text
stringlengths 5
708
| id
int64 1
2.07k
| event
list |
|---|---|---|
于2020年2月起，患者反复出现活动后乏力，间断于我科输血治疗。 | 1,735 | [
{
"anatomy_list": [],
"character": [
"活动后",
"反复"
],
"core_name": "乏力",
"tendency": ""
}
] |
患者于2017-1-21日在某医院行盲肠癌根治术，术后恢复好，病理诊断：（右半结肠）溃疡型低分腺癌，侵及全层；累及阑尾；肠周淋巴结转移（13/15）,见4个癌结节。 | 927 | [
{
"anatomy_list": [
"右半结肠"
],
"character": [
"溃疡型",
"低分化",
"侵及全层",
"累及阑尾"
],
"core_name": "腺癌",
"tendency": ""
},
{
"anatomy_list": [
"肠周淋巴结"
],
"character": [],
"core_name": "转移",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"癌",
"4个"
],
"core_name": "结节",
"tendency": ""
}
] |
上腹部ct提示胰头部见小片状低密度影，局限性扩张的副胰管？小囊肿？行"左颈部淋巴结切除活检术"提示为低分化鳞状细胞癌。 | 1,554 | [
{
"anatomy_list": [
"胰头部"
],
"character": [
"低",
"小片状"
],
"core_name": "密度影",
"tendency": ""
},
{
"anatomy_list": [
"副胰管"
],
"character": [
"局限性"
],
"core_name": "扩张",
"tendency": "不确定"
},
{
"anatomy_list": [
"胰"
],
"character": [
"小"
],
"core_name": "囊肿",
"tendency": "不确定"
},
{
"anatomy_list": [
"左颈部"
],
"character": [
"低分化"
],
"core_name": "鳞癌",
"tendency": ""
}
] |
患者昨日复查时，发现肿瘤胸壁转移，遂入院治疗 患者自起病以来，精神可，胃纳可，大便如常，小便如常，体重未见明显下降。 | 123 | [
{
"anatomy_list": [
"胸壁"
],
"character": [
"转移"
],
"core_name": "肿瘤",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"可"
],
"core_name": "精神",
"tendency": ""
},
{
"anatomy_list": [
"胃"
],
"character": [
"可"
],
"core_name": "胃纳",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"如常"
],
"core_name": "大便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"如常"
],
"core_name": "小便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"明显"
],
"core_name": "体重下降",
"tendency": "否定"
}
] |
遂于今日入我院，门诊以“子宫内膜肿瘤”收入入院。 | 1,145 | [
{
"anatomy_list": [
"子宫内膜"
],
"character": [],
"core_name": "肿瘤",
"tendency": ""
}
] |
1年前，患者出现咳嗽、咳痰，伴活动后喘息，不伴胸痛、痰中带血、咯血，无声嘶，无吞咽困难，予以常规抗感染治疗及止咳等对症治疗，疗效不明显，我院就诊，胸腔镜结果回示：（右上叶开口）送检支气管粘膜内见单个、散在异型细胞，结合组化腺癌可能性大。 | 985 | [
{
"anatomy_list": [],
"character": [],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "咳痰",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"活动后"
],
"core_name": "喘息",
"tendency": ""
},
{
"anatomy_list": [
"胸"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"带血"
],
"core_name": "咳痰",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "咯血",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "声嘶",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"困难"
],
"core_name": "吞咽",
"tendency": "否定"
},
{
"anatomy_list": [
"支气管黏膜"
],
"character": [
"单个",
"散在"
],
"core_name": "异形细胞",
"tendency": ""
},
{
"anatomy_list": [
"支气管"
],
"character": [],
"core_name": "腺癌",
"tendency": "不确定"
}
] |
入院前2年患者开始出现活动后喘累、气促，开始为爬楼感喘累，后进展为快走平路即感喘累。 | 189 | [
{
"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": [
"爬楼"
],
"core_name": "喘累",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"快走平路"
],
"core_name": "喘累",
"tendency": ""
}
] |
现患者时有咳嗽咳痰，稍活动即现呼吸喘促，未述发热寒战、头痛胸闷等不适。 | 1,515 | [
{
"anatomy_list": [],
"character": [],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "咳痰",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"稍活动"
],
"core_name": "呼吸喘促",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "发热",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "寒颤",
"tendency": "否定"
},
{
"anatomy_list": [
"头"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [
"胸"
],
"character": [],
"core_name": "胸闷",
"tendency": "否定"
}
] |
3、肝脏少许钙化灶。 | 1,234 | [
{
"anatomy_list": [
"肝脏"
],
"character": [
"少许"
],
"core_name": "钙化灶",
"tendency": ""
}
] |
入院前1天，无明显诱因于休息时再次出现鼻出血，血液由前鼻孔和口腔内流出，伴头部闷胀感，无发热、咳嗽、咳痰、头晕、头痛、恶性、呕吐，无咯血、胸痛，无潮热、盗汗、全身乏力、食欲减退，自行按压鼻部缓解，出血量较多，具体不详，今为求进一步诊治就诊于我科门诊，行电子鼻咽喉镜检查示：鼻出血/鼻咽部新生物/慢性咽炎/慢性扁桃体炎，建议患者住院治疗，患者考虑后同意，即以“鼻咽部新生物”收入院。 | 1,959 | [
{
"anatomy_list": [
"鼻"
],
"character": [],
"core_name": "出血",
"tendency": ""
},
{
"anatomy_list": [
"前鼻孔",
"口腔"
],
"character": [],
"core_name": "血液流出",
"tendency": ""
},
{
"anatomy_list": [
"头部"
],
"character": [],
"core_name": "闷胀感",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "发热",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "咳嗽",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "咳痰",
"tendency": "否定"
},
{
"anatomy_list": [
"头"
],
"character": [],
"core_name": "头晕",
"tendency": "否定"
},
{
"anatomy_list": [
"头部"
],
"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": "咯血",
"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": [
"全身"
],
"character": [],
"core_name": "乏力",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "食欲减退",
