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stringlengths 5
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| id
int64 1
2.07k
| event
list |
|---|---|---|
<胆管下端切缘，切缘胆管壁>为见癌组织。 | 1,339 | [
{
"anatomy_list": [
"胆管下端切缘",
"切缘胆管壁"
],
"character": [],
"core_name": "癌组织",
"tendency": "否定"
}
] |
入院前1+年，患者无明显诱因出现全身乏力，夜尿增多，约4-5次/晚，伴胸闷、怕冷、烦渴、多饮，伴四肢麻木，无视物模糊，无腹痛、腹泻，无恶心、呕吐，无心前区疼痛，患者未重视，未诊治。 | 234 | [
{
"anatomy_list": [
"全身"
],
"character": [],
"core_name": "乏力",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "夜尿增多",
"tendency": ""
},
{
"anatomy_list": [
"胸"
],
"character": [],
"core_name": "胸闷",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "怕冷",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "烦渴",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "多饮",
"tendency": ""
},
{
"anatomy_list": [
"四肢"
],
"character": [],
"core_name": "麻木",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "视物模糊",
"tendency": "否定"
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "腹泻",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "恶心",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "呕吐",
"tendency": "否定"
},
{
"anatomy_list": [
"心前区"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
}
] |
患者因“便血”于2018-1-18于胃肠外科住院治疗，行妇科彩超示: 子宫术后：子宫、双侧卵巢未见显示；盆腔内探及两个大小分别约5.6x4.1cm、2.3x1.6cm偏低回声团块，形态不规则，边界不清晰，内回声不均质，较大者与直肠相连，cdfi:内探及较丰富血流信号；提示：盆腔内偏低回声团块，考虑转移性ca。 | 1,032 | [
{
"anatomy_list": [],
"character": [],
"core_name": "便血",
"tendency": ""
},
{
"anatomy_list": [
"子宫"
],
"character": [
"子宫术后"
],
"core_name": "显示",
"tendency": "否定"
},
{
"anatomy_list": [
"双侧卵巢"
],
"character": [
"子宫术后"
],
"core_name": "显示",
"tendency": "否定"
},
{
"anatomy_list": [
"子宫"
],
"character": [
"术后"
],
"core_name": "术后",
"tendency": ""
},
{
"anatomy_list": [
"盆腔"
],
"character": [
"偏低回声",
"边界不清晰",
"内回声不均质",
"较大者与直肠相连"
],
"core_name": "团块",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"丰富",
"血流"
],
"core_name": "信号",
"tendency": ""
},
{
"anatomy_list": [
"盆腔内"
],
"character": [
"偏低回声"
],
"core_name": "团块",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"转移"
],
"core_name": "癌",
"tendency": "不确定"
}
] |
左室顺应性降低。 | 604 | [
{
"anatomy_list": [
"左室"
],
"character": [],
"core_name": "顺应性降低",
"tendency": ""
}
] |
紧急就诊于某急救中心完善相关检查示右肩胛骨骨折、肋骨多处骨折（1-6肋，3、4肋断端错位）、肺挫伤。 | 1,512 | [
{
"anatomy_list": [
"右肩胛骨"
],
"character": [],
"core_name": "骨折",
"tendency": ""
},
{
"anatomy_list": [
"3、4肋"
],
"character": [
"断端"
],
"core_name": "错位",
"tendency": ""
},
{
"anatomy_list": [
"1-6肋骨"
],
"character": [
"多处"
],
"core_name": "骨折",
"tendency": ""
},
{
"anatomy_list": [
"肺"
],
"character": [],
"core_name": "挫伤",
"tendency": ""
}
] |
今患者为进一步就诊遂入我院，门诊以“干燥综合征”收入我科。 | 934 | [
{
"anatomy_list": [],
"character": [],
"core_name": "干燥综合征",
"tendency": ""
}
] |
无畏寒、发热、盗汗，无体重下降。 | 479 | [
{
"anatomy_list": [],
"character": [],
"core_name": "畏寒",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "发热",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "盗汗",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "体重下降",
"tendency": "否定"
}
] |
于2015年3月11日行“膀胱镜检+新生物活检，同时行经尿道或经肛门前列腺活检”手术，活检结果提示：前列腺癌（gleason评+分4+5分），侵及膀胱；分别于3-26我科行前列腺、膀胱占位、盆腔淋巴引流区精确放疗，累计放疗：dt：pgtv：64.4G/28f，ptv1：56G/28f，ptv2：50.4G/28f，放疗后患者尿频、尿痛症状较前稍有缓解，复查ct提示前列腺及膀胱病灶缩小，评价为pr。 | 1,849 | [
{
"anatomy_list": [
"前列腺"
],
"character": [
"gleason评+分4+5分"
],
"core_name": "癌",
"tendency": ""
},
{
"anatomy_list": [
"膀胱"
],
"character": [
"侵及"
],
"core_name": "癌",
"tendency": ""
},
{
"anatomy_list": [
"前列腺",
"膀胱"
],
"character": [],
"core_name": "占位",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"稍有缓解"
],
"core_name": "尿频",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"稍有缓解"
],
"core_name": "尿痛",
"tendency": ""
},
{
"anatomy_list": [
"前列腺",
"膀胱"
],
"character": [
"缩小"
],
"core_name": "病灶",
"tendency": ""
}
] |
患者自发病以来，精神可，食欲较差，睡眠可，大便如常，小便如常，体重无明显变化。 | 1,561 | [
{
"anatomy_list": [],
"character": [
"可"
],
"core_name": "精神",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"较差"
],
"core_name": "食欲",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"可"
],
"core_name": "睡眠",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"如常"
],
"core_name": "大便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"如常"
],
"core_name": "小便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"明显"
],
"core_name": "体重改变",
"tendency": "否定"
}
] |
并分别于2016.12.26、2017.2.2、2017.03.13予以da（柔红霉素70mg*3天+阿糖胞苷200mg*7天)巩固化疗3次，并于2017.1.5、2017.2.10、2017.03.20、2017.03.31行腰椎穿刺术，给予鞘内注射甲氨蝶呤15mg、地塞米松5mg预防中枢神经系统白血病，之后复查pml/rara（双色双融合）(15/17)：信号表达正常。 | 2,038 | [
{
"anatomy_list": [
"中枢神经系统"
],
"character": [],
"core_name": "白血病",
"tendency": ""
}
] |
患者4月前出现右乳隐痛不适，无乳头溢液，无乳头凹陷等，遂就诊于某医院，行乳腺彩超示：双乳异常回声（纤维腺瘤可能），予以口服药物治疗（具体不详）后无明显好转，患者为进一步治疗，今来我院，门诊以“双乳包块待查”收治入科。 | 1,836 | [
{
"anatomy_list": [
"右乳"
],
"character": [
"隐痛"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"右乳"
],
"character": [],
"core_name": "右乳不适",
"tendency": ""
},
{
"anatomy_list": [
"乳头"
],
"character": [],
"core_name": "溢液",
"tendency": "否定"
},
{
"anatomy_list": [
"乳头"
],
"character": [],
"core_name": "凹陷",
"tendency": "否定"
},
{
"anatomy_list": [
"双乳"
],
"character": [],
"core_name": "异常回声",
"tendency": ""
},
{
"anatomy_list": [
"双乳"
],
"character": [
"纤维腺"
],
"core_name": "瘤",
"tendency": "不确定"
},
{
"anatomy_list": [
"双乳"
],
"character": [],
"core_name": "包块",
"tendency": "不确定"
}
] |
后患者定期复查，17个月前复查腹部ct提示：肝左叶内段结节结节灶，性质待定，不典型血管瘤？并于2011-6-7局麻下行肝癌介入术，术后予以保肝、阿德福韦酯抗病毒等对症治疗后好转出院。 | 1,998 | [
{
"anatomy_list": [
"肝左叶内段"
],
"character": [
"性质待定"
],
"core_name": "结节灶",
"tendency": ""
},
{
"anatomy_list": [
"肝左叶内段"
],
"character": [
"非典型",
"血管"
],
"core_name": "瘤",
"tendency": "不确定"
}
] |
<门静脉旁，腹主动脉旁，腹腔干旁>淋巴结未见癌转移（分别0/3.0/1.0/5）。 | 1,342 | [
{
"anatomy_list": [
"腹腔干旁淋巴结",
"门静脉旁淋巴结",
"腹主动脉旁淋巴结"
],
"character": [
"转移"
],
"core_name": "癌",
"tendency": "否定"
}
] |
诊断为:直肠腺癌 （t2n0M0）。 | 1,092 | [
{
"anatomy_list": [
"直肠"
],
"character": [
"t2n0M0"
],
"core_name": "腺癌",
"tendency": ""
}
] |
患者现为求术后第4次化疗再次就诊于我院，门诊拟“右肺上叶腺癌术后化疗”收住院治疗。 | 1,532 | [
{
"anatomy_list": [
"右肺上叶"
],
"character": [
"术后化疗"
],
"core_name": "腺癌",
"tendency": ""
}
] |
入院前7年，患者渐感劳力性呼吸困难，以上楼、上坡或剧烈活动后明显，间断出现双下肢水肿，不伴夜间阵发性呼吸困难或端坐呼吸，多次在外院就医诊治，诊断为“慢性阻塞性肺疾病、慢性肺源性心脏病”，长期服用平喘等药物控制症状。 | 792 | [
{
"anatomy_list": [],
"character": [
"劳力性",
"以上楼、上坡或剧烈活动后明显"
],
"core_name": "呼吸困难",
"tendency": ""
},
{
