } + ] + }, + { + "id": 1859, + "text": "现患者无恶心、呕吐、腹痛、腹胀、便血等表现,遵医嘱于今日至我院行直肠癌术后第一次化疗。", + "event": [ + { + "core_name": "恶心", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "呕吐", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "疼痛", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "腹" + ] + }, + { + "core_name": "腹胀", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "腹" + ] + }, + { + "core_name": "便血", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "癌", + "tendency": "", + "character": [ + "术后第一次化" + ], + "anatomy_list": [ + "直肠" + ] + } + ] + }, + { + "id": 881, + "text": "发现血糖升高4月,现予以瑞格列奈1mg降糖治疗,监测血糖波动在:9.5-13mm13mmol/l之间。", + "event": [ + { + "core_name": "血糖", + "tendency": "", + "character": [ + "升高" + ], + "anatomy_list": [] + }, + { + "core_name": "血糖", + "tendency": "", + "character": [ + "波动" + ], + "anatomy_list": [] + } + ] + }, + { + "id": 820, + "text": "入院前4个月,患者因“胃癌”,在某医院行“胃癌根治术”(具体术式及术中情况不详),术后诊��为胃贲门贲门中低分化腺癌 t4n3M,术后恢复好。", + "event": [ + { + "core_name": "癌", + "tendency": "", + "character": [], + "anatomy_list": [ + "胃" + ] + }, + { + "core_name": "腺癌", + "tendency": "", + "character": [ + "中低分化", + "t4n3M" + ], + "anatomy_list": [ + "胃贲门" + ] + } + ] + }, + { + "id": 1823, + "text": "遂于某医院完善相关检查诊断:宫颈鳞癌iiib期,因无手术指征,2017年6月8日行体外照射(具体不详),放疗后患者阴道流血停止,放疗后行5周期化疗(具体化疗方案及剂量不详),化疗期间无明显化疗副反应,化疗后出现骨髓抑制(具体不详),予以“重组人粒细胞刺激因子”治疗后骨髓抑制好转。", + "event": [ + { + "core_name": "鳞癌", + "tendency": "", + "character": [ + "iiib期" + ], + "anatomy_list": [ + "宫颈" + ] + }, + { + "core_name": "出血", + "tendency": "", + "character": [ + "停止", + "放疗后" + ], + "anatomy_list": [ + "阴道" + ] + }, + { + "core_name": "骨髓抑制", + "tendency": "", + "character": [ + "化疗后" + ], + "anatomy_list": [ + "骨髓" + ] + }, + { + "core_name": "骨髓抑制", + "tendency": "", + "character": [ + "治疗后好转" + ], + "anatomy_list": [ + "骨髓" + ] + }, + { + "core_name": "副反应", + "tendency": "否定", + "character": [ + "化疗期间" + ], + "anatomy_list": [] + } + ] + }, + { + "id": 1576, + "text": "患者自发病以来,精神可,食欲可,睡眠可,大便2-3次/日,小便如常,体重无明显变化。", + "event": [ + { + "core_name": "精神", + "tendency": "", + "character": [ + "可" + ], + "anatomy_list": [] + }, + { + "core_name": "食欲", + "tendency": "", + "character": [ + "可" + ], + "anatomy_list": [] + }, + { + "core_name": "睡眠", + "tendency": "", + "character": [ + "可" + ], + "anatomy_list": [] + }, + { + "core_name": "大便", + "tendency": "", + "character": [ + "2-3次/日" + ], + "anatomy_list": [] + }, + { + "core_name": "小便", + "tendency": "", + "character": [ + "如常" + ], + "anatomy_list": [] + }, + { + "core_name": "体重改变", + "tendency": "否定", + "character": [ + "明显" + ], + "anatomy_list": [] + } + ] + }, + { + "id": 1346, + "text": "2+月前患者患者无明显诱因出现全身皮肤及巩膜黄染,伴发热,最高高体温38.5℃,伴小便深黄,量尚可,大便颜色正常,全身皮肤瘙痒,伴有纳差、乏力、闷油,无明显腹痛、腹胀,无恶心、呕吐,无呕血、黑便,患者于某医院就诊,予以输注“多烯磷脂酰胆碱+谷胱甘肽”保肝治疗后无明显好转,其后于我院就诊,入院后完善ct考虑诊断为:胆管癌术后复发。", + "event": [ + { + "core_name": "黄染", + "tendency": "", + "character": [], + "anatomy_list": [ + "巩膜" + ] + }, + { + "core_name": "黄染", + "tendency": "", + "character": [], + "anatomy_list": [ + "全身皮肤" + ] + }, + { + "core_name": "发热", + "tendency": "", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "小便", + "tendency": "", + "character": [ + "深黄" + ], + "anatomy_list": [] + }, + { + "core_name": "大便", + "tendency": "", + "character": [ + "颜色正常" + ], + "anatomy_list": [] + }, + { + "core_name": "瘙痒", + "tendency": "", + "character": [], + "anatomy_list": [ + "全身皮肤" + ] + }, + { + "core_name": "纳差", + "tendency": "", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "乏力", + "tendency": "", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "闷油", + "tendency": "", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "疼痛", + "tendency": "否定", + "character": [ + "明显" + ], + "anatomy_list": [ + "腹" + ] + }, + { + "core_name": "腹胀", + "tendency": "否定", + "character": [ + "明显" + ], + "anatomy_list": [ + "腹" + ] + }, + { + "core_name": "恶心", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "呕吐", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "呕血", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "黑便", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "癌", + "tendency": "不确定", + "character": [ + "术后", + "复发" + ], + "anatomy_list": [ + "胆管" + ] + } + ] + }, + { + "id": 639, + "text": "术后予以予以禁食水、补液、抗感染等对症支持治疗,术后第1010天,期间患者反复发热,最高高体温40摄氏度,患者血培养提示格兰阳性球菌感染,血象提示感染征象高。", + "event": [ + { + "core_name": "发热", + "tendency": "", + "character": [ + "反复" + ], + "anatomy_list": [] + }, + { + "core_name": "体温", + "tendency": "", + "character": [ + "升高" + ], + "anatomy_list": [] + }, + { + "core_name": "感染", + "tendency": "", + "character": [ + "格兰阳性球菌" + ], + "anatomy_list": [] + }, + { + "core_name": "感染", + "tendency": "", + "character": [ + "征象高" + ], + "anatomy_list": [] + } + ] + }, + { + "id": 1649, + "text": "无寒战高热,无心慌胸闷,无呼吸困难,无四肢乏力。", + "event": [ + { + "core_name": "寒颤", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "发热", + "tendency": "否定", + "character": [ + "高" + ], + "anatomy_list": [] + }, + { + "core_name": "心慌", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "心" + ] + }, + { + "core_name": "胸闷", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "胸" + ] + }, + { + "core_name": "呼吸困难", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "乏力", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "四肢" + ] + } + ] + }, + { + "id": 1948, + "text": "确诊为多发性骨髓瘤(igg/lambda)型,分别于2016-3-22、2016-04-26、2016-5-24、2016-6-22以vadt方案联合化疗,过程顺利,现患者为巩固化疗入院。", + "event": [ + { + "core_name": "瘤", + "tendency": "", + "character": [ + "多发性", + "(igg/lambda)型" + ], + "anatomy_list": [ + "骨髓" + ] + } + ] + }, + { + "id": 1552, + "text": "后患者感上述包块进行性长大,遂于2014年8月到我院门诊就诊,行左颈淋巴结穿刺提示\"符合淋巴结转移鳞癌\"。", + "event": [ + { + "core_name": "包块", + "tendency": "", + "character": [ + "进行性长大" + ], + "anatomy_list": [] + }, + { + "core_name": "鳞癌", + "tendency": "", + "character": [ + "转移" + ], + "anatomy_list": [ + "淋巴结" + ] + } + ] + }, + { + "id": 2043, + "text": "患者白血病复发,建议上级医院就诊,患者家属拒绝上级医院就诊,患者左侧胸壁包块及阴茎部位赘生物,破溃,建议穿刺活检,患者家属拒绝,患者发热伴干咳,胸痛,最高高体温40℃,考虑肺部感染,口腔涂片:涂片找g菌查见;涂片找真菌查见;痰中找霉菌查见;g+球菌查见.", + "event": [ + { + "core_name": "白血病", + "tendency": "", + "character": [ + "复发" + ], + "anatomy_list": [] + }, + { + "core_name": "包块", + "tendency": "", + "character": [], + "anatomy_list": [ + "左侧胸壁" + ] + }, + { + "core_name": "赘生物", + "tendency": "", + "character": [], + "anatomy_list": [ + "阴茎" + ] + }, + { + "core_name": "破溃", + "tendency": "", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "发��", + "tendency": "", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "咳嗽", + "tendency": "", + "character": [ + "干" + ], + "anatomy_list": [] + }, + { + "core_name": "疼痛", + "tendency": "", + "character": [], + "anatomy_list": [ + "胸" + ] + }, + { + "core_name": "体温", + "tendency": "", + "character": [ + "升高" + ], + "anatomy_list": [] + }, + { + "core_name": "感染", + "tendency": "不确定", + "character": [], + "anatomy_list": [ + "肺部" + ] + } + ] + }, + { + "id": 1637, + "text": "肠镜示:盲肠息肉。", + "event": [ + { + "core_name": "息肉", + "tendency": "", + "character": [], + "anatomy_list": [ + "盲肠" + ] + } + ] + }, + { + "id": 405, + "text": "患者遂转诊我院肛肠科,行乙状结肠镜见直肠下段半环状包块,3*2.5cm大小,表面凹凸不平,糜烂出血,质硬,边界不清。", + "event": [ + { + "core_name": "包块", + "tendency": "", + "character": [ + "环状", + "表面凹凸不平", + "糜烂出血", + "质硬", + "边界不清" + ], + "anatomy_list": [ + "直肠下段" + ] + } + ] + }, + { + "id": 80, + "text": "遂于我院急诊就诊,行双乳彩超提示:1.左乳腺低回声肿块伴钙化;2.左侧腋窝淋巴结显影。", + "event": [ + { + "core_name": "肿块", + "tendency": "", + "character": [ + "低回声" + ], + "anatomy_list": [ + "左乳腺" + ] + }, + { + "core_name": "钙化", + "tendency": "", + "character": [], + "anatomy_list": [ + "左乳腺" + ] + }, + { + "core_name": "显影", + "tendency": "", + "character": [], + "anatomy_list": [ + "左侧腋窝淋巴结" + ] + } + ] + }, + { + "id": 1336, + "text": "患者1天前出现纳差不适,食欲下降2/3,无恶心、呕吐,无反酸、嗳气,无乏力,无腹痛、腹胀、腹泻,无尿频、尿急、尿痛,无黑便、便血,无肛门停止排便排气,伴咳嗽、咳痰,白色泡沫痰,无呼吸困难、喘累不适,今日至我院门诊完善腹部彩超提示:胆囊结石,为行进一步检查及治疗入院,以“消化不良、胆囊结石”收住院。", + "event": [ + { + "core_name": "纳差", + "tendency": "", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "食欲", + "tendency": "", + "character": [ + "下降" + ], + "anatomy_list": [] + }, + { + "core_name": "恶心", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "呕吐", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "反酸", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "嗳气", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "乏力", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "疼痛", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "腹" + ] + }, + { + "core_name": "腹胀", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "腹" + ] + }, + { + "core_name": "腹泻", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "腹" + ] + }, + { + "core_name": "尿频", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "尿急", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "尿痛", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "黑便", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "便血", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "排便", + "tendency": "否定", + "character": [ + "停止" + ], + "anatomy_list": [ + "肛门" + ] + }, + { + "core_name": "排气", + "tendency": "否定", + "character": [ + "停止" + ], + "anatomy_list": [ + "肛门" + ] + }, + { + "core_name": "咳嗽", + "tendency": "", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "咳痰", + "tendency": "", + "character": [ + "白色", + "泡沫痰" + ], + "anatomy_list": [] + }, + { + "core_name": "呼吸困难", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "喘累不适", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "结石", + "tendency": "", + "character": [], + "anatomy_list": [ + "胆囊" + ] + }, + { + "core_name": "消化不良", + "tendency": "", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "结石", + "tendency": "", + "character": [], + "anatomy_list": [ + "胆囊" + ] + } + ] + }, + { + "id": 951, + "text": "入院前3天患者无明显出现黑便不适,为黑色不成形大便,量约80g,仍有嗳气、上腹胀不适,不伴有头晕、心悸、出冷汗等不适。", + "event": [ + { + "core_name": "黑便", + "tendency": "", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "大便", + "tendency": "", + "character": [ + "黑色", + "不成形" + ], + "anatomy_list": [] + }, + { + "core_name": "嗳气", + "tendency": "", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "腹胀", + "tendency": "", + "character": [], + "anatomy_list": [ + "上腹" + ] + }, + { + "core_name": "头晕", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "头" + ] + }, + { + "core_name": "心悸", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "心" + ] + }, + { + "core_name": "出冷汗", + "tendency": "否定", + "character": [], + "anatomy_list": [] + } + ] + }, + { + "id": 576, + "text": "今为进一步诊治到我院门诊诊治,门诊以“卵巢癌术后第二次化疗” 收入我科住院治疗。", + "event": [ + { + "core_name": "癌", + "tendency": "", + "character": [ + "术后", + "第二次化疗" + ], + "anatomy_list": [ + "卵巢" + ] + } + ] + }, + { + "id": 1627, + "text": "今患者为进一步治疗于我院就诊,门诊以“宫颈恶性肿瘤”收入我科。", + "event": [ + { + "core_name": "肿瘤", + "tendency": "", + "character": [ + "恶性" + ], + "anatomy_list": [ + "宫颈" + ] + } + ] + }, + { + "id": 838, + "text": "腋窝淋巴结未见癌转移(0/16)。", + "event": [ + { + "core_name": "癌", + "tendency": "否定", + "character": [ + "转移" + ], + "anatomy_list": [ + "腋窝淋巴结" + ] + } + ] + }, + { + "id": 588, + "text": "患者入院前5+年,无明显诱因出现进食后梗咽感,进食固体食物及半流质食物明显,无恶心、呕吐、反酸,不伴呕血、黑便。", + "event": [ + { + "core_name": "哽噎感", + "tendency": "", + "character": [ + "进食后", + "进食固体食物明显", + "进食半流质食物明显" + ], + "anatomy_list": [] + }, + { + "core_name": "恶心", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "呕吐", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "反酸", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "呕血", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "黑便", + "tendency": "否定", + "character": [], + "anatomy_list": [] + } + ] + }, + { + "id": 594, + "text": "胸腹部ct:1、胃贲门癌:较2018-2-5片比较,贲门处软组织影较前无明显变化。", + "event": [ + { + "core_name": "癌", + "tendency": "", + "character": [], + "anatomy_list": [ + "胃贲门" + ] + }, + { + "core_name": "软组织影", + "tendency": "", + "character": [ + "较前无明显变化" + ], + "anatomy_list": [ + "贲门" + ] + } + ] + }, + { + "id": 517, + "text": "2天前患者感左侧腹痛,咳嗽时明显。", + "event": [ + { + "core_name": "疼痛", + "tendency": "", + "character": [ + "咳嗽时明显" + ], + "anatomy_list": [ + "左侧腹" + ] + } + ] + }, + { + "id": 603, + "text": "肺动脉瓣关闭不全(轻度)。", + "event": [ + { + "core_name": "关闭不全", + "tendency": "", + "character": [ + "轻度" + ], + "anatomy_list": [ + "肺动脉瓣" + ] + } + ] + }, + { + "id": 896, + "text": "入院前1+年患者无明显诱因出现双下肢水肿,伴颜面浮肿,伴泡沫尿及尿量减少,无恶心、呕吐,无胸闷、气促,无腹痛、腹泻,患者诉自服药物后无效,遂在我院住院检查:尿微量白蛋白定量 >3000mg/L,总胆固醇 6.36mmol/l、肌酐 118.8 μmol/l、白蛋白 28.5g/l,诊断肾病综合征,予以利尿、抗凝、纠正蛋白等治疗,建议患者到上级医院行肾脏穿刺但患者拒绝。", + "event": [ + { + "core_name": "水肿", + "tendency": "", + "character": [], + "anatomy_list": [ + "双下肢" + ] + }, + { + "core_name": "浮肿", + "tendency": "", + "character": [], + "anatomy_list": [ + "颜面" + ] + }, + { + "core_name": "泡沫尿", + "tendency": "", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "小便", + "tendency": "", + "character": [ + "量减少" + ], + "anatomy_list": [] + }, + { + "core_name": "恶心", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "呕吐", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "胸闷", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "胸" + ] + }, + { + "core_name": "气促", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "疼痛", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "腹" + ] + }, + { + "core_name": "腹泻", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "腹" + ] + }, + { + "core_name": "肾病综合征", + "tendency": "", + "character": [], + "anatomy_list": [ + "肾" + ] + } + ] + }, + { + "id": 1918, + "text": "疗效评价pr,经医疗组内讨论后行第三周期tp方案化疗,化疗期间患者未诉特殊不适,患者好转出院,出院后反复发热、咳嗽、咳痰,今日患者诉行走时伴头晕、心累,无胸闷、胸痛,无腹痛、腹泻等,随来我院就诊,我科以“肺癌”收入治疗。", + "event": [ + { + "core_name": "发热", + "tendency": "", + "character": [ + "反复" + ], + "anatomy_list": [] + }, + { + "core_name": "咳嗽", + "tendency": "", + "character": [ + "反复" + ], + "anatomy_list": [] + }, + { + "core_name": "咳痰", + "tendency": "", + "character": [ + "反复" + ], + "anatomy_list": [] + }, + { + "core_name": "头晕", + "tendency": "", + "character": [ + "行走时" + ], + "anatomy_list": [ + "头" + ] + }, + { + "core_name": "心累", + "tendency": "", + "character": [ + "行走时" + ], + "anatomy_list": [ + "心" + ] + }, + { + "core_name": "胸闷", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "胸" + ] + }, + { + "core_name": "疼痛", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "胸" + ] + }, + { + "core_name": "疼痛", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "腹" + ] + }, + { + "core_name": "腹泻", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "腹" + ] + }, + { + "core_name": "癌", + "tendency": "", + "character": [], + "anatomy_list": [ + "肺" + ] + } + ] + }, + { + "id": 1142, + "text": "5月27日再次出现阴道流血,量少,无下腹及腰骶部疼痛疼痛不适,无发热、无头晕、晕厥、乏力,无尿频尿急、无尿痛,无腹泻,遂于某医院就诊,诊刮病检提示:子宫颈管恶性肿瘤;子宫腔恶性肿瘤,建议行免疫组化检查,明确病变性质及组织类型。", + "event": [ + { + "core_name": "出血", + "tendency": "", + "character": [ + "量少" + ], + "anatomy_list": [ + "阴道" + ] + }, + { + "core_name": "疼痛", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "下腹", + "腰骶部" + ] + }, + { + "core_name": "发热", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "头晕", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "头" + ] + }, + { + "core_name": "晕厥", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "乏力", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "尿频", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "尿急", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "尿痛", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "腹泻", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "腹" + ] + }, + { + "core_name": "肿瘤", + "tendency": "", + "character": [ + "恶性" + ], + "anatomy_list": [ + "子宫颈管" + ] + }, + { + "core_name": "肿瘤", + "tendency": "", + "character": [ + "恶性" + ], + "anatomy_list": [ + "子宫腔" + ] + } + ] + }, + { + "id": 899, + "text": "入院前1+周患者感双下肢水肿加重,伴咳嗽喘累明显,夜间不能平卧,伴咳嗽咳痰,痰呈白色粘痰,否认有痰中带血,伴呼吸困难气促,否认意识障碍、大小便失禁、视物旋转、胸闷、胸痛、恶心、呕吐、腹胀、腹痛、黑便等不适,来院复诊透析,门诊以“尿毒症、肺癌”收入我科住院治疗。", + "event": [ + { + "core_name": "水肿", + "tendency": "", + "character": [ + "加重" + ], + "anatomy_list": [ + "双下肢" + ] + }, + { + "core_name": "咳嗽", + "tendency": "", + "character": [ + "明显", + "夜间", + "夜间不能平卧" + ], + "anatomy_list": [] + }, + { + "core_name": "喘累", + "tendency": "", + "character": [ + "明显", + "夜间", + "夜间不能平卧" + ], + "anatomy_list": [] + }, + { + "core_name": "咳嗽", + "tendency": "", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "咳痰", + "tendency": "", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "咳痰", + "tendency": "", + "character": [ + "白色", + "粘性" + ], + "anatomy_list": [] + }, + { + "core_name": "咳痰", + "tendency": "否定", + "character": [ + "带血" + ], + "anatomy_list": [] + }, + { + "core_name": "呼吸困难", + "tendency": "", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "气促", + "tendency": "", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "意识障碍", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "大小便", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "视物旋转", + "tendency": "否定", + "character": [ + "旋转" + ], + "anatomy_list": [] + }, + { + "core_name": "胸闷", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "胸" + ] + }, + { + "core_name": "疼痛", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "胸" + ] + }, + { + "core_name": "恶心", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "呕吐", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "腹胀", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "腹" + ] + }, + { + "core_name": "疼痛", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "腹" + ] + }, + { + "core_name": "黑便", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "尿毒症", + "tendency": "", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "癌", + "tendency": "", + "character": [], + "anatomy_list": [ + "肺" + ] + } + ] + }, + { + "id": 883, + "text": "于2020-03就诊于某医学检查中心,完善腹部彩超提示肝内占位性病变,进一步完善上腹部ct提示肝内多发占位性病变,并考虑腹腔内淋巴结转移及肺内多发转移(具体报告未见)。", + "event": [ + { + "core_name": "病变", + "tendency": "", + "character": [ + "占位性" + ], + "anatomy_list": [ + "肝内" + ] + }, + { + "core_name": "病变", + "tendency": "", + "character": [ + "多发", + "占位性" + ], + "anatomy_list": [ + "肝内" + ] + }, + { + "core_name": "转移", + "tendency": "不确定", + "character": [], + "anatomy_list": [ + "腹腔内淋巴结" + ] + }, + { + "core_name": "转移", + "tendency": "不确定", + "character": [ + "多发" + ], + "anatomy_list": [ + "肺内" + ] + } + ] + }, + { + "id": 1079, + "text": "今入我院就诊,门诊以“痛风”收治入院。", + "event": [ + { + "core_name": "痛风", + "tendency": "", + "character": [], + "anatomy_list": [] + } + ] + }, + { + "id": 677, + "text": "2.右肺中叶及下叶炎症,建议治疗后短期复查”予以比阿培南、他唑仙抗感染,2017-1-15复查胸部ct示“1.