"tendency": "否定"
},
{
"anatomy_list": [
"鼻部"
],
"character": [
"量较多"
],
"core_name": "出血",
"tendency": ""
},
{
"anatomy_list": [
"鼻"
],
"character": [],
"core_name": "出血",
"tendency": ""
},
{
"anatomy_list": [
"鼻咽部"
],
"character": [],
"core_name": "新生物",
"tendency": ""
},
{
"anatomy_list": [
"咽"
],
"character": [
"慢性"
],
"core_name": "咽炎",
"tendency": ""
},
{
"anatomy_list": [
"扁桃体"
],
"character": [
"慢性"
],
"core_name": "扁桃体炎",
"tendency": ""
},
{
"anatomy_list": [
"鼻咽部"
],
"character": [],
"core_name": "新生物",
"tendency": ""
}
] |
院外患者偶有受凉后咳嗽，以干咳为主，伴心累、气促，无畏寒、发热，无头晕、头痛，无咯血、痰中带血，无胸闷、胸痛，无腹胀、腹泻，无恶心、呕吐，无四肢关节关节疼痛等表现，今患者因拟行第五次再次就诊于我院，门诊以“右肺癌化疗后”收入我科。 | 1,271 | [
{
"anatomy_list": [],
"character": [
"偶有",
"受凉后"
],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"干"
],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [
"心"
],
"character": [],
"core_name": "心累",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "气促",
"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": "头晕",
"tendency": "否定"
},
{
"anatomy_list": [
"头"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "咯血",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"带血"
],
"core_name": "咳痰",
"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": [
"腹"
],
"character": [],
"core_name": "腹胀",
"tendency": "否定"
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "腹泻",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "恶心",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "呕吐",
"tendency": "否定"
},
{
"anatomy_list": [
"四肢关节"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [
"右肺"
],
"character": [
"化疗后"
],
"core_name": "癌",
"tendency": ""
}
] |
入院前2+年，患者于无明显诱因出现心悸，无明显诱因，突然发作，自感心跳加快，持续10+分钟后症状缓解，无胸闷、胸痛，无黑蒙、晕厥、意识障碍，无咯血、呼吸困难，患者未重视，未进一步诊治。 | 702 | [
{
"anatomy_list": [
"心"
],
"character": [
"突然发作"
],
"core_name": "心悸",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"加快",
"持续10+分钟后症状缓解"
],
"core_name": "心跳",
"tendency": ""
},
{
"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": "黑朦",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "晕厥",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "意识障碍",
"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"
}
] |
入院前10天，患者自觉右上肢关节疼痛较前加剧，伴上肢凹陷性水肿，疼痛处皮肤无红、肿，无发热、寒战、畏寒，伴双侧髋关节关节疼痛，活动后明显，平静休息后可缓解，余未见特殊不适，遂至我院就诊，完善肾功示：肌酐 391umol/L、胱抑素c(cysc) 3.50mg/L、α1微球蛋白(α1-mg) 99.4mg/L、尿酸(ua) 387umol/L、尿素(urea) 19.48mmol/L；泌尿系彩超：1.双肾肾缩小，双肾弥漫性病变，请结合临床。 | 874 | [
{
"anatomy_list": [
"右上肢关节"
],
"character": [
"较前加剧"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"上肢"
],
"character": [
"凹陷性"
],
"core_name": "水肿",
"tendency": ""
},
{
"anatomy_list": [
"右上肢",
"关节"
],
"character": [
"无皮肤红",
"无皮肤肿"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "发热",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "寒战",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "畏寒",
"tendency": "否定"
},
{
"anatomy_list": [
"双侧髋关节"
],
"character": [
"活动后明显",
"平静休息后缓解"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"双肾"
],
"character": [],
"core_name": "缩小",
"tendency": ""
},
{
"anatomy_list": [
"双肾"
],
"character": [
"弥漫性"
],
"core_name": "病变",
"tendency": ""
}
] |
1月前患者无诱因出现咳嗽、干咳为主，无昼夜节律，伴活动后喘累明显，伴右侧肋缘上区持续胸痛，具体性质描述不详，发现体重减轻3斤，无畏寒、发热、咯血等不适，患者于我科住院治疗，完善气管镜检查，找到癌细胞，小细胞未分化癌。 | 206 | [
{
"anatomy_list": [],
"character": [
"干性为主",
"无昼夜节律"
],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"活动后明显"
],
"core_name": "喘累",
"tendency": ""
},
{
"anatomy_list": [
"右侧肋缘上区",
"胸"
],
"character": [
"持续"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "体重减轻",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "畏寒",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "发热",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "咯血",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"气管镜检查"
],
"core_name": "癌细胞",
"tendency": ""
},
{
"anatomy_list": [
"小细胞"
],
"character": [
"未分化",
"气管镜检查"
],
"core_name": "癌",
"tendency": ""
}
] |
骨髓活检提示：骨髓增生明显活跃，粒系增生，单核细胞增多，需注意慢性粒单核细胞白血病，外送骨髓流式未见异常，bcr-abl基因、calr、jak2v6f阴性。 | 1,499 | [
{
"anatomy_list": [
"骨髓"
],
"character": [
"明显活跃"
],
"core_name": "骨髓增生",
"tendency": ""
},
{
"anatomy_list": [
"粒单核细胞"
],
"character": [
"慢性"
],
"core_name": "白血病",
"tendency": ""
}
] |
1周前患者再次出现上述症状，伴双下肢抽搐，夜间加重，左下肢从足底沿胫前区放射至膝部，右下肢从足底沿胫前放射至大腿中部，伴喷嚏、流涕，不伴咳嗽、咳痰，伴反酸、嗳气，不伴腹痛、腹胀。 | 1,568 | [
{
"anatomy_list": [
"双下肢"
],
"character": [
"夜间加重"
],
"core_name": "抽搐",
"tendency": ""
},
{