"anatomy_list": [
"双下肢"
],
"character": [
"间断"
],
"core_name": "水肿",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"夜间",
"阵发性"
],
"core_name": "呼吸困难",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "端坐呼吸",
"tendency": "否定"
},
{
"anatomy_list": [
"肺"
],
"character": [
"慢性",
"阻塞性"
],
"core_name": "肺疾病",
"tendency": ""
},
{
"anatomy_list": [
"心脏"
],
"character": [
"慢性",
"肺源性"
],
"core_name": "心脏病",
"tendency": ""
}
] |
6月前至我院行第一次化疗，并于2017-4-18、2017-05-09于我科行dp(多西他赛100mg+奈达铂120mg)化疗治疗，无明显化疗副反应，2017-6-7行第三次化疗（多西他赛100mg+奈达铂100mg),出院后患者自觉偶有干咳，伴恶心、嗳气、食欲下降，伴活动后喘息、气促。 | 988 | [
{
"anatomy_list": [],
"character": [
"干性",
"偶有"
],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "恶心",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "嗳气",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"下降"
],
"core_name": "食欲下降",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"活动后"
],
"core_name": "喘息",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"活动后"
],
"core_name": "气促",
"tendency": ""
}
] |
2014年2月患者再发右下腹痛，无恶心、呕吐，无腹胀、阴道流血，自行口服药物后无缓解，于我院复查示ca-125大于1000U/ml，全腹部ct未见转移病灶,腹腔内网膜增厚及部分小肠小肠粘连聚集。 | 1,124 | [
{
"anatomy_list": [
"右下腹"
],
"character": [],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "恶心",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "呕吐",
"tendency": "否定"
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "腹胀",
"tendency": "否定"
},
{
"anatomy_list": [
"阴道"
],
"character": [],
"core_name": "出血",
"tendency": "否定"
},
{
"anatomy_list": [
"腹腔内网膜"
],
"character": [],
"core_name": "增厚",
"tendency": ""
},
{
"anatomy_list": [
"小肠"
],
"character": [],
"core_name": "粘连聚集",
"tendency": ""
}
] |
2年前于某医院行右侧腕部瘢痕修复术，术中病理检查结果提示鳞状细胞癌，术后腕部有一处经久不愈，于我科室行瘢痕修复术及植皮术，创面愈合良好。 | 914 | [
{
"anatomy_list": [
"右腕部"
],
"character": [],
"core_name": "鳞癌",
"tendency": ""
},
{
"anatomy_list": [
"腕部"
],
"character": [
"术后"
],
"core_name": "经久不愈",
"tendency": ""
}
] |
腹部ct示：1、结肠癌术后表现，腹膜后多发淋巴结多发淋巴结转移癌，吻合口上方淋巴结增大；2、轻度脂肪肝，脾大；3、双肾小囊肿；4、下腹、盆腔ct未见明显异常。 | 1,933 | [
{
"anatomy_list": [
"结肠"
],
"character": [
"术后"
],
"core_name": "癌",
"tendency": ""
},
{
"anatomy_list": [
"腹膜后淋巴结"
],
"character": [
"多发",
"转移"
],
"core_name": "癌",
"tendency": ""
},
{
"anatomy_list": [
"吻合口上方淋巴结"
],
"character": [],
"core_name": "增大",
"tendency": ""
},
{
"anatomy_list": [
"肝"
],
"character": [
"轻度"
],
"core_name": "脂肪肝",
"tendency": ""
},
{
"anatomy_list": [
"脾"
],
"character": [],
"core_name": "脾大",
"tendency": ""
},
{
"anatomy_list": [
"双肾"
],
"character": [
"小"
],
"core_name": "囊肿",
"tendency": ""
}
] |
院外间断服用“地高辛、美托洛尔、单硝酸异山梨酯”，心累、气促、胸闷、心悸等症状仍旧反复发作，多次于我院住院治疗，治疗好转后出院。 | 1,597 | [
{
"anatomy_list": [
"心"
],
"character": [
"反复发作"
],
"core_name": "心累",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"反复发作"
],
"core_name": "气促",
"tendency": ""
},
{
"anatomy_list": [
"胸"
],
"character": [
"反复发作"
],
"core_name": "胸闷",
"tendency": ""
},
{
"anatomy_list": [
"心"
],
"character": [
"反复发作"
],
"core_name": "心悸",
"tendency": ""
}
] |
发病以来，精神、睡眠可，清淡饮食，大小便正常，近期体重无明显改变。 | 1,641 | [
{
"anatomy_list": [],
"character": [
"可"
],
"core_name": "精神",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"可"
],
"core_name": "睡眠",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"正常"
],
"core_name": "大小便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"明显"
],
"core_name": "体重改变",
"tendency": "否定"
}
] |
入院前4余年，患者开始出现咳嗽、咳痰症状，主要为咳白色泡沫痰，好发于冬春季或受凉后，每年发病时间累计大于3个月。 | 187 | [
{
"anatomy_list": [],
"character": [],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "咳痰",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"白色",
"泡沫痰",
"好发于冬春季或受凉后"
],
"core_name": "咳痰",
"tendency": ""
}
] |
术后病检结果提示为：尿路上皮癌，术后继续规律膀胱灌注治疗，3月前患者复查b超未见明显异常，患者未诉解血尿、腰痛等不适，患者为求复查今日于我科门诊再次就诊，门诊以“膀胱癌”收住入院。 | 1,435 | [
{
"anatomy_list": [
"尿路上皮"
],
"character": [],
"core_name": "癌",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "血尿",
"tendency": "否定"
},
{
"anatomy_list": [
"腰"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [
"膀胱"
],
"character": [],
"core_name": "癌",
"tendency": ""
}
] |
后转入我科,行纤支镜示：血中见较多支气管粘膜上皮上皮细胞和少许散落异型细胞,倾向腺癌细胞,后分别于2014-10-24、2014-10-30在ct引导下行经皮肺穿刺右肺肺癌穿刺活检+放射性粒子植入术2次（共注入放射性粒子200粒）,术后病检提示：血块中散落极个别异型性细胞,免疫组化提示肺腺癌,复查胸部ct增强(2014-11-13)示：右肺下叶肿块明显缩小,根据基因检测,于2014-11-17行“吉西他滨 2000mg d1,d8+奈达铂150mg d1”方案化疗,化疗后出现骨髓抑制,予特尔津升白细胞治疗后好转出院。 | 25 | [
{
"anatomy_list": [
"支气管粘膜上皮",
"上皮细胞"
],
"character": [
"少许",
"散落",
"异型",
"血中见较多"
],
"core_name": "异型细胞",
"tendency": ""
},
{
"anatomy_list": [
"支气管粘膜上皮"
],
"character": [],
"core_name": "腺癌细胞",
"tendency": "不确定"
},
{
"anatomy_list": [],
"character": [
"血块中散落",
"极个别异型性"
],
"core_name": "异形性细胞",
"tendency": ""
},
{
"anatomy_list": [
"肺"
],
"character": [],
"core_name": "腺癌",
"tendency": ""
},
{
"anatomy_list": [
"右肺下叶"
],
"character": [
"明显",
"缩小"
],
"core_name": "肿块",
"tendency": ""
},
{
"anatomy_list": [
"骨髓"
],
"character": [
"化疗后"
],
"core_name": "骨髓抑制",
"tendency": ""
}
] |
建议住院治疗，患者因经济原因，未住院治疗，到诊所输液及中药治疗（具体治疗不详），患者1月前出现上腹部隐痛，间断性，夜间明显，疼痛与体位变化无明显关系，每次疼痛10余分钟按压上腹部逐渐缓解，伴反酸，嗳气及烧心，无明显胸骨后疼痛，无肩部放射痛，无腰部疼痛，大便仍不成形，偶伴粘液脓血及里急后重，到诊所就诊，考虑胃肠炎，给予相关治疗（具体不详），患者经过上述治疗，尿黄眼黄及皮肤瘙痒逐渐加重，2天前遂再次到某医院就诊，考虑“肝门部占位并胆管梗阻”，告知相关情况，建议住院治疗，患者为进一步治疗，遂急来我院，门诊以“1.原发性肝癌？2.梗阻性黄疸原因待查”收入病房。 | 210 | [
{
"anatomy_list": [
"上腹部"
],
"character": [
"隐痛",
"间断性",
"夜间明显",
"与体位变化无明显关系",
"每次疼痛10余分钟按压上腹部逐渐缓解"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "反酸",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "嗳气",
"tendency": ""
},
{
"anatomy_list": [
"心"
],
"character": [],
"core_name": "烧心",
"tendency": ""
},
{
"anatomy_list": [
"胸骨后"
],
"character": [
"明显"
],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [
"肩部"
],
"character": [
"发射性"
],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [
"腰部"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"不成形"
],
"core_name": "大便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"粘液脓血"
],
"core_name": "大便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "里急后重",
"tendency": ""
},
{
"anatomy_list": [
"胃",
"肠"
],
"character": [],
"core_name": "胃肠炎",
"tendency": "不确定"
},
{
"anatomy_list": [],
"character": [
"逐渐加重"
],
"core_name": "尿黄",
"tendency": ""
},
{
"anatomy_list": [
"眼"
],
"character": [
"逐渐加重"
],
"core_name": "黄染",
"tendency": ""
},
{
"anatomy_list": [
"皮肤"
],
"character": [
"逐渐加重"
],
"core_name": "皮肤瘙痒",
"tendency": ""
},
{
"anatomy_list": [
"肝门"
],
"character": [],
"core_name": "占位",
"tendency": "不确定"
},
{
