Rosenberg/CHIP-CDEE · Datasets at Hugging Face

text stringlengths 5 708	id int64 1 2.07k	event list
体重减轻5斤。	1,411	[ { "anatomy_list": [], "character": [], "core_name": "体重减轻", "tendency": "" } ]
病程中，患者神志清，精神可，饮食睡眠正常，大小便正常，体重无异常变化。	114	[ { "anatomy_list": [], "character": [ "清" ], "core_name": "神志", "tendency": "" }, { "anatomy_list": [], "character": [ "可" ], "core_name": "精神", "tendency": "" }, { "anatomy_list": [], "character": [ "正常" ], "core_name": "饮食", "tendency": "" }, { "anatomy_list": [], "character": [ "正常" ], "core_name": "睡眠", "tendency": "" }, { "anatomy_list": [], "character": [ "正常" ], "core_name": "大小便", "tendency": "" }, { "anatomy_list": [], "character": [ "异常" ], "core_name": "体重变化", "tendency": "否定" } ]
于2015年8月11日行神经导航下开路探查+左侧前颅底路况沟通肿瘤纤维切除术，术中可见肿瘤位于左侧前颅底，已经将蝶骨脊及眼眶外侧板侵蚀破坏，起源于硬脑膜，硬膜外及硬膜下均可见肿瘤，硬膜下肿瘤呈肉红色，血供丰富，与周围脑组织边界尚清，粘连明显，完整切除肿瘤致肿瘤镜下全切，之后切除眼眶内肿瘤，探查肿瘤位于框内，与周围骨质两联紧密，深部侵及眶外脂肪层，小心游离眼眶内肿瘤后完整切除肿瘤。	419	[ { "anatomy_list": [ "左侧前颅底" ], "character": [], "core_name": "肿瘤", "tendency": "" }, { "anatomy_list": [ "眼眶外侧板", "蝶骨脊" ], "character": [], "core_name": "侵蚀破坏", "tendency": "" }, { "anatomy_list": [ "硬脑膜", "硬膜外", "硬膜下" ], "character": [], "core_name": "肿瘤", "tendency": "" }, { "anatomy_list": [ "硬膜下" ], "character": [ "呈肉红色", "血供丰富", "与周围脑组织边界尚清", "粘连明显" ], "core_name": "肿瘤", "tendency": "" }, { "anatomy_list": [ "眼眶内" ], "character": [ "与周围骨质两联紧密", "深部侵及眶外脂肪层" ], "core_name": "肿瘤", "tendency": "" } ]
2+年前，患者无明显诱因反复出现咳嗽，多为干咳，偶咳白色泡沫痰，偶有发热，体温多为38℃左右，无畏寒、盗汗，无胸闷、胸痛，无咯血，于某医院输液治疗（具体不详）后可好转，未予以进一步检查。	544	[ { "anatomy_list": [], "character": [ "反复出现" ], "core_name": "咳嗽", "tendency": "" }, { "anatomy_list": [], "character": [ "干性", "反复出现" ], "core_name": "咳嗽", "tendency": "" }, { "anatomy_list": [], "character": [ "偶尔", "白色", "泡沫痰" ], "core_name": "咳痰", "tendency": "" }, { "anatomy_list": [], "character": [ "偶有" ], "core_name": "发热", "tendency": "" }, { "anatomy_list": [], "character": [ "升高", "偶有" ], "core_name": "体温", "tendency": "" }, { "anatomy_list": [], "character": [], "core_name": "畏寒", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "盗汗", "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": [], "character": [], "core_name": "咯血", "tendency": "否定" } ]
7+月前至某医院医院复查妇科彩超：左附件区可见64mm×35mm的无回声区，查ca125、he4均正常，hpv-dna均阴性，建议手术，患者仍未做。	825	[ { "anatomy_list": [ "左附件" ], "character": [], "core_name": "无回声", "tendency": "" } ]
入院3天前再次出现意识丧失（家属未看到），发病形式、过程不详。	740	[ { "anatomy_list": [], "character": [ "家属未看到", "发病形式", "过程不详" ], "core_name": "意识丧失", "tendency": "" } ]
于2019-3-27给予e-chop方案（依托泊苷100mg d1-2、吡柔比星20mg d1-3、环磷酰胺400mg d1-3、地塞米松20mg d1-5、长春新碱1.5mg d1、d8）方案化疗1周期，于2019-4-23、2019-5-17给予re-chop方案（美罗华600mg d1、依托泊苷100mg d1-2、吡柔比星60mg d1、环磷酰胺400mg d1-3、地塞米松20mg d1-5、长春新碱3mg d1）化疗第2周期，化疗后患者出现ii°骨髓抑制，给予升白治疗后骨髓抑制纠正，今日为行下一周期化疗来我科，以“弥漫大b细胞淋巴瘤（iv期 b组）化疗后复发”收入住院治疗。	1,072	[ { "anatomy_list": [ "骨髓" ], "character": [ "化疗后", "ii°" ], "core_name": "骨髓抑制", "tendency": "" }, { "anatomy_list": [ "骨髓" ], "character": [ "矫正" ], "core_name": "骨髓抑制", "tendency": "" }, { "anatomy_list": [ "淋巴", "大B细胞" ], "character": [ "弥漫性", "iv期 b组", "化疗后", "复发" ], "core_name": "瘤", "tendency": "" } ]
院外于某医院行内分泌治疗及抗溶骨治疗，患者近期左侧腰部及下肢疼痛明显，为求进一步治疗，以“乳腺癌骨转移”收入我科住院治疗。	1,291	[ { "anatomy_list": [ "左侧腰部", "下肢" ], "character": [ "近期", "明显" ], "core_name": "疼痛", "tendency": "" }, { "anatomy_list": [ "乳腺", "骨" ], "character": [ "骨转移" ], "core_name": "癌", "tendency": "" } ]
后一直我院随访，肿瘤病灶稳定，1年前前，患者在我科复查腹部mri提示肝右后叶小富血供结节，不排除原发性肝癌hifu术后复发可能，于2013年12月30日行tae治疗，于2014年1月4日在全身麻醉下行原发性肝癌姑息性hifu术，术后患者恢复可，多次复查腹部mri提示肿瘤控制可，现为求再次复查入住我科。	1,006	[ { "anatomy_list": [], "character": [ "肿瘤", "稳定" ], "core_name": "病灶", "tendency": "" }, { "anatomy_list": [ "肝右后叶" ], "character": [ "小", "富血供" ], "core_name": "结节", "tendency": "" }, { "anatomy_list": [ "肝" ], "character": [ "原发性", "hifu术后", "复发" ], "core_name": "癌", "tendency": "不确定" }, { "anatomy_list": [], "character": [ "控制可" ], "core_name": "肿瘤", "tendency": "" } ]
院外一直口服中成药治疗（具体用药）治疗，并于2011年5月和2011年9月、2012年3月22日和2012年7月到我科复查，行相关检查，提示肿瘤尚无进展。	724	[ { "anatomy_list": [], "character": [ "进展" ], "core_name": "肿瘤", "tendency": "否定" } ]
肠壁上淋巴结见癌转移（1/15）。	748	[ { "anatomy_list": [ "肠壁上淋巴结" ], "character": [ "转移" ], "core_name": "癌", "tendency": "" } ]
到某医院就诊，行胸片示肺上局部钙化钙化灶（未见报告），未予特殊治疗。	2,025	[ { "anatomy_list": [ "肺上局部" ], "character": [ "局部" ], "core_name": "钙化灶", "tendency": "" } ]
患者1+月前出现咳嗽咳痰，咳嗽声音正常，不伴有鸡鸣样咳嗽，不伴有刺激性干咳，咳嗽时有胸痛症状。	368	[ { "anatomy_list": [], "character": [], "core_name": "咳嗽", "tendency": "" }, { "anatomy_list": [], "character": [], "core_name": "咳痰", "tendency": "" }, { "anatomy_list": [], "character": [ "声音正常" ], "core_name": "咳嗽", "tendency": "" }, { "anatomy_list": [], "character": [ "鸡鸣样" ], "core_name": "咳嗽", "tendency": "否定" }, { "anatomy_list": [], "character": [ "刺激性", "干" ], "core_name": "咳嗽", "tendency": "否定" }, { "anatomy_list": [ "胸" ], "character": [ "咳嗽时" ], "core_name": "疼痛", "tendency": "" } ]
后续于2016年12月25日、2017年1月18日、2017年2月15日行3周期原方案原剂量化疗,未见明显骨髓抑制；后于2017年3月14日、2017年4月8日予以吡柔比星50mg d1+紫杉醇240mg d2+环磷酰胺800mg d3化疗；化疗期间患者均无明显恶心、呕吐、骨髓抑制等副反应。	20	[ { "anatomy_list": [ "骨髓" ], "character": [ "明显" ], "core_name": "骨髓抑制", "tendency": "否定" }, { "anatomy_list": [], "character": [ "明显" ], "core_name": "恶心", "tendency": "否定" }, { "anatomy_list": [], "character": [ "明显" ], "core_name": "呕吐", "tendency": "否定" }, { "anatomy_list": [ "骨髓" ], "character": [ "明显" ], "core_name": "骨髓抑制", "tendency": "否定" } ]
2+年前（2018年3月）患者于某医院因体检腹部彩超发现左侧肾脏下级占位，左肾积水，无腰痛、无腹胀腹痛，无恶心呕吐，无尿频尿急尿痛，无肉眼血尿等不适。	162	[ { "anatomy_list": [ "左侧肾脏下级" ], "character": [], "core_name": "占位", "tendency": "" }, { "anatomy_list": [ "左肾" ], "character": [], "core_name": "积水", "tendency": "" }, { "anatomy_list": [ "腰" ], "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": "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": "尿频", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "尿急", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "尿痛", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "血尿", "tendency": "否定" } ]
右上肺肺陈旧性病灶,以纤维化为主；右上肺结节影,考虑为纤维结节可能,不除外肿瘤性病变。食道中下段壁可疑稍增厚。	7	[ { "anatomy_list": [ "右上肺" ], "character": [ "陈旧性" ], "core_name": "病灶", "tendency": "" }, { "anatomy_list": [ "右上肺" ], "character": [], "core_name": "纤维化", "tendency": "" }, { "anatomy_list": [ "右上肺" ], "character": [], "core_name": "结节影", "tendency": "" }, { "anatomy_list": [ "右上肺" ], "character": [], "core_name": "纤维结节", "tendency": "不确定" }, { "anatomy_list": [ "右上肺" ], "character": [ "肿瘤性" ], "core_name": "病变", "tendency": "不确定" }, { "anatomy_list": [ "食道中下段壁" ], "character": [ "稍" ], "core_name": "增厚", "tendency": "不确定" } ]
现为求进一步诊疗到我院，急诊以“消化道出血原因待查”收入院。	1,990	[ { "anatomy_list": [ "消化道" ], "character": [], "core_name": "出血", "tendency": "不确定" } ]
2018年4月患者发现左侧腹股沟腹股沟包块较前明显增大、增多，左侧腹股沟穿刺病理提示“<左腹股沟淋巴结穿刺活检标本>淋巴组织结构破坏，于组织细胞及淋巴细胞背景中查见散在r-s样细胞，结合免疫组化及t细胞基因重排满负荷经典型霍奇金淋巴瘤（混合细胞亚型）”，全身pet/ct示“腹膜后、盆腔、左侧腹股沟可见多发淋巴结肿大，fdg代谢异常增高”，未行骨髓穿刺检查。	852	[ { "anatomy_list": [ "左侧腹股沟淋巴结" ], "character": [ "明显增大、增多" ], "core_name": "包块", "tendency": "" }, { "anatomy_list": [ "左侧腹股沟淋巴结组织结构" ], "character": [], "core_name": "破坏", "tendency": "" }, { "anatomy_list": [ "r-s样细胞" ], "character": [ "组织细胞及淋巴细胞背景中查见", "散在" ], "core_name": "r-s样细胞", "tendency": "" }, { "anatomy_list": [ "淋巴" ], "character": [ "混合细胞亚型" ], "core_name": "瘤", "tendency": "" }, { "anatomy_list": [ "淋巴" ], "character": [ "经典型", "霍奇金" ], "core_name": "瘤", "tendency": "" }, { "anatomy_list": [ "腹膜后淋巴结" ], "character": [ "多发" ], "core_name": "肿大", "tendency": "" }, { "anatomy_list": [ "盆腔淋巴结" ], "character": [ "多发" ], "core_name": "肿大", "tendency": "" }, { "anatomy_list": [ "左侧腹股沟淋巴结" ], "character": [ "多发" ], "core_name": "肿大", "tendency": "" }, { "anatomy_list": [], "character": [ "异常增高" ], "core_name": "fdg代谢", "tendency": "" } ]
现患者为求进一步诊疗，门诊以“冠心病、慢性阻塞性肺疾病、心力衰竭”收入我科住院治疗。	815	[ { "anatomy_list": [ "心" ], "character": [], "core_name": "冠心病", "tendency": "" }, { "anatomy_list": [ "肺" ], "character": [ "慢性", "阻塞性" ], "core_name": "肺疾病", "tendency": "" }, { "anatomy_list": [ "心" ], "character": [], "core_name": "心力衰竭", "tendency": "" } ]
今患者为求进一步治疗，至我院门诊就诊，门诊以“膀胱占位”收入我科住院治疗。	1,831	[ { "anatomy_list": [ "膀胱" ], "character": [], "core_name": "占位", "tendency": "" } ]
患者自起病以来，精神可，胃纳略差，大便如常，尿急，体重未见明显下降。	1,171	[ { "anatomy_list": [], "character": [ "可" ], "core_name": "精神", "tendency": "" }, { "anatomy_list": [ "胃" ], "character": [ "略差" ], "core_name": "胃纳", "tendency": "" }, { "anatomy_list": [], "character": [ "如常" ], "core_name": "大便", "tendency": "" }, { "anatomy_list": [], "character": [], "core_name": "尿急", "tendency": "" }, { "anatomy_list": [], "character": [ "明显" ], "core_name": "体重下降", "tendency": "否定" } ]
3月余前，患者出现胸前区疼痛，为阵发性胀痛，于夜间采取侧卧位时疼痛明显，休息后自行缓解，无压榨感，无胸闷、心悸、气促，无头痛、头晕，无咳嗽、咯血、呼吸困难，无畏寒、寒战，无潮热、盗汗，无吞咽困难，出现喉部异物感，遂于某中医院就诊，行胸部ct提示：左中上纵膈混杂密度占位影，考虑肿瘤性病变，胸腺瘤（侵袭性）可能；左侧后肋肋胸膜胸膜局限性增厚，不除外胸膜转移可能。	1,479	[ { "anatomy_list": [ "胸前区" ], "character": [ "阵发性", "胀痛", "夜间采取侧卧位时疼痛明显", "休息后自行缓解" ], "core_name": "疼痛", "tendency": "" }, { "anatomy_list": [ "胸前区" ], "character": [], "core_name": "压榨感", "tendency": "否定" }, { "anatomy_list": [ "胸" ], "character": [], "core_name": "胸闷", "tendency": "否定" }, { "anatomy_list": [ "心" ], "character": [], "core_name": "心悸", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "气促", "tendency": "否定" }, { "anatomy_list": [ "头" ], "character": [], "core_name": "疼痛", "tendency": "否定" }, { "anatomy_list": [ "头" ], "character": [], "core_name": "头晕", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "咳嗽", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "咯血", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "呼吸困难", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "畏寒", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "寒颤", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "潮热", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "盗汗", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "吞咽困难", "tendency": "否定" }, { "anatomy_list": [ "喉部" ], "character": [], "core_name": "异物感", "tendency": "" }, { "anatomy_list": [ "左中上纵膈" ], "character": [ "混杂密度" ], "core_name": "占位影", "tendency": "" }, { "anatomy_list": [ "左中上纵膈" ], "character": [ "肿瘤性" ], "core_name": "病变", "tendency": "不确定" }, { "anatomy_list": [ "胸腺" ], "character": [ "侵袭性" ], "core_name": "瘤", "tendency": "不确定" }, { "anatomy_list": [ "左侧后肋", "肋胸膜" ], "character": [ "局限性" ], "core_name": "增厚", "tendency": "" }, { "anatomy_list": [ "胸膜" ], "character": [], "core_name": "转移", "tendency": "不确定" } ]
患者自患病以来精神、食欲、睡眠可，大小便正常，近期体重无明显变化。	1,693	[ { "anatomy_list": [], "character": [ "可" ], "core_name": "精神", "tendency": "" }, { "anatomy_list": [], "character": [ "可" ], "core_name": "食欲", "tendency": "" }, { "anatomy_list": [], "character": [ "可" ], "core_name": "睡眠", "tendency": "" }, { "anatomy_list": [], "character": [ "正常" ], "core_name": "大小便", "tendency": "" }, { "anatomy_list": [], "character": [ "明显" ], "core_name": "体重改变", "tendency": "否定" } ]