"anatomy_list": [
"左下肢从足底沿胫前区至膝部"
],
"character": [
"放射性"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"右下肢从足底沿胫前至大腿中部"
],
"character": [
"放射性"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "喷嚏",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "流涕",
"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": "反酸",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "嗳气",
"tendency": ""
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "腹胀",
"tendency": "否定"
}
] |
1月前，患者体检发现血压升高为：150/？mmhg，无头痛、头晕，无胸闷、心悸，无突眼，无大便次数增多，无怕热，无突发性面色苍白、潮红，无四肢无力，无咳嗽、咳痰，无恶心、呕吐，无腹痛、腹胀、腹泻，无双下肢凹陷性水肿，未重视，未治疗。 | 1,428 | [
{
"anatomy_list": [],
"character": [
"升高"
],
"core_name": "血压",
"tendency": ""
},
{
"anatomy_list": [
"头"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [
"头"
],
"character": [],
"core_name": "头晕",
"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": [
"眼"
],
"character": [],
"core_name": "突眼",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"次数增多"
],
"core_name": "大便",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "怕热",
"tendency": "否定"
},
{
"anatomy_list": [
"面"
],
"character": [
"突发性"
],
"core_name": "面色潮红",
"tendency": "否定"
},
{
"anatomy_list": [
"面"
],
"character": [
"突发性"
],
"core_name": "面色苍白",
"tendency": "否定"
},
{
"anatomy_list": [
"四肢"
],
"character": [],
"core_name": "无力",
"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": "恶心",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "呕吐",
"tendency": "否定"
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "腹胀",
"tendency": "否定"
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "腹泻",
"tendency": "否定"
},
{
"anatomy_list": [
"双下肢"
],
"character": [
"凹陷性"
],
"core_name": "水肿",
"tendency": ""
}
] |
30天前患者受凉后出现咳嗽症状加重，夜间及活动后尤甚，伴咳白色黏痰，夜间为主，无明显缓解及加重因素，无畏寒、寒战、咯血、胸痛等不适，发热不详，自行服用药物（具体不详）未见好转，于我院就诊，胸部ct示“1.双肺气肿并双肺间质改变。 | 676 | [
{
"anatomy_list": [],
"character": [
"受凉后",
"夜间及活动后尤甚"
],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"白色",
"粘性",
"夜间为主",
"无明显缓解及加重因素"
],
"core_name": "咳痰",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "畏寒",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "寒颤",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "咯血",
"tendency": "否定"
},
{
"anatomy_list": [
"胸"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"不详"
],
"core_name": "发热",
"tendency": ""
},
{
"anatomy_list": [
"双肺"
],
"character": [],
"core_name": "肺气肿",
"tendency": ""
},
{
"anatomy_list": [
"双肺"
],
"character": [],
"core_name": "间质改变",
"tendency": ""
}
] |
入院前1月，患者体检，彩超提示“左甲状腺甲状腺多发结节、右侧乳腺包块”（未见具体报告），左侧颈部包块、左乳包块均未触及，无疼痛，侧颈部包块不随吞咽上下移动，无声嘶、饮水呛咳，无进食哽噎、吞咽困难，无恶心、呕吐，无呼吸困难，患者未引起重视，未予院外行相关诊治，今患者未行进一步诊治，遂至我院就诊，门诊以“左甲状腺甲状腺多发结节”收入我科住院治疗。 | 69 | [
{
"anatomy_list": [
"左甲状腺"
],
"character": [
"多发"
],
"core_name": "结节",
"tendency": ""
},
{
"anatomy_list": [
"右侧乳腺"
],
"character": [],
"core_name": "包块",
"tendency": ""
},
{
"anatomy_list": [
"左侧颈部"
],
"character": [],
"core_name": "包块",
"tendency": "否定"
},
{
"anatomy_list": [
"左乳"
],
"character": [],
"core_name": "包块",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [
"侧颈部"
],
"character": [
"不随吞咽上下移动"
],
"core_name": "包块",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "声嘶",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "饮水呛咳",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "进食哽噎",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"困难"
],
"core_name": "吞咽",
"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": "呼吸困难",
"tendency": "否定"
},
{
"anatomy_list": [
"左甲状腺"
],
"character": [
"多发"
],
"core_name": "结节",
"tendency": ""
}
] |
肝脏未见确切占位。 | 1,781 | [
{
"anatomy_list": [
"肝脏"
],
"character": [],
"core_name": "占位",
"tendency": "不确定"
}
] |
入院 5年前，患者无明显诱因出现腹胀、乏力、腹围增大， 不伴双下肢水肿 ， 不伴腹痛、腹泻 ，无反酸、恶心、呕吐、呕血、便血、身黄、尿黄、胸痛、腹痛、皮肤粘膜出血、颜面及下肢水肿、意识障碍，患者我院门诊就诊，乙肝标志物阳性，腹部彩超提示肝硬化，诊断为"乙型肝炎肝硬化"，长期使用阿德福韦酯10mg抗病毒治疗。 | 375 | [
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "腹胀",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "乏力",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"增大"
],
"core_name": "腹围",
"tendency": ""
},
{
"anatomy_list": [
"双下肢"
],
"character": [],
"core_name": "水肿",
"tendency": "否定"
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "腹泻",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "反酸",
"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": "呕血",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "便血",
"tendency": "否定"
},