"anatomy_list": [
"胆管"
],
"character": [],
"core_name": "梗阻",
"tendency": "不确定"
},
{
"anatomy_list": [
"肝"
],
"character": [
"原发性"
],
"core_name": "癌",
"tendency": "不确定"
},
{
"anatomy_list": [],
"character": [
"梗阻性"
],
"core_name": "黄疸",
"tendency": ""
}
] |
纤支镜活检提示（2018年7月27日）：（左肺支气管支气管粘膜）送检物见少许异性腺体，肺腺癌待排。 | 275 | [
{
"anatomy_list": [
"左肺",
"支气管粘膜"
],
"character": [
"少许"
],
"core_name": "异性腺体",
"tendency": ""
},
{
"anatomy_list": [
"肺"
],
"character": [],
"core_name": "腺癌",
"tendency": "不确定"
}
] |
7天前，患者无明显诱因出现夜间胸闷，伴呼吸困难，无前期压榨感，无左肩、及手指放射痛，持续几个小时可自行缓解，伴腹胀，伴反酸、嗳气，伴出汗、心悸、头昏、视物模糊，伴四肢麻木疼痛，为针刺样疼痛，无易饥多食，无便秘、腹泻，无畏寒、发热、咳嗽、咳痰等不适，遂于我院消化内科门诊就诊，行腹部彩超示：脂肪肝，于心血管内科门诊行心电图示：正常心电图，心肌损伤检查：tnt：29.9pg/ml，myo：60.7ng/ml，ck-mb:1.4ng/ml。 | 1,885 | [
{
"anatomy_list": [
"胸"
],
"character": [
"夜间"
],
"core_name": "胸闷",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "呼吸困难",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "压榨感",
"tendency": "否定"
},
{
"anatomy_list": [
"左肩",
"手指"
],
"character": [
"放射性"
],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [
"左肩",
"手指"
],
"character": [
"持续几个小时可自行缓解"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "腹胀",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "返酸",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "嗳气",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "出汗",
"tendency": ""
},
{
"anatomy_list": [
"心"
],
"character": [],
"core_name": "心悸",
"tendency": ""
},
{
"anatomy_list": [
"头"
],
"character": [],
"core_name": "头昏",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "视物模糊",
"tendency": ""
},
{
"anatomy_list": [
"四肢"
],
"character": [],
"core_name": "麻木",
"tendency": ""
},
{
"anatomy_list": [
"四肢"
],
"character": [],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"针刺样"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "易饥多食",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "便秘",
"tendency": "否定"
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "腹泻",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "畏寒",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "发热",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "咳嗽",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "咳痰",
"tendency": "否定"
},
{
"anatomy_list": [
"肝"
],
"character": [],
"core_name": "脂肪肝",
"tendency": ""
}
] |
自发病以来，精神稍差，未进食，睡眠可，大便如常，小便如常，体重无明显变化。 | 784 | [
{
"anatomy_list": [],
"character": [
"稍差"
],
"core_name": "精神",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"未"
],
"core_name": "进食",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"可"
],
"core_name": "睡眠",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"如常"
],
"core_name": "大便",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"如常"
],
"core_name": "小便",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"明显"
],
"core_name": "体重改变",
"tendency": "否定"
}
] |
入院前1+年无明显诱因出现鼻阻，双侧交替性，鼻根胀痛不适，伴嗅觉稍下降，受凉后咳嗽、咳痰，无鼻痒、打喷嚏，无记忆力下降，无发热、听力下降、眩晕、耳鸣、潮热、乏力等症状。 | 2,065 | [
{
"anatomy_list": [
"鼻"
],
"character": [
"双侧交替性"
],
"core_name": "鼻阻",
"tendency": ""
},
{
"anatomy_list": [
"鼻根"
],
"character": [
"胀痛"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"鼻根"
],
"character": [],
"core_name": "鼻根不适",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"稍"
],
"core_name": "嗅觉下降",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"受凉后"
],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"受凉后"
],
"core_name": "咳痰",
"tendency": ""
},
{
"anatomy_list": [
"鼻"
],
"character": [],
"core_name": "鼻痒",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "打喷嚏",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "记忆力下降",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "发热",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "听觉下降",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "眩晕",
"tendency": "否定"
},
{
"anatomy_list": [
"耳"
],
"character": [],
"core_name": "耳鸣",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "潮热",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "乏力",
"tendency": "否定"
}
] |
11月5日查血常规示“白细胞数目1.98*10^9/L↓，血红蛋白43g/l↓，血小板数目41*10^9/L↓，中性粒细胞数目0.65*10^9/L↓”，11月7日复查骨髓穿刺示“1.红系增生旺盛，粒、红、巨三系可见病态造血2.细胞外铁：+++，细胞内铁：72%，环铁占26%”，予以口服环孢素治疗。 | 1,734 | [
{
"anatomy_list": [
"红系"
],
"character": [
"旺盛"
],
"core_name": "红系增生",
"tendency": ""
},
{
"anatomy_list": [
"粒、红、巨三系"
],
"character": [],
"core_name": "病态造血",
"tendency": ""
}
] |
3+年前因“体重下降”就诊我科完善相关检查后考虑“2型糖尿病”，2月前体检时查糖化血红蛋白11.5%，葡萄糖13.55mmol/L。 | 843 | [
{
"anatomy_list": [],
"character": [],
"core_name": "体重下降",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"2型"
],
"core_name": "糖尿病",
"tendency": "不确定"
}
] |
于2015-2-28日在局麻下行右乳肿物麦默通旋切活检，冰冻活检示：（右乳）浸润性癌。 | 1,187 | [
{
"anatomy_list": [
"右乳"
],
"character": [
"浸润性"
],
"core_name": "癌",
"tendency": ""
}
] |
2月余前，患者因“咳嗽、咳痰2月，痰中带血1月，院外发现右肺包块”至我科就诊，入院查胸部ct提示：右肺门占位伴周围阻塞性炎症、右肺上叶支气管闭塞，肺ca？右肺多发结节影，转移？纵隔、右肺门及锁骨下多发淋巴结肿大。 | 569 | [
{
"anatomy_list": [],
"character": [],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "咳痰",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"带血"
],
"core_name": "咳痰",
"tendency": ""
},
{
"anatomy_list": [
"右肺"
],
"character": [],
"core_name": "包块",
"tendency": ""
},
{
"anatomy_list": [
"右肺门"
],
"character": [],
"core_name": "占位",
"tendency": ""
},
{
"anatomy_list": [
"右肺门周围"
],
"character": [
"阻塞性"
],
"core_name": "炎症",
"tendency": ""
},
{
"anatomy_list": [
"右肺上叶支气管"
],
"character": [],
"core_name": "闭塞",
"tendency": ""
},
{
"anatomy_list": [
"肺"
],
"character": [],
"core_name": "癌",
"tendency": "不确定"
},
{
"anatomy_list": [
"右肺"
],
"character": [
"多发"
],
"core_name": "结节影",
"tendency": ""
},
{
"anatomy_list": [
"右肺"
],
"character": [],
"core_name": "转移",
"tendency": "不确定"
},
{
"anatomy_list": [
"纵隔淋巴结",
"右肺门淋巴结",
"锁骨下淋巴结"
],
"character": [
"多发"
],
"core_name": "肿大",
"tendency": ""
}
] |
患者平素月经规则，有痛经，lmp：2017.2.3；10+小时前患者于走路时无明显诱因突然出现右下腹阵发性剧烈疼痛，位置相对固定，无转移性放射至后背部，改变体位缓解不明显，伴恶心呕吐，冷汗，无发热、寒颤。 | 1,819 | [
{
"anatomy_list": [],
"character": [
"规则"
],
"core_name": "月经",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "痛经",
"tendency": ""
},
{
"anatomy_list": [
"右下腹"
],
"character": [
"走路时",
"阵发性",
"剧烈",
"位置相对固定",
"改变体位缓解不明显"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"后背部"
],
"character": [
"转移性放射"
],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "恶心",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "呕吐",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "冷汗",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "发热",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "寒颤",