半月前患者无明显诱因再次血糖控制不佳，监测血糖空腹波动在15-16mm16mmol/L，餐后血糖在21-22mm22mmol/L，患者近期均进食稀饭，现患者有耳鸣，偶有恶心、反酸，无畏寒、发热，无头痛、头晕，无呕吐，有胸闷、心悸，偶有胸痛，伴上腹部不适，伴腹胀、腹泻，无双下肢凹陷性水肿，患者现使用胰岛素剂量为“门冬胰岛素早餐前14u，午餐前14u，晚餐前14u，甘精胰岛素睡前34u”，为进一步治疗就诊，门诊以“糖尿病、糖尿病肾病”收住院治疗。	538	[ { "anatomy_list": [], "character": [ "控制不佳" ], "core_name": "血糖", "tendency": "" }, { "anatomy_list": [], "character": [ "空腹", "波动", "升高" ], "core_name": "血糖", "tendency": "" }, { "anatomy_list": [], "character": [ "餐后", "波动", "升高" ], "core_name": "血糖", "tendency": "" }, { "anatomy_list": [], "character": [ "稀饭" ], "core_name": "进食", "tendency": "" }, { "anatomy_list": [ "耳" ], "character": [], "core_name": "耳鸣", "tendency": "" }, { "anatomy_list": [], "character": [ "偶有" ], "core_name": "恶心", "tendency": "" }, { "anatomy_list": [], "character": [ "偶有" ], "core_name": "反酸", "tendency": "" }, { "anatomy_list": [], "character": [], "core_name": "畏寒", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "发热", "tendency": "否定" }, { "anatomy_list": [ "头" ], "character": [], "core_name": "疼痛", "tendency": "否定" }, { "anatomy_list": [ "头" ], "character": [], "core_name": "头晕", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "呕吐", "tendency": "否定" }, { "anatomy_list": [ "胸" ], "character": [], "core_name": "胸闷", "tendency": "" }, { "anatomy_list": [ "心" ], "character": [], "core_name": "心悸", "tendency": "" }, { "anatomy_list": [ "胸" ], "character": [ "偶有" ], "core_name": "疼痛", "tendency": "" }, { "anatomy_list": [ "上腹部" ], "character": [], "core_name": "不适", "tendency": "" }, { "anatomy_list": [ "腹" ], "character": [], "core_name": "腹胀", "tendency": "" }, { "anatomy_list": [ "腹" ], "character": [], "core_name": "腹泻", "tendency": "" }, { "anatomy_list": [ "双下肢" ], "character": [ "凹陷性" ], "core_name": "水肿", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "糖尿病", "tendency": "" }, { "anatomy_list": [ "肾" ], "character": [ "糖尿病" ], "core_name": "肾病", "tendency": "" } ]
患者今为进一步诊治，来我院就诊，门诊以"lsil"收入我科。	1,402	[ { "anatomy_list": [], "character": [], "core_name": "低度鳞状上皮内病变", "tendency": "" } ]
1周前出现喘累不适，无明显缓解，胸水b超定位提示：右侧胸腔积液，最大前后径约148mm。	1,247	[ { "anatomy_list": [], "character": [ "无明显缓解" ], "core_name": "喘累", "tendency": "" }, { "anatomy_list": [ "胸" ], "character": [], "core_name": "胸水", "tendency": "" }, { "anatomy_list": [ "右侧胸腔" ], "character": [], "core_name": "积液", "tendency": "" } ]
无禁忌症，于10.19开始给予颈部转移病灶调强放射治疗，dt:66G/33f，放疗过程中出现放射性皮炎，给予局部外敷康复新促进皮肤修护治疗，建议患者行化疗，患者拒绝。	1,110	[ { "anatomy_list": [ "颈部" ], "character": [ "转移" ], "core_name": "病灶", "tendency": "" }, { "anatomy_list": [ "颈部", "皮" ], "character": [ "放射性" ], "core_name": "皮炎", "tendency": "" } ]
3月前患者无明显诱因出现腰痛，伴尿黄，无腹胀、腹痛，无胸闷、胸痛，无尿频、尿急、尿痛，院外就诊诊断为“肾结石、肝功异常”，当时未予重视，自行院外输液治疗（具体用药及诊断不详）后腰痛缓解，未复查及随访。	650	[ { "anatomy_list": [ "腰" ], "character": [], "core_name": "疼痛", "tendency": "" }, { "anatomy_list": [], "character": [], "core_name": "尿黄", "tendency": "" }, { "anatomy_list": [ "腹" ], "character": [], "core_name": "腹胀", "tendency": "否定" }, { "anatomy_list": [ "腹" ], "character": [], "core_name": "疼痛", "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": [], "character": [], "core_name": "尿频", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "尿急", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "尿痛", "tendency": "否定" }, { "anatomy_list": [ "肾" ], "character": [], "core_name": "结石", "tendency": "" }, { "anatomy_list": [ "肝" ], "character": [], "core_name": "肝功能异常", "tendency": "" }, { "anatomy_list": [ "腰" ], "character": [ "输液治疗缓解" ], "core_name": "疼痛", "tendency": "" } ]
无腹胀、腹痛，恶心、呕吐，无里急后重。患者未予以重视。	1,444	[ { "anatomy_list": [ "腹" ], "character": [], "core_name": "腹胀", "tendency": "否定" }, { "anatomy_list": [ "腹" ], "character": [], "core_name": "疼痛", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "恶心", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "呕吐", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "里急后重", "tendency": "否定" } ]
患者今为求进一步治疗，门诊以“消化道出血”收治我科。	1,445	[ { "anatomy_list": [ "消化道" ], "character": [], "core_name": "出血", "tendency": "" } ]
之后上述症状反复发作，每次发作均无明显诱因，均突然发作，持续数分钟至10+分钟后自行缓解，性质同前，未治疗；近1月来，患者发作频率较前增加，间隔时间减短，约每小时1-2次，持续10+分钟，无胸闷、气促、胸痛，无黑蒙、晕厥、意识障碍，无咯血、呼吸困难等不适。	703	[ { "anatomy_list": [ "胸" ], "character": [], "core_name": "胸闷", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "气促", "tendency": "否定" }, { "anatomy_list": [ "胸" ], "character": [], "core_name": "疼痛", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "黑朦", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "晕厥", "tendency": "否定" }, { "anatomy_list": [], "character": [ "障碍" ], "core_name": "意识", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "咯血", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "呼吸困难", "tendency": "否定" } ]
原始肿物位于左侧乳房与乳头内侧，大小约为2*2cm。	401	[ { "anatomy_list": [ "左侧乳房与乳头内侧" ], "character": [ "原始" ], "core_name": "肿物", "tendency": "" } ]
发现血压增高5年，血压最高达170/105mmHg，长期口服“苯磺酸氨氯地平”降压，血压控制情况不详。	267	[ { "anatomy_list": [], "character": [ "增高" ], "core_name": "血压", "tendency": "" } ]
患者既往月经规律，自然绝经20+年，绝经后无阴道阴道流血流液。	313	[ { "anatomy_list": [], "character": [ "规律" ], "core_name": "月经", "tendency": "" }, { "anatomy_list": [ "阴道" ], "character": [ "绝经后" ], "core_name": "出血", "tendency": "否定" }, { "anatomy_list": [ "阴道" ], "character": [ "绝经后" ], "core_name": "流液", "tendency": "否定" } ]
左颈部软组织影，考虑淋巴结转移可能。	183	[ { "anatomy_list": [ "左颈部" ], "character": [ "软组织" ], "core_name": "组织影", "tendency": "" }, { "anatomy_list": [ "淋巴结" ], "character": [], "core_name": "转移", "tendency": "不确定" } ]
平时白带较不多，无异味。	1,399	[ { "anatomy_list": [], "character": [ "较不多" ], "core_name": "白带", "tendency": "" }, { "anatomy_list": [], "character": [ "异味" ], "core_name": "白带", "tendency": "否定" } ]
22月前患者为进一步治疗来我科，完善术前检查，于2015-10-12行原发性肝癌介入术，2015-10-19复查ct提示碘油沉积可，2015-10-23行原发性肝癌姑息性hifu术，术后给予保肝、消炎、增强免疫、抗肿瘤等治疗，患者术后多次复查腹部mr提示肿瘤无复发。	451	[ { "anatomy_list": [], "character": [ "可" ], "core_name": "碘油沉积", "tendency": "" }, { "anatomy_list": [], "character": [ "复发" ], "core_name": "肿瘤", "tendency": "否定" } ]
入院前10年，患者受凉后咳嗽，咯白色泡沫痰，以晨起明显。	1,327	[ { "anatomy_list": [], "character": [ "受凉后" ], "core_name": "咳嗽", "tendency": "" }, { "anatomy_list": [], "character": [ "白色", "泡沫痰", "晨起明显" ], "core_name": "咳痰", "tendency": "" } ]
21年来患者反复心悸、胸痛、胸闷，偶伴心前区疼痛及压榨感，每次持续20秒，呈锐痛，含服硝酸甘油后症状可立即缓解，偶伴头晕、头痛，无视物旋转、一过性黑朦，11年前在我科住院治疗，经冠状动脉造影示lad开口狭窄、并行支架成型术。	1,567	[ { "anatomy_list": [ "心" ], "character": [ "反复" ], "core_name": "心悸", "tendency": "" }, { "anatomy_list": [ "胸" ], "character": [ "反复" ], "core_name": "疼痛", "tendency": "" }, { "anatomy_list": [ "胸" ], "character": [ "反复" ], "core_name": "胸闷", "tendency": "" }, { "anatomy_list": [ "心前区" ], "character": [ "偶" ], "core_name": "疼痛", "tendency": "" }, { "anatomy_list": [ "心前区" ], "character": [ "偶" ], "core_name": "压榨感", "tendency": "" }, { "anatomy_list": [ "心前区" ], "character": [ "锐痛" ], "core_name": "疼痛", "tendency": "" }, { "anatomy_list": [ "头" ], "character": [ "偶" ], "core_name": "头晕", "tendency": "" }, { "anatomy_list": [ "头" ], "character": [ "偶" ], "core_name": "疼痛", "tendency": "" }, { "anatomy_list": [], "character": [ "一过性" ], "core_name": "黑朦", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "视物旋转", "tendency": "否定" }, { "anatomy_list": [ "冠状动脉lad开口" ], "character": [], "core_name": "狭窄", "tendency": "" } ]
后患者颈部包块逐渐增大，2020年10月开始出现咳嗽、咳痰，咳白色粘痰，咳嗽剧烈时伴有呼吸困难。	482	[ { "anatomy_list": [ "颈部" ], "character": [ "逐渐", "增大" ], "core_name": "包块增大", "tendency": "" }, { "anatomy_list": [], "character": [], "core_name": "咳嗽", "tendency": "" }, { "anatomy_list": [], "character": [], "core_name": "咳痰", "tendency": "" }, { "anatomy_list": [], "character": [ "白色", "粘性" ], "core_name": "咳痰", "tendency": "" }, { "anatomy_list": [], "character": [ "咳嗽剧烈时" ], "core_name": "呼吸困难", "tendency": "" } ]
患者本次发病以来，食欲下降，感进食后饱胀不适。	1,313	[ { "anatomy_list": [], "character": [ "下降" ], "core_name": "食欲", "tendency": "" }, { "anatomy_list": [], "character": [ "进食后" ], "core_name": "饱胀", "tendency": "" } ]
入院前半年，患者站立时扪及右侧腹股沟区一大拇指大小包块，质地较软，移动可，可回纳，活动后伴右侧腹股沟区胀痛，取平卧位可明显减轻，不伴腹痛、腹胀、恶心、呕吐、肛门停止排便排气等，患者未予重视及相关诊治。	1,473	[ { "anatomy_list": [ "右侧腹股沟区" ], "character": [ "一大拇指大小", "质地较软", "移动可", "可回纳" ], "core_name": "包块", "tendency": "" }, { "anatomy_list": [ "右侧腹股沟区" ], "character": [ "活动后胀痛", "平卧位可明显减轻" ], "core_name": "疼痛", "tendency": "" }, { "anatomy_list": [ "腹" ], "character": [], "core_name": "疼痛", "tendency": "否定" }, { "anatomy_list": [ "腹" ], "character": [], "core_name": "腹胀", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "恶心", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "呕吐", "tendency": "否定" }, { "anatomy_list": [ "肛门" ], "character": [], "core_name": "排便", "tendency": "否定" }, { "anatomy_list": [ "肛门" ], "character": [], "core_name": "排气", "tendency": "否定" } ]
2017-3-9某医院复查肠镜示：结肠癌术后表现。	1,932	[ { "anatomy_list": [ "结肠" ], "character": [ "术后" ], "core_name": "癌", "tendency": "" } ]
4.肝囊肿。	1,262	[ { "anatomy_list": [ "肝" ], "character": [], "core_name": "囊肿", "tendency": "" } ]
2017-8-16 ect检查报告：全身骨显像与2017-5-5全身骨显像比较：1.出现新增病灶：左侧第5前肋肋缘，考虑肋骨损伤可能大。	459	[ { "anatomy_list": [ "左侧第5前肋肋缘" ], "character": [ "新增" ], "core_name": "病灶", "tendency": "" }, { "anatomy_list": [ "肋骨" ], "character": [ "可能大" ], "core_name": "损伤", "tendency": "不确定" } ]
治疗上予以禁食水、补液、胃肠减压、灌肠等治疗后腹痛、腹胀症状明显缓解，后请我科会诊后转入我科治疗，请肛肠科会诊行直肠病灶活检提示腺癌。	1,544	[ { "anatomy_list": [ "腹" ], "character": [ "明显缓解" ], "core_name": "疼痛", "tendency": "" }, { "anatomy_list": [ "腹" ], "character": [ "明显缓解" ], "core_name": "腹胀", "tendency": "" }, { "anatomy_list": [ "直肠" ], "character": [], "core_name": "腺癌", "tendency": "" } ]
遂于我院行胸部ct提示肺内占位（具体报告未见）；后患者于某医院行ct引导下经皮肺穿刺活检术，术后病理示：非小细胞肺癌；行基因检测未见阳性突变。	381	[ { "anatomy_list": [ "肺内" ], "character": [], "core_name": "占位", "tendency": "" }, { "anatomy_list": [ "肺" ], "character": [], "core_name": "非小细胞癌", "tendency": "" }, { "anatomy_list": [], "character": [ "阳性" ], "core_name": "突变", "tendency": "否定" } ]
入院前4月，患者无明显诱因出现右腿疼痛，为持续性，无阵发性加重，活动时明显，不伴下肢麻木等不适，患者就诊于我院，腰椎mri示腰椎间盘突出症、骨盆多发骨质破坏。	1,704	[ { "anatomy_list": [ "右腿" ], "character": [ "持续性", "无阵发性加重", "活动时明显" ], "core_name": "疼痛", "tendency": "" }, { "anatomy_list": [ "下肢" ], "character": [], "core_name": "麻木", "tendency": "否定" }, { "anatomy_list": [ "腰椎间盘" ], "character": [], "core_name": "突出症", "tendency": "" }, { "anatomy_list": [ "骨盆" ], "character": [ "多发" ], "core_name": "骨质破坏", "tendency": "" } ]
入院前1年，患者出现口干，进食干食需用水送服，伴反复腮腺炎，患者仍未重视，故未治疗。	932	[ { "anatomy_list": [ "口" ], "character": [ "进食干食需用水送服" ], "core_name": "口干", "tendency": "" }, { "anatomy_list": [ "腮腺" ], "character": [ "反复" ], "core_name": "腮腺炎", "tendency": "" } ]
入院前2日发现患儿无明显诱因发热，以高热为主，最高高体温39.8℃，自行予退烧药口服后，体温能降至正常。	902	[ { "anatomy_list": [], "character": [], "core_name": "发热", "tendency": "" }, { "anatomy_list": [], "character": [ "高" ], "core_name": "发热", "tendency": "" }, { "anatomy_list": [], "character": [ "升高" ], "core_name": "体温", "tendency": "" }, { "anatomy_list": [], "character": [ "降至正常", "予退烧药口服后" ], "core_name": "体温", "tendency": "" } ]
入院前4月，患者无明显诱因出现胸闷，诉活动后明显，偶有心前区压榨感，胸闷明显时伴有呼吸困难，休息后胸闷好转，患者无咳嗽、咳痰，无发热，无咯血，偶有胸部刺痛，偶有午后潮热及夜间盗汗，无明显乏力、消瘦，无声嘶，无呛咳，无心慌、心悸，无下肢水肿等不适，病后患者未重视，未行特殊治疗，患者胸闷仍反复发作，现患者胸闷仍明显，遂来我院，门诊胸部ct结果提示“左上肺结节：考虑纤维灶可能，肺部肿瘤不除外”，为进一步诊治，门诊以“左肺结节”收入我科。	1,404	[ { "anatomy_list": [ "胸" ], "character": [ "活动后明显" ], "core_name": "胸闷", "tendency": "" }, { "anatomy_list": [ "心前区" ], "character": [], "core_name": "压榨感", "tendency": "" }, { "anatomy_list": [], "character": [], "core_name": "呼吸困难", "tendency": "" }, { "anatomy_list": [ "胸" ], "character": [ "休息后好转" ], "core_name": "胸闷", "tendency": "" }, { "anatomy_list": [], "character": [], "core_name": "咳嗽", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "咳痰", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "发热", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "咯血", "tendency": "否定" }, { "anatomy_list": [ "胸部" ], "character": [ "刺痛" ], "core_name": "疼痛", "tendency": "" }, { "anatomy_list": [], "character": [ "午后" ], "core_name": "潮热", "tendency": "" }, { "anatomy_list": [], "character": [ "夜间" ], "core_name": "盗汗", "tendency": "" }, { "anatomy_list": [], "character": [ "明显" ], "core_name": "乏力", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "消瘦", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "声嘶", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "呛咳", "tendency": "否定" }, { "anatomy_list": [ "心" ], "character": [], "core_name": "心慌", "tendency": "否定" }, { "anatomy_list": [ "心" ], "character": [], "core_name": "心悸", "tendency": "否定" }, { "anatomy_list": [ "下肢" ], "character": [], "core_name": "水肿", "tendency": "否定" }, { "anatomy_list": [ "胸" ], "character": [ "反复发作" ], "core_name": "胸闷", "tendency": "" }, { "anatomy_list": [ "胸" ], "character": [ "明显" ], "core_name": "胸闷", "tendency": "" }, { "anatomy_list": [ "左上肺" ], "character": [], "core_name": "结节", "tendency": "" }, { "anatomy_list": [ "左上肺" ], "character": [], "core_name": "纤维灶", "tendency": "不确定" }, { "anatomy_list": [ "肺部" ], "character": [], "core_name": "肿瘤", "tendency": "不确定" }, { "anatomy_list": [ "左肺" ], "character": [], "core_name": "结节", "tendency": "" } ]