{
"anatomy_list": [
"身"
],
"character": [],
"core_name": "黄染",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "尿黄",
"tendency": "否定"
},
{
"anatomy_list": [
"胸"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [
"皮肤粘膜"
],
"character": [],
"core_name": "出血",
"tendency": "否定"
},
{
"anatomy_list": [
"颜面"
],
"character": [],
"core_name": "水肿",
"tendency": "否定"
},
{
"anatomy_list": [
"下肢"
],
"character": [],
"core_name": "水肿",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "意识障碍",
"tendency": "否定"
},
{
"anatomy_list": [
"肝"
],
"character": [
"阳性"
],
"core_name": "乙肝标志物",
"tendency": ""
},
{
"anatomy_list": [
"肝"
],
"character": [],
"core_name": "硬化",
"tendency": ""
},
{
"anatomy_list": [
"肝"
],
"character": [
"乙型肝炎"
],
"core_name": "硬化",
"tendency": ""
}
] |
6.肛管局部fdg代谢增高，倾向于炎性病变。 | 1,907 | [
{
"anatomy_list": [
"肛管"
],
"character": [
"炎性"
],
"core_name": "病变",
"tendency": ""
},
{
"anatomy_list": [
"肛管"
],
"character": [
"局部",
"增高"
],
"core_name": "fdg代谢",
"tendency": ""
}
] |
ect示：右侧肱骨上段、左侧肩胛下角、左侧第5后肋起始部、多个椎体、骨盆多处放射性浓聚，骨转移？考虑患者右上肺肺腺癌iv期，鉴于患者脱落细胞数量少，不宜行基因监测，建议患者行放化疗，患者及家属拒绝后自动出院。 | 778 | [
{
"anatomy_list": [
"右侧肱骨上段",
"左侧肩胛下角",
"左侧第5后肋起始部",
"椎体",
"骨盆"
],
"character": [
"多处",
"放射性"
],
"core_name": "浓聚",
"tendency": ""
},
{
"anatomy_list": [
"骨"
],
"character": [],
"core_name": "转移",
"tendency": "不确定"
},
{
"anatomy_list": [
"右上肺"
],
"character": [
"iv期"
],
"core_name": "腺癌",
"tendency": "不确定"
},
{
"anatomy_list": [],
"character": [
"数量少"
],
"core_name": "脱落细胞",
"tendency": ""
}
] |
缘于2019年5月，患者无明显诱因出现右侧口腔包块，约蚕豆大小，触及时轻微疼痛，同时发现右侧颈部包块，约豌豆大小，伴有瘙痒、刺痛无破溃。 | 478 | [
{
"anatomy_list": [
"右侧口腔"
],
"character": [
"蚕豆大小",
"触及时轻微疼痛"
],
"core_name": "包块",
"tendency": ""
},
{
"anatomy_list": [
"右侧颈部"
],
"character": [
"约豌豆大小"
],
"core_name": "包块",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "瘙痒",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"刺痛"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "破溃",
"tendency": "否定"
}
] |
纤维支气管镜检及病理结果为肺鳞癌，诊断为：肺鳞癌伴骨转移 iv期。 | 1,938 | [
{
"anatomy_list": [
"肺"
],
"character": [],
"core_name": "鳞癌",
"tendency": ""
},
{
"anatomy_list": [
"肺"
],
"character": [
"iv期"
],
"core_name": "鳞癌",
"tendency": ""
},
{
"anatomy_list": [
"骨"
],
"character": [
"转移",
"iv期"
],
"core_name": "鳞癌",
"tendency": ""
}
] |
患者肿瘤稳定，予以保肝、增强免疫、抗肿瘤治疗，患者好转出院。 | 463 | [
{
"anatomy_list": [],
"character": [
"稳定"
],
"core_name": "肿瘤",
"tendency": ""
}
] |
今患者为求进一步治疗，遂来我院门诊，门诊以“类风湿性关节炎”收入我科住院治疗。 | 553 | [
{
"anatomy_list": [
"关节"
],
"character": [
"类风湿性"
],
"core_name": "关节炎",
"tendency": ""
}
] |
乳头未见癌累及。 | 117 | [
{
"anatomy_list": [
"乳头"
],
"character": [
"累及"
],
"core_name": "癌",
"tendency": "否定"
}
] |
入院前3+年，患者无明显诱因出现右膝膝部疼痛，疼痛为间断性胀痛，能忍受，久站及久行后加重，休息后可缓解，双下肢无麻木、乏力，无潮热、盗汗，无咳嗽、咳痰，无胸闷、气促，无大小便失禁等；遂于某医院就诊，诊断“膝关节骨性关节炎”，予以口服药、止痛、玻璃酸钠注射等治疗后好转。 | 356 | [
{
"anatomy_list": [
"右膝"
],
"character": [
"间断性胀痛",
"能忍受",
"久站及久行后加重",
"休息后可缓解"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"双下肢"
],
"character": [],
"core_name": "麻木",
"tendency": "否定"
},
{
"anatomy_list": [
"双下肢"
],
"character": [],
"core_name": "乏力",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "潮热",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "盗汗",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "咳嗽",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "咳痰",
"tendency": "否定"
},
{
"anatomy_list": [
"胸"
],
"character": [],
"core_name": "胸闷",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "气促",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"失禁"
],
"core_name": "大小便",
"tendency": "否定"
},
{
"anatomy_list": [
"膝关节"
],
"character": [
"骨性"
],
"core_name": "关节炎",
"tendency": ""
}
] |
6天前患者患者感吞咽梗阻、困难，进食稀饭顺畅，遂来我院，门诊行胃镜提示：“食管距门齿20cm见吻合口吻合口肛侧端粘膜呈半球形隆起，占据2/3管腔。 | 1,926 | [
{
"anatomy_list": [],
"character": [
"进食稀饭顺畅"
],
"core_name": "吞咽梗阻",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"进食稀饭顺畅"
],
"core_name": "吞咽困难",
"tendency": ""
},
{
"anatomy_list": [
"吻合口肛侧端粘膜"
],
"character": [
"占据2/3管腔",
"半球形"
],
"core_name": "隆起",
"tendency": ""
}
] |
患者于入院前16月于发现解小便次数及尿量均减少（具体不详）,伴泡沫尿,偶有双侧踝关节轻中度凹陷对称性水肿,无尿急、尿痛,未予以重视,未予以对症治疗。 | 27 | [
{
"anatomy_list": [],
"character": [
"次数减少"
],
"core_name": "小便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"减少"
],
"core_name": "尿量",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "泡沫尿",
"tendency": ""
},
{
"anatomy_list": [
"双侧踝关节"
],
"character": [
"轻中度"
],