"tendency": "否定"
}
] |
上腹部饱胀，饮食差，夜间反酸、烧心，阵发性心悸不适，夜间明显，自诉端坐位后可缓解，无夜间阵发性呼吸困难、咯粉红色泡沫痰，无呕吐、黑便，自服奥美拉唑胶囊无缓解，今日自觉腹胀明显，为进一步诊治，以“慢性阻塞性肺疾病急性发作 、心房纤颤 ，胃炎？”收入我科。 | 1,524 | [
{
"anatomy_list": [
"上腹部"
],
"character": [],
"core_name": "饱胀感",
"tendency": ""
},
{
"anatomy_list": [
"差"
],
"character": [],
"core_name": "饮食",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"夜间"
],
"core_name": "反酸",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"夜间"
],
"core_name": "烧心",
"tendency": ""
},
{
"anatomy_list": [
"心"
],
"character": [
"阵发性",
"夜间明显",
"端坐位后可缓解"
],
"core_name": "心悸",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"阵发性",
"夜间"
],
"core_name": "呼吸困难",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"粉红色",
"泡沫"
],
"core_name": "咳痰",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "呕吐",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "黑便",
"tendency": "否定"
},
{
"anatomy_list": [
"腹"
],
"character": [
"明显"
],
"core_name": "腹胀",
"tendency": ""
},
{
"anatomy_list": [
"肺"
],
"character": [
"急性发作",
"慢性",
"阻塞性"
],
"core_name": "肺疾病",
"tendency": ""
},
{
"anatomy_list": [
"心房"
],
"character": [],
"core_name": "心房纤颤",
"tendency": ""
},
{
"anatomy_list": [
"胃"
],
"character": [],
"core_name": "胃炎",
"tendency": "不确定"
}
] |
2、子宫腺肌症。 | 1,583 | [
{
"anatomy_list": [
"子宫"
],
"character": [],
"core_name": "腺肌症",
"tendency": ""
}
] |
入院前1+月，患者于我科住院治疗，诊断为“1、多发性骨髓瘤iga к型 ds iiia期；2、肺部感染 双侧胸腔积液；3、心包积液；4、天疱疮；5、肝损害；6、低蛋白血症；7、电解质紊乱；8、慢性胃炎”，予以抗肿瘤、增强免疫力、补钙、促进造血、ctp方案化疗、护胃、抗感染、补充白蛋白、活血、通便、利尿、抗病毒、保肝、雾化、补钙、碱化尿液、促进胃肠动力、止汗等治疗后症状好转出院，现患者诉目前右褪疼痛较前稍加重，行走时右脚不实，如踏棉花，右腿麻木，今为行巩固化疗于我科住院治疗。 | 1,712 | [
{
"anatomy_list": [
"骨髓"
],
"character": [
"多发性",
"iga к型 ds iiia期"
],
"core_name": "瘤",
"tendency": ""
},
{
"anatomy_list": [
"肺部"
],
"character": [],
"core_name": "感染",
"tendency": ""
},
{
"anatomy_list": [
"双侧胸腔"
],
"character": [],
"core_name": "积液",
"tendency": ""
},
{
"anatomy_list": [
"心包"
],
"character": [],
"core_name": "积液",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "天疱疮",
"tendency": ""
},
{
"anatomy_list": [
"肝"
],
"character": [],
"core_name": "损害",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "低蛋白血症",
"tendency": ""
},
{
"anatomy_list": [
"胃"
],
"character": [
"慢性"
],
"core_name": "胃炎",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "电解质紊乱",
"tendency": ""
},
{
"anatomy_list": [
"右腿"
],
"character": [
"较前稍加重"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"右脚"
],
"character": [
"行走时",
"如踏棉花"
],
"core_name": "右脚不实",
"tendency": ""
},
{
"anatomy_list": [
"右腿"
],
"character": [],
"core_name": "麻木",
"tendency": ""
}
] |
诊断“霍奇金淋巴瘤（混合细胞型，Ⅱ期a组”，同年5月起至2019年4月给予abvd方案化疗8周期，化疗后腹股沟包块缩小至黄豆大小。10月29日在某医院复查胸部+全腹部ct示“1、右肺上叶尖段及水平裂陈旧性病灶2、双肺多发结节，考虑转移性肿瘤3、双肺多发病变，考虑炎性病变，部分小空洞形成”，考虑淋巴瘤细胞侵犯双肺，建议至血液科就诊。于11月4日就诊于我科，行全身pet/ct示“腹主动脉左旁（双侧髂总血管分叉处上方）、左侧髂外血管旁及左侧腹股沟腹股沟区淋巴结显示，未见异常fdg摄取，提示肿瘤活性受抑；右肺上叶尖段陈旧结核，两肺多发病变，考虑炎性病变，两肺上叶上叶胸膜胸膜增厚，左侧胸膜多发钙化，两肺门及纵膈淋巴结炎性增生可能”。 | 853 | [
{
"anatomy_list": [],
"character": [
"混合细胞型",
"Ⅱ期a组"
],
"core_name": "霍奇金淋巴瘤",
"tendency": ""
},
{
"anatomy_list": [
"腹股沟"
],
"character": [
"化疗后",
"缩小至黄豆大小"
],
"core_name": "包块",
"tendency": ""
},
{
"anatomy_list": [
"右肺上叶尖段及水平裂"
],
"character": [
"陈旧性"
],
"core_name": "病灶",
"tendency": ""
},
{
"anatomy_list": [
"双肺"
],
"character": [
"多发"
],
"core_name": "结节",
"tendency": ""
},
{
"anatomy_list": [
"双肺"
],
"character": [
"转移性"
],
"core_name": "肿瘤",
"tendency": "不确定"
},
{
"anatomy_list": [
"双肺"
],
"character": [
"炎性"
],
"core_name": "病变",
"tendency": "不确定"
},
{
"anatomy_list": [
"双肺"
],
"character": [
"部分",
"小"
],
"core_name": "空洞形成",
"tendency": ""
},
{
"anatomy_list": [
"淋巴",
"细胞"
],
"character": [
"侵犯双肺"
],
"core_name": "瘤",
"tendency": "不确定"
},
{
"anatomy_list": [],
"character": [
"异常"
],
"core_name": "fdg摄取",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"活性受抑"
],
"core_name": "肿瘤",
"tendency": ""
},
{
"anatomy_list": [
"右肺上叶尖段"
],
"character": [
"陈旧"
],
"core_name": "结核",
"tendency": ""
},
{
"anatomy_list": [
"两肺"
],
"character": [
"多发性"
],
"core_name": "病变",
"tendency": ""
},
{
"anatomy_list": [
"两肺"
],
"character": [
"炎性"
],
"core_name": "病变",
"tendency": "不确定"
},
{
"anatomy_list": [
"两肺上叶胸膜"
],
"character": [],
"core_name": "增厚",
"tendency": ""
},
{
"anatomy_list": [
"左侧胸膜"
],
"character": [
"多发",
"钙化"
],
"core_name": "钙化",
"tendency": ""
},
{
"anatomy_list": [
"两肺门淋巴结"
],
"character": [
"炎性"
],
"core_name": "增生",
"tendency": "不确定"
},
{
"anatomy_list": [
"纵膈淋巴结"
],
"character": [
"炎性"
],
"core_name": "增生",
"tendency": "不确定"
}
] |
取病检示（1813818）：小细胞恶性肿瘤，建议免疫组化协助诊断。 | 407 | [
{
"anatomy_list": [
"小细胞"
],
"character": [
"恶性"
],
"core_name": "肿瘤",
"tendency": ""
}
] |
10-19再入我科，完善相关检查：全腹部增强ct提示：1.子宫颈形态不规则，增强扫描可见强化，宫颈癌待排，建议mr增强扫描检查。 | 1,617 | [
{
"anatomy_list": [
"子宫颈"
],
"character": [
"增强扫描可强化"
],
"core_name": "形态不规则",
"tendency": ""
},
{
"anatomy_list": [
"子宫颈"
],
"character": [],
"core_name": "癌",
"tendency": "不确定"
}
] |
入院前11+月，患者因“发现左乳包块2天”入院，于2016年10月21日行左乳癌改良根治术，术后病检（病检号123456）：左乳浸润性癌，非特殊类型，ii级7分。 | 1,642 | [
{
"anatomy_list": [
"左乳"
],
"character": [],
"core_name": "包块",
"tendency": ""
},
{
"anatomy_list": [
"左乳"
],
"character": [
"浸润性",
"非特殊类型",
"ii级7分"
],
"core_name": "癌",
"tendency": ""
}
] |
入院前2+月，患者因气促加重于我院住院，胸水找脱落细胞中查见肿瘤细胞，院外行基因检测后，目前口服吉非替尼治疗，1+月前，患者再次感气促加重，不能活动，伴咳嗽，较多黄色粘液痰，遂再次来院，胸部ct示与2017-10-28同部位片相比双侧胸腔积液较前增多，左肺上叶结节影较前稍增大，双肺内肺内斑片影较前明显增多并部分为新出现病灶，诊断“1.肺癌伴胸膜转移；2.间质性肺炎；3.低蛋白血症，4.肝功异常”。 | 893 | [
{
"anatomy_list": [],
"character": [
"加重"
],
"core_name": "气促",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"加重",
"不能活动"
],
"core_name": "气促",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"较多",
"黄色",
"粘液"
],
"core_name": "咳痰",
"tendency": ""
},
{
"anatomy_list": [
"双侧胸腔"
],
"character": [
"增多"
],
"core_name": "积液",
"tendency": ""
},
{
"anatomy_list": [
"左肺上叶"
],
"character": [
"稍增大"
],
"core_name": "结节影",
"tendency": ""
},
{
"anatomy_list": [
"双肺内"
],
"character": [
"明显增多"
],
"core_name": "斑片影",
"tendency": ""
},
{
"anatomy_list": [
"双肺内"
],
"character": [
"新出现",
"部分"
],
"core_name": "病灶",
"tendency": ""
},
{
"anatomy_list": [
"肺"
],
"character": [
"胸膜转移"
],
"core_name": "癌",
"tendency": ""
},
{
"anatomy_list": [
"肺"
],
"character": [
"间质性"
],
"core_name": "肺炎",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "低蛋白血症",