患者既往于我院行同步放化疗及后装治疗后复查盆腔ct提示宫颈病灶明显减小，鳞癌癌细胞抗原已降至正常范围内，但盆腔ct提示宫颈形状不规则、仍有强化；妇科检查示：宫颈表现颗粒状增生、触血，前穹隆消失，右侧穹隆变浅。	1,624	[ { "anatomy_list": [ "宫颈" ], "character": [ "明显", "减小" ], "core_name": "病灶", "tendency": "" }, { "anatomy_list": [ "宫颈" ], "character": [ "仍有强化" ], "core_name": "形态不规则", "tendency": "" }, { "anatomy_list": [ "宫颈" ], "character": [ "颗粒状" ], "core_name": "增生", "tendency": "" }, { "anatomy_list": [ "宫颈" ], "character": [], "core_name": "出血", "tendency": "" }, { "anatomy_list": [ "宫颈前穹隆" ], "character": [], "core_name": "消失", "tendency": "" }, { "anatomy_list": [ "宫颈右侧穹隆" ], "character": [], "core_name": "变浅", "tendency": "" } ]
患者lmp：2020-3-20，停经40+天自测尿hcg阳性，就诊于某卫生院，超声提示宫内未见孕囊，次日就诊于某医院，血hcg阳性（具体数值不详）、孕酮偏低。	686	[ { "anatomy_list": [], "character": [], "core_name": "停经", "tendency": "" }, { "anatomy_list": [ "宫内" ], "character": [ "未见" ], "core_name": "孕囊", "tendency": "" }, { "anatomy_list": [], "character": [ "阳性" ], "core_name": "血hcg", "tendency": "" }, { "anatomy_list": [], "character": [ "阳性" ], "core_name": "尿hcg", "tendency": "" }, { "anatomy_list": [], "character": [ "偏低" ], "core_name": "孕酮", "tendency": "" } ]
入院前4天，患者无明显诱因出现腰背部酸胀，弯腰、负重及久坐后加重，卧床休息后可缓解；双下肢无放射痛，无麻木、乏力。	269	[ { "anatomy_list": [ "腰背部" ], "character": [ "弯腰、负重及久坐后加重", "卧床休息后可缓解" ], "core_name": "酸胀", "tendency": "" }, { "anatomy_list": [ "双下肢" ], "character": [ "放射性" ], "core_name": "疼痛", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "麻木", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "乏力", "tendency": "否定" } ]
13月前，患者在左锁骨上触一大小约2x3cm的包块，体表包块b超提示：临床扪及包块处探及低回声结节，性质待定，考虑肿大淋巴结可能。	305	[ { "anatomy_list": [ "左锁骨上" ], "character": [], "core_name": "包块", "tendency": "" }, { "anatomy_list": [], "character": [], "core_name": "包块", "tendency": "" }, { "anatomy_list": [], "character": [ "低回声" ], "core_name": "结节", "tendency": "" }, { "anatomy_list": [ "淋巴结" ], "character": [], "core_name": "肿大", "tendency": "不确定" } ]
2020/6/1ct：腹膜后偏左侧占位，结合病史考虑转移瘤伴周围结构多发侵犯，与2020-04-27片对比，肿块较前缩小，胃内较多积液、积气。	185	[ { "anatomy_list": [ "腹膜后偏左侧" ], "character": [], "core_name": "占位", "tendency": "" }, { "anatomy_list": [], "character": [ "转移" ], "core_name": "瘤", "tendency": "不确定" }, { "anatomy_list": [ "周围结构" ], "character": [ "多发" ], "core_name": "侵犯", "tendency": "" }, { "anatomy_list": [], "character": [ "较前缩小" ], "core_name": "肿块", "tendency": "" }, { "anatomy_list": [ "胃内" ], "character": [ "较多" ], "core_name": "积液", "tendency": "" }, { "anatomy_list": [ "胃内" ], "character": [ "较多" ], "core_name": "积气", "tendency": "" } ]
患者本次发病以来,食欲正常,神志清醒,精神尚可,睡眠尚可,大便正常,小便正常,体重无明显变化。	46	[ { "anatomy_list": [], "character": [ "正常" ], "core_name": "食欲", "tendency": "" }, { "anatomy_list": [], "character": [ "清醒" ], "core_name": "神志", "tendency": "" }, { "anatomy_list": [], "character": [ "尚可" ], "core_name": "精神", "tendency": "" }, { "anatomy_list": [], "character": [ "尚可" ], "core_name": "睡眠", "tendency": "" }, { "anatomy_list": [], "character": [ "正常" ], "core_name": "大便", "tendency": "" }, { "anatomy_list": [], "character": [ "正常" ], "core_name": "小便", "tendency": "" }, { "anatomy_list": [], "character": [ "明显" ], "core_name": "体重变化", "tendency": "否定" } ]
进一步完善肾脏ct示：左肾下极占位，大小约3cm，考虑肿瘤性病变，透明细胞癌可能。	1,197	[ { "anatomy_list": [ "左肾下极" ], "character": [], "core_name": "占位", "tendency": "" }, { "anatomy_list": [], "character": [ "肿瘤性" ], "core_name": "病变", "tendency": "不确定" }, { "anatomy_list": [ "透明细胞" ], "character": [], "core_name": "癌", "tendency": "不确定" } ]
１周前，患者出现咳嗽、咳痰较前加重，伴活动后喘累气促，进食减少，食欲差，伴全身乏力，无恶心、呕吐，无心悸、胸闷，无胸痛，无咯血，无发热，未重视。	983	[ { "anatomy_list": [], "character": [ "加重" ], "core_name": "咳嗽", "tendency": "" }, { "anatomy_list": [], "character": [ "加重" ], "core_name": "咳痰", "tendency": "" }, { "anatomy_list": [], "character": [ "活动后" ], "core_name": "喘累", "tendency": "" }, { "anatomy_list": [], "character": [ "活动后" ], "core_name": "气促", "tendency": "" }, { "anatomy_list": [], "character": [], "core_name": "进食减少", "tendency": "" }, { "anatomy_list": [], "character": [ "差" ], "core_name": "食欲", "tendency": "" }, { "anatomy_list": [ "全身" ], "character": [], "core_name": "乏力", "tendency": "" }, { "anatomy_list": [], "character": [], "core_name": "恶心", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "呕吐", "tendency": "否定" }, { "anatomy_list": [ "心" ], "character": [], "core_name": "心悸", "tendency": "否定" }, { "anatomy_list": [ "胸" ], "character": [], "core_name": "胸闷", "tendency": "否定" }, { "anatomy_list": [ "胸" ], "character": [], "core_name": "疼痛", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "咯血", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "发热", "tendency": "否定" } ]
今患者为进一步明确诊治来我院，门诊以“糖尿病”收入我科。	1,277	[ { "anatomy_list": [], "character": [], "core_name": "糖尿病", "tendency": "" } ]
化疗过程顺利，后再入我院行第2次化疗，方案为dp方案（多西他赛120mg+顺铂130mg静脉化疗），化疗过程患者出现便秘不适，今患者诉右侧髋部疼痛较前明显，为复查就诊于我院门诊，门诊拟“右上肺肺腺癌”收住院治疗。	1,441	[ { "anatomy_list": [], "character": [ "化疗过程" ], "core_name": "便秘", "tendency": "" }, { "anatomy_list": [ "右侧髋部" ], "character": [ "较前明显" ], "core_name": "疼痛", "tendency": "" }, { "anatomy_list": [ "右上肺" ], "character": [], "core_name": "腺癌", "tendency": "" } ]
骨扫描：左肩关节、胸骨、脊柱（约胸55椎体及上位颈椎明显）、右侧髋臼多发异常显像剂浓聚灶，考虑肿瘤骨转移，予以止痛对症后患者疼痛控制。	944	[ { "anatomy_list": [ "左肩关节" ], "character": [ "多发", "异常", "显像剂" ], "core_name": "浓聚灶", "tendency": "" }, { "anatomy_list": [ "胸骨" ], "character": [ "多发", "异常", "显像剂" ], "core_name": "浓聚灶", "tendency": "" }, { "anatomy_list": [ "脊柱" ], "character": [ "多发", "异常", "显像剂", "约胸55椎体及上位颈椎明显" ], "core_name": "浓聚灶", "tendency": "" }, { "anatomy_list": [ "右侧髋臼" ], "character": [ "多发", "异常", "显像剂" ], "core_name": "浓聚灶", "tendency": "" }, { "anatomy_list": [], "character": [ "骨转移" ], "core_name": "肿瘤", "tendency": "不确定" }, { "anatomy_list": [], "character": [ "控制" ], "core_name": "疼痛", "tendency": "" } ]
2+月前，患者出现双侧肩胛骨骨疼痛，疼痛剧烈，口服吗啡疼痛无明显缓解，于9月5日在我科行右侧肩胛骨放疗，累计放疗：dt：30G/10f，患者疼痛缓解出院。	1,851	[ { "anatomy_list": [ "双侧肩胛骨" ], "character": [], "core_name": "疼痛", "tendency": "" }, { "anatomy_list": [ "双侧肩胛骨" ], "character": [ "剧烈" ], "core_name": "疼痛", "tendency": "" }, { "anatomy_list": [], "character": [ "缓解" ], "core_name": "疼痛", "tendency": "否定" }, { "anatomy_list": [], "character": [ "缓解" ], "core_name": "疼痛", "tendency": "" } ]
为进一步诊治，遂来我科住院，门诊以“上消化道出血，肝硬化失代偿”收入我科。	861	[ { "anatomy_list": [ "上消化道" ], "character": [], "core_name": "出血", "tendency": "" }, { "anatomy_list": [ "肝" ], "character": [ "失代偿" ], "core_name": "硬化", "tendency": "" } ]
（左乳左、右、上、下、后切缘）未见癌累及。	1,761	[ { "anatomy_list": [ "左乳左、右、上、下、后切缘" ], "character": [ "累及" ], "core_name": "癌", "tendency": "否定" } ]
1+月前患者排尿不畅症状明显，并伴排尿费力，尿频、尿急、尿痛，尿不尽，尿线变细，排尿滴沥，偶有全身疼痛感。	2,021	[ { "anatomy_list": [], "character": [ "明显" ], "core_name": "排尿不畅", "tendency": "" }, { "anatomy_list": [], "character": [], "core_name": "排尿费力", "tendency": "" }, { "anatomy_list": [], "character": [], "core_name": "尿频", "tendency": "" }, { "anatomy_list": [], "character": [], "core_name": "尿急", "tendency": "" }, { "anatomy_list": [], "character": [], "core_name": "尿痛", "tendency": "" }, { "anatomy_list": [], "character": [], "core_name": "尿不尽", "tendency": "" }, { "anatomy_list": [], "character": [], "core_name": "尿线变细", "tendency": "" }, { "anatomy_list": [], "character": [], "core_name": "排尿滴沥", "tendency": "" }, { "anatomy_list": [ "全身" ], "character": [ "偶有" ], "core_name": "疼痛", "tendency": "" } ]
入院前7年，患者体检中发现发现血压升高，最高血压180+/？mmhg，长期予以苯磺酸氨氯地平5mg qd降压，自诉近期血压控制在150-160/？mmhg，有视物模糊不适；入院前6年，患者无意间发现左侧第一跖趾关节及左侧膝关节出现无痛性结节，未重视及处理。	872	[ { "anatomy_list": [], "character": [ "升高" ], "core_name": "血压", "tendency": "" }, { "anatomy_list": [], "character": [], "core_name": "视物模糊", "tendency": "" }, { "anatomy_list": [ "左侧第1跖趾关节" ], "character": [ "无痛性" ], "core_name": "结节", "tendency": "" }, { "anatomy_list": [ "左侧膝关节" ], "character": [ "无痛性" ], "core_name": "结节", "tendency": "" } ]
入院5+年前患者无明显诱因出现咳嗽、咳痰、喘累，痰为白色泡沫痰，无潮热、盗汗，病程中冬春季易发，每年持续时间大于3月，患者未予重视。	1,518	[ { "anatomy_list": [], "character": [], "core_name": "咳嗽", "tendency": "" }, { "anatomy_list": [], "character": [ "白色", "泡沫痰" ], "core_name": "咳痰", "tendency": "" }, { "anatomy_list": [], "character": [], "core_name": "喘累", "tendency": "" }, { "anatomy_list": [], "character": [], "core_name": "潮热", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "盗汗", "tendency": "否定" } ]
5+年前，患者述腰背部伴双侧大腿前侧间断性痛，疼痛尚可忍受，无麻木、乏力不能行走，患者未予以重视，自服药物或膏药治疗（具体用药不详）后缓解，其后间断疼痛，为予以特别重视，自行好转，患者10+月前我院体检发现乳腺包块，其后于某医院行spect检查提示：左侧髂骨异常成骨增强灶，考虑肿瘤骨转移可能性大，于行新辅助化疗后于某医院行左侧乳腺癌保乳术，术后病检提示：（左侧乳腺）浸润性癌，非特殊类型。iii级。	1,288	[ { "anatomy_list": [ "双侧大腿前侧", "腰部", "背部" ], "character": [ "间断性", "尚可忍受" ], "core_name": "疼痛", "tendency": "" }, { "anatomy_list": [ "双侧大腿" ], "character": [], "core_name": "麻木", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "乏力", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "行走障碍", "tendency": "否定" }, { "anatomy_list": [], "character": [ "间断" ], "core_name": "疼痛", "tendency": "" }, { "anatomy_list": [ "乳腺" ], "character": [], "core_name": "包块", "tendency": "" }, { "anatomy_list": [ "左侧髂骨" ], "character": [ "异常成骨" ], "core_name": "增强灶", "tendency": "" }, { "anatomy_list": [ "骨" ], "character": [ "转移" ], "core_name": "肿瘤", "tendency": "不确定" }, { "anatomy_list": [ "左侧乳腺" ], "character": [ "浸润性", "非特殊类型", "iii级" ], "core_name": "癌", "tendency": "" } ]
院外期间仍有烦渴、多饮，全身乏力，胸闷怕冷等症状。	235	[ { "anatomy_list": [], "character": [], "core_name": "烦渴", "tendency": "" }, { "anatomy_list": [], "character": [], "core_name": "多饮", "tendency": "" }, { "anatomy_list": [ "全身" ], "character": [], "core_name": "乏力", "tendency": "" }, { "anatomy_list": [ "胸" ], "character": [], "core_name": "胸闷", "tendency": "" }, { "anatomy_list": [], "character": [], "core_name": "怕冷", "tendency": "" } ]
诊断为“中央型肺癌肺癌伴淋巴结转移”，未行手术及放化疗，经抗感染、止咳、祛痰等对症支持治疗后，病情好转后出院。症状反复发生，未见明显加重。	1,701	[ { "anatomy_list": [ "肺" ], "character": [ "中央型" ], "core_name": "癌", "tendency": "" }, { "anatomy_list": [ "淋巴结" ], "character": [ "转移" ], "core_name": "癌", "tendency": "" } ]
无化疗禁忌症，分别于2016-3-11、2016-4-1、2016-4-22行tp方案（紫杉醇240mg+奈达铂140mg）化疗，化疗后出现明显骨髓抑制，予以生白细胞治疗后好转出院，院外未诉特殊不适。	1,286	[ { "anatomy_list": [ "骨髓" ], "character": [ "明显" ], "core_name": "骨髓抑制", "tendency": "" } ]
患者期间仍感右上胸部针刺样疼痛，阵发性，呼吸咳嗽加重，可向肩背部放射，未予以特殊处理。	963	[ { "anatomy_list": [ "右上胸部" ], "character": [ "针刺样", "阵发性" ], "core_name": "疼痛", "tendency": "" }, { "anatomy_list": [], "character": [ "加重" ], "core_name": "咳嗽", "tendency": "" }, { "anatomy_list": [ "肩背部" ], "character": [ "放射性" ], "core_name": "疼痛", "tendency": "" } ]