"core_name": "凹陷",
"tendency": ""
},
{
"anatomy_list": [
"双侧踝关节"
],
"character": [
"对称性"
],
"core_name": "水肿",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "尿急",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "尿痛",
"tendency": "否定"
}
] |
患者未引起重视，未行进一步诊治，此后颈部包块进行性增大，于2020-09-28到我科住院治疗，行浅表淋巴结彩超:右侧颈部低回声团（考虑转移灶），建议进一步检查。左侧颈部、双侧腋窝、双侧腹股沟区腹股沟区淋巴结可见。 | 1,108 | [
{
"anatomy_list": [
"颈部"
],
"character": [
"进行性",
"增大"
],
"core_name": "包块",
"tendency": ""
},
{
"anatomy_list": [
"右侧颈部"
],
"character": [
"低"
],
"core_name": "回声团",
"tendency": ""
},
{
"anatomy_list": [
"右侧颈部"
],
"character": [],
"core_name": "转移灶",
"tendency": "不确定"
},
{
"anatomy_list": [
"左侧颈部",
"双侧腋窝",
"双侧腹股沟区"
],
"character": [],
"core_name": "淋巴结",
"tendency": ""
}
] |
患者及家属因经费原因，拒绝行头颅mri检查，患者诊断左肺鳞癌iib期，因肿瘤紧临肺动脉，手术风险高，术后可能需icu辅助对症治疗，费用昂贵，患者及家属表示费用过高，不能承受。 | 216 | [
{
"anatomy_list": [
"左肺"
],
"character": [
"iib期"
],
"core_name": "鳞癌",
"tendency": ""
}
] |
3+月前（2017年7月12日），患者因“腹痛、腹胀伴肛门坠胀”再次就诊于我院胃肠外科；复查ct(2017-07-13 某医院)提示1.肝内多发结节，考虑转移瘤，与前片比较病灶增多、增大；部分肝肝内胆管轻度扩张。 | 1,540 | [
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "腹胀",
"tendency": ""
},
{
"anatomy_list": [
"肛门"
],
"character": [],
"core_name": "坠胀",
"tendency": ""
},
{
"anatomy_list": [
"肝内"
],
"character": [
"多发"
],
"core_name": "结节",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"转移"
],
"core_name": "瘤",
"tendency": "不确定"
},
{
"anatomy_list": [],
"character": [
"增多",
"增大"
],
"core_name": "病灶",
"tendency": ""
},
{
"anatomy_list": [
"肝内胆管"
],
"character": [
"轻度"
],
"core_name": "扩张",
"tendency": ""
}
] |
入院前4+月，患者无意中发现右乳上方有一“绿豆”大小包块，偶感疼痛。 | 1,562 | [
{
"anatomy_list": [
"右乳上方"
],
"character": [
"绿豆大小"
],
"core_name": "包块",
"tendency": ""
},
{
"anatomy_list": [
"右乳上方"
],
"character": [
"偶感"
],
"core_name": "疼痛",
"tendency": ""
}
] |
未引起重视，3+月前，患者体检时发现肺部阴影，行支气管镜检查提示“小细胞肺癌”,肾功能：尿素18.4mmol/l，尿酸 616.4umol/l，肌酐 420.9umol/l，肾内科会诊诊断为：慢性肾脏病5期，高尿酸血症。 | 1,956 | [
{
"anatomy_list": [
"肺部"
],
"character": [],
"core_name": "阴影",
"tendency": ""
},
{
"anatomy_list": [
"肺",
"小细胞"
],
"character": [],
"core_name": "癌",
"tendency": ""
},
{
"anatomy_list": [
"肾脏"
],
"character": [
"慢性",
"5期"
],
"core_name": "肾脏病",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "高尿酸血症",
"tendency": ""
}
] |
患者自发病以来，精神一般，食欲差，睡眠可，大便正常，小便如常，体重无明显变化。 | 1,827 | [
{
"anatomy_list": [],
"character": [
"一般"
],
"core_name": "精神",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"差"
],
"core_name": "食欲",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"可"
],
"core_name": "睡眠",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"正常"
],
"core_name": "大便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"如常"
],
"core_name": "小便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"明显"
],
"core_name": "体重改变",
"tendency": "否定"
}
] |
今患者为进一步治疗入我科门诊，门诊以“蜂窝组织炎”收入我科。 | 1,791 | [
{
"anatomy_list": [],
"character": [],
"core_name": "蜂窝组织炎",
"tendency": ""
}
] |
彩超示：右乳乳晕区一不规则低回声区（3.5×4.0×0.9cm）。 | 1,185 | [
{
"anatomy_list": [
"右乳乳晕区"
],
"character": [
"不规则",
"低"
],
"core_name": "回声",
"tendency": ""
}
] |
1+年患者因宫颈癌化疗术后左输尿管狭窄伴积水，行了左输尿管内支架植入术，术后恢复良好，半年后更换内支架管，患者今来我院，要求更换内支架管，遂门诊以“左输尿管内支架植入术，宫颈癌放化疗术后”入院。 | 1,392 | [
{
"anatomy_list": [
"左输尿管"
],
"character": [
"宫颈癌化疗术后"
],
"core_name": "狭窄",
"tendency": ""
},
{
"anatomy_list": [
"左输尿管"
],
"character": [
"宫颈癌化疗术后"
],
"core_name": "积水",
"tendency": ""
},
{
"anatomy_list": [
"宫颈"
],
"character": [
"放化疗术后"
],
"core_name": "癌",
"tendency": ""
}
] |
患者于2017年8月无意中发现左侧腹股沟腹股沟包块，质硬，不可活动，无发热、畏寒，无腹痛、腹泻。 | 850 | [
{
"anatomy_list": [
"左侧腹股沟"
],
"character": [
"质硬",
"不可活动"
],
"core_name": "包块",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "发热",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "畏寒",
"tendency": "否定"
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "腹泻",
"tendency": "否定"
}
] |
半月前，患者无明显诱因出现心累气促加重，伴出汗，伴咳嗽咳痰，咳出白色泡沫痰，量多，以夜间及晨起为重，无咯血、痰中带血，无畏寒、高热，无胸闷、胸痛，无潮热、盗汗，无双下肢水肿，无端坐呼吸及夜间阵发性呼吸困难。 | 662 | [
{
"anatomy_list": [],
"character": [
"加重"
],
"core_name": "心累",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"加重"
],
"core_name": "气促",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "出汗",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "咳痰",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"白色",
"泡沫痰",
"量多",
"以夜间及晨起为重"
],
"core_name": "咳痰",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "咯血",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"带血"