"tendency": ""
},
{
"anatomy_list": [
"肝"
],
"character": [],
"core_name": "肝功能异常",
"tendency": ""
}
] |
鳞癌癌细胞抗原0.75ng/mL。 | 1,623 | [
{
"anatomy_list": [],
"character": [],
"core_name": "鳞癌",
"tendency": ""
}
] |
患者此次患病以来，精神状态欠佳，小便正常，大便黄色软便。 | 1,410 | [
{
"anatomy_list": [],
"character": [
"欠佳"
],
"core_name": "精神",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"正常"
],
"core_name": "小便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"黄色",
"软"
],
"core_name": "大便",
"tendency": ""
}
] |
患者既往有“高血压病”病史20+年，最高血压180/？mmhg，长期口服硝苯地平控释片控制血压，血压控制情况不详。 | 138 | [
{
"anatomy_list": [],
"character": [
"病史20+年"
],
"core_name": "高血压",
"tendency": ""
}
] |
4+年患者受凉后开始出现咳嗽、咳痰,无明显昼夜差异,闻及刺激性气味咳嗽无诱发或加重,痰为白色泡沫痰,量不多,无喘息,伴活动后气促、心悸,休息后缓解,无胸痛,无双下肢水肿等不适。 | 35 | [
{
"anatomy_list": [],
"character": [
"明显昼夜差异",
"受凉"
],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"明显昼夜差异",
"受凉"
],
"core_name": "咳痰",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"闻及刺激性气味无诱发或加重"
],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"白色",
"泡沫痰",
"量不多"
],
"core_name": "咳痰",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "喘息",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"活动后",
"休息后缓解"
],
"core_name": "气促",
"tendency": ""
},
{
"anatomy_list": [
"心"
],
"character": [
"活动后",
"休息后缓解"
],
"core_name": "心悸",
"tendency": ""
},
{
"anatomy_list": [
"胸"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [
"双下肢"
],
"character": [],
"core_name": "水肿",
"tendency": "否定"
}
] |
2、（食管旁）淋巴结未见癌转移（0/7）。 | 199 | [
{
"anatomy_list": [
"食管旁淋巴结"
],
"character": [
"转移"
],
"core_name": "癌",
"tendency": "否定"
}
] |
门诊以“腰椎滑脱”收入院。 | 1,510 | [
{
"anatomy_list": [
"腰椎"
],
"character": [],
"core_name": "滑脱",
"tendency": ""
}
] |
2017年患者自觉脾脏逐渐开始增大，但仍未调整治疗。 | 1,180 | [
{
"anatomy_list": [
"脾脏"
],
"character": [
"逐渐"
],
"core_name": "增大",
"tendency": ""
}
] |
术前术后共行5疗程辅助化疗，方案为吡柔比星+多西他赛，化疗期产生药物毒性副反应，重度骨髓抑制，无明显胃肠道反应。现为进一步治疗入院。 | 355 | [
{
"anatomy_list": [],
"character": [
"药物毒性"
],
"core_name": "副反应",
"tendency": ""
},
{
"anatomy_list": [
"骨髓"
],
"character": [
"重度"
],
"core_name": "骨髓抑制",
"tendency": ""
},
{
"anatomy_list": [
"胃肠道"
],
"character": [
"明显"
],
"core_name": "胃肠道反应",
"tendency": "否定"
}
] |
入院6月余前患者无明显诱因出现反酸、烧心，常于进食后及平卧位、身体前驱时出现，影响夜间休息，持续时间数小时不等，伴有上腹胀、嗳气，无腹痛、恶心、呕吐，无胸闷、胸痛、心悸、呼吸困难，无食欲减退、体重减轻、厌油、纳差，患者2017-02-07我院行胃镜检查提示反流性食管炎（la d级）、食管裂孔疝、浅表性胃窦炎，患者服用“莫沙比利、耐信、铝碳酸镁片”后，症状缓解；近期患者停用口服药物后，上述症状再次出现，且程度较前加重，现患者为进一步治疗于我院就诊，门诊拟“反流性食管炎”收住我科。 | 1,269 | [
{
"anatomy_list": [],
"character": [
"进食后、平卧位、身体前驱时出现",
"影响夜间休息",
"持续时间数小时不等"
],
"core_name": "反酸",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"进食后、平卧位、身体前驱时出现",
"影响夜间休息",
"持续时间数小时不等"
],
"core_name": "烧心",
"tendency": ""
},
{
"anatomy_list": [
"上腹"
],
"character": [],
"core_name": "腹胀",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "嗳气",
"tendency": ""
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "恶心",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "呕吐",
"tendency": "否定"
},
{
"anatomy_list": [
"胸"
],
"character": [],
"core_name": "胸闷",
"tendency": "否定"
},
{
"anatomy_list": [
"胸"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [
"心"
],
"character": [],
"core_name": "心悸",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "呼吸困难",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"减退"
],
"core_name": "食欲",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "体重减轻",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "厌油",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "纳差",
"tendency": "否定"
},
{
"anatomy_list": [
"食管"
],
"character": [
"反流性"
],
"core_name": "食管炎",
"tendency": ""
},
{
"anatomy_list": [
"食管裂孔"
],
"character": [],
"core_name": "疝",
"tendency": ""
},
{
"anatomy_list": [
"胃窦"
],
"character": [
"浅表性"
],
"core_name": "胃窦炎",
"tendency": ""
},
{
"anatomy_list": [
"食管"
],
"character": [
"反流性"
],
"core_name": "食管炎",
"tendency": ""
}
] |
放疗后程出现白细胞、血小板下降，予以“粒细胞刺激因子、咖啡酸片”升白细胞及升血小板治疗后恢复正常。 | 1,616 | [
{
"anatomy_list": [],
"character": [
"下降"
],
"core_name": "白细胞",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"下降"
],
"core_name": "血小板",
"tendency": ""
}
] |
患病来精神、饮食一般，大便正常，尿量约700ml/天。 | 900 | [
{
"anatomy_list": [],
"character": [
"一般"
],
"core_name": "精神",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"一般"
],
"core_name": "进食",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"正常"
],
"core_name": "大便",
"tendency": ""
}
] |
<13组组淋巴结>见癌组织。 | 830 | [
{
"anatomy_list": [
"13组淋巴结"
],
"character": [],
"core_name": "癌组织",
"tendency": ""
}
] |
患者多次因“气促伴喘累、咳嗽、进食哽咽感”在我科住院治疗,经抗感染、止咳化痰、平喘等对症治疗后好转出院,病程中反复出现双下肢浮肿及胸腔积液。 | 5 | [
{
"anatomy_list": [],
"character": [],
"core_name": "气促",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "喘累",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"进食"
],
"core_name": "哽噎感",
"tendency": ""
},
{
"anatomy_list": [
"双下肢"
],
"character": [
"反复出现"
],
"core_name": "浮肿",
"tendency": ""
},
{
"anatomy_list": [
"胸腔"
],
"character": [
"反复出现"
],
"core_name": "积液",
"tendency": ""
}
] |
10月11日至某医院就诊，行右侧颈部包块穿刺活检报告：（右侧面部）送检少许组织示淋巴组织增生性病变，结合病史及免疫组化考虑结外黏膜相关淋巴结组织边缘区淋巴瘤，免疫组化：cd20（+），cd21散在（+），cd3灶（+），bcl-2（+），cd79a（+），pax-5（+），ki67约10%（+）。建议至上级医院就诊。 | 483 | [
{
"anatomy_list": [
"右侧颈部"
],
"character": [],
"core_name": "包块",
"tendency": ""
},
{
"anatomy_list": [
"右侧面部淋巴组织"
],
"character": [
"增生性"
],
"core_name": "病变",
"tendency": ""
},
{
"anatomy_list": [
"淋巴结组织边缘区",
"淋巴"
],
"character": [
"结外黏膜相关"
],
"core_name": "瘤",
"tendency": "不确定"
}
] |
现为输血治疗，患者今日就诊于我科，门诊以“骨髓增生异常综合征”收住院。 | 1,741 | [
{
"anatomy_list": [
"骨髓"
],
"character": [],
"core_name": "骨髓增生异常综合征",
"tendency": ""
}
] |
术后患者规律化疗9次，分别于2019年4月24日、2019年5月6日、2019年5月13日，2019年6月13日，2019年6月21日,2019年6月29日，2019年7月23日，2019年7月30日，2019年8月7日行吉西他滨1000mg+白蛋白紫杉醇100mg静脉化疗，化疗后患者无明显腹胀、腹痛，无恶心、呕吐，无反酸、嗳气。 | 1,345 | [
{
"anatomy_list": [
"腹"
],
"character": [
"明显"
],
"core_name": "腹胀",
"tendency": "否定"
},
{
"anatomy_list": [
"腹"
],
"character": [
"明显"
],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "恶心",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "呕吐",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "反酸",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "嗳气",
"tendency": "否定"
}
] |
门诊以“左乳包块待查”收入我科住院治疗。 | 1,565 | [
{
"anatomy_list": [
"左乳"
],
"character": [],
"core_name": "包块",
"tendency": "不确定"
}
] |
二尖瓣关闭不全（轻度）。 | 601 | [
{
"anatomy_list": [