遂于我院行乳腺b超检查提示：左侧乳腺2点钟方向距乳头约40mm处可见大小约24*22mm低回声包块，边界不清不规则。	497	[ { "anatomy_list": [ "左侧乳腺2点钟方向距乳头约40mm处" ], "character": [ "低回声", "边界不清不规则" ], "core_name": "包块", "tendency": "" } ]
2年前患者于外院行辅助检查，考虑诊断为“肝癌”，遂行肝癌切除术，住院期间因患者肾功能差，改用“替比夫定”抗病毒治疗。	91	[ { "anatomy_list": [ "肝" ], "character": [], "core_name": "癌", "tendency": "不确定" }, { "anatomy_list": [ "肾" ], "character": [], "core_name": "肾功能差", "tendency": "" } ]
与2018-8-29片比较：病灶较明显增大。	1,026	[ { "anatomy_list": [], "character": [ "明显", "增大" ], "core_name": "病灶", "tendency": "" } ]
入院前3+年，患者排尿时出现全程血尿，鲜红色，伴尿频、尿急及尿痛，行b超检查提示前列腺增生。	1,792	[ { "anatomy_list": [], "character": [ "鲜红色" ], "core_name": "血尿", "tendency": "" }, { "anatomy_list": [], "character": [], "core_name": "尿频", "tendency": "" }, { "anatomy_list": [], "character": [], "core_name": "尿急", "tendency": "" }, { "anatomy_list": [], "character": [], "core_name": "尿痛", "tendency": "" }, { "anatomy_list": [ "前列腺" ], "character": [], "core_name": "增生", "tendency": "" } ]
2.甲状腺左叶上份稍低密度影，结合图像融合考虑：结节性甲状腺中可能。	253	[ { "anatomy_list": [ "甲状腺左叶上" ], "character": [ "稍低" ], "core_name": "密度影", "tendency": "" }, { "anatomy_list": [ "甲状腺" ], "character": [ "结节性" ], "core_name": "肿", "tendency": "不确定" } ]
就诊于某医院整形美容科，行浅表淋巴结超声提示：左侧腹股沟腹股沟区可见数个低回声结节结节影，较大者大小约5.7×2.7cm，并行左侧腹股沟腹股沟区淋巴结淋巴结活检，活检病理提示：（左侧腹股沟淋巴结）淋巴组织增生，建议免疫组化进一步诊断。患者随后未行任何检查及治疗。	851	[ { "anatomy_list": [ "左侧腹股沟" ], "character": [ "数个", "低回声" ], "core_name": "结节影", "tendency": "" }, { "anatomy_list": [ "左侧腹股沟淋巴结组织" ], "character": [], "core_name": "增生", "tendency": "" } ]
现患儿精神食欲可，大便2次/天，稀水样，无血丝及粘液，小便黄清，尿量无减少。	367	[ { "anatomy_list": [], "character": [ "可" ], "core_name": "精神", "tendency": "" }, { "anatomy_list": [], "character": [ "可" ], "core_name": "食欲", "tendency": "" }, { "anatomy_list": [], "character": [ "2次/天", "稀水样", "无血丝及粘液" ], "core_name": "大便", "tendency": "" }, { "anatomy_list": [], "character": [ "黄清" ], "core_name": "小便", "tendency": "" }, { "anatomy_list": [], "character": [ "无减少" ], "core_name": "尿量", "tendency": "" } ]
病程中患者精神、饮食稍差，大小便正常，体重无明显下降。	1,088	[ { "anatomy_list": [], "character": [ "稍差" ], "core_name": "精神", "tendency": "" }, { "anatomy_list": [], "character": [ "稍差" ], "core_name": "饮食", "tendency": "" }, { "anatomy_list": [], "character": [ "正常" ], "core_name": "大便", "tendency": "" }, { "anatomy_list": [], "character": [ "正常" ], "core_name": "小便", "tendency": "" }, { "anatomy_list": [], "character": [ "明显" ], "core_name": "体重下降", "tendency": "否定" } ]
入院前5-月，患者因"升结肠癌"于2019-03-19全麻下行腹腔镜下右半结肠癌根治术（扩大）、腹腔镜下肠粘连松解术，手术顺利，术后病检（右半结肠）粘液腺癌，侵及肠壁全层。	636	[ { "anatomy_list": [ "升结肠" ], "character": [], "core_name": "癌", "tendency": "" }, { "anatomy_list": [ "右半结肠" ], "character": [ "粘液", "侵及肠壁" ], "core_name": "腺癌", "tendency": "" } ]
现患者为求第五次新辅助化疗，就诊于我院，门诊以“胰腺癌伴肝转移”收住入院。	1,670	[ { "anatomy_list": [ "胰腺" ], "character": [], "core_name": "癌", "tendency": "" }, { "anatomy_list": [ "肝" ], "character": [ "转移" ], "core_name": "癌", "tendency": "" } ]
胸片：双下肺少许感染，主动脉球少许钙化，胸椎退行性变。	519	[ { "anatomy_list": [ "双下肺" ], "character": [ "少许" ], "core_name": "感染", "tendency": "" }, { "anatomy_list": [ "主动脉球" ], "character": [ "少许" ], "core_name": "钙化", "tendency": "" }, { "anatomy_list": [ "胸椎" ], "character": [ "退行性" ], "core_name": "病变", "tendency": "" } ]
患者入院前10年无明显诱因出现排尿踌躇、费力、不尽感,夜尿4-5次，尿线无力、分叉、变细、终末滴沥，未予重视，未予特殊处理，7年前患者到某医院行前列腺电切术，术后排尿困难症状无明显改善，夜尿7-8次，6年前患者出现排尿困难加重，排尿费力，偶有尿线中断，排尿滴沥明显，患者遂到某医院就诊，予以扩尿道2次，患者排尿困难稍有改善。	1,080	[ { "anatomy_list": [], "character": [ "踌躇", "费力", "不尽感" ], "core_name": "排尿", "tendency": "" }, { "anatomy_list": [], "character": [ "4-5次" ], "core_name": "夜尿", "tendency": "" }, { "anatomy_list": [], "character": [], "core_name": "尿线无力", "tendency": "" }, { "anatomy_list": [], "character": [], "core_name": "尿线分叉", "tendency": "" }, { "anatomy_list": [], "character": [], "core_name": "尿线变细", "tendency": "" }, { "anatomy_list": [], "character": [ "终末滴沥" ], "core_name": "排尿", "tendency": "" }, { "anatomy_list": [], "character": [ "术后", "无明显改善" ], "core_name": "排尿困难", "tendency": "" }, { "anatomy_list": [], "character": [ "7-8次" ], "core_name": "夜尿", "tendency": "" }, { "anatomy_list": [], "character": [ "加重" ], "core_name": "排尿困难", "tendency": "" }, { "anatomy_list": [], "character": [], "core_name": "排尿费力", "tendency": "" }, { "anatomy_list": [], "character": [ "偶有" ], "core_name": "尿线中断", "tendency": "" }, { "anatomy_list": [], "character": [ "明显" ], "core_name": "排尿滴沥", "tendency": "" }, { "anatomy_list": [], "character": [ "稍有改善" ], "core_name": "排尿困难", "tendency": "" } ]
与患者及家属沟通可选择的治疗方案，计划予以dp方案（多西他赛+顺铂）化疗，于2020-04-02、2020-04-24予以2周期dp方案化疗（多西他赛100mg1+顺铂50mg1-2，q3w），化疗期间出现恶心、食欲下降，予以奥美拉唑抑酸，昂丹司琼止吐等治疗后缓解。	217	[ { "anatomy_list": [], "character": [], "core_name": "恶心", "tendency": "" }, { "anatomy_list": [], "character": [ "下降" ], "core_name": "食欲", "tendency": "" } ]
患者住院期间多次输注血小板、悬浮红细胞，输注过程中及输注后均无不良反应。	1,658	[ { "anatomy_list": [], "character": [ "输注过程中" ], "core_name": "不良反应", "tendency": "否定" }, { "anatomy_list": [], "character": [ "输注后" ], "core_name": "不良反应", "tendency": "否定" } ]
无畏寒发热，无胸闷气紧，无心慌心悸，无黑便便血血便，无肉眼血尿。	1,131	[ { "anatomy_list": [], "character": [], "core_name": "畏寒", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "发热", "tendency": "否定" }, { "anatomy_list": [ "胸" ], "character": [], "core_name": "胸闷", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "气紧", "tendency": "否定" }, { "anatomy_list": [ "心" ], "character": [], "core_name": "心慌", "tendency": "否定" }, { "anatomy_list": [ "心" ], "character": [], "core_name": "心悸", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "黑便", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "血便", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "便血", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "血尿", "tendency": "否定" } ]
术后口服“替格瑞洛90mg bid”治疗，入院前12小时（2017-11-04 22:00），患者自觉剑突下绞痛，伴胸骨后哽咽感及喉部不适，持续约20分20分钟左右，无胸痛、胸部压榨感，无大汗、乏力，无头昏、头痛，无黑曚、意识障碍，含服“速效救心丸”可缓解，入院前8小时，患者再次感剑突下不适，稍疼痛，持续约10分10分钟，后自行缓解，入院前3小时，患者自行口服“阿司匹林300mg、替格瑞洛180mg”后入我院，以“冠心病”收入我科。	1,215	[ { "anatomy_list": [ "剑突下" ], "character": [ "绞痛" ], "core_name": "疼痛", "tendency": "" }, { "anatomy_list": [ "胸骨后" ], "character": [], "core_name": "哽咽感", "tendency": "" }, { "anatomy_list": [ "喉部" ], "character": [], "core_name": "喉部不适", "tendency": "" }, { "anatomy_list": [ "胸" ], "character": [], "core_name": "疼痛", "tendency": "否定" }, { "anatomy_list": [ "胸部" ], "character": [], "core_name": "压榨感", "tendency": "否定" }, { "anatomy_list": [], "character": [ "大汗" ], "core_name": "出汗", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "乏力", "tendency": "否定" }, { "anatomy_list": [ "头" ], "character": [], "core_name": "头昏", "tendency": "否定" }, { "anatomy_list": [ "头" ], "character": [], "core_name": "疼痛", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "黒朦", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "意识障碍", "tendency": "否定" }, { "anatomy_list": [ "剑突下" ], "character": [], "core_name": "剑突下不适", "tendency": "" }, { "anatomy_list": [ "剑突下" ], "character": [ "稍" ], "core_name": "疼痛", "tendency": "" }, { "anatomy_list": [ "冠状动脉", "心脏" ], "character": [ "硬化性", "粥样" ], "core_name": "心脏病", "tendency": "" } ]
门诊以“肺占位性病变”收住院治疗。	126	[ { "anatomy_list": [ "肺" ], "character": [ "占位性" ], "core_name": "病变", "tendency": "" } ]
伴心悸、胸闷，无发热、无潮热、盗汗，无咳血、咯血，无胸痛。	444	[ { "anatomy_list": [ "心" ], "character": [], "core_name": "心悸", "tendency": "" }, { "anatomy_list": [ "胸" ], "character": [], "core_name": "胸闷", "tendency": "" }, { "anatomy_list": [], "character": [], "core_name": "发热", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "潮热", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "盗汗", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "咳血", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "咯血", "tendency": "否定" }, { "anatomy_list": [ "胸" ], "character": [], "core_name": "疼痛", "tendency": "否定" } ]
完善胸部ct提示左肺下野片团影，慢性炎症？肿瘤待排。	1,553	[ { "anatomy_list": [ "左肺下野" ], "character": [ "片" ], "core_name": "团影", "tendency": "" }, { "anatomy_list": [ "左肺下野" ], "character": [ "慢性" ], "core_name": "炎症", "tendency": "不确定" }, { "anatomy_list": [ "左肺下野" ], "character": [], "core_name": "肿瘤", "tendency": "不确定" } ]
患者1年前因进行性吞咽困难在我院胸外科住院，2015年03月28日胸部ct：1.食管下段改变，考虑食管癌可能性大，考虑食管肿瘤，于2015年03月31日在全麻下行胸-腹腔镜食管癌根治术+食管-胃颈部吻合+空肠造瘘术，术后病检：（食管）高分化鳞状细胞癌。	197	[ { "anatomy_list": [], "character": [ "进行性" ], "core_name": "吞咽困难", "tendency": "" }, { "anatomy_list": [ "食管下段" ], "character": [], "core_name": "改变", "tendency": "" }, { "anatomy_list": [ "食管" ], "character": [], "core_name": "癌", "tendency": "不确定" }, { "anatomy_list": [ "食管" ], "character": [], "core_name": "肿瘤", "tendency": "不确定" }, { "anatomy_list": [ "食管" ], "character": [ "高分化" ], "core_name": "鳞癌", "tendency": "" } ]
患者4月多前无明显诱因出现双肩关节疼痛，伴双上臂上举困难，未予特殊治疗，2月余前受凉后出现流涕，伴咳嗽咳痰，偶有脓痰，于当地诊所服用中药后疼痛稍好转，继出现左踝关节关节肿痛，于某医院就诊，行踝关节平片、查肾功提示尿酸 178umol/L，未予进一步处理。	1,837	[ { "anatomy_list": [ "双肩关节" ], "character": [], "core_name": "疼痛", "tendency": "" }, { "anatomy_list": [ "双上臂" ], "character": [], "core_name": "上举困难", "tendency": "" }, { "anatomy_list": [], "character": [ "受凉后" ], "core_name": "流涕", "tendency": "" }, { "anatomy_list": [], "character": [], "core_name": "咳嗽", "tendency": "" }, { "anatomy_list": [], "character": [], "core_name": "咳痰", "tendency": "" }, { "anatomy_list": [], "character": [ "偶有", "脓痰" ], "core_name": "咳痰", "tendency": "" }, { "anatomy_list": [], "character": [ "服用中药后稍好转" ], "core_name": "疼痛", "tendency": "" }, { "anatomy_list": [ "左踝关节" ], "character": [ "肿痛" ], "core_name": "疼痛", "tendency": "" } ]
今患者为进一步治疗食道赘生物遂于我院门诊求诊，门诊以“食道肿瘤”收入我科住院治疗。	1,192	[ { "anatomy_list": [ "食道" ], "character": [], "core_name": "赘生物", "tendency": "" }, { "anatomy_list": [ "食道" ], "character": [], "core_name": "肿瘤", "tendency": "" } ]
曾连续2年以上发作，每次发作均在3月以上，诊断为“慢性支气管炎、肺气肿”。	789	[ { "anatomy_list": [ "支气管" ], "character": [ "慢性" ], "core_name": "支气管炎", "tendency": "" }, { "anatomy_list": [ "肺" ], "character": [], "core_name": "肺气肿", "tendency": "" } ]
门诊拟“腰椎压缩性骨折”收住我科。	806	[ { "anatomy_list": [ "腰椎" ], "character": [ "压缩性" ], "core_name": "骨折", "tendency": "" } ]
患者于1月前，因不慎受凉后出现咳嗽，咳痰，痰为白色粘液痰，无发热、胸痛、潮热、盗汗，无乏力等不适，曾在我院诊断为“肺炎”，予“头孢米诺抗感染，氨溴索止咳化痰”等治疗后好转，未坚持治疗，仍间断咳嗽、咳痰。	1,671	[ { "anatomy_list": [], "character": [ "受凉后" ], "core_name": "咳嗽", "tendency": "" }, { "anatomy_list": [], "character": [ "受凉后" ], "core_name": "咳痰", "tendency": "" }, { "anatomy_list": [], "character": [ "白色", "粘液" ], "core_name": "咳痰", "tendency": "" }, { "anatomy_list": [], "character": [], "core_name": "发热", "tendency": "否定" }, { "anatomy_list": [ "胸" ], "character": [], "core_name": "疼痛", "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": "乏力", "tendency": "否定" }, { "anatomy_list": [ "肺" ], "character": [], "core_name": "肺炎", "tendency": "" }, { "anatomy_list": [], "character": [ "间断" ], "core_name": "咳嗽", "tendency": "" }, { "anatomy_list": [], "character": [ "间断" ], "core_name": "咳痰", "tendency": "" } ]
入院前1+天，患者因胸背部疼痛于我院门诊就诊，行胸部ct示：1.双肺下叶多发结节，性质待定，请结合其他进一步检查。	1,379	[ { "anatomy_list": [ "胸部", "背部" ], "character": [], "core_name": "疼痛", "tendency": "" }, { "anatomy_list": [ "双肺下叶" ], "character": [ "多发" ], "core_name": "结节", "tendency": "" } ]
多次于外院就诊，行心脏彩超检查示：左房、左室增大，伴左室壁肥厚，主动脉深部增宽。	470	[ { "anatomy_list": [ "左房", "左室" ], "character": [], "core_name": "增大", "tendency": "" }, { "anatomy_list": [ "左室壁" ], "character": [], "core_name": "肥厚", "tendency": "" }, { "anatomy_list": [ "主动脉深部" ], "character": [], "core_name": "增宽", "tendency": "" } ]