],
"core_name": "咳痰",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "畏寒",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"高"
],
"core_name": "发热",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "胸闷",
"tendency": "否定"
},
{
"anatomy_list": [
"胸"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "潮热",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "盗汗",
"tendency": "否定"
},
{
"anatomy_list": [
"双下肢"
],
"character": [],
"core_name": "水肿",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "端坐呼吸",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"夜间",
"阵发性"
],
"core_name": "呼吸困难",
"tendency": "否定"
}
] |
患者平素有咳嗽、咳痰、盗汗、头晕、乏力、反酸、烧心等病史，今为求进一步诊治，遂至我科住院治疗。 | 1,492 | [
{
"anatomy_list": [],
"character": [],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "咳痰",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "盗汗",
"tendency": ""
},
{
"anatomy_list": [
"头"
],
"character": [],
"core_name": "头晕",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "乏力",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "反酸",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "烧心",
"tendency": ""
}
] |
患者于入院前6月因发现左乳肿块我院，行微创手术活检确诊为左乳浸润性癌，免疫组化：er（+++）80%pr（+++）90%cerbb-2（+），给予et方案（多西他赛120mg+吡柔比星60mg）化疗半疗程后行了左乳癌根治术，腋窝淋巴结1/9转移。 | 432 | [
{
"anatomy_list": [
"左乳"
],
"character": [],
"core_name": "肿块",
"tendency": ""
},
{
"anatomy_list": [
"左乳"
],
"character": [
"浸润性"
],
"core_name": "癌",
"tendency": ""
},
{
"anatomy_list": [
"腋窝淋巴结"
],
"character": [],
"core_name": "转移",
"tendency": ""
}
] |
为进一步检查，入院前1月患者在我科住院，腹部mr增强示：1.肝右后叶占位及左叶小结节，考虑原发性肝ca伴肝内转移可能。 | 151 | [
{
"anatomy_list": [
"肝右后叶"
],
"character": [],
"core_name": "占位",
"tendency": ""
},
{
"anatomy_list": [
"肝左叶"
],
"character": [
"小"
],
"core_name": "结节",
"tendency": ""
},
{
"anatomy_list": [
"肝"
],
"character": [
"原发性"
],
"core_name": "癌",
"tendency": "不确定"
},
{
"anatomy_list": [
"肝内"
],
"character": [
"转移"
],
"core_name": "癌",
"tendency": "不确定"
}
] |
后分别于2010.12.6，2010.12.31，2011.01.21，2011.02.11,2011.03.3，2011.3.24行表柔比星+奈达铂全身静脉化疗，化疗过程较顺利，未见明显化疗相关副反应。 | 2,047 | [
{
"anatomy_list": [],
"character": [
"明显"
],
"core_name": "化疗相关副反应",
"tendency": "否定"
}
] |
患者于31年前因臀部疼痛（具体不详），于某医院确诊为神经纤维瘤，予以手术治疗，之后发现盆腔内转移，先后6次于某医院行手术治疗。 | 617 | [
{
"anatomy_list": [
"臀部"
],
"character": [],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"神经纤维"
],
"core_name": "瘤",
"tendency": ""
},
{
"anatomy_list": [
"盆腔内"
],
"character": [
"转移"
],
"core_name": "瘤",
"tendency": ""
}
] |
患者于10年前起出现反复头晕、颈部胀痛，疼痛呈持续性，视物模糊，常于活动时发作，每次持续1小时左右，伴有头痛，程度较轻，休息后头昏及头痛症状可自行缓解，曾在多家医院就诊，多次测血压均高于180/100mmHg，诊断“高血压病”，口服“清脑降压片”治疗。 | 1,629 | [
{
"anatomy_list": [
"头"
],
"character": [
"反复"
],
"core_name": "头晕",
"tendency": ""
},
{
"anatomy_list": [
"颈部"
],
"character": [
"持续性",
"反复",
"胀痛"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "视物模糊",
"tendency": ""
},
{
"anatomy_list": [
"头"
],
"character": [
"程度较轻"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"头"
],
"character": [
"休息后可自行缓解"
],
"core_name": "头昏",
"tendency": ""
},
{
"anatomy_list": [
"头"
],
"character": [
"休息后可自行缓解"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"升高"
],
"core_name": "血压",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "高血压",
"tendency": ""
}
] |
入院前2+月，患者于外院检查发现宫颈病变，取宫颈多点活检术，病检结果回示：子宫颈（3、6、9、12点）宫颈鳞状细胞癌。 | 1,356 | [
{
"anatomy_list": [
"宫颈"
],
"character": [],
"core_name": "病变",
"tendency": ""
},
{
"anatomy_list": [
"子宫颈（3、6、9、12点）"
],
"character": [],
"core_name": "鳞癌",
"tendency": ""
}
] |
现患者为求进一步诊治来我院就诊，门诊以“肝占位”收入我科。 | 1,724 | [
{
"anatomy_list": [
"肝"
],
"character": [],
"core_name": "占位",
"tendency": ""
}
] |
门诊遂以“卵巢子宫内膜异位囊肿”收住入院。 | 828 | [
{
"anatomy_list": [
"卵巢"
],
"character": [
"子宫内膜异位"
],
"core_name": "囊肿",
"tendency": ""
}
] |
患者自发病以来，精神、食欲、睡眠差，大便无明显异常，小便可。 | 774 | [
{
"anatomy_list": [],
"character": [
"差"
],
"core_name": "精神",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"差"
],
"core_name": "食欲",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"差"
],
"core_name": "睡眠质量",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"明显",
"异常"
],
"core_name": "大便",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"可"
],
"core_name": "小便",
"tendency": ""
}
] |
院外患者多次胸部彩超示：1、右侧胸腔大量积液,故多次行胸腔穿刺抽液，并送胸水检验：大量增生活跃的间皮细胞和部分炎细胞。 | 987 | [
{
"anatomy_list": [
"右侧胸腔"
],
"character": [
"大量"
],
"core_name": "积液",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"部分"