"二尖瓣"
],
"character": [
"轻度"
],
"core_name": "关闭不全",
"tendency": ""
}
] |
10+天前无明显诱因患者出现咳嗽、咳痰，伴喘累，痰为白色黏痰，不易咳出。 | 514 | [
{
"anatomy_list": [],
"character": [],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "咳痰",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "喘累",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"白色",
"黏痰",
"不易咳出"
],
"core_name": "咳痰",
"tendency": ""
}
] |
入院前10余年，患者无明显诱因出现排尿困难症状，主要表现为尿线变细、排尿滴沥、尿不尽感，伴有夜尿次数增多，4-5次/晚，患者未重视，未行特殊诊治。 | 1,895 | [
{
"anatomy_list": [],
"character": [
"困难"
],
"core_name": "排尿",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "尿线变细",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"滴沥"
],
"core_name": "排尿",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "尿不尽感",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"次数增多"
],
"core_name": "夜尿",
"tendency": ""
}
] |
后于我院门诊行胸片（2014-10-03）示：右下肺门区及右上肺团片影，双下肺肺炎症改变，双肺间质改变，双上胸膜增厚，遂收住我院呼吸科继续治疗，入院后积极予以抗感染、解痉祛痰、活血化瘀等治疗，行胸部ct增强（2014-10-04）提示：右肺门、右肺上叶及右肺下叶肿块肿块影，考虑中央型肺癌可能大，淋巴瘤待除外，行纤支镜（2014-10-08）见：右上叶后段内见肉芽肿新生物，组织病理检查回示：（右上叶后段）鳞癌，行全腹部mri增强（2014-10-14）提示：脾脏内多发异常信号异常信号灶，结合病史，考虑转移可能，双侧腹股沟腹股沟淋巴结显示。 | 546 | [
{
"anatomy_list": [
"右下肺门区",
"右上肺"
],
"character": [],
"core_name": "团片影",
"tendency": ""
},
{
"anatomy_list": [
"双下肺"
],
"character": [],
"core_name": "炎症改变",
"tendency": ""
},
{
"anatomy_list": [
"双肺间质"
],
"character": [],
"core_name": "改变",
"tendency": ""
},
{
"anatomy_list": [
"双上胸膜"
],
"character": [],
"core_name": "增厚",
"tendency": ""
},
{
"anatomy_list": [
"右肺门",
"右肺上叶",
"右肺下叶"
],
"character": [],
"core_name": "肿块",
"tendency": ""
},
{
"anatomy_list": [
"右肺门",
"右肺上叶",
"右肺下叶"
],
"character": [],
"core_name": "肿块影",
"tendency": ""
},
{
"anatomy_list": [
"肺"
],
"character": [
"中央型"
],
"core_name": "癌",
"tendency": "不确定"
},
{
"anatomy_list": [
"淋巴"
],
"character": [],
"core_name": "瘤",
"tendency": "不确定"
},
{
"anatomy_list": [
"肺右上叶后段"
],
"character": [],
"core_name": "肉芽肿新生物",
"tendency": ""
},
{
"anatomy_list": [
"肺右上叶后段"
],
"character": [],
"core_name": "鳞癌",
"tendency": ""
},
{
"anatomy_list": [
"脾脏内"
],
"character": [
"多发",
"异常"
],
"core_name": "信号灶",
"tendency": ""
},
{
"anatomy_list": [
"脾脏内"
],
"character": [
"肺鳞癌"
],
"core_name": "转移",
"tendency": "不确定"
},
{
"anatomy_list": [
"双侧腹股沟淋巴结"
],
"character": [],
"core_name": "显示",
"tendency": ""
}
] |
2.动脉期多发富血供小结节，灌注异常？胸部平扫+增强：1.双肺间质性改变。 | 152 | [
{
"anatomy_list": [],
"character": [
"动脉期",
"多发",
"富血供",
"小"
],
"core_name": "结节",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "灌注异常",
"tendency": "不确定"
},
{
"anatomy_list": [
"双肺"
],
"character": [],
"core_name": "间质改变",
"tendency": ""
}
] |
1天前，患者发热至38.4℃且红肿呈线形蔓延至右大腿根部，右小腿红肿、胀痛明显，故于我院门诊就诊，拟诊“蜂窝组织炎”，予以青霉素抗感染等治疗。 | 1,790 | [
{
"anatomy_list": [],
"character": [],
"core_name": "发热",
"tendency": ""
},
{
"anatomy_list": [
"右大腿根部"
],
"character": [
"线形"
],
"core_name": "红肿",
"tendency": ""
},
{
"anatomy_list": [
"右小腿"
],
"character": [
"明显"
],
"core_name": "红肿",
"tendency": ""
},
{
"anatomy_list": [
"右小腿"
],
"character": [
"明显",
"胀痛"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"右小腿"
],
"character": [],
"core_name": "蜂窝组织炎",
"tendency": ""
}
] |
自患病以来，患者精神、食欲、睡眠一般，二便正常，体重未见明显变化。 | 1,417 | [
{
"anatomy_list": [],
"character": [
"一般"
],
"core_name": "精神",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"一般"
],
"core_name": "食欲",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"一般"
],
"core_name": "睡眠",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"正常"
],
"core_name": "大便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"正常"
],
"core_name": "小便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"明显"
],
"core_name": "体重改变",
"tendency": ""
}
] |
后2018-04-28于某医院行腹部mri示：腹膜后约平腰2-腰44椎体前缘可见团块状异常信号影，呈等t1等t2信号改变，大小约3.7×3.0×6.9cm，增强扫描呈不均匀环形强化。 | 171 | [
{
"anatomy_list": [
"腹膜后平腰椎L2L4椎体前缘"
],
"character": [
"团块状",
"等t1等t2信号改变"
],
"core_name": "异常信号影",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"不均匀",
"环形"
],
"core_name": "强化",
"tendency": ""
}
] |
解暗红色血便1次，呈稀糊状，约150g。 | 1,987 | [
{
"anatomy_list": [],
"character": [
"暗红色",
"稀糊状"
],
"core_name": "血便",
"tendency": ""
}
] |
5月前，患者因视力下降于我院眼科就诊，完善相关辅助检查，诊断为：1.双眼糖尿病性视网膜病变；2.双眼青光眼；3.左眼球占位后待查；3.双眼白内障术后人工晶体眼；5.2型糖尿病；6.原发性高血压病；7.脑梗死。 | 1,882 | [
{
"anatomy_list": [],
"character": [],
"core_name": "视力下降",
"tendency": ""
},
{
"anatomy_list": [
"双眼",
"视网膜"
],
"character": [
"糖尿病性"
],
"core_name": "病变",
"tendency": ""
},
{
"anatomy_list": [
"双眼"
],
"character": [],
"core_name": "青光眼",
"tendency": ""
},
{
"anatomy_list": [
"左眼球"
],
"character": [],
"core_name": "占位",
"tendency": ""
},
{
"anatomy_list": [
"双眼"
],
"character": [
"术后",
"人工晶体眼"
],
"core_name": "白内障",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"2型"
],
"core_name": "糖尿病",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"原发性"
],
"core_name": "高血压",
"tendency": ""
},
{
"anatomy_list": [
"脑"
],
"character": [],
"core_name": "梗死",
"tendency": ""
}
] |
入院前1天，患者再次出现畏寒、发热、寒战，体温约38.5℃。 | 1,777 | [
{
"anatomy_list": [],
"character": [],
"core_name": "畏寒",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "发热",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "寒颤",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"升高"
],
"core_name": "体温",
"tendency": ""
}
] |
病后无腹泻，无恶心，无呕吐，无抽搐，无意识障碍，无出血倾向，无心悸,无颈部包块。 | 1,296 | [
{
"anatomy_list": [
"腹"
],
"character": [
"病后"
],
"core_name": "腹泻",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "恶心",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "呕吐",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "抽搐",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "意识障碍",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "出血倾向",
"tendency": "否定"
},
{
"anatomy_list": [
"心"
],
"character": [],
"core_name": "心悸",
"tendency": "否定"
},
{
"anatomy_list": [
"颈部"
],
"character": [],
"core_name": "包块",
"tendency": "否定"
}
] |
故以"直肠癌术后第一次化疗"收入我科住院治疗。 | 1,860 | [
{
"anatomy_list": [
"直肠"
],
"character": [
"术后",
"第一次化疗"
],
"core_name": "癌",
"tendency": ""
}
] |
<7、8、9、10、11、12组>淋巴结未见癌转移。 | 831 | [
{
"anatomy_list": [
"7、8、9、10、11、12组淋巴结"
],
"character": [
"转移"
],
"core_name": "癌",
"tendency": "否定"
}
] |
患者自发病以来， 精神可 ， 食欲可 ， 睡眠可 ， 大便如常 ， 小便尿频 ， 体重无明显变化 。 | 1,393 | [
{
"anatomy_list": [],
"character": [
"可"
],
"core_name": "精神",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"可"
],
"core_name": "食欲",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"可"