体重减轻5斤。

1,411

[ { "anatomy_list": [], "character": [], "core_name": "体重减轻", "tendency": "" } ]

病程中，患者神志清，精神可，饮食睡眠正常，大小便正常，体重无异常变化。

114

[ { "anatomy_list": [], "character": [ "清" ], "core_name": "神志", "tendency": "" }, { "anatomy_list": [], "character": [ "可" ], "core_name": "精神", "tendency": "" }, { "anatomy_list": [], "character": [ "正常" ], "core_name": "饮食", "tendency": "" }, { "anatomy_list": [], "character": [ "正常" ], "core_name": "睡眠", "tendency": "" }, { "anatomy_list": [], "character": [ "正常" ], "core_name": "大小便", "tendency": "" }, { "anatomy_list": [], "character": [ "异常" ], "core_name": "体重变化", "tendency": "否定" } ]

于2015年8月11日行神经导航下开路探查+左侧前颅底路况沟通肿瘤纤维切除术，术中可见肿瘤位于左侧前颅底，已经将蝶骨脊及眼眶外侧板侵蚀破坏，起源于硬脑膜，硬膜外及硬膜下均可见肿瘤，硬膜下肿瘤呈肉红色，血供丰富，与周围脑组织边界尚清，粘连明显，完整切除肿瘤致肿瘤镜下全切，之后切除眼眶内肿瘤，探查肿瘤位于框内，与周围骨质两联紧密，深部侵及眶外脂肪层，小心游离眼眶内肿瘤后完整切除肿瘤。

419

[ { "anatomy_list": [ "左侧前颅底" ], "character": [], "core_name": "肿瘤", "tendency": "" }, { "anatomy_list": [ "眼眶外侧板", "蝶骨脊" ], "character": [], "core_name": "侵蚀破坏", "tendency": "" }, { "anatomy_list": [ "硬脑膜", "硬膜外", "硬膜下" ], "character": [], "core_name": "肿瘤", "tendency": "" }, { "anatomy_list": [ "硬膜下" ], "character": [ "呈肉红色", "血供丰富", "与周围脑组织边界尚清", "粘连明显" ], "core_name": "肿瘤", "tendency": "" }, { "anatomy_list": [ "眼眶内" ], "character": [ "与周围骨质两联紧密", "深部侵及眶外脂肪层" ], "core_name": "肿瘤", "tendency": "" } ]

2+年前，患者无明显诱因反复出现咳嗽，多为干咳，偶咳白色泡沫痰，偶有发热，体温多为38℃左右，无畏寒、盗汗，无胸闷、胸痛，无咯血，于某医院输液治疗（具体不详）后可好转，未予以进一步检查。

544

[ { "anatomy_list": [], "character": [ "反复出现" ], "core_name": "咳嗽", "tendency": "" }, { "anatomy_list": [], "character": [ "干性", "反复出现" ], "core_name": "咳嗽", "tendency": "" }, { "anatomy_list": [], "character": [ "偶尔", "白色", "泡沫痰" ], "core_name": "咳痰", "tendency": "" }, { "anatomy_list": [], "character": [ "偶有" ], "core_name": "发热", "tendency": "" }, { "anatomy_list": [], "character": [ "升高", "偶有" ], "core_name": "体温", "tendency": "" }, { "anatomy_list": [], "character": [], "core_name": "畏寒", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "盗汗", "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": [], "character": [], "core_name": "咯血", "tendency": "否定" } ]

7+月前至某医院医院复查妇科彩超：左附件区可见64mm×35mm的无回声区，查ca125、he4均正常，hpv-dna均阴性，建议手术，患者仍未做。

825

[ { "anatomy_list": [ "左附件" ], "character": [], "core_name": "无回声", "tendency": "" } ]

入院3天前再次出现意识丧失（家属未看到），发病形式、过程不详。

740

[ { "anatomy_list": [], "character": [ "家属未看到", "发病形式", "过程不详" ], "core_name": "意识丧失", "tendency": "" } ]

于2019-3-27给予e-chop方案（依托泊苷100mg d1-2、吡柔比星20mg d1-3、环磷酰胺400mg d1-3、地塞米松20mg d1-5、长春新碱1.5mg d1、d8）方案化疗1周期，于2019-4-23、2019-5-17给予re-chop方案（美罗华600mg d1、依托泊苷100mg d1-2、吡柔比星60mg d1、环磷酰胺400mg d1-3、地塞米松20mg d1-5、长春新碱3mg d1）化疗第2周期，化疗后患者出现ii°骨髓抑制，给予升白治疗后骨髓抑制纠正，今日为行下一周期化疗来我科，以“弥漫大b细胞淋巴瘤（iv期 b组）化疗后复发”收入住院治疗。

1,072

[ { "anatomy_list": [ "骨髓" ], "character": [ "化疗后", "ii°" ], "core_name": "骨髓抑制", "tendency": "" }, { "anatomy_list": [ "骨髓" ], "character": [ "矫正" ], "core_name": "骨髓抑制", "tendency": "" }, { "anatomy_list": [ "淋巴", "大B细胞" ], "character": [ "弥漫性", "iv期 b组", "化疗后", "复发" ], "core_name": "瘤", "tendency": "" } ]

院外于某医院行内分泌治疗及抗溶骨治疗，患者近期左侧腰部及下肢疼痛明显，为求进一步治疗，以“乳腺癌骨转移”收入我科住院治疗。

1,291

[ { "anatomy_list": [ "左侧腰部", "下肢" ], "character": [ "近期", "明显" ], "core_name": "疼痛", "tendency": "" }, { "anatomy_list": [ "乳腺", "骨" ], "character": [ "骨转移" ], "core_name": "癌", "tendency": "" } ]

后一直我院随访，肿瘤病灶稳定，1年前前，患者在我科复查腹部mri提示肝右后叶小富血供结节，不排除原发性肝癌hifu术后复发可能，于2013年12月30日行tae治疗，于2014年1月4日在全身麻醉下行原发性肝癌姑息性hifu术，术后患者恢复可，多次复查腹部mri提示肿瘤控制可，现为求再次复查入住我科。

1,006

[ { "anatomy_list": [], "character": [ "肿瘤", "稳定" ], "core_name": "病灶", "tendency": "" }, { "anatomy_list": [ "肝右后叶" ], "character": [ "小", "富血供" ], "core_name": "结节", "tendency": "" }, { "anatomy_list": [ "肝" ], "character": [ "原发性", "hifu术后", "复发" ], "core_name": "癌", "tendency": "不确定" }, { "anatomy_list": [], "character": [ "控制可" ], "core_name": "肿瘤", "tendency": "" } ]

院外一直口服中成药治疗（具体用药）治疗，并于2011年5月和2011年9月、2012年3月22日和2012年7月到我科复查，行相关检查，提示肿瘤尚无进展。

724

[ { "anatomy_list": [], "character": [ "进展" ], "core_name": "肿瘤", "tendency": "否定" } ]

肠壁上淋巴结见癌转移（1/15）。

748

[ { "anatomy_list": [ "肠壁上淋巴结" ], "character": [ "转移" ], "core_name": "癌", "tendency": "" } ]

到某医院就诊，行胸片示肺上局部钙化钙化灶（未见报告），未予特殊治疗。

2,025

[ { "anatomy_list": [ "肺上局部" ], "character": [ "局部" ], "core_name": "钙化灶", "tendency": "" } ]

患者1+月前出现咳嗽咳痰，咳嗽声音正常，不伴有鸡鸣样咳嗽，不伴有刺激性干咳，咳嗽时有胸痛症状。

368

[ { "anatomy_list": [], "character": [], "core_name": "咳嗽", "tendency": "" }, { "anatomy_list": [], "character": [], "core_name": "咳痰", "tendency": "" }, { "anatomy_list": [], "character": [ "声音正常" ], "core_name": "咳嗽", "tendency": "" }, { "anatomy_list": [], "character": [ "鸡鸣样" ], "core_name": "咳嗽", "tendency": "否定" }, { "anatomy_list": [], "character": [ "刺激性", "干" ], "core_name": "咳嗽", "tendency": "否定" }, { "anatomy_list": [ "胸" ], "character": [ "咳嗽时" ], "core_name": "疼痛", "tendency": "" } ]

后续于2016年12月25日、2017年1月18日、2017年2月15日行3周期原方案原剂量化疗,未见明显骨髓抑制；后于2017年3月14日、2017年4月8日予以吡柔比星50mg d1+紫杉醇240mg d2+环磷酰胺800mg d3化疗；化疗期间患者均无明显恶心、呕吐、骨髓抑制等副反应。

20

[ { "anatomy_list": [ "骨髓" ], "character": [ "明显" ], "core_name": "骨髓抑制", "tendency": "否定" }, { "anatomy_list": [], "character": [ "明显" ], "core_name": "恶心", "tendency": "否定" }, { "anatomy_list": [], "character": [ "明显" ], "core_name": "呕吐", "tendency": "否定" }, { "anatomy_list": [ "骨髓" ], "character": [ "明显" ], "core_name": "骨髓抑制", "tendency": "否定" } ]

2+年前（2018年3月）患者于某医院因体检腹部彩超发现左侧肾脏下级占位，左肾积水，无腰痛、无腹胀腹痛，无恶心呕吐，无尿频尿急尿痛，无肉眼血尿等不适。

162

[ { "anatomy_list": [ "左侧肾脏下级" ], "character": [], "core_name": "占位", "tendency": "" }, { "anatomy_list": [ "左肾" ], "character": [], "core_name": "积水", "tendency": "" }, { "anatomy_list": [ "腰" ], "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": "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": "尿频", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "尿急", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "尿痛", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "血尿", "tendency": "否定" } ]

右上肺肺陈旧性病灶,以纤维化为主；右上肺结节影,考虑为纤维结节可能,不除外肿瘤性病变。食道中下段壁可疑稍增厚。

7

[ { "anatomy_list": [ "右上肺" ], "character": [ "陈旧性" ], "core_name": "病灶", "tendency": "" }, { "anatomy_list": [ "右上肺" ], "character": [], "core_name": "纤维化", "tendency": "" }, { "anatomy_list": [ "右上肺" ], "character": [], "core_name": "结节影", "tendency": "" }, { "anatomy_list": [ "右上肺" ], "character": [], "core_name": "纤维结节", "tendency": "不确定" }, { "anatomy_list": [ "右上肺" ], "character": [ "肿瘤性" ], "core_name": "病变", "tendency": "不确定" }, { "anatomy_list": [ "食道中下段壁" ], "character": [ "稍" ], "core_name": "增厚", "tendency": "不确定" } ]

现为求进一步诊疗到我院，急诊以“消化道出血原因待查”收入院。

1,990

[ { "anatomy_list": [ "消化道" ], "character": [], "core_name": "出血", "tendency": "不确定" } ]

2018年4月患者发现左侧腹股沟腹股沟包块较前明显增大、增多，左侧腹股沟穿刺病理提示“<左腹股沟淋巴结穿刺活检标本>淋巴组织结构破坏，于组织细胞及淋巴细胞背景中查见散在r-s样细胞，结合免疫组化及t细胞基因重排满负荷经典型霍奇金淋巴瘤（混合细胞亚型）”，全身pet/ct示“腹膜后、盆腔、左侧腹股沟可见多发淋巴结肿大，fdg代谢异常增高”，未行骨髓穿刺检查。

852

[ { "anatomy_list": [ "左侧腹股沟淋巴结" ], "character": [ "明显增大、增多" ], "core_name": "包块", "tendency": "" }, { "anatomy_list": [ "左侧腹股沟淋巴结组织结构" ], "character": [], "core_name": "破坏", "tendency": "" }, { "anatomy_list": [ "r-s样细胞" ], "character": [ "组织细胞及淋巴细胞背景中查见", "散在" ], "core_name": "r-s样细胞", "tendency": "" }, { "anatomy_list": [ "淋巴" ], "character": [ "混合细胞亚型" ], "core_name": "瘤", "tendency": "" }, { "anatomy_list": [ "淋巴" ], "character": [ "经典型", "霍奇金" ], "core_name": "瘤", "tendency": "" }, { "anatomy_list": [ "腹膜后淋巴结" ], "character": [ "多发" ], "core_name": "肿大", "tendency": "" }, { "anatomy_list": [ "盆腔淋巴结" ], "character": [ "多发" ], "core_name": "肿大", "tendency": "" }, { "anatomy_list": [ "左侧腹股沟淋巴结" ], "character": [ "多发" ], "core_name": "肿大", "tendency": "" }, { "anatomy_list": [], "character": [ "异常增高" ], "core_name": "fdg代谢", "tendency": "" } ]

现患者为求进一步诊疗，门诊以“冠心病、慢性阻塞性肺疾病、心力衰竭”收入我科住院治疗。

815

[ { "anatomy_list": [ "心" ], "character": [], "core_name": "冠心病", "tendency": "" }, { "anatomy_list": [ "肺" ], "character": [ "慢性", "阻塞性" ], "core_name": "肺疾病", "tendency": "" }, { "anatomy_list": [ "心" ], "character": [], "core_name": "心力衰竭", "tendency": "" } ]

今患者为求进一步治疗，至我院门诊就诊，门诊以“膀胱占位”收入我科住院治疗。

1,831

[ { "anatomy_list": [ "膀胱" ], "character": [], "core_name": "占位", "tendency": "" } ]

患者自起病以来，精神可，胃纳略差，大便如常，尿急，体重未见明显下降。

1,171

[ { "anatomy_list": [], "character": [ "可" ], "core_name": "精神", "tendency": "" }, { "anatomy_list": [ "胃" ], "character": [ "略差" ], "core_name": "胃纳", "tendency": "" }, { "anatomy_list": [], "character": [ "如常" ], "core_name": "大便", "tendency": "" }, { "anatomy_list": [], "character": [], "core_name": "尿急", "tendency": "" }, { "anatomy_list": [], "character": [ "明显" ], "core_name": "体重下降", "tendency": "否定" } ]

3月余前，患者出现胸前区疼痛，为阵发性胀痛，于夜间采取侧卧位时疼痛明显，休息后自行缓解，无压榨感，无胸闷、心悸、气促，无头痛、头晕，无咳嗽、咯血、呼吸困难，无畏寒、寒战，无潮热、盗汗，无吞咽困难，出现喉部异物感，遂于某中医院就诊，行胸部ct提示：左中上纵膈混杂密度占位影，考虑肿瘤性病变，胸腺瘤（侵袭性）可能；左侧后肋肋胸膜胸膜局限性增厚，不除外胸膜转移可能。

1,479

[ { "anatomy_list": [ "胸前区" ], "character": [ "阵发性", "胀痛", "夜间采取侧卧位时疼痛明显", "休息后自行缓解" ], "core_name": "疼痛", "tendency": "" }, { "anatomy_list": [ "胸前区" ], "character": [], "core_name": "压榨感", "tendency": "否定" }, { "anatomy_list": [ "胸" ], "character": [], "core_name": "胸闷", "tendency": "否定" }, { "anatomy_list": [ "心" ], "character": [], "core_name": "心悸", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "气促", "tendency": "否定" }, { "anatomy_list": [ "头" ], "character": [], "core_name": "疼痛", "tendency": "否定" }, { "anatomy_list": [ "头" ], "character": [], "core_name": "头晕", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "咳嗽", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "咯血", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "呼吸困难", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "畏寒", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "寒颤", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "潮热", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "盗汗", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "吞咽困难", "tendency": "否定" }, { "anatomy_list": [ "喉部" ], "character": [], "core_name": "异物感", "tendency": "" }, { "anatomy_list": [ "左中上纵膈" ], "character": [ "混杂密度" ], "core_name": "占位影", "tendency": "" }, { "anatomy_list": [ "左中上纵膈" ], "character": [ "肿瘤性" ], "core_name": "病变", "tendency": "不确定" }, { "anatomy_list": [ "胸腺" ], "character": [ "侵袭性" ], "core_name": "瘤", "tendency": "不确定" }, { "anatomy_list": [ "左侧后肋", "肋胸膜" ], "character": [ "局限性" ], "core_name": "增厚", "tendency": "" }, { "anatomy_list": [ "胸膜" ], "character": [], "core_name": "转移", "tendency": "不确定" } ]

患者自患病以来精神、食欲、睡眠可，大小便正常，近期体重无明显变化。

1,693

[ { "anatomy_list": [], "character": [ "可" ], "core_name": "精神", "tendency": "" }, { "anatomy_list": [], "character": [ "可" ], "core_name": "食欲", "tendency": "" }, { "anatomy_list": [], "character": [ "可" ], "core_name": "睡眠", "tendency": "" }, { "anatomy_list": [], "character": [ "正常" ], "core_name": "大小便", "tendency": "" }, { "anatomy_list": [], "character": [ "明显" ], "core_name": "体重改变", "tendency": "否定" } ]