双肺气肿;右肺中叶及下叶炎症,与(2017.1.5)ct平扫相比右下叶下叶炎症较前稍增加;其余改变同前,建议抗炎后短期复查”。", + "event": [ + { + "core_name": "炎症", + "tendency": "", + "character": [], + "anatomy_list": [ + "右肺中叶及下叶" + ] + }, + { + "core_name": "肺气肿", + "tendency": "", + "character": [], + "anatomy_list": [ + "双肺" + ] + }, + { + "core_name": "炎症", + "tendency": "", + "character": [], + "anatomy_list": [ + "右肺中叶及下叶" + ] + }, + { + "core_name": "炎症", + "tendency": "", + "character": [ + "较前稍增加" + ], + "anatomy_list": [ + "右肺中叶及下叶" + ] + } + ] + }, + { + "id": 78, + "text": "入院前10月余,患者无明显诱因出现左乳疼痛,疼痛较剧,无法忍受。", + "event": [ + { + "core_name": "疼痛", + "tendency": "", + "character": [ + "较剧", + "无法忍受" + ], + "anatomy_list": [ + "左乳" + ] + } + ] + }, + { + "id": 931, + "text": "期间患者仍反复出现皮肤瘙痒症状。", + "event": [ + { + "core_name": "皮肤瘙痒", + "tendency": "", + "character": [ + "反复出现" + ], + "anatomy_list": [] + } + ] + }, + { + "id": 1128, + "text": "化疗后肿瘤标志物较前下降,遂于2015-06-15予以紫杉醇脂质体180mg ivgtt d1+奈达铂40mg d1-2化疗,2015-07-13入院复查提示病情稳定,于2015-07-21采用原方案行第3周期化疗,化疗后出现轻度胃肠道反应,后好转出院,院外一般情况可,进食可,现为行下一周期化疗,门诊以“卵巢癌”收住我科。", + "event": [ + { + "core_name": "肿瘤标志物", + "tendency": "", + "character": [ + "较前下降" + ], + "anatomy_list": [] + }, + { + "core_name": "胃肠道反应", + "tendency": "", + "character": [ + "轻度" + ], + "anatomy_list": [ + "胃肠道" + ] + }, + { + "core_name": "进食", + "tendency": "", + "character": [ + "可" + ], + "anatomy_list": [] + }, + { + "core_name": "癌", + "tendency": "", + "character": [], + "anatomy_list": [ + "卵巢" + ] + } + ] + }, + { + "id": 756, + "text": "4.部分胸椎内高密度影请随访复查。", + "event": [ + { + "core_name": "密度影", + "tendency": "", + "character": [ + "高" + ], + "anatomy_list": [ + "部分胸椎内" + ] + } + ] + }, + { + "id": 1111, + "text": "今日患者拟行化疗来院,遂以“右肺癌术后化疗后复发复发伴颈部淋巴结转移放疗后”收入我科。", + "event": [ + { + "core_name": "复发", + "tendency": "", + "character": [ + "术后", + "化疗后" + ], + "anatomy_list": [ + "右肺" + ] + }, + { + "core_name": "转移", + "tendency": "", + "character": [ + "放疗后" + ], + "anatomy_list": [ + "颈部", + "淋巴结" + ] + } + ] + }, + { + "id": 1181, + "text": "2018年5月25日某医院血常规提示:白细胞总数163.41×109/l,红细胞计数4.74×1012/l,血红蛋白128g/L,血小板262×109/l;骨穿提示:慢性髓细胞白血病(慢性期);患者继续予以伊马替尼400mg维持治疗,血常规提示白细胞长长期处于升高状态。", + "event": [ + { + "core_name": "白血病", + "tendency": "", + "character": [ + "慢性", + "髓细胞", + "慢性期" + ], + "anatomy_list": [ + "髓细胞" + ] + }, + { + "core_name": "白细胞升高", + "tendency": "", + "character": [ + "长期" + ], + "anatomy_list": [ + "白细胞" + ] + } + ] + }, + { + "id": 462, + "text": "4.双手小关节、双侧膝关节良性病变较前无明显变化。", + "event": [ + { + "core_name": "病变", + "tendency": "", + "character": [ + "良性", + "较前无明显变化" + ], + "anatomy_list": [ + "双手小关节", + "双侧膝关节" + ] + } + ] + }, + { + "id": 247, + "text": "后患者于洗澡时摸到右下腹包块,遂就诊于某医院,行腹部增强ct示:肝内多发团块状高密度影,最大者直径约12cm,增强扫描动脉期呈不均匀明显强化,考虑为肝癌并肝内转移可能性大。", + "event": [ + { + "core_name": "包块", + "tendency": "", + "character": [], + "anatomy_list": [ + "右下腹" + ] + }, + { + "core_name": "密度影", + "tendency": "", + "character": [ + "高", + "多发", + "团块状", + "最大者直径约12cm" + ], + "anatomy_list": [ + "肝内" + ] + }, + { + "core_name": "强化", + "tendency": "", + "character": [ + "增强扫描", + "动脉期呈不均匀", + "明显" + ], + "anatomy_list": [] + }, + { + "core_name": "癌", + "tendency": "不确定", + "character": [], + "anatomy_list": [ + "肝" + ] + }, + { + "core_name": "转移", + "tendency": "不确定", + "character": [], + "anatomy_list": [ + "肝内" + ] + } + ] + }, + { + "id": 930, + "text": "入院前7年,患者无明显诱因出现皮肤瘙痒,主要表现在双手前臂尺侧及下腹部,搔抓后可呈风团样,每次服用“湿毒清胶囊“10余天后可明显缓解,缓解后可留有色素沉着,患者未重视,未进行正规治疗。", + "event": [ + { + "core_name": "瘙痒", + "tendency": "", + "character": [ + "搔抓后可呈风团样" + ], + "anatomy_list": [ + "双前臂尺侧皮肤" + ] + }, + { + "core_name": "瘙痒", + "tendency": "", + "character": [ + "搔抓后可呈风团样" + ], + "anatomy_list": [ + "下腹部皮肤" + ] + }, + { + "core_name": "色素沉着", + "tendency": "", + "character": [ + "缓解后" + ], + "anatomy_list": [] + } + ] + }, + { + "id": 966, + "text": "20天前患者因胸痛加重,行pet- ct提示右胸膜转移转移灶,遂到某医院就诊,于2016-4-26至2016-5-10行伽马刀治疗,治疗右肺右胸膜病灶,以50%等剂量曲线包绕,边缘单次剂量400cgy,总剂量4000cgy,过程顺利,未诉不适。", + "event": [ + { + "core_name": "疼痛", + "tendency": "", + "character": [ + "加重" + ], + "anatomy_list": [ + "胸" + ] + }, + { + "core_name": "转移灶", + "tendency": "", + "character": [], + "anatomy_list": [ + "右胸膜" + ] + }, + { + "core_name": "病���", + "tendency": "", + "character": [], + "anatomy_list": [ + "右肺" + ] + }, + { + "core_name": "病灶", + "tendency": "", + "character": [], + "anatomy_list": [ + "右肺胸膜" + ] + } + ] + }, + { + "id": 1326, + "text": "与患者及家属沟通后于2019-4-23至今更换方案为哌柏西利125mg*21d+氟维司群500mg30d,患者于3天前出现头晕伴呕吐,不伴发热寒战等不适,现患者为行进一步治疗,故来我科。", + "event": [ + { + "core_name": "头晕", + "tendency": "", + "character": [], + "anatomy_list": [ + "头" + ] + }, + { + "core_name": "呕吐", + "tendency": "", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "发热", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "寒颤", + "tendency": "否定", + "character": [], + "anatomy_list": [] + } + ] + }, + { + "id": 1773, + "text": "乳头未见累及,腋窝淋巴结见癌转移(4/11),免疫组化:er(-),pr(-),her-2(+),ki676730%,术后予tec方案化疗,化疗后无不良反应,今患者为行第2次化疗入我科住院治疗,门诊以“左乳癌术后,第1次化疗后”。", + "event": [ + { + "core_name": "累及", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "乳头" + ] + }, + { + "core_name": "癌", + "tendency": "", + "character": [ + "转移" + ], + "anatomy_list": [ + "腋窝淋巴结" + ] + }, + { + "core_name": "不良反应", + "tendency": "否定", + "character": [ + "化疗后" + ], + "anatomy_list": [] + }, + { + "core_name": "癌", + "tendency": "", + "character": [ + "术后", + "第1次化疗后" + ], + "anatomy_list": [ + "左乳" + ] + } + ] + }, + { + "id": 1058, + "text": "到某医院查:“胃镜:慢性胃窦炎,腹部ct:未见明显异常”,予“雷贝拉唑、莫沙必利”等治疗后可好转,但症状反复。", + "event": [ + { + "core_name": "胃窦炎", + "tendency": "", + "character": [ + "慢性" + ], + "anatomy_list": [ + "胃窦" + ] + } + ] + }, + { + "id": 1465, + "text": "诊断为“冠状动脉粥样硬化性心脏病”,术后规律冠心病二级预防治疗(阿托伐他汀钙片、硫酸氢氯吡格雷),于3天前因“咯血”停用硫酸氢氯吡格雷,病灶中偶有心前区不适及间断双下肢水肿。", + "event": [ + { + "core_name": "心脏病", + "tendency": "", + "character": [ + "粥样", + "硬化性" + ], + "anatomy_list": [ + "冠状动脉", + "心脏" + ] + }, + { + "core_name": "咯血", + "tendency": "", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "病灶", + "tendency": "", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "心前区不适", + "tendency": "", + "character": [], + "anatomy_list": [ + "心前区" + ] + }, + { + "core_name": "水肿", + "tendency": "", + "character": [ + "间断" + ], + "anatomy_list": [ + "双下肢" + ] + } + ] + }, + { + "id": 96, + "text": "病程中伴有头晕、乏力症状,无头痛、腹痛及腹胀等。", + "event": [ + { + "core_name": "头晕", + "tendency": "", + "character": [], + "anatomy_list": [ + "头" + ] + }, + { + "core_name": "乏力", + "tendency": "", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "疼痛", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "头" + ] + }, + { + "core_name": "疼痛", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "腹" + ] + }, + { + "core_name": "腹胀", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "腹" + ] + } + ] + }, + { + "id": 