],
"core_name": "睡眠质量",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"如常"
],
"core_name": "大便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "尿频",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"明显"
],
"core_name": "体重改变",
"tendency": "否定"
}
] |
入院前20+年，患者偶然发现左上眼睑长新生物，并渐渐增大，伴轻微异物感，无其他特殊不适，患者未引起重视未做治疗；入院前4+年曾就诊于某医院就诊，因血糖控制不佳，故没有进行后续手术治疗，入院1+年患者发现肿物生长迅速，偶有有眼痛、眼胀，眼痒，流泪无畏光、虹视，复视等不适，为求进一步诊治，遂于今日我院门诊就诊，门诊完善相关检查后以"左眼上睑新生物 "收入。 | 1,335 | [
{
"anatomy_list": [
"左上眼睑"
],
"character": [
"渐渐增大"
],
"core_name": "新生物",
"tendency": ""
},
{
"anatomy_list": [
"左上眼睑"
],
"character": [
"轻微"
],
"core_name": "异物感",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"控制不佳"
],
"core_name": "血糖",
"tendency": ""
},
{
"anatomy_list": [
"左上眼睑"
],
"character": [
"生长迅速"
],
"core_name": "肿物",
"tendency": ""
},
{
"anatomy_list": [
"眼"
],
"character": [],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"眼"
],
"character": [],
"core_name": "眼胀",
"tendency": ""
},
{
"anatomy_list": [
"眼"
],
"character": [],
"core_name": "瘙痒",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "流泪",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "畏光",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "虹视",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "复视",
"tendency": "否定"
},
{
"anatomy_list": [
"左眼上睑"
],
"character": [],
"core_name": "新生物",
"tendency": ""
}
] |
3.乳头未见癌组织累及。 | 2,006 | [
{
"anatomy_list": [
"乳头"
],
"character": [
"累及"
],
"core_name": "癌组织",
"tendency": "否定"
}
] |
患者自患病以来，精神食欲可，大小便正常，体重无明显改变。 | 477 | [
{
"anatomy_list": [],
"character": [
"可"
],
"core_name": "精神",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"可"
],
"core_name": "食欲",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"正常"
],
"core_name": "大小便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"明显"
],
"core_name": "体重改变",
"tendency": "否定"
}
] |
患者一般情况良好，无畏寒、发热，无咯血、胸痛、呼吸困难，无胸闷、气促、心悸，无潮热、盗汗，无咳嗽、咳痰，无头晕、头痛，无恶心、呕吐，无腹痛、腹泻等不适。 | 125 | [
{
"anatomy_list": [],
"character": [],
"core_name": "畏寒",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "发热",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "咯血",
"tendency": "否定"
},
{
"anatomy_list": [
"胸"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "呼吸困难",
"tendency": "否定"
},
{
"anatomy_list": [
"胸"
],
"character": [],
"core_name": "胸闷",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "气促",
"tendency": "否定"
},
{
"anatomy_list": [
"心"
],
"character": [],
"core_name": "心悸",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "潮热",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "盗汗",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "咳嗽",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "咳痰",
"tendency": "否定"
},
{
"anatomy_list": [
"头"
],
"character": [],
"core_name": "头晕",
"tendency": "否定"
},
{
"anatomy_list": [
"头"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "恶心",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "呕吐",
"tendency": "否定"
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "腹泻",
"tendency": "否定"
}
] |
2.左侧筛窦筛窦炎。 | 1,613 | [
{
"anatomy_list": [
"左侧筛窦"
],
"character": [],
"core_name": "筛窦炎",
"tendency": ""
}
] |
患者平素月经欠规律，初潮年龄14岁，4-6/3030-35天，lmp：2019-01-10。 | 465 | [
{
"anatomy_list": [],
"character": [
"欠规律"
],
"core_name": "月经",
"tendency": ""
}
] |
我院门诊彩超提示：右乳低回声结节，性质待定，建议穿刺活检。右乳bi-rads 4c。 | 133 | [
{
"anatomy_list": [
"右乳"
],
"character": [
"低回声"
],
"core_name": "结节",
"tendency": ""
}
] |
患者于2016年9月至2017年9月在某医院先后化疗5次（具体不详），化疗后出现恶心、呕吐及iii度骨髓抑制，予以升白细胞、输血纠正贫血及对症等治疗后好转。 | 732 | [
{
"anatomy_list": [],
"character": [
"化疗后"
],
"core_name": "恶心",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"化疗后"
],
"core_name": "呕吐",
"tendency": ""
},
{
"anatomy_list": [
"骨髓"
],
"character": [
"化疗后",
"iii度"
],
"core_name": "骨髓抑制",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "贫血",
"tendency": ""
}
] |
患者入院前4天无明显诱因出现头昏，稍有头痛，伴眩晕、恶心、呕吐，耳鸣，呕吐非喷射状，同时有上腹部腹胀、腹部隐痛、反酸、嗳气，进食后明显，无放射痛，无腹泻、黑便，有肛门坠胀感，大便呈细条状，偶有咳嗽、咳痰，无胸闷、心悸，在某镇医输液3天后头昏有好转，今日出现大便带鲜血，曾滴沥状，无黑便，现为就诊来我院，门诊以“腹痛便血待查”收入我科。 | 745 | [
{
"anatomy_list": [
"头"
],
"character": [],
"core_name": "头昏",
"tendency": ""
},
{
"anatomy_list": [
"头"
],
"character": [
"稍有"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "眩晕",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "恶心",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "呕吐",
"tendency": ""
},
{
"anatomy_list": [
"耳"
],
"character": [],
"core_name": "耳鸣",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"非喷射状"
],
"core_name": "呕吐",
"tendency": ""
},
{
"anatomy_list": [
"上腹"
],
"character": [],
"core_name": "腹胀",
"tendency": ""
},
{
"anatomy_list": [
"腹"
],
"character": [
"隐痛"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "反酸",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"进食后明显"
],
"core_name": "嗳气",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"放射性"
],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "腹泻",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "黑便",
"tendency": "否定"
},
{
"anatomy_list": [
"肛门"
],
"character": [],
"core_name": "坠胀感",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"细条状"
],
"core_name": "大便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"偶有"
],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"偶有"
],
"core_name": "咳痰",
"tendency": ""
},
{
"anatomy_list": [
"胸"
],
"character": [],
"core_name": "胸闷",
"tendency": "否定"
},
{
"anatomy_list": [
"心"
],
"character": [],
"core_name": "心悸",
"tendency": "否定"
},
{
"anatomy_list": [
"头"
],
"character": [
"输液3天后",
"好转"
],
"core_name": "头昏",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"带血",
"滴沥状"
],
"core_name": "大便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "黑便",
"tendency": "否定"
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "便血",
"tendency": ""
}
] |
三尖瓣重度反流，肺动脉增宽，肺动脉高压；二尖瓣中度反流；主动脉瓣钙化伴中度狭窄。 | 528 | [
{
"anatomy_list": [
"三尖瓣"
],
"character": [
"重度"
],
"core_name": "反流",
"tendency": ""
},
{
"anatomy_list": [
"肺动脉"
],
"character": [],
"core_name": "增宽",
"tendency": ""
},
{
"anatomy_list": [
"肺动脉"
],
"character": [],
"core_name": "高压",
"tendency": ""
},
{
"anatomy_list": [
"二尖瓣"
],
"character": [
"中度"
],
"core_name": "反流",
"tendency": ""
},
{
"anatomy_list": [
"主动脉瓣"
],
"character": [],
"core_name": "钙化",
"tendency": ""
},
{
"anatomy_list": [
"主动脉瓣"
],
"character": [
"中度"
],
"core_name": "狭窄",
"tendency": ""