半月前患者无明显诱因再次血糖控制不佳，监测血糖空腹波动在15-16mm16mmol/L，餐后血糖在21-22mm22mmol/L，患者近期均进食稀饭，现患者有耳鸣，偶有恶心、反酸，无畏寒、发热，无头痛、头晕，无呕吐，有胸闷、心悸，偶有胸痛，伴上腹部不适，伴腹胀、腹泻，无双下肢凹陷性水肿，患者现使用胰岛素剂量为“门冬胰岛素早餐前14u，午餐前14u，晚餐前14u，甘精胰岛素睡前34u”，为进一步治疗就诊，门诊以“糖尿病、糖尿病肾病”收住院治疗。

538

[ { "anatomy_list": [], "character": [ "控制不佳" ], "core_name": "血糖", "tendency": "" }, { "anatomy_list": [], "character": [ "空腹", "波动", "升高" ], "core_name": "血糖", "tendency": "" }, { "anatomy_list": [], "character": [ "餐后", "波动", "升高" ], "core_name": "血糖", "tendency": "" }, { "anatomy_list": [], "character": [ "稀饭" ], "core_name": "进食", "tendency": "" }, { "anatomy_list": [ "耳" ], "character": [], "core_name": "耳鸣", "tendency": "" }, { "anatomy_list": [], "character": [ "偶有" ], "core_name": "恶心", "tendency": "" }, { "anatomy_list": [], "character": [ "偶有" ], "core_name": "反酸", "tendency": "" }, { "anatomy_list": [], "character": [], "core_name": "畏寒", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "发热", "tendency": "否定" }, { "anatomy_list": [ "头" ], "character": [], "core_name": "疼痛", "tendency": "否定" }, { "anatomy_list": [ "头" ], "character": [], "core_name": "头晕", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "呕吐", "tendency": "否定" }, { "anatomy_list": [ "胸" ], "character": [], "core_name": "胸闷", "tendency": "" }, { "anatomy_list": [ "心" ], "character": [], "core_name": "心悸", "tendency": "" }, { "anatomy_list": [ "胸" ], "character": [ "偶有" ], "core_name": "疼痛", "tendency": "" }, { "anatomy_list": [ "上腹部" ], "character": [], "core_name": "不适", "tendency": "" }, { "anatomy_list": [ "腹" ], "character": [], "core_name": "腹胀", "tendency": "" }, { "anatomy_list": [ "腹" ], "character": [], "core_name": "腹泻", "tendency": "" }, { "anatomy_list": [ "双下肢" ], "character": [ "凹陷性" ], "core_name": "水肿", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "糖尿病", "tendency": "" }, { "anatomy_list": [ "肾" ], "character": [ "糖尿病" ], "core_name": "肾病", "tendency": "" } ]

患者今为进一步诊治，来我院就诊，门诊以"lsil"收入我科。

1,402

[ { "anatomy_list": [], "character": [], "core_name": "低度鳞状上皮内病变", "tendency": "" } ]

1周前出现喘累不适，无明显缓解，胸水b超定位提示：右侧胸腔积液，最大前后径约148mm。

1,247

[ { "anatomy_list": [], "character": [ "无明显缓解" ], "core_name": "喘累", "tendency": "" }, { "anatomy_list": [ "胸" ], "character": [], "core_name": "胸水", "tendency": "" }, { "anatomy_list": [ "右侧胸腔" ], "character": [], "core_name": "积液", "tendency": "" } ]

无禁忌症，于10.19开始给予颈部转移病灶调强放射治疗，dt:66G/33f，放疗过程中出现放射性皮炎，给予局部外敷康复新促进皮肤修护治疗，建议患者行化疗，患者拒绝。

1,110

[ { "anatomy_list": [ "颈部" ], "character": [ "转移" ], "core_name": "病灶", "tendency": "" }, { "anatomy_list": [ "颈部", "皮" ], "character": [ "放射性" ], "core_name": "皮炎", "tendency": "" } ]

3月前患者无明显诱因出现腰痛，伴尿黄，无腹胀、腹痛，无胸闷、胸痛，无尿频、尿急、尿痛，院外就诊诊断为“肾结石、肝功异常”，当时未予重视，自行院外输液治疗（具体用药及诊断不详）后腰痛缓解，未复查及随访。

650

[ { "anatomy_list": [ "腰" ], "character": [], "core_name": "疼痛", "tendency": "" }, { "anatomy_list": [], "character": [], "core_name": "尿黄", "tendency": "" }, { "anatomy_list": [ "腹" ], "character": [], "core_name": "腹胀", "tendency": "否定" }, { "anatomy_list": [ "腹" ], "character": [], "core_name": "疼痛", "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": [], "character": [], "core_name": "尿频", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "尿急", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "尿痛", "tendency": "否定" }, { "anatomy_list": [ "肾" ], "character": [], "core_name": "结石", "tendency": "" }, { "anatomy_list": [ "肝" ], "character": [], "core_name": "肝功能异常", "tendency": "" }, { "anatomy_list": [ "腰" ], "character": [ "输液治疗缓解" ], "core_name": "疼痛", "tendency": "" } ]

无腹胀、腹痛，恶心、呕吐，无里急后重。患者未予以重视。

1,444

[ { "anatomy_list": [ "腹" ], "character": [], "core_name": "腹胀", "tendency": "否定" }, { "anatomy_list": [ "腹" ], "character": [], "core_name": "疼痛", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "恶心", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "呕吐", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "里急后重", "tendency": "否定" } ]

患者今为求进一步治疗，门诊以“消化道出血”收治我科。

1,445

[ { "anatomy_list": [ "消化道" ], "character": [], "core_name": "出血", "tendency": "" } ]

之后上述症状反复发作，每次发作均无明显诱因，均突然发作，持续数分钟至10+分钟后自行缓解，性质同前，未治疗；近1月来，患者发作频率较前增加，间隔时间减短，约每小时1-2次，持续10+分钟，无胸闷、气促、胸痛，无黑蒙、晕厥、意识障碍，无咯血、呼吸困难等不适。

703

[ { "anatomy_list": [ "胸" ], "character": [], "core_name": "胸闷", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "气促", "tendency": "否定" }, { "anatomy_list": [ "胸" ], "character": [], "core_name": "疼痛", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "黑朦", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "晕厥", "tendency": "否定" }, { "anatomy_list": [], "character": [ "障碍" ], "core_name": "意识", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "咯血", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "呼吸困难", "tendency": "否定" } ]

原始肿物位于左侧乳房与乳头内侧，大小约为2*2cm。

401

[ { "anatomy_list": [ "左侧乳房与乳头内侧" ], "character": [ "原始" ], "core_name": "肿物", "tendency": "" } ]

发现血压增高5年，血压最高达170/105mmHg，长期口服“苯磺酸氨氯地平”降压，血压控制情况不详。

267

[ { "anatomy_list": [], "character": [ "增高" ], "core_name": "血压", "tendency": "" } ]

患者既往月经规律，自然绝经20+年，绝经后无阴道阴道流血流液。

313

[ { "anatomy_list": [], "character": [ "规律" ], "core_name": "月经", "tendency": "" }, { "anatomy_list": [ "阴道" ], "character": [ "绝经后" ], "core_name": "出血", "tendency": "否定" }, { "anatomy_list": [ "阴道" ], "character": [ "绝经后" ], "core_name": "流液", "tendency": "否定" } ]

左颈部软组织影，考虑淋巴结转移可能。

183

[ { "anatomy_list": [ "左颈部" ], "character": [ "软组织" ], "core_name": "组织影", "tendency": "" }, { "anatomy_list": [ "淋巴结" ], "character": [], "core_name": "转移", "tendency": "不确定" } ]

平时白带较不多，无异味。

1,399

[ { "anatomy_list": [], "character": [ "较不多" ], "core_name": "白带", "tendency": "" }, { "anatomy_list": [], "character": [ "异味" ], "core_name": "白带", "tendency": "否定" } ]

22月前患者为进一步治疗来我科，完善术前检查，于2015-10-12行原发性肝癌介入术，2015-10-19复查ct提示碘油沉积可，2015-10-23行原发性肝癌姑息性hifu术，术后给予保肝、消炎、增强免疫、抗肿瘤等治疗，患者术后多次复查腹部mr提示肿瘤无复发。

451

[ { "anatomy_list": [], "character": [ "可" ], "core_name": "碘油沉积", "tendency": "" }, { "anatomy_list": [], "character": [ "复发" ], "core_name": "肿瘤", "tendency": "否定" } ]

入院前10年，患者受凉后咳嗽，咯白色泡沫痰，以晨起明显。

1,327

[ { "anatomy_list": [], "character": [ "受凉后" ], "core_name": "咳嗽", "tendency": "" }, { "anatomy_list": [], "character": [ "白色", "泡沫痰", "晨起明显" ], "core_name": "咳痰", "tendency": "" } ]

21年来患者反复心悸、胸痛、胸闷，偶伴心前区疼痛及压榨感，每次持续20秒，呈锐痛，含服硝酸甘油后症状可立即缓解，偶伴头晕、头痛，无视物旋转、一过性黑朦，11年前在我科住院治疗，经冠状动脉造影示lad开口狭窄、并行支架成型术。

1,567

[ { "anatomy_list": [ "心" ], "character": [ "反复" ], "core_name": "心悸", "tendency": "" }, { "anatomy_list": [ "胸" ], "character": [ "反复" ], "core_name": "疼痛", "tendency": "" }, { "anatomy_list": [ "胸" ], "character": [ "反复" ], "core_name": "胸闷", "tendency": "" }, { "anatomy_list": [ "心前区" ], "character": [ "偶" ], "core_name": "疼痛", "tendency": "" }, { "anatomy_list": [ "心前区" ], "character": [ "偶" ], "core_name": "压榨感", "tendency": "" }, { "anatomy_list": [ "心前区" ], "character": [ "锐痛" ], "core_name": "疼痛", "tendency": "" }, { "anatomy_list": [ "头" ], "character": [ "偶" ], "core_name": "头晕", "tendency": "" }, { "anatomy_list": [ "头" ], "character": [ "偶" ], "core_name": "疼痛", "tendency": "" }, { "anatomy_list": [], "character": [ "一过性" ], "core_name": "黑朦", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "视物旋转", "tendency": "否定" }, { "anatomy_list": [ "冠状动脉lad开口" ], "character": [], "core_name": "狭窄", "tendency": "" } ]

后患者颈部包块逐渐增大，2020年10月开始出现咳嗽、咳痰，咳白色粘痰，咳嗽剧烈时伴有呼吸困难。

482

[ { "anatomy_list": [ "颈部" ], "character": [ "逐渐", "增大" ], "core_name": "包块增大", "tendency": "" }, { "anatomy_list": [], "character": [], "core_name": "咳嗽", "tendency": "" }, { "anatomy_list": [], "character": [], "core_name": "咳痰", "tendency": "" }, { "anatomy_list": [], "character": [ "白色", "粘性" ], "core_name": "咳痰", "tendency": "" }, { "anatomy_list": [], "character": [ "咳嗽剧烈时" ], "core_name": "呼吸困难", "tendency": "" } ]

患者本次发病以来，食欲下降，感进食后饱胀不适。

1,313

[ { "anatomy_list": [], "character": [ "下降" ], "core_name": "食欲", "tendency": "" }, { "anatomy_list": [], "character": [ "进食后" ], "core_name": "饱胀", "tendency": "" } ]

入院前半年，患者站立时扪及右侧腹股沟区一大拇指大小包块，质地较软，移动可，可回纳，活动后伴右侧腹股沟区胀痛，取平卧位可明显减轻，不伴腹痛、腹胀、恶心、呕吐、肛门停止排便排气等，患者未予重视及相关诊治。

1,473

[ { "anatomy_list": [ "右侧腹股沟区" ], "character": [ "一大拇指大小", "质地较软", "移动可", "可回纳" ], "core_name": "包块", "tendency": "" }, { "anatomy_list": [ "右侧腹股沟区" ], "character": [ "活动后胀痛", "平卧位可明显减轻" ], "core_name": "疼痛", "tendency": "" }, { "anatomy_list": [ "腹" ], "character": [], "core_name": "疼痛", "tendency": "否定" }, { "anatomy_list": [ "腹" ], "character": [], "core_name": "腹胀", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "恶心", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "呕吐", "tendency": "否定" }, { "anatomy_list": [ "肛门" ], "character": [], "core_name": "排便", "tendency": "否定" }, { "anatomy_list": [ "肛门" ], "character": [], "core_name": "排气", "tendency": "否定" } ]

2017-3-9某医院复查肠镜示：结肠癌术后表现。

1,932

[ { "anatomy_list": [ "结肠" ], "character": [ "术后" ], "core_name": "癌", "tendency": "" } ]

4.肝囊肿。

1,262

[ { "anatomy_list": [ "肝" ], "character": [], "core_name": "囊肿", "tendency": "" } ]

2017-8-16 ect检查报告：全身骨显像与2017-5-5全身骨显像比较：1.出现新增病灶：左侧第5前肋肋缘，考虑肋骨损伤可能大。

459

[ { "anatomy_list": [ "左侧第5前肋肋缘" ], "character": [ "新增" ], "core_name": "病灶", "tendency": "" }, { "anatomy_list": [ "肋骨" ], "character": [ "可能大" ], "core_name": "损伤", "tendency": "不确定" } ]

治疗上予以禁食水、补液、胃肠减压、灌肠等治疗后腹痛、腹胀症状明显缓解，后请我科会诊后转入我科治疗，请肛肠科会诊行直肠病灶活检提示腺癌。

1,544

[ { "anatomy_list": [ "腹" ], "character": [ "明显缓解" ], "core_name": "疼痛", "tendency": "" }, { "anatomy_list": [ "腹" ], "character": [ "明显缓解" ], "core_name": "腹胀", "tendency": "" }, { "anatomy_list": [ "直肠" ], "character": [], "core_name": "腺癌", "tendency": "" } ]

遂于我院行胸部ct提示肺内占位（具体报告未见）；后患者于某医院行ct引导下经皮肺穿刺活检术，术后病理示：非小细胞肺癌；行基因检测未见阳性突变。

381

[ { "anatomy_list": [ "肺内" ], "character": [], "core_name": "占位", "tendency": "" }, { "anatomy_list": [ "肺" ], "character": [], "core_name": "非小细胞癌", "tendency": "" }, { "anatomy_list": [], "character": [ "阳性" ], "core_name": "突变", "tendency": "否定" } ]

入院前4月，患者无明显诱因出现右腿疼痛，为持续性，无阵发性加重，活动时明显，不伴下肢麻木等不适，患者就诊于我院，腰椎mri示腰椎间盘突出症、骨盆多发骨质破坏。

1,704

[ { "anatomy_list": [ "右腿" ], "character": [ "持续性", "无阵发性加重", "活动时明显" ], "core_name": "疼痛", "tendency": "" }, { "anatomy_list": [ "下肢" ], "character": [], "core_name": "麻木", "tendency": "否定" }, { "anatomy_list": [ "腰椎间盘" ], "character": [], "core_name": "突出症", "tendency": "" }, { "anatomy_list": [ "骨盆" ], "character": [ "多发" ], "core_name": "骨质破坏", "tendency": "" } ]

入院前1年，患者出现口干，进食干食需用水送服，伴反复腮腺炎，患者仍未重视，故未治疗。

932

[ { "anatomy_list": [ "口" ], "character": [ "进食干食需用水送服" ], "core_name": "口干", "tendency": "" }, { "anatomy_list": [ "腮腺" ], "character": [ "反复" ], "core_name": "腮腺炎", "tendency": "" } ]

入院前2日发现患儿无明显诱因发热，以高热为主，最高高体温39.8℃，自行予退烧药口服后，体温能降至正常。

902

[ { "anatomy_list": [], "character": [], "core_name": "发热", "tendency": "" }, { "anatomy_list": [], "character": [ "高" ], "core_name": "发热", "tendency": "" }, { "anatomy_list": [], "character": [ "升高" ], "core_name": "体温", "tendency": "" }, { "anatomy_list": [], "character": [ "降至正常", "予退烧药口服后" ], "core_name": "体温", "tendency": "" } ]

入院前4月，患者无明显诱因出现胸闷，诉活动后明显，偶有心前区压榨感，胸闷明显时伴有呼吸困难，休息后胸闷好转，患者无咳嗽、咳痰，无发热，无咯血，偶有胸部刺痛，偶有午后潮热及夜间盗汗，无明显乏力、消瘦，无声嘶，无呛咳，无心慌、心悸，无下肢水肿等不适，病后患者未重视，未行特殊治疗，患者胸闷仍反复发作，现患者胸闷仍明显，遂来我院，门诊胸部ct结果提示“左上肺结节：考虑纤维灶可能，肺部肿瘤不除外”，为进一步诊治，门诊以“左肺结节”收入我科。