215, + "text": "随后于我科住院,完善腹部彩超(2020-3-31):左肾结石;右肾结晶沉着。", + "event": [ + { + "core_name": "结石", + "tendency": "", + "character": [], + "anatomy_list": [ + "左肾" + ] + }, + { + "core_name": "结晶", + "tendency": "", + "character": [ + "沉着" + ], + "anatomy_list": [ + "右肾" + ] + } + ] + }, + { + "id": 9, + "text": "近半年来患者反复感咳嗽气喘,长期在我院及某医院就诊,患者逐渐有心累并下肢浮肿,间断服用利尿剂。", + "event": [ + { + "core_name": "咳嗽", + "tendency": "", + "character": [ + "反复" + ], + "anatomy_list": [] + }, + { + "core_name": "气喘", + "tendency": "", + "character": [ + "反复" + ], + "anatomy_list": [] + }, + { + "core_name": "浮肿", + "tendency": "", + "character": [ + "逐渐" + ], + "anatomy_list": [ + "下肢" + ] + }, + { + "core_name": "心累", + "tendency": "", + "character": [ + "逐渐" + ], + "anatomy_list": [ + "心" + ] + } + ] + }, + { + "id": 309, + "text": "术后予以抗感染、祛痰、雾化等对症支持治疗,拔除胸引管后出院,患者现诉无咳嗽咳痰、胸痛胸闷气促、头痛头晕、骨痛、心慌等不适,今患者为行化疗就诊于我院门诊,并以“右肺恶性肿瘤术后”收入我科。", + "event": [ + { + "core_name": "咳嗽", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "咳痰", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "疼痛", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "胸" + ] + }, + { + "core_name": "胸闷", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "胸" + ] + }, + { + "core_name": "气促", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "疼痛", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "头" + ] + }, + { + "core_name": "头晕", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "头" + ] + }, + { + "core_name": "疼痛", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "骨" + ] + }, + { + "core_name": "心慌", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "心" + ] + }, + { + "core_name": "肿瘤", + "tendency": "", + "character": [ + "术后", + "恶性" + ], + "anatomy_list": [ + "右肺" + ] + } + ] + }, + { + "id": 940, + "text": "2019-6-6于我院复查胸腹部ct示:1、胸部与2018-11-6片比较:右肺上叶病灶略有增大,周围肺叶更明显。", + "event": [ + { + "core_name": "病灶", + "tendency": "", + "character": [ + "略有增大" + ], + "anatomy_list": [ + "右肺上叶" + ] + }, + { + "core_name": "病灶", + "tendency": "", + "character": [ + "更明显" + ], + "anatomy_list": [ + "周围肺叶" + ] + } + ] + }, + { + "id": 147, + "text": "今患者为求进一步治疗,遂至我院,门诊以“左侧输尿管支架置入术后,泌尿系结核,糖尿病”收入我科住院治疗。", + "event": [ + { + "core_name": "结核", + "tendency": "", + "character": [], + "anatomy_list": [ + "泌尿系" + ] + }, + { + "core_name": "糖尿病", + "tendency": "", + "character": [], + "anatomy_list": [] + } + ] + }, + { + "id": 548, + "text": "院外患者仍咳嗽、咳痰,伴右侧胸闷,伴乏力、活动后喘累,自服止咳药物后症状无明显缓解,遂入住我科,行ect(2014-10-29)未见明显骨转移,与患者家属沟通后,同意化疗,遂于2014-11-05、2014-11-29、2014-12-24、2015-01-21行“奈达铂100mg d1+吉西他滨1200mg d1、8”方案化疗4周期,化疗后,患者自觉咳嗽、胸闷、活动后喘累明显好转,于2015-01-09复查胸部增强ct提示右肺占位较化疗前明显缩小,于2015-02-07我院门诊复查血常规提示:白细胞 1.85×109/l,中性粒细胞 0.94×109/l,血小板 34×109/l。", + "event": [ + { + "core_name": "咳嗽", + "tendency": "", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "咳痰", + "tendency": "", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "胸闷", + "tendency": "", + "character": [ + "右侧" + ], + "anatomy_list": [ + "胸" + ] + }, + { + "core_name": "乏力", + "tendency": "", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "喘累", + "tendency": "", + "character": [ + "活动后" + ], + "anatomy_list": [] + }, + { + "core_name": "转移", + "tendency": "否定", + "character": [ + "明显" + ], + "anatomy_list": [ + "骨组织" + ] + }, + { + "core_name": "咳嗽", + "tendency": "", + "character": [ + "明显好转" + ], + "anatomy_list": [] + }, + { + "core_name": "胸闷", + "tendency": "", + "character": [ + "明显好转" + ], + "anatomy_list": [ + "胸" + ] + }, + { + "core_name": "喘累", + "tendency": "", + "character": [ + "活动后", + "明显好转" + ], + "anatomy_list": [] + }, + { + "core_name": "占位", + "tendency": "", + "character": [ + "明显", + "缩小", + "较化疗前" + ], + "anatomy_list": [ + "右肺" + ] + } + ] + }, + { + "id": 2060, + "text": "患者本次发病以来,食欲正常,神志清醒,精神尚可,睡眠尚可,大便正常,小便正常,体重无明显变化。", + "event": [ + { + "core_name": "食欲", + "tendency": "", + "character": [ + "正常" + ], + "anatomy_list": [] + }, + { + "core_name": "神志", + "tendency": "", + "character": [ + "清醒" + ], + "anatomy_list": [] + }, + { + "core_name": "精神", + "tendency": "", + "character": [ + "尚可" + ], + "anatomy_list": [] + }, + { + "core_name": "睡眠", + "tendency": "", + "character": [ + "尚可" + ], + "anatomy_list": [] + }, + { + "core_name": "大便", + "tendency": "", + "character": [ + "正常" + ], + "anatomy_list": [] + }, + { + "core_name": "小便", + "tendency": "", + "character": [ + "正常" + ], + "anatomy_list": [] + }, + { + "core_name": "体重改变", + "tendency": "否定", + "character": [ + "明显" + ], + "anatomy_list": [] + } + ] + }, + { + "id": 701, + "text": "7天前,患者感上腹胀程度较前加重,遂就诊于当地某诊所,给予输液治疗(具体不详),症状无好转,患者为求进一步诊治,就诊于我院,门诊以“上腹胀待查”收入我科住院治疗。", + "event": [ + { + "core_name": "腹胀", + "tendency": "", + "character": [ + "较前加重" + ], + "anatomy_list": [ + "上腹" + ] + }, + { + "core_name": "腹胀", + "tendency": "", + "character": [], + "anatomy_list": [ + "上腹" + ] + } + ] + }, + { + "id": 1068, + "text": "遂于某医院就诊,行浅表淋巴结彩超示:左侧腹股沟腹股沟区淋巴结淋巴结增大,行左侧腹股沟淋巴结腹股沟淋巴结活检示:(左侧腹股沟)淋巴结 弥漫大b细胞淋巴瘤。", + "event": [ + { + "core_name": "增大", + "tendency": "", + "character": [], + "anatomy_list": [ + "左侧腹股沟区淋巴结" + ] + }, + { + "core_name": "瘤", + "tendency": "", + "character": [ + "弥漫" + ], + "anatomy_list": [ + "左侧腹股沟淋巴结", + "大B细胞" + ] + } + ] + }, + { + "id": 532, + "text": "患者20余年前无明显诱因出现口干、多饮、多尿,每日饮食量及尿量不详,伴夜尿增多,至某医院测血糖12.7mmol/L,给予口服药治疗(具体方案不详),未规律监测血糖。", + "event": [ + { + "core_name": "口干", + "tendency": "", + "character": [], + "anatomy_list": [ + "口" + ] + }, + { + "core_name": "多饮", + "tendency": "", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "多尿", + "tendency": "", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "饮食量", + "tendency": "", + "character": [ + "每日", + "不详" + ], + "anatomy_list": [] + }, + { + "core_name": "尿量", + "tendency": "", + "character": [ + "每日", + "不详" + ], + "anatomy_list": [] + }, + { + "core_name": "排尿", + "tendency": "", + "character": [ + "夜间", + "增多" + ], + "anatomy_list": [] + } + ] + }, + { + "id": 326, + "text": "现患者为求进一步诊治遂入我院,门诊以“左乳包块待查”收入我科。", + "event": [ + { + "core_name": "包块", + "tendency": "不确定", + "character": [], + "anatomy_list": [ + "左乳" + ] + } + ] + }, + { + "id": 1980, + "text": "患者本次发病以来,食欲正常, 神志清醒,精神尚可,睡眠尚可,大便正常,小便正常,近7月体重减轻约5kg。", + "event": [ + { + "core_name": "食欲", + "tendency": "", + "character": [ + "正常" + ], + "anatomy_list": [] + }, + { + "core_name": "神志", + "tendency": "", + "character": [ + "清醒" + ], + "anatomy_list": [] + }, + { + "core_name": "精神", + "tendency": "", + "character": [ + "尚可" + ], + "anatomy_list": [] + }, + { + "core_name": "睡眠", + "tendency": "", + "character": [ + "尚可" + ], + "anatomy_list": [] + }, + { + "core_name": "大便", + "tendency": "", + "character": [ + "正常" + ], + "anatomy_list": [] + }, + { + "core_name": "小便", + "tendency": "", + "character": [ + "正常" + ], + "anatomy_list": [] + }, + { + "core_name": "体重减轻", + "tendency": "", + "character": [], + "anatomy_list": [] + } + ] + }, + { + "id": 1299, + "text": "患者无声嘶、呼吸困难,无畏寒、发热,无恶心、呕吐,无心悸、食欲亢进、大汗淋漓等不适,3天前于我院门诊就诊,完善彩超提示:(2018-06-15)甲状腺双侧低回声结节,建议穿刺活检;今患者为进一步治疗,遂来我院就诊,门诊以“双侧甲状腺甲状腺包块待查?”