}
] |
化疗过程顺利，患者未诉特殊不适，右乳包块变软、缩小。 | 1,189 | [
{
"anatomy_list": [
"右乳"
],
"character": [
"变软",
"缩小"
],
"core_name": "包块",
"tendency": ""
}
] |
伴有疼痛，月经前明显，月经后缓解，局部皮肤无红肿、瘙痒，无发热、恶心、潮热、盗汗、腹痛、腹胀等不适，患者规律服用乳增宁片治疗，乳腺疼痛较前明显缓解。 | 579 | [
{
"anatomy_list": [],
"character": [
"月经前明显",
"月经后缓解"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"皮肤"
],
"character": [
"局部"
],
"core_name": "红肿",
"tendency": "否定"
},
{
"anatomy_list": [
"皮肤"
],
"character": [
"局部"
],
"core_name": "瘙痒",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "发热",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "恶心",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "潮热",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "盗汗",
"tendency": "否定"
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "腹胀",
"tendency": "否定"
},
{
"anatomy_list": [
"乳腺"
],
"character": [
"较前明显缓解"
],
"core_name": "疼痛",
"tendency": ""
}
] |
现患者无发热、恶心、呕吐等，无腹痛、腹胀、腹泻等，今为进一步治疗入院。 | 464 | [
{
"anatomy_list": [],
"character": [],
"core_name": "发热",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "恶心",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "呕吐",
"tendency": "否定"
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "腹胀",
"tendency": "否定"
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "腹泻",
"tendency": "否定"
}
] |
5月前，患者于我院住院时后查体发现双侧下颌下下颌下淋巴结淋巴结肿大，具体检查诊断不详，诊断“颈动脉狭窄、胸椎椎管内髓外病变:肿瘤性病变?、亚临床甲状腺功能减退症?”，患者椎管内髓外病变未进一步处理。 | 1,459 | [
{
"anatomy_list": [
"双侧下颌下淋巴结"
],
"character": [],
"core_name": "肿大",
"tendency": ""
},
{
"anatomy_list": [
"颈动脉"
],
"character": [],
"core_name": "狭窄",
"tendency": ""
},
{
"anatomy_list": [
"胸椎椎管内",
"髓外"
],
"character": [],
"core_name": "病变",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"肿瘤性"
],
"core_name": "病变",
"tendency": "不确定"
},
{
"anatomy_list": [
"甲状腺"
],
"character": [],
"core_name": "亚临床甲状腺功能减退症",
"tendency": "不确定"
},
{
"anatomy_list": [
"椎管内",
"髓外"
],
"character": [],
"core_name": "病变",
"tendency": ""
}
] |
2016-08-01 血液分析(门诊)wbc 3.52*10^9/L，plt 274*10^9/L，hb 92g/L，anc 2.22*10^9/L；今为行间期治疗1-8周第2次静脉化疗入院，门诊以“急性前b淋巴细胞淋巴细胞白血病”收入我科。 | 1,727 | [
{
"anatomy_list": [],
"character": [
"急性",
"前B淋巴细胞"
],
"core_name": "白血病",
"tendency": ""
}
] |
术后诊断：1.食管贲门腺癌；2.慢性浅表性胃窦炎胃窦炎伴糜烂。 | 500 | [
{
"anatomy_list": [
"食管",
"贲门"
],
"character": [],
"core_name": "腺癌",
"tendency": ""
},
{
"anatomy_list": [
"胃窦"
],
"character": [
"慢性",
"浅表性"
],
"core_name": "胃窦炎",
"tendency": ""
},
{
"anatomy_list": [
"胃窦"
],
"character": [],
"core_name": "糜烂",
"tendency": ""
}
] |
胸部增强ct+肺动脉cta+头颅mri、纤维支气管镜等，诊断为：右肺腺癌伴纵膈、锁骨上淋巴结转移、胸膜、心包、颅内转移，t3n3Mm1b，诊断明确后给予培美曲赛及铂类化疗3次。 | 1,245 | [
{
"anatomy_list": [
"右肺"
],
"character": [],
"core_name": "腺癌",
"tendency": ""
},
{
"anatomy_list": [
"纵膈淋巴结",
"锁骨上淋巴结",
"胸膜",
"心包",
"颅内"
],
"character": [],
"core_name": "转移",
"tendency": ""
}
] |
不伴胸骨后灼烧感，不伴厌油、乏力、黄疸。 | 589 | [
{
"anatomy_list": [
"胸骨后"
],
"character": [],
"core_name": "灼烧感",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "厌油",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "乏力",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "黄疸",
"tendency": "否定"
}
] |
2、肠系膜扭转，肠系膜密度增高、模糊，小肠管较多积液。请结合临床。 | 1,233 | [
{
"anatomy_list": [
"肠系膜"
],
"character": [],
"core_name": "扭转",
"tendency": ""
},
{
"anatomy_list": [
"肠系膜"
],
"character": [
"增高",
"模糊"
],
"core_name": "密度",
"tendency": ""
},
{
"anatomy_list": [
"小肠管"
],
"character": [
"较多"
],
"core_name": "积液",
"tendency": ""
}
] |
不伴畏寒，寒战，高热；不伴潮热、盗汗及午后低热；不咯鲜血及痰中带血；不伴胸痛，气促及呼吸困难；不伴体重减轻及食欲下降。 | 787 | [
{
"anatomy_list": [],
"character": [],
"core_name": "畏寒",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "寒颤",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"高"
],
"core_name": "发热",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "潮热",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "盗汗",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"午后",
"低"
],
"core_name": "发热",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"鲜红色"
],
"core_name": "咯血",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"带血"
],
"core_name": "咳痰",
"tendency": "否定"
},
{
"anatomy_list": [
"胸"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "气促",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "呼吸困难",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "体重减轻",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "食欲下降",
"tendency": "否定"
}
] |
自述反复冷汗、头昏、饥饿感明显，自测指血糖2.5mmol/L左右。 | 1,881 | [
{
"anatomy_list": [],
"character": [
"反复"
],
"core_name": "冷汗",
"tendency": ""
},
{
"anatomy_list": [
"头"
],
"character": [
"反复"
],
"core_name": "头昏",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"明显"
],
"core_name": "饥饿感",
"tendency": ""
}
] |
2.双肺多发结节影，转移可能，请随访复查。 | 754 | [
{
"anatomy_list": [
"双肺"
],
"character": [
"多发"
],
"core_name": "结节影",
"tendency": ""
},
{
"anatomy_list": [
"双肺"
],
"character": [],
"core_name": "转移",
"tendency": "不确定"
}
] |
门诊遂以“慢性肾脏病”收入我科。 | 877 | [
{
"anatomy_list": [
"肾"
],
"character": [
"慢性"
],
"core_name": "肾病",
"tendency": ""
}
] |
今日为进一步检查治疗转入我院，门诊以“头部外伤、左颞骨骨折”收住入院。 | 1,805 | [
{
"anatomy_list": [
"头部"
],
"character": [],
"core_name": "外伤",
"tendency": ""
},
{
"anatomy_list": [
"左颞骨"
],
"character": [],
"core_name": "骨折",
"tendency": ""
}
] |
不伴发热、畏寒、寒战、反酸、烧心、嗳气、呃逆、头痛、胸闷、胸痛、气促，到重医附一院就诊行腹部ct检查提示“1、肝硬化，脾大，食道胃底静脉曲张，2、肝癌待排，查乙肝标志物示hbsag阳性。 | 857 | [
{
"anatomy_list": [],
"character": [],
"core_name": "发热",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "畏寒",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "寒颤",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "反酸",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "烧心",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "嗳气",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "呃逆",
"tendency": "否定"
},
{
"anatomy_list": [
"头"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "胸闷",
"tendency": "否定"
},
{
"anatomy_list": [
"胸"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "气促",
"tendency": "否定"
},
{
"anatomy_list": [
"肝"
],
"character": [],
"core_name": "硬化",
"tendency": ""
},
{
"anatomy_list": [
"脾"
],
"character": [],
"core_name": "脾大",
"tendency": ""
},
{
"anatomy_list": [
"食管静脉",
"胃底静脉"
],
"character": [],
"core_name": "曲张",
"tendency": ""
},
{
"anatomy_list": [
"肝"
],
"character": [],
"core_name": "癌",
"tendency": "不确定"
},
{
"anatomy_list": [],
"character": [
"阳性"
],
"core_name": "hbsag",
"tendency": ""
}
] |