],
"core_name": "炎细胞",
"tendency": ""
}
] |
患者发病以来，神志 清晰，精神可，胃纳可，大便如常，小便正常，体重未见明显下降。 | 849 | [
{
"anatomy_list": [],
"character": [
"清晰"
],
"core_name": "神志",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"可"
],
"core_name": "精神",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"可"
],
"core_name": "胃纳",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"如常"
],
"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"
}
] |
于2018-03-20行腹腔镜下左侧腹膜后占位探查术及活检术，术后病理示（左侧腹膜后肿物）癌侵润。 | 170 | [
{
"anatomy_list": [
"左侧腹膜后"
],
"character": [],
"core_name": "肿物",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"侵润"
],
"core_name": "癌",
"tendency": ""
}
] |
患者在某医院上腹部彩超检查发现肝脏占位性病变，为进一步诊治，故来我科就诊。 | 111 | [
{
"anatomy_list": [
"肝脏"
],
"character": [
"占位性"
],
"core_name": "病变",
"tendency": ""
}
] |
4月前，患者无明显诱因出现咳嗽、咯血，咳黄色黏痰，咯血为痰中混血，夜间及晨起明显，无发热、畏寒、盗汗，无乏力、纳差，无胸闷、胸痛、心悸、夜间阵发性呼吸困难，无双下肢水肿，未进一步就诊及处理。 | 1,456 | [
{
"anatomy_list": [],
"character": [],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "咯血",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"黄色",
"粘痰"
],
"core_name": "咳痰",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"痰中混血",
"夜间及晨起明显"
],
"core_name": "咯血",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "发热",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "畏寒",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "盗汗",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "乏力",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "纳差",
"tendency": "否定"
},
{
"anatomy_list": [
"胸"
],
"character": [],
"core_name": "胸闷",
"tendency": "否定"
},
{
"anatomy_list": [
"胸"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [
"心"
],
"character": [],
"core_name": "心悸",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"夜间",
"阵发性"
],
"core_name": "呼吸困难",
"tendency": "否定"
},
{
"anatomy_list": [
"双下肢"
],
"character": [],
"core_name": "水肿",
"tendency": "否定"
}
] |
患者遂于某医院就诊，胸部彩超提示左侧胸腔大量积液，予以抽胸水化验，结果不详，考虑诊断：胸腔积液原因待查：恶性胸腔积液？结核性胸腔积液？，后予以诊断性抗结核治疗（具体不详），患者服用抗结核药后出现恶心、食欲下降、乏力等不适，患者诉查肝功异常，遂停抗结核药，予以保肝、护胃等对症治疗。 | 229 | [
{
"anatomy_list": [
"左侧胸腔"
],
"character": [
"大量"
],
"core_name": "积液",
"tendency": ""
},
{
"anatomy_list": [
"胸腔"
],
"character": [],
"core_name": "积液",
"tendency": "不确定"
},
{
"anatomy_list": [
"胸腔"
],
"character": [
"恶性"
],
"core_name": "积液",
"tendency": "不确定"
},
{
"anatomy_list": [
"胸腔"
],
"character": [
"结核性"
],
"core_name": "积液",
"tendency": "不确定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "恶心",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"下降"
],
"core_name": "食欲",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "乏力",
"tendency": ""
},
{
"anatomy_list": [
"肝"
],
"character": [],
"core_name": "肝功能异常",
"tendency": ""
}
] |
术前术后共行te方案（吡柔比星40mg d1 30mg d2，多西他赛（艾素）140mg d2））6疗程化疗，化疗过程顺利，患者无明显骨髓抑制等副反应。 | 817 | [
{
"anatomy_list": [
"骨髓"
],
"character": [
"明显"
],
"core_name": "骨髓抑制",
"tendency": "否定"
}
] |
4+月前因“腰痛”于我院完善腰椎mri提示“腰椎间盘突出”，未予特殊处理。 | 141 | [
{
"anatomy_list": [
"腰"
],
"character": [],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"腰椎间盘"
],
"character": [],
"core_name": "突出",
"tendency": ""
}
] |
入院前10+年，患者无明显诱因出现咳嗽、咳痰，无明显发热、盗汗，胸闷、胸痛等不适，自行购买感冒药（具体不详）服用后咳嗽、咳痰缓解。 | 1,258 | [
{
"anatomy_list": [],
"character": [],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "咳痰",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"明显"
],
"core_name": "发热",
"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": [
"缓解"
],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"缓解"
],
"core_name": "咳痰",
"tendency": ""
}
] |
出院期间，患者诉四肢乏力，无便血、便秘、稀便、里急后重、腹痛、腹胀，无恶心、呕吐、胸闷、气急等。 | 1,038 | [
{
"anatomy_list": [
"四肢"
],
"character": [],
"core_name": "乏力",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "便血",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "便秘",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"稀便"
],
"core_name": "大便",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "里急后重",
"tendency": "否定"
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "腹胀",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "恶心",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "呕吐",
"tendency": "否定"
},
{
"anatomy_list": [
"胸"
],
"character": [],
"core_name": "胸闷",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "气急",
"tendency": "否定"
}
] |
10天前患者无明显诱因出现阴道多量黄白色分泌物，有异味，遂于我院门诊就诊，妇科检查提示阴道多量分泌物，阴道壁充血，白带常规检查提示：清洁度iii，考虑“老年性阴道炎”，给予“硝呋太尔”阴道上药6天，行b超检查提示“宫腔内见范围约37x22mm异常回声，透声差，内见细密点状稍强回声，未探及血流信号，宫腔下段见一横向强回声伴声尾，其右侧达右侧壁肌层，左侧端似达左侧壁浆膜层，考虑：宫腔积血，节育器嵌顿”。 | 315 | [