收入我科住院治疗。", + "event": [ + { + "core_name": "声嘶", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "呼吸困难", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "畏寒", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "发热", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "恶心", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "呕吐", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "心悸", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "心" + ] + }, + { + "core_name": "食欲", + "tendency": "否定", + "character": [ + "亢进" + ], + "anatomy_list": [] + }, + { + "core_name": "出汗", + "tendency": "否定", + "character": [ + "大汗" + ], + "anatomy_list": [] + }, + { + "core_name": "结节", + "tendency": "", + "character": [ + "低回声" + ], + "anatomy_list": [ + "甲状腺双侧" + ] + }, + { + "core_name": "包块", + "tendency": "不确定", + "character": [], + "anatomy_list": [ + "双侧甲状腺" + ] + } + ] + }, + { + "id": 258, + "text": "腹部不适与进食、活动、体位无明显关系,无肩背部放射痛。", + "event": [ + { + "core_name": "腹部不适", + "tendency": "", + "character": [ + "与进食、活动、体位无明显关系" + ], + "anatomy_list": [ + "腹部" + ] + }, + { + "core_name": "疼痛", + "tendency": "否定", + "character": [ + "放射性" + ], + "anatomy_list": [ + "肩", + "背部" + ] + } + ] + }, + { + "id": 706, + "text": "今患者为求进一步治疗,来我院,门诊以“心律失常”收入我科。", + "event": [ + { + "core_name": "心律失常", + "tendency": "", + "character": [], + "anatomy_list": [ + "心" + ] + } + ] + }, + { + "id": 765, + "text": "基因检测(胸水):egfr基因为T790M和19-del突变,b-raf基因、met基因、ros1基因、alk基因均为阴性。", + "event": [ + { + "core_name": "胸水", + "tendency": "", + "character": [], + "anatomy_list": [ + "胸" + ] + } + ] + }, + { + "id": 1730, + "text": "为进一步明确诊治血象改变原因遂就诊血液科,查心电图正常,骨髓“增生性贫血骨髓象”,骨髓活检未见异常,诊断“骨髓增生异常综合征(ms-rcmd)”,给予“利可君、维生素b6、维生素b4、生血宝合剂、骨化三醇、复方皂凡丸、胸腺肽”等药物治疗,血小板曾恢复正常,血色素有所提升。", + "event": [ + { + "core_name": "血象", + "tendency": "不确定", + "character": [ + "改变" + ], + "anatomy_list": [] + }, + { + "core_name": "骨髓象", + "tendency": "", + "character": [ + "增生性", + "贫血" + ], + "anatomy_list": [ + "骨髓" + ] + }, + { + "core_name": "骨髓增生异常综合征", + "tendency": "", + "character": [], + "anatomy_list": [ + "骨髓" + ] + } + ] + }, + { + "id": 1967, + "text": "无呕血、粘液脓血便。", + "event": [ + { + "core_name": "呕血", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "大便", + "tendency": "否定", + "character": [ + "粘液", + "血", + "脓" + ], + "anatomy_list": [] + } + ] + }, + { + "id": 1380, + "text": "2.右肺中叶内侧段、下叶背段、左肺上叶尖后段、下叶后基底段纤维化灶。", + "event": [ + { + "core_name": "纤维化灶", + "tendency": "", + "character": [], + "anatomy_list": [ + "右肺中叶内侧段、下叶背段", + "左肺上叶尖后段、下叶后基底段" + ] + } + ] + }, + { + "id": 1952, + "text": "、给予患者曲普瑞林3.75mg每月1次+比卡鲁胺50mg内分泌治疗、唑来膦酸抑制骨破坏以及多西他赛化疗,治疗后患者夜尿增多症状明显好转,今为求第三周期化疗于我院就诊,门诊以\"前列腺癌伴骨转移\"收住入院.", + "event": [ + { + "core_name": "夜尿增多", + "tendency": "", + "character": [ + "治疗后", + "明显好转" + ], + "anatomy_list": [] + }, + { + "core_name": "癌", + "tendency": "", + "character": [], + "anatomy_list": [ + "前列腺" + ] + }, + { + "core_name": "癌", + "tendency": "", + "character": [ + "转移" + ], + "anatomy_list": [ + "骨" + ] + } + ] + }, + { + "id": 1525, + "text": "病程中患者精神、饮食稍差,大便干燥,小便口服利尿剂尚可,体重无明显下降。", + "event": [ + { + "core_name": "精神", + "tendency": "", + "character": [ + "稍差" + ], + "anatomy_list": [] + }, + { + "core_name": "饮食", + "tendency": "", + "character": [ + "稍差" + ], + "anatomy_list": [] + }, + { + "core_name": "大便", + "tendency": "", + "character": [ + "干燥" + ], + "anatomy_list": [] + }, + { + "core_name": "小便", + "tendency": "", + "character": [ + "口服利尿剂尚可" + ], + "anatomy_list": [] + }, + { + "core_name": "体重下降", + "tendency": "否定", + "character": [ + "明显" + ], + "anatomy_list": [] + } + ] + }, + { + "id": 1360, + "text": "遂于2016-08-26在某卫生院完善胸部ct:1.左肺类圆形软组织密度影,建议进一步确诊;2.慢支改变;3.左侧胸膜肥厚伴钙化。", + "event": [ + { + "core_name": "密度影", + "tendency": "不确定", + "character": [ + "类圆形", + "软组织" + ], + "anatomy_list": [ + "左肺" + ] + }, + { + "core_name": "支气管炎", + "tendency": "", + "character": [ + "慢性" + ], + "anatomy_list": [ + "支气管" + ] + }, + { + "core_name": "钙化", + "tendency": "", + "character": [], + "anatomy_list": [ + "左侧胸膜" + ] + }, + { + "core_name": "肥厚", + "tendency": "", + "character": [], + "anatomy_list": [ + "左侧胸膜" + ] + } + ] + }, + { + "id": 722, + "text": "术后恢复可,遂行第1周期化疗(奥沙利铂150mg d1),化疗中出现严重消化道反应,无骨髓抑制,经对症处理后好转。", + "event": [ + { + "core_name": "消化道反应", + "tendency": "", + "character": [ + "严重" + ], + "anatomy_list": [ + "消化道" + ] + }, + { + "core_name": "骨髓抑制", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "骨髓" + ] + } + ] + }, + { + "id": 511, + "text": "术后患者诉进食梗阻感较术前好转,无特殊不适。", + "event": [ + { + "core_name": "梗阻感", + "tendency": "", + "character": [ + "进食", + "较术前好转" + ], + "anatomy_list": [] + } + ] + }, + { + "id": 506, + "text": "入院 2+月 前,不明原因出现进食干性食物时吞咽梗阻,常在进食过多、过快时发生,进食半流质及流质食物无梗阻,无胸骨后疼痛,无饮水呛咳、烧心、泛酸、嗳气,无胸闷及心前区压榨感,未予重视及诊治。", + "event": [ + { + "core_name": "吞咽梗阻", + "tendency": "", + "character": [ + "进食干性食物时", + "进食过多、过快时发生" + ], + "anatomy_list": [] + }, + { + "core_name": "梗阻", + "tendency": "否定", + "character": [ + "进食半流质及流质食物" + ], + "anatomy_list": [] + }, + { + "core_name": "疼痛", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "胸骨后" + ] + }, + { + "core_name": "呛咳", + "tendency": "否定", + "character": [ + "饮水" + ], + "anatomy_list": [] + }, + { + "core_name": "烧心", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "泛酸", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "嗳气", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "胸闷", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "胸" + ] + }, + { + "core_name": "压榨感", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "心前区" + ] + } + ] + }, + { + "id": 