1,404

[ { "anatomy_list": [ "胸" ], "character": [ "活动后明显" ], "core_name": "胸闷", "tendency": "" }, { "anatomy_list": [ "心前区" ], "character": [], "core_name": "压榨感", "tendency": "" }, { "anatomy_list": [], "character": [], "core_name": "呼吸困难", "tendency": "" }, { "anatomy_list": [ "胸" ], "character": [ "休息后好转" ], "core_name": "胸闷", "tendency": "" }, { "anatomy_list": [], "character": [], "core_name": "咳嗽", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "咳痰", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "发热", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "咯血", "tendency": "否定" }, { "anatomy_list": [ "胸部" ], "character": [ "刺痛" ], "core_name": "疼痛", "tendency": "" }, { "anatomy_list": [], "character": [ "午后" ], "core_name": "潮热", "tendency": "" }, { "anatomy_list": [], "character": [ "夜间" ], "core_name": "盗汗", "tendency": "" }, { "anatomy_list": [], "character": [ "明显" ], "core_name": "乏力", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "消瘦", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "声嘶", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "呛咳", "tendency": "否定" }, { "anatomy_list": [ "心" ], "character": [], "core_name": "心慌", "tendency": "否定" }, { "anatomy_list": [ "心" ], "character": [], "core_name": "心悸", "tendency": "否定" }, { "anatomy_list": [ "下肢" ], "character": [], "core_name": "水肿", "tendency": "否定" }, { "anatomy_list": [ "胸" ], "character": [ "反复发作" ], "core_name": "胸闷", "tendency": "" }, { "anatomy_list": [ "胸" ], "character": [ "明显" ], "core_name": "胸闷", "tendency": "" }, { "anatomy_list": [ "左上肺" ], "character": [], "core_name": "结节", "tendency": "" }, { "anatomy_list": [ "左上肺" ], "character": [], "core_name": "纤维灶", "tendency": "不确定" }, { "anatomy_list": [ "肺部" ], "character": [], "core_name": "肿瘤", "tendency": "不确定" }, { "anatomy_list": [ "左肺" ], "character": [], "core_name": "结节", "tendency": "" } ]

患者既往于我院行同步放化疗及后装治疗后复查盆腔ct提示宫颈病灶明显减小，鳞癌癌细胞抗原已降至正常范围内，但盆腔ct提示宫颈形状不规则、仍有强化；妇科检查示：宫颈表现颗粒状增生、触血，前穹隆消失，右侧穹隆变浅。

1,624

[ { "anatomy_list": [ "宫颈" ], "character": [ "明显", "减小" ], "core_name": "病灶", "tendency": "" }, { "anatomy_list": [ "宫颈" ], "character": [ "仍有强化" ], "core_name": "形态不规则", "tendency": "" }, { "anatomy_list": [ "宫颈" ], "character": [ "颗粒状" ], "core_name": "增生", "tendency": "" }, { "anatomy_list": [ "宫颈" ], "character": [], "core_name": "出血", "tendency": "" }, { "anatomy_list": [ "宫颈前穹隆" ], "character": [], "core_name": "消失", "tendency": "" }, { "anatomy_list": [ "宫颈右侧穹隆" ], "character": [], "core_name": "变浅", "tendency": "" } ]

患者lmp：2020-3-20，停经40+天自测尿hcg阳性，就诊于某卫生院，超声提示宫内未见孕囊，次日就诊于某医院，血hcg阳性（具体数值不详）、孕酮偏低。

686

[ { "anatomy_list": [], "character": [], "core_name": "停经", "tendency": "" }, { "anatomy_list": [ "宫内" ], "character": [ "未见" ], "core_name": "孕囊", "tendency": "" }, { "anatomy_list": [], "character": [ "阳性" ], "core_name": "血hcg", "tendency": "" }, { "anatomy_list": [], "character": [ "阳性" ], "core_name": "尿hcg", "tendency": "" }, { "anatomy_list": [], "character": [ "偏低" ], "core_name": "孕酮", "tendency": "" } ]

入院前4天，患者无明显诱因出现腰背部酸胀，弯腰、负重及久坐后加重，卧床休息后可缓解；双下肢无放射痛，无麻木、乏力。

269

[ { "anatomy_list": [ "腰背部" ], "character": [ "弯腰、负重及久坐后加重", "卧床休息后可缓解" ], "core_name": "酸胀", "tendency": "" }, { "anatomy_list": [ "双下肢" ], "character": [ "放射性" ], "core_name": "疼痛", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "麻木", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "乏力", "tendency": "否定" } ]

13月前，患者在左锁骨上触一大小约2x3cm的包块，体表包块b超提示：临床扪及包块处探及低回声结节，性质待定，考虑肿大淋巴结可能。

305

[ { "anatomy_list": [ "左锁骨上" ], "character": [], "core_name": "包块", "tendency": "" }, { "anatomy_list": [], "character": [], "core_name": "包块", "tendency": "" }, { "anatomy_list": [], "character": [ "低回声" ], "core_name": "结节", "tendency": "" }, { "anatomy_list": [ "淋巴结" ], "character": [], "core_name": "肿大", "tendency": "不确定" } ]

2020/6/1ct：腹膜后偏左侧占位，结合病史考虑转移瘤伴周围结构多发侵犯，与2020-04-27片对比，肿块较前缩小，胃内较多积液、积气。

185

[ { "anatomy_list": [ "腹膜后偏左侧" ], "character": [], "core_name": "占位", "tendency": "" }, { "anatomy_list": [], "character": [ "转移" ], "core_name": "瘤", "tendency": "不确定" }, { "anatomy_list": [ "周围结构" ], "character": [ "多发" ], "core_name": "侵犯", "tendency": "" }, { "anatomy_list": [], "character": [ "较前缩小" ], "core_name": "肿块", "tendency": "" }, { "anatomy_list": [ "胃内" ], "character": [ "较多" ], "core_name": "积液", "tendency": "" }, { "anatomy_list": [ "胃内" ], "character": [ "较多" ], "core_name": "积气", "tendency": "" } ]

患者本次发病以来,食欲正常,神志清醒,精神尚可,睡眠尚可,大便正常,小便正常,体重无明显变化。

46

[ { "anatomy_list": [], "character": [ "正常" ], "core_name": "食欲", "tendency": "" }, { "anatomy_list": [], "character": [ "清醒" ], "core_name": "神志", "tendency": "" }, { "anatomy_list": [], "character": [ "尚可" ], "core_name": "精神", "tendency": "" }, { "anatomy_list": [], "character": [ "尚可" ], "core_name": "睡眠", "tendency": "" }, { "anatomy_list": [], "character": [ "正常" ], "core_name": "大便", "tendency": "" }, { "anatomy_list": [], "character": [ "正常" ], "core_name": "小便", "tendency": "" }, { "anatomy_list": [], "character": [ "明显" ], "core_name": "体重变化", "tendency": "否定" } ]

进一步完善肾脏ct示：左肾下极占位，大小约3cm，考虑肿瘤性病变，透明细胞癌可能。

1,197

[ { "anatomy_list": [ "左肾下极" ], "character": [], "core_name": "占位", "tendency": "" }, { "anatomy_list": [], "character": [ "肿瘤性" ], "core_name": "病变", "tendency": "不确定" }, { "anatomy_list": [ "透明细胞" ], "character": [], "core_name": "癌", "tendency": "不确定" } ]

１周前，患者出现咳嗽、咳痰较前加重，伴活动后喘累气促，进食减少，食欲差，伴全身乏力，无恶心、呕吐，无心悸、胸闷，无胸痛，无咯血，无发热，未重视。

983

[ { "anatomy_list": [], "character": [ "加重" ], "core_name": "咳嗽", "tendency": "" }, { "anatomy_list": [], "character": [ "加重" ], "core_name": "咳痰", "tendency": "" }, { "anatomy_list": [], "character": [ "活动后" ], "core_name": "喘累", "tendency": "" }, { "anatomy_list": [], "character": [ "活动后" ], "core_name": "气促", "tendency": "" }, { "anatomy_list": [], "character": [], "core_name": "进食减少", "tendency": "" }, { "anatomy_list": [], "character": [ "差" ], "core_name": "食欲", "tendency": "" }, { "anatomy_list": [ "全身" ], "character": [], "core_name": "乏力", "tendency": "" }, { "anatomy_list": [], "character": [], "core_name": "恶心", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "呕吐", "tendency": "否定" }, { "anatomy_list": [ "心" ], "character": [], "core_name": "心悸", "tendency": "否定" }, { "anatomy_list": [ "胸" ], "character": [], "core_name": "胸闷", "tendency": "否定" }, { "anatomy_list": [ "胸" ], "character": [], "core_name": "疼痛", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "咯血", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "发热", "tendency": "否定" } ]

今患者为进一步明确诊治来我院，门诊以“糖尿病”收入我科。

1,277

[ { "anatomy_list": [], "character": [], "core_name": "糖尿病", "tendency": "" } ]

化疗过程顺利，后再入我院行第2次化疗，方案为dp方案（多西他赛120mg+顺铂130mg静脉化疗），化疗过程患者出现便秘不适，今患者诉右侧髋部疼痛较前明显，为复查就诊于我院门诊，门诊拟“右上肺肺腺癌”收住院治疗。

1,441

[ { "anatomy_list": [], "character": [ "化疗过程" ], "core_name": "便秘", "tendency": "" }, { "anatomy_list": [ "右侧髋部" ], "character": [ "较前明显" ], "core_name": "疼痛", "tendency": "" }, { "anatomy_list": [ "右上肺" ], "character": [], "core_name": "腺癌", "tendency": "" } ]

骨扫描：左肩关节、胸骨、脊柱（约胸55椎体及上位颈椎明显）、右侧髋臼多发异常显像剂浓聚灶，考虑肿瘤骨转移，予以止痛对症后患者疼痛控制。

944

[ { "anatomy_list": [ "左肩关节" ], "character": [ "多发", "异常", "显像剂" ], "core_name": "浓聚灶", "tendency": "" }, { "anatomy_list": [ "胸骨" ], "character": [ "多发", "异常", "显像剂" ], "core_name": "浓聚灶", "tendency": "" }, { "anatomy_list": [ "脊柱" ], "character": [ "多发", "异常", "显像剂", "约胸55椎体及上位颈椎明显" ], "core_name": "浓聚灶", "tendency": "" }, { "anatomy_list": [ "右侧髋臼" ], "character": [ "多发", "异常", "显像剂" ], "core_name": "浓聚灶", "tendency": "" }, { "anatomy_list": [], "character": [ "骨转移" ], "core_name": "肿瘤", "tendency": "不确定" }, { "anatomy_list": [], "character": [ "控制" ], "core_name": "疼痛", "tendency": "" } ]

2+月前，患者出现双侧肩胛骨骨疼痛，疼痛剧烈，口服吗啡疼痛无明显缓解，于9月5日在我科行右侧肩胛骨放疗，累计放疗：dt：30G/10f，患者疼痛缓解出院。

1,851

[ { "anatomy_list": [ "双侧肩胛骨" ], "character": [], "core_name": "疼痛", "tendency": "" }, { "anatomy_list": [ "双侧肩胛骨" ], "character": [ "剧烈" ], "core_name": "疼痛", "tendency": "" }, { "anatomy_list": [], "character": [ "缓解" ], "core_name": "疼痛", "tendency": "否定" }, { "anatomy_list": [], "character": [ "缓解" ], "core_name": "疼痛", "tendency": "" } ]

为进一步诊治，遂来我科住院，门诊以“上消化道出血，肝硬化失代偿”收入我科。

861

[ { "anatomy_list": [ "上消化道" ], "character": [], "core_name": "出血", "tendency": "" }, { "anatomy_list": [ "肝" ], "character": [ "失代偿" ], "core_name": "硬化", "tendency": "" } ]

（左乳左、右、上、下、后切缘）未见癌累及。

1,761

[ { "anatomy_list": [ "左乳左、右、上、下、后切缘" ], "character": [ "累及" ], "core_name": "癌", "tendency": "否定" } ]

1+月前患者排尿不畅症状明显，并伴排尿费力，尿频、尿急、尿痛，尿不尽，尿线变细，排尿滴沥，偶有全身疼痛感。

2,021

[ { "anatomy_list": [], "character": [ "明显" ], "core_name": "排尿不畅", "tendency": "" }, { "anatomy_list": [], "character": [], "core_name": "排尿费力", "tendency": "" }, { "anatomy_list": [], "character": [], "core_name": "尿频", "tendency": "" }, { "anatomy_list": [], "character": [], "core_name": "尿急", "tendency": "" }, { "anatomy_list": [], "character": [], "core_name": "尿痛", "tendency": "" }, { "anatomy_list": [], "character": [], "core_name": "尿不尽", "tendency": "" }, { "anatomy_list": [], "character": [], "core_name": "尿线变细", "tendency": "" }, { "anatomy_list": [], "character": [], "core_name": "排尿滴沥", "tendency": "" }, { "anatomy_list": [ "全身" ], "character": [ "偶有" ], "core_name": "疼痛", "tendency": "" } ]

入院前7年，患者体检中发现发现血压升高，最高血压180+/？mmhg，长期予以苯磺酸氨氯地平5mg qd降压，自诉近期血压控制在150-160/？mmhg，有视物模糊不适；入院前6年，患者无意间发现左侧第一跖趾关节及左侧膝关节出现无痛性结节，未重视及处理。

872

[ { "anatomy_list": [], "character": [ "升高" ], "core_name": "血压", "tendency": "" }, { "anatomy_list": [], "character": [], "core_name": "视物模糊", "tendency": "" }, { "anatomy_list": [ "左侧第1跖趾关节" ], "character": [ "无痛性" ], "core_name": "结节", "tendency": "" }, { "anatomy_list": [ "左侧膝关节" ], "character": [ "无痛性" ], "core_name": "结节", "tendency": "" } ]

入院5+年前患者无明显诱因出现咳嗽、咳痰、喘累，痰为白色泡沫痰，无潮热、盗汗，病程中冬春季易发，每年持续时间大于3月，患者未予重视。

1,518

[ { "anatomy_list": [], "character": [], "core_name": "咳嗽", "tendency": "" }, { "anatomy_list": [], "character": [ "白色", "泡沫痰" ], "core_name": "咳痰", "tendency": "" }, { "anatomy_list": [], "character": [], "core_name": "喘累", "tendency": "" }, { "anatomy_list": [], "character": [], "core_name": "潮热", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "盗汗", "tendency": "否定" } ]

5+年前，患者述腰背部伴双侧大腿前侧间断性痛，疼痛尚可忍受，无麻木、乏力不能行走，患者未予以重视，自服药物或膏药治疗（具体用药不详）后缓解，其后间断疼痛，为予以特别重视，自行好转，患者10+月前我院体检发现乳腺包块，其后于某医院行spect检查提示：左侧髂骨异常成骨增强灶，考虑肿瘤骨转移可能性大，于行新辅助化疗后于某医院行左侧乳腺癌保乳术，术后病检提示：（左侧乳腺）浸润性癌，非特殊类型。iii级。

1,288

[ { "anatomy_list": [ "双侧大腿前侧", "腰部", "背部" ], "character": [ "间断性", "尚可忍受" ], "core_name": "疼痛", "tendency": "" }, { "anatomy_list": [ "双侧大腿" ], "character": [], "core_name": "麻木", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "乏力", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "行走障碍", "tendency": "否定" }, { "anatomy_list": [], "character": [ "间断" ], "core_name": "疼痛", "tendency": "" }, { "anatomy_list": [ "乳腺" ], "character": [], "core_name": "包块", "tendency": "" }, { "anatomy_list": [ "左侧髂骨" ], "character": [ "异常成骨" ], "core_name": "增强灶", "tendency": "" }, { "anatomy_list": [ "骨" ], "character": [ "转移" ], "core_name": "肿瘤", "tendency": "不确定" }, { "anatomy_list": [ "左侧乳腺" ], "character": [ "浸润性", "非特殊类型", "iii级" ], "core_name": "癌", "tendency": "" } ]

院外期间仍有烦渴、多饮，全身乏力，胸闷怕冷等症状。

235

[ { "anatomy_list": [], "character": [], "core_name": "烦渴", "tendency": "" }, { "anatomy_list": [], "character": [], "core_name": "多饮", "tendency": "" }, { "anatomy_list": [ "全身" ], "character": [], "core_name": "乏力", "tendency": "" }, { "anatomy_list": [ "胸" ], "character": [], "core_name": "胸闷", "tendency": "" }, { "anatomy_list": [], "character": [], "core_name": "怕冷", "tendency": "" } ]

诊断为“中央型肺癌肺癌伴淋巴结转移”，未行手术及放化疗，经抗感染、止咳、祛痰等对症支持治疗后，病情好转后出院。症状反复发生，未见明显加重。

1,701

[ { "anatomy_list": [ "肺" ], "character": [ "中央型" ], "core_name": "癌", "tendency": "" }, { "anatomy_list": [ "淋巴结" ], "character": [ "转移" ], "core_name": "癌", "tendency": "" } ]

无化疗禁忌症，分别于2016-3-11、2016-4-1、2016-4-22行tp方案（紫杉醇240mg+奈达铂140mg）化疗，化疗后出现明显骨髓抑制，予以生白细胞治疗后好转出院，院外未诉特殊不适。

1,286

[ { "anatomy_list": [ "骨髓" ], "character": [ "明显" ], "core_name": "骨髓抑制", "tendency": "" } ]

患者期间仍感右上胸部针刺样疼痛，阵发性，呼吸咳嗽加重，可向肩背部放射，未予以特殊处理。

963

[ { "anatomy_list": [ "右上胸部" ], "character": [ "针刺样", "阵发性" ], "core_name": "疼痛", "tendency": "" }, { "anatomy_list": [], "character": [ "加重" ], "core_name": "咳嗽", "tendency": "" }, { "anatomy_list": [ "肩背部" ], "character": [ "放射性" ], "core_name": "疼痛", "tendency": "" } ]