262, + "text": "门诊以“胃溃疡”收入我科。", + "event": [ + { + "core_name": "溃疡", + "tendency": "", + "character": [], + "anatomy_list": [ + "胃" + ] + } + ] + }, + { + "id": 562, + "text": "今为求进一步诊治来我院,门诊以“腹痛待查”收治入院。", + "event": [ + { + "core_name": "疼痛", + "tendency": "", + "character": [], + "anatomy_list": [ + "腹" + ] + } + ] + }, + { + "id": 1370, + "text": "入院前1+月,患者单位体检时查血常规提示白细胞升高(不详),无畏寒、发热,无头昏、乏力,无耳鸣,无视力障碍,无鼻塞、流涕,无头痛、呕吐及意识障碍,无咽痛、咳嗽、咳痰,无皮下瘀斑、瘀点,无牙龈出血,无关节疼痛,无呕血、黑便、便血,无腹痛、腹泻,无肛周疼痛,无尿频、尿急、尿痛及肉眼血尿等,在某医院查骨髓涂片、骨髓活检、流式检测等检查后诊断为慢性粒细胞白血病(未见报告),院外口服羟基脲2片、bid治疗,患者今日为求进一步诊治来院,我科以“慢性粒细胞白细胞”收住入院。", + "event": [ + { + "core_name": "白细胞升高", + "tendency": "", + "character": [], + "anatomy_list": [ + "白细胞" + ] + }, + { + "core_name": "畏寒", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "发热", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "头昏", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "头" + ] + }, + { + "core_name": "乏力", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "耳鸣", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "耳" + ] + }, + { + "core_name": "视力障碍", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "鼻塞", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "鼻" + ] + }, + { + "core_name": "流涕", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "疼痛", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "头" + ] + }, + { + "core_name": "呕吐", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "意识障碍", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "疼痛", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "咽" + ] + }, + { + "core_name": "咳嗽", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "咳痰", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "瘀斑", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "皮下" + ] + }, + { + "core_name": "瘀点", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "皮下" + ] + }, + { + "core_name": "出血", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "牙龈" + ] + }, + { + "core_name": "疼痛", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "关节" + ] + }, + { + "core_name": "呕血", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "黑便", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "便血", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "疼痛", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "腹" + ] + }, + { + "core_name": "腹泻", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "腹" + ] + }, + { + "core_name": "疼痛", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "肛周" + ] + }, + { + "core_name": "尿频", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "尿急", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "尿痛", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "血尿", + "tendency": "", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "白血病", + "tendency": "", + "character": [ + "慢性" + ], + "anatomy_list": [ + "粒细胞" + ] + } + ] + }, + { + "id": 1715, + "text": "入院前5天,患者无意中发现左侧乳房乳房包块,包块如“豌豆”大小,无明显疼痛感,无乳头溢脓、渗液、出血,无乳房表面皮肤发红、皲裂、皱褶,遂来我院就诊,查乳腺彩超提示:左乳腺异常回声,bi-rads4b类,为求进一步诊治,门诊以“乳房肿块”收入我科。", + "event": [ + { + "core_name": "包块", + "tendency": "", + "character": [ + "豌豆大小", + "无明显疼痛感" + ], + "anatomy_list": [ + "左侧乳房" + ] + }, + { + "core_name": "疼痛", + "tendency": "否定", + "character": [ + "明显" + ], + "anatomy_list": [ + "左侧乳房" + ] + }, + { + "core_name": "溢脓", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "乳头" + ] + }, + { + "core_name": "渗液", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "乳头" + ] + }, + { + "core_name": "出血", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "乳头" + ] + }, + { + "core_name": "发红", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "乳房表面皮肤" + ] + }, + { + "core_name": "皲裂", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "乳房表面皮肤" + ] + }, + { + "core_name": "皱褶", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "乳房表面皮肤" + ] + }, + { + "core_name": "异常回声", + "tendency": "", + "character": [ + "bi-rads4b类" + ], + "anatomy_list": [ + "左乳腺" + ] + }, + { + "core_name": "肿块", + "tendency": "", + "character": [], + "anatomy_list": [ + "乳房" + ] + } + ] + }, + { + "id": 1287, + "text": "今为求进一步放疗,以“宫颈癌”收入我科住院治疗。", + "event": [ + { + "core_name": "癌", + "tendency": "", + "character": [], + "anatomy_list": [ + "宫颈" + ] + } + ] + }, + { + "id": 481, + "text": "2020年1月包块增大,至某医院就诊,行口腔包块切除,嘱患者观察颈部包块。", + "event": [ + { + "core_name": "包块增大", + "tendency": "", + "character": [ + "增大" + ], + "anatomy_list": [] + }, + { + "core_name": "包块", + "tendency": "", + "character": [], + "anatomy_list": [ + "颈部" + ] + } + ] + }, + { + "id": 889, + "text": "患者本次发病以来,食欲正常,神志清醒,精神尚可,睡眠尚可,大小便如上所述,体重无明显变化。", + "event": [ + { + "core_name": "食欲", + "tendency": "", + "character": [ + "正常" + ], + "anatomy_list": [] + }, + { + "core_name": "神志", + "tendency": "", + "character": [ + "清醒" + ], + "anatomy_list": [] + }, + { + "core_name": "精神", + "tendency": "", + "character": [ + "尚可" + ], + "anatomy_list": [] + }, + { + "core_name": "睡眠", + "tendency": "", + "character": [ + "尚可" + ], + "anatomy_list": [] + }, + { + "core_name": "体重改变", + "tendency": "否定", + "character": [ + "明显" + ], + "anatomy_list": [] + } + ] + }, + { + "id": 1509, + "text": "入院前1+月,患者无明显出现左侧下肢部疼痛,为持续性胀痛,久坐、久站后加重,卧位休息可缓解,腰骶部疼痛反复发作,以左大腿后侧后外侧、小腿后侧,为进一步诊疗,遂来我院就诊,行腰椎ct提示:腰椎退行性变;腰44椎体i°滑脱,腰1椎体向后右侧移位,腰33椎体向左移位,椎间盘变性,腰11/2、3/4、4/5、腰5/骶1椎间盘膨出。", + "event": [ + { + "core_name": "疼痛", + "tendency": "", + "character": [ + "为持续性胀痛", + "久坐久站后加重", + "卧位休息可缓解" + ], + "anatomy_list": [ + "左侧下肢" + ] + }, + { + "core_name": "疼痛", + "tendency": "", + "character": [ + "反复发作" + ], + "anatomy_list": [ + "腰骶部" + ] + }, + { + "core_name": "病变", + "tendency": "", + "character": [ + "退行性" + ], + "anatomy_list": [ + "腰椎" + ] + }, + { + "core_name": "滑脱", + "tendency": "", + "character": [ + "i°" + ], + "anatomy_list": [ + "腰L4椎体" + ] + }, + { + "core_name": "移位", + "tendency": "", + "character": [ + "向后右侧" + ], + "anatomy_list": [ + "腰L1椎体" + ] + }, + { + "core_name": "移位", + "tendency": "", + "character": [ + "向左" + ], + "anatomy_list": [ + "腰L3椎体" + ] + }, + { + "core_name": "变性", + "tendency": "", + "character": [ + "向左" + ], + "anatomy_list": [ + "腰3椎体", + "椎间盘" + ] + }, + { + "core_name": "膨出", + "tendency": "", + "character": [], + "anatomy_list": [ + "腰1/2、3/4、4/5、腰5/骶1椎间盘" + ] + } + ] + }, + { + "id": 1983, + "text": "入院前8小时,患者在夜间洗澡受凉后突然出现头晕,呈持续性,体位变化时头晕加重,伴恶心、呕吐非血性胃内容物,伴畏寒、寒战,偶有心前区不适感,患者不能准确描述是否有视物旋转,无耳鸣、耳聋,无发热、咳嗽、咳痰,无意识障碍、肢体活动障碍、肢体抽搐、大小便失禁。