遂于我院行乳腺b超检查提示：左侧乳腺2点钟方向距乳头约40mm处可见大小约24*22mm低回声包块，边界不清不规则。

497

[ { "anatomy_list": [ "左侧乳腺2点钟方向距乳头约40mm处" ], "character": [ "低回声", "边界不清不规则" ], "core_name": "包块", "tendency": "" } ]

2年前患者于外院行辅助检查，考虑诊断为“肝癌”，遂行肝癌切除术，住院期间因患者肾功能差，改用“替比夫定”抗病毒治疗。

91

[ { "anatomy_list": [ "肝" ], "character": [], "core_name": "癌", "tendency": "不确定" }, { "anatomy_list": [ "肾" ], "character": [], "core_name": "肾功能差", "tendency": "" } ]

与2018-8-29片比较：病灶较明显增大。

1,026

[ { "anatomy_list": [], "character": [ "明显", "增大" ], "core_name": "病灶", "tendency": "" } ]

入院前3+年，患者排尿时出现全程血尿，鲜红色，伴尿频、尿急及尿痛，行b超检查提示前列腺增生。

1,792

[ { "anatomy_list": [], "character": [ "鲜红色" ], "core_name": "血尿", "tendency": "" }, { "anatomy_list": [], "character": [], "core_name": "尿频", "tendency": "" }, { "anatomy_list": [], "character": [], "core_name": "尿急", "tendency": "" }, { "anatomy_list": [], "character": [], "core_name": "尿痛", "tendency": "" }, { "anatomy_list": [ "前列腺" ], "character": [], "core_name": "增生", "tendency": "" } ]

2.甲状腺左叶上份稍低密度影，结合图像融合考虑：结节性甲状腺中可能。

253

[ { "anatomy_list": [ "甲状腺左叶上" ], "character": [ "稍低" ], "core_name": "密度影", "tendency": "" }, { "anatomy_list": [ "甲状腺" ], "character": [ "结节性" ], "core_name": "肿", "tendency": "不确定" } ]

就诊于某医院整形美容科，行浅表淋巴结超声提示：左侧腹股沟腹股沟区可见数个低回声结节结节影，较大者大小约5.7×2.7cm，并行左侧腹股沟腹股沟区淋巴结淋巴结活检，活检病理提示：（左侧腹股沟淋巴结）淋巴组织增生，建议免疫组化进一步诊断。患者随后未行任何检查及治疗。

851

[ { "anatomy_list": [ "左侧腹股沟" ], "character": [ "数个", "低回声" ], "core_name": "结节影", "tendency": "" }, { "anatomy_list": [ "左侧腹股沟淋巴结组织" ], "character": [], "core_name": "增生", "tendency": "" } ]

现患儿精神食欲可，大便2次/天，稀水样，无血丝及粘液，小便黄清，尿量无减少。

367

[ { "anatomy_list": [], "character": [ "可" ], "core_name": "精神", "tendency": "" }, { "anatomy_list": [], "character": [ "可" ], "core_name": "食欲", "tendency": "" }, { "anatomy_list": [], "character": [ "2次/天", "稀水样", "无血丝及粘液" ], "core_name": "大便", "tendency": "" }, { "anatomy_list": [], "character": [ "黄清" ], "core_name": "小便", "tendency": "" }, { "anatomy_list": [], "character": [ "无减少" ], "core_name": "尿量", "tendency": "" } ]

病程中患者精神、饮食稍差，大小便正常，体重无明显下降。

1,088

[ { "anatomy_list": [], "character": [ "稍差" ], "core_name": "精神", "tendency": "" }, { "anatomy_list": [], "character": [ "稍差" ], "core_name": "饮食", "tendency": "" }, { "anatomy_list": [], "character": [ "正常" ], "core_name": "大便", "tendency": "" }, { "anatomy_list": [], "character": [ "正常" ], "core_name": "小便", "tendency": "" }, { "anatomy_list": [], "character": [ "明显" ], "core_name": "体重下降", "tendency": "否定" } ]

入院前5-月，患者因"升结肠癌"于2019-03-19全麻下行腹腔镜下右半结肠癌根治术（扩大）、腹腔镜下肠粘连松解术，手术顺利，术后病检（右半结肠）粘液腺癌，侵及肠壁全层。

636

[ { "anatomy_list": [ "升结肠" ], "character": [], "core_name": "癌", "tendency": "" }, { "anatomy_list": [ "右半结肠" ], "character": [ "粘液", "侵及肠壁" ], "core_name": "腺癌", "tendency": "" } ]

现患者为求第五次新辅助化疗，就诊于我院，门诊以“胰腺癌伴肝转移”收住入院。

1,670

[ { "anatomy_list": [ "胰腺" ], "character": [], "core_name": "癌", "tendency": "" }, { "anatomy_list": [ "肝" ], "character": [ "转移" ], "core_name": "癌", "tendency": "" } ]

胸片：双下肺少许感染，主动脉球少许钙化，胸椎退行性变。

519

[ { "anatomy_list": [ "双下肺" ], "character": [ "少许" ], "core_name": "感染", "tendency": "" }, { "anatomy_list": [ "主动脉球" ], "character": [ "少许" ], "core_name": "钙化", "tendency": "" }, { "anatomy_list": [ "胸椎" ], "character": [ "退行性" ], "core_name": "病变", "tendency": "" } ]

患者入院前10年无明显诱因出现排尿踌躇、费力、不尽感,夜尿4-5次，尿线无力、分叉、变细、终末滴沥，未予重视，未予特殊处理，7年前患者到某医院行前列腺电切术，术后排尿困难症状无明显改善，夜尿7-8次，6年前患者出现排尿困难加重，排尿费力，偶有尿线中断，排尿滴沥明显，患者遂到某医院就诊，予以扩尿道2次，患者排尿困难稍有改善。

1,080

[ { "anatomy_list": [], "character": [ "踌躇", "费力", "不尽感" ], "core_name": "排尿", "tendency": "" }, { "anatomy_list": [], "character": [ "4-5次" ], "core_name": "夜尿", "tendency": "" }, { "anatomy_list": [], "character": [], "core_name": "尿线无力", "tendency": "" }, { "anatomy_list": [], "character": [], "core_name": "尿线分叉", "tendency": "" }, { "anatomy_list": [], "character": [], "core_name": "尿线变细", "tendency": "" }, { "anatomy_list": [], "character": [ "终末滴沥" ], "core_name": "排尿", "tendency": "" }, { "anatomy_list": [], "character": [ "术后", "无明显改善" ], "core_name": "排尿困难", "tendency": "" }, { "anatomy_list": [], "character": [ "7-8次" ], "core_name": "夜尿", "tendency": "" }, { "anatomy_list": [], "character": [ "加重" ], "core_name": "排尿困难", "tendency": "" }, { "anatomy_list": [], "character": [], "core_name": "排尿费力", "tendency": "" }, { "anatomy_list": [], "character": [ "偶有" ], "core_name": "尿线中断", "tendency": "" }, { "anatomy_list": [], "character": [ "明显" ], "core_name": "排尿滴沥", "tendency": "" }, { "anatomy_list": [], "character": [ "稍有改善" ], "core_name": "排尿困难", "tendency": "" } ]

与患者及家属沟通可选择的治疗方案，计划予以dp方案（多西他赛+顺铂）化疗，于2020-04-02、2020-04-24予以2周期dp方案化疗（多西他赛100mg1+顺铂50mg1-2，q3w），化疗期间出现恶心、食欲下降，予以奥美拉唑抑酸，昂丹司琼止吐等治疗后缓解。

217

[ { "anatomy_list": [], "character": [], "core_name": "恶心", "tendency": "" }, { "anatomy_list": [], "character": [ "下降" ], "core_name": "食欲", "tendency": "" } ]

患者住院期间多次输注血小板、悬浮红细胞，输注过程中及输注后均无不良反应。

1,658

[ { "anatomy_list": [], "character": [ "输注过程中" ], "core_name": "不良反应", "tendency": "否定" }, { "anatomy_list": [], "character": [ "输注后" ], "core_name": "不良反应", "tendency": "否定" } ]

无畏寒发热，无胸闷气紧，无心慌心悸，无黑便便血血便，无肉眼血尿。

1,131

[ { "anatomy_list": [], "character": [], "core_name": "畏寒", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "发热", "tendency": "否定" }, { "anatomy_list": [ "胸" ], "character": [], "core_name": "胸闷", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "气紧", "tendency": "否定" }, { "anatomy_list": [ "心" ], "character": [], "core_name": "心慌", "tendency": "否定" }, { "anatomy_list": [ "心" ], "character": [], "core_name": "心悸", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "黑便", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "血便", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "便血", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "血尿", "tendency": "否定" } ]

术后口服“替格瑞洛90mg bid”治疗，入院前12小时（2017-11-04 22:00），患者自觉剑突下绞痛，伴胸骨后哽咽感及喉部不适，持续约20分20分钟左右，无胸痛、胸部压榨感，无大汗、乏力，无头昏、头痛，无黑曚、意识障碍，含服“速效救心丸”可缓解，入院前8小时，患者再次感剑突下不适，稍疼痛，持续约10分10分钟，后自行缓解，入院前3小时，患者自行口服“阿司匹林300mg、替格瑞洛180mg”后入我院，以“冠心病”收入我科。

1,215

[ { "anatomy_list": [ "剑突下" ], "character": [ "绞痛" ], "core_name": "疼痛", "tendency": "" }, { "anatomy_list": [ "胸骨后" ], "character": [], "core_name": "哽咽感", "tendency": "" }, { "anatomy_list": [ "喉部" ], "character": [], "core_name": "喉部不适", "tendency": "" }, { "anatomy_list": [ "胸" ], "character": [], "core_name": "疼痛", "tendency": "否定" }, { "anatomy_list": [ "胸部" ], "character": [], "core_name": "压榨感", "tendency": "否定" }, { "anatomy_list": [], "character": [ "大汗" ], "core_name": "出汗", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "乏力", "tendency": "否定" }, { "anatomy_list": [ "头" ], "character": [], "core_name": "头昏", "tendency": "否定" }, { "anatomy_list": [ "头" ], "character": [], "core_name": "疼痛", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "黒朦", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "意识障碍", "tendency": "否定" }, { "anatomy_list": [ "剑突下" ], "character": [], "core_name": "剑突下不适", "tendency": "" }, { "anatomy_list": [ "剑突下" ], "character": [ "稍" ], "core_name": "疼痛", "tendency": "" }, { "anatomy_list": [ "冠状动脉", "心脏" ], "character": [ "硬化性", "粥样" ], "core_name": "心脏病", "tendency": "" } ]

门诊以“肺占位性病变”收住院治疗。

126

[ { "anatomy_list": [ "肺" ], "character": [ "占位性" ], "core_name": "病变", "tendency": "" } ]

伴心悸、胸闷，无发热、无潮热、盗汗，无咳血、咯血，无胸痛。

444

[ { "anatomy_list": [ "心" ], "character": [], "core_name": "心悸", "tendency": "" }, { "anatomy_list": [ "胸" ], "character": [], "core_name": "胸闷", "tendency": "" }, { "anatomy_list": [], "character": [], "core_name": "发热", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "潮热", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "盗汗", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "咳血", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "咯血", "tendency": "否定" }, { "anatomy_list": [ "胸" ], "character": [], "core_name": "疼痛", "tendency": "否定" } ]

完善胸部ct提示左肺下野片团影，慢性炎症？肿瘤待排。

1,553

[ { "anatomy_list": [ "左肺下野" ], "character": [ "片" ], "core_name": "团影", "tendency": "" }, { "anatomy_list": [ "左肺下野" ], "character": [ "慢性" ], "core_name": "炎症", "tendency": "不确定" }, { "anatomy_list": [ "左肺下野" ], "character": [], "core_name": "肿瘤", "tendency": "不确定" } ]

患者1年前因进行性吞咽困难在我院胸外科住院，2015年03月28日胸部ct：1.食管下段改变，考虑食管癌可能性大，考虑食管肿瘤，于2015年03月31日在全麻下行胸-腹腔镜食管癌根治术+食管-胃颈部吻合+空肠造瘘术，术后病检：（食管）高分化鳞状细胞癌。

197

[ { "anatomy_list": [], "character": [ "进行性" ], "core_name": "吞咽困难", "tendency": "" }, { "anatomy_list": [ "食管下段" ], "character": [], "core_name": "改变", "tendency": "" }, { "anatomy_list": [ "食管" ], "character": [], "core_name": "癌", "tendency": "不确定" }, { "anatomy_list": [ "食管" ], "character": [], "core_name": "肿瘤", "tendency": "不确定" }, { "anatomy_list": [ "食管" ], "character": [ "高分化" ], "core_name": "鳞癌", "tendency": "" } ]

患者4月多前无明显诱因出现双肩关节疼痛，伴双上臂上举困难，未予特殊治疗，2月余前受凉后出现流涕，伴咳嗽咳痰，偶有脓痰，于当地诊所服用中药后疼痛稍好转，继出现左踝关节关节肿痛，于某医院就诊，行踝关节平片、查肾功提示尿酸 178umol/L，未予进一步处理。

1,837

[ { "anatomy_list": [ "双肩关节" ], "character": [], "core_name": "疼痛", "tendency": "" }, { "anatomy_list": [ "双上臂" ], "character": [], "core_name": "上举困难", "tendency": "" }, { "anatomy_list": [], "character": [ "受凉后" ], "core_name": "流涕", "tendency": "" }, { "anatomy_list": [], "character": [], "core_name": "咳嗽", "tendency": "" }, { "anatomy_list": [], "character": [], "core_name": "咳痰", "tendency": "" }, { "anatomy_list": [], "character": [ "偶有", "脓痰" ], "core_name": "咳痰", "tendency": "" }, { "anatomy_list": [], "character": [ "服用中药后稍好转" ], "core_name": "疼痛", "tendency": "" }, { "anatomy_list": [ "左踝关节" ], "character": [ "肿痛" ], "core_name": "疼痛", "tendency": "" } ]

今患者为进一步治疗食道赘生物遂于我院门诊求诊，门诊以“食道肿瘤”收入我科住院治疗。

1,192

[ { "anatomy_list": [ "食道" ], "character": [], "core_name": "赘生物", "tendency": "" }, { "anatomy_list": [ "食道" ], "character": [], "core_name": "肿瘤", "tendency": "" } ]

曾连续2年以上发作，每次发作均在3月以上，诊断为“慢性支气管炎、肺气肿”。

789

[ { "anatomy_list": [ "支气管" ], "character": [ "慢性" ], "core_name": "支气管炎", "tendency": "" }, { "anatomy_list": [ "肺" ], "character": [], "core_name": "肺气肿", "tendency": "" } ]

门诊拟“腰椎压缩性骨折”收住我科。

806

[ { "anatomy_list": [ "腰椎" ], "character": [ "压缩性" ], "core_name": "骨折", "tendency": "" } ]

患者于1月前，因不慎受凉后出现咳嗽，咳痰，痰为白色粘液痰，无发热、胸痛、潮热、盗汗，无乏力等不适，曾在我院诊断为“肺炎”，予“头孢米诺抗感染，氨溴索止咳化痰”等治疗后好转，未坚持治疗，仍间断咳嗽、咳痰。

1,671

[ { "anatomy_list": [], "character": [ "受凉后" ], "core_name": "咳嗽", "tendency": "" }, { "anatomy_list": [], "character": [ "受凉后" ], "core_name": "咳痰", "tendency": "" }, { "anatomy_list": [], "character": [ "白色", "粘液" ], "core_name": "咳痰", "tendency": "" }, { "anatomy_list": [], "character": [], "core_name": "发热", "tendency": "否定" }, { "anatomy_list": [ "胸" ], "character": [], "core_name": "疼痛", "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": "乏力", "tendency": "否定" }, { "anatomy_list": [ "肺" ], "character": [], "core_name": "肺炎", "tendency": "" }, { "anatomy_list": [], "character": [ "间断" ], "core_name": "咳嗽", "tendency": "" }, { "anatomy_list": [], "character": [ "间断" ], "core_name": "咳痰", "tendency": "" } ]

入院前1+天，患者因胸背部疼痛于我院门诊就诊，行胸部ct示：1.双肺下叶多发结节，性质待定，请结合其他进一步检查。

1,379

[ { "anatomy_list": [ "胸部", "背部" ], "character": [], "core_name": "疼痛", "tendency": "" }, { "anatomy_list": [ "双肺下叶" ], "character": [ "多发" ], "core_name": "结节", "tendency": "" } ]

多次于外院就诊，行心脏彩超检查示：左房、左室增大，伴左室壁肥厚，主动脉深部增宽。

470

[ { "anatomy_list": [ "左房", "左室" ], "character": [], "core_name": "增大", "tendency": "" }, { "anatomy_list": [ "左室壁" ], "character": [], "core_name": "肥厚", "tendency": "" }, { "anatomy_list": [ "主动脉深部" ], "character": [], "core_name": "增宽", "tendency": "" } ]