患者未予以重视及处理。", + "event": [ + { + "core_name": "头晕", + "tendency": "", + "character": [ + "持续性", + "夜间洗澡受凉后" + ], + "anatomy_list": [ + "头" + ] + }, + { + "core_name": "头晕", + "tendency": "", + "character": [ + "体位变化时加重" + ], + "anatomy_list": [ + "头" + ] + }, + { + "core_name": "恶心", + "tendency": "", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "呕吐", + "tendency": "", + "character": [ + "非血性胃内容物" + ], + "anatomy_list": [] + }, + { + "core_name": "畏寒", + "tendency": "", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "寒颤", + "tendency": "", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "心前区不适感", + "tendency": "", + "character": [ + "偶有" + ], + "anatomy_list": [ + "心前区" + ] + }, + { + "core_name": "视物旋转", + "tendency": "不确定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "耳鸣", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "耳" + ] + }, + { + "core_name": "耳聋", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "耳" + ] + }, + { + "core_name": "发热", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "咳嗽", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "咳痰", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "意识障碍", + "tendency": "", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "活动障碍", + "tendency": "", + "character": [], + "anatomy_list": [ + "肢体" + ] + }, + { + "core_name": "抽搐", + "tendency": "", + "character": [], + "anatomy_list": [ + "肢体" + ] + }, + { + "core_name": "大小便失禁", + "tendency": "", + "character": [ + "失禁" + ], + "anatomy_list": [] + } + ] + }, + { + "id": 907, + "text": "病后精神尚可,食欲好,小便正常,大便正常。", + "event": [ + { + "core_name": "精神", + "tendency": "", + "character": [ + "尚可" + ], + "anatomy_list": [] + }, + { + "core_name": "食欲", + "tendency": "", + "character": [ + "好" + ], + "anatomy_list": [] + }, + { + "core_name": "小便", + "tendency": "", + "character": [ + "正常" + ], + "anatomy_list": [] + }, + { + "core_name": "大便", + "tendency": "", + "character": [ + "正常" + ], + "anatomy_list": [] + } + ] + }, + { + "id": 685, + "text": "遂至某医院行petct检查提示:胸腺瘤,恶性可能性较大(未见报告);于2016-11-03在全麻下行胸腔镜下纵隔肿瘤切除术+心包部分切除术,术中见胸膜腔腔内广泛粘连,无明显积液,手术顺利,标本送病检(病理号123456)提示:胸腺鳞状细胞癌;术后好转出院,偶有咳嗽、头昏,无明显胸闷、呼吸困难,无咯血,无畏寒、发热,无恶心呕吐,无腹胀、腹泻等症状;现患者为行第一次化疗,遂至我院就诊,门诊以“胸腺癌术后”收入我科住院治疗。", + "event": [ + { + "core_name": "瘤", + "tendency": "不确定", + "character": [ + "恶性" + ], + "anatomy_list": [ + "胸腺" + ] + }, + { + "core_name": "粘连", + "tendency": "", + "character": [ + "广泛" + ], + "anatomy_list": [ + "胸膜腔内" + ] + }, + { + "core_name": "积液", + "tendency": "否定", + "character": [ + "明显" + ], + "anatomy_list": [ + "胸膜腔内" + ] + }, + { + "core_name": "鳞癌", + "tendency": "", + "character": [], + "anatomy_list": [ + "胸腺" + ] + }, + { + "core_name": "咳嗽", + "tendency": "", + "character": [ + "偶有" + ], + "anatomy_list": [] + }, + { + "core_name": "头昏", + "tendency": "", + "character": [ + "偶有" + ], + "anatomy_list": [ + "头" + ] + }, + { + "core_name": "胸闷", + "tendency": "否定", + "character": [ + "明显" + ], + "anatomy_list": [ + "胸" + ] + }, + { + "core_name": "呼吸困难", + "tendency": "否定", + "character": [ + "明显" + ], + "anatomy_list": [] + }, + { + "core_name": "咯血", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "畏寒", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "发热", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "恶心", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "呕吐", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "腹胀", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "腹" + ] + }, + { + "core_name": "腹泻", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "腹" + ] + }, + { + "core_name": "癌", + "tendency": "", + "character": [ + "术后" + ], + "anatomy_list": [ + "胸腺" + ] + } + ] + }, + { + "id": 735, + "text": "入院前10天,患者受凉后出现咳嗽、咳痰,为白色泡沫痰,伴痰中带鲜红色血,量少,无发热、畏寒、寒战,无胸痛、胸闷、呼吸困难,无头昏、头痛,无端坐呼吸及夜间阵发性呼吸困难,无双下肢水肿,于当地诊所自行购买感冒药(具体药物不详)后无好转,入院2天前,患者咳嗽、咳痰仍明显,为求进一步治疗,遂至我院,门诊行胸部ct提示右肺下叶支气管气管周围肿块,考虑中央型肺癌,门诊以“左肺块待查”收入我科住院治疗。", + "event": [ + { + "core_name": "咳嗽", + "tendency": "", + "character": [ + "受凉后" + ], + "anatomy_list": [] + }, + { + "core_name": "咳痰", + "tendency": "", + "character": [ + "受凉后", + "白色", + "泡沫痰" + ], + "anatomy_list": [] + }, + { + "core_name": "咳痰", + "tendency": "", + "character": [ + "鲜红色血", + "量少" + ], + "anatomy_list": [] + }, + { + "core_name": "发热", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "畏寒", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "寒战", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "疼痛", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "胸" + ] + }, + { + "core_name": "胸闷", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "胸" + ] + }, + { + "core_name": "呼吸困难", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "头昏", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "头" + ] + }, + { + "core_name": "疼痛", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "头" + ] + }, + { + "core_name": "端坐呼吸", + "tendency": "否定", + "character": [], + "anatomy_list": [] + }, + { + "core_name": "呼吸困难", + "tendency": "否定", + "character": [ + "夜间", + "阵发性" + ], + "anatomy_list": [] + }, + { + "core_name": "水肿", + "tendency": "否定", + "character": [], + "anatomy_list": [ + "双下肢" + ] + }, + { + "core_name": "咳嗽", + "tendency": "", + "character": [ + "明显" + ], + "anatomy_list": [] + }, + { + "core_name": "咳痰", + "tendency": "", + "character": [ + "明显" + ], + "anatomy_list": [] + }, + { + "core_name": "肿块", + "tendency": "", + "character": [], + "anatomy_list": [ + "右肺下叶", + "支气管气管周围" + ] + }, + { + "core_name": "癌", + "tendency": "不确定", + "character": [ + "中央型" + ], + "anatomy_list": [ + "肺" + ] + }, + { + "core_name": "肿块", + "tendency": "", + "character": [], + "anatomy_list": [ + "左肺" + ] + } + ] + }, + { + "id": 1227, + "text": "1天前,患者无明显诱因再次出现阴道流血,量不详,伴腹痛,患者为进一步治疗入我院,门诊以“宫颈癌”收入我科住院治疗。", + "event": [ + { + "core_name": "出血", + "tendency": "", + "character": [ + "量不详" + ], + "anatomy_list": [ + "阴道" + ] + }, + { + "core_name": "疼痛", + "tendency": "", + "character": [], + "anatomy_list": [ + "腹" + ] + }, + { + "core_name": "癌", + "tendency": "", + "character": [], + "anatomy_list": [ + "宫颈" + ] + } + ] + } +] \ No newline at end of file