{
"anatomy_list": [
"阴道"
],
"character": [
"多量",
"黄白色",
"有异味"
],
"core_name": "分泌物",
"tendency": ""
},
{
"anatomy_list": [
"阴道"
],
"character": [
"多量"
],
"core_name": "分泌物",
"tendency": ""
},
{
"anatomy_list": [
"阴道壁"
],
"character": [],
"core_name": "充血",
"tendency": ""
},
{
"anatomy_list": [
"阴道"
],
"character": [
"老年性"
],
"core_name": "阴道炎",
"tendency": "不确定"
},
{
"anatomy_list": [],
"character": [
"透声差",
"内见细密点状稍强回声",
"未探及血流信号"
],
"core_name": "异常回声",
"tendency": ""
},
{
"anatomy_list": [
"宫腔下段"
],
"character": [
"强",
"伴声尾",
"其右侧达右侧壁肌层",
"左侧端似达左侧壁浆膜层"
],
"core_name": "回声",
"tendency": ""
},
{
"anatomy_list": [
"宫腔"
],
"character": [],
"core_name": "积血",
"tendency": "不确定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "节育器嵌顿",
"tendency": "不确定"
}
] |
停经10+5周（2020-6-4）我院复查妇科超声提示宫内早孕，卵黄囊可见，直径4.3mm，胎芽可见，长径约19mm（相当于8w3d），建议患者1月后来院行nt超声检查。 | 690 | [
{
"anatomy_list": [],
"character": [],
"core_name": "停经",
"tendency": ""
},
{
"anatomy_list": [
"宫内"
],
"character": [],
"core_name": "早孕",
"tendency": ""
},
{
"anatomy_list": [
"宫内"
],
"character": [
"可见"
],
"core_name": "卵黄囊",
"tendency": ""
},
{
"anatomy_list": [
"宫内"
],
"character": [
"可见"
],
"core_name": "胎芽",
"tendency": ""
}
] |
有慢性胃炎病史多年，长期感上腹饱胀，反酸，间断服药治疗，2015.02.06我院行消化道钡餐提示：慢性胃炎，胃底粘膜粘膜聚集，溃疡？占位？，建议进一步检查，十二指肠降部憩室。 | 2,064 | [
{
"anatomy_list": [
"胃"
],
"character": [
"慢性"
],
"core_name": "胃炎",
"tendency": ""
},
{
"anatomy_list": [
"上腹"
],
"character": [],
"core_name": "饱胀",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "反酸",
"tendency": ""
},
{
"anatomy_list": [
"胃"
],
"character": [
"慢性"
],
"core_name": "胃炎",
"tendency": ""
},
{
"anatomy_list": [
"胃底"
],
"character": [
"粘膜"
],
"core_name": "聚集",
"tendency": ""
},
{
"anatomy_list": [
"胃底"
],
"character": [],
"core_name": "溃疡",
"tendency": "不确定"
},
{
"anatomy_list": [
"胃底"
],
"character": [],
"core_name": "占位",
"tendency": "不确定"
},
{
"anatomy_list": [
"十二指肠降部"
],
"character": [],
"core_name": "憩室",
"tendency": ""
}
] |
9月前，患者无明显诱因出现上腹部阵发性隐痛，偶有左上腹牵扯痛，无肩背部及腹股沟区放射痛，进食后可稍加重，弯曲体位时腹痛可稍缓解。 | 1,405 | [
{
"anatomy_list": [
"上腹部"
],
"character": [
"阵发性",
"隐痛"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"左上腹"
],
"character": [
"牵扯痛"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"肩背部",
"腹股沟区"
],
"character": [
"放射痛"
],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [
"腹"
],
"character": [
"进食后可稍加重",
"弯曲体位时可稍缓"
],
"core_name": "疼痛",
"tendency": ""
}
] |
患者于2月余受凉后出现咳嗽，咯少量白色泡沫痰或粘痰，伴痰中带少量血丝，伴咽喉疼痛，伴肩背酸痛，不伴恶寒发热，无潮热盗汗，无胸闷、气促，无喘息、呼吸困难，无关节疼痛，无消瘦。 | 1,716 | [
{
"anatomy_list": [],
"character": [
"受凉后"
],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"少量",
"白色",
"泡沫",
"粘痰"
],
"core_name": "咳痰",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"少量血丝"
],
"core_name": "咳痰",
"tendency": ""
},
{
"anatomy_list": [
"咽",
"喉"
],
"character": [],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"肩",
"背"
],
"character": [
"酸痛"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "恶寒",
"tendency": "否定"
},
{
"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": [
"胸"
],
"character": [],
"core_name": "胸闷",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "气促",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "喘息",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "呼吸困难",
"tendency": "否定"
},
{
"anatomy_list": [
"关节"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "消瘦",
"tendency": "否定"
}
] |
患病以来，精神、食欲可，睡眠欠佳。 | 494 | [
{
"anatomy_list": [],
"character": [
"好"
],
"core_name": "精神",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"好"
],
"core_name": "食欲",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"欠佳"
],
"core_name": "睡眠",
"tendency": ""
}
] |
遂来我院就诊，门诊胸部ct提示：1.左肺上叶结节，肺ca可能性大；2.左肺下叶结节，肺ca或炎症皆不除外。 | 1,162 | [
{
"anatomy_list": [
"左肺上叶"
],
"character": [],
"core_name": "结节",
"tendency": ""
},
{
"anatomy_list": [
"肺"
],
"character": [],
"core_name": "癌",
"tendency": "不确定"
},
{
"anatomy_list": [
"左肺下叶"
],
"character": [],
"core_name": "结节",
"tendency": ""
},
{
"anatomy_list": [
"肺"
],
"character": [],
"core_name": "癌",
"tendency": "不确定"
},
{
"anatomy_list": [
"肺"
],
"character": [],
"core_name": "炎症",
"tendency": "不确定"
}
] |
半年前患者因血糖控制不佳入我科，完善相关检查，诊断为：2型糖尿病、糖尿病性肾病v期、糖尿病性视网膜病变、糖尿病周围血管病变、慢性肾衰竭尿毒症期、冠状动脉性心脏病、心功能Ⅲ级、右上肺肺癌伴双肺、胸膜转移、慢性阻塞性肺病、高血压3极极高危、高血压性心脏病、血脂代谢异常、慢性胃炎、颈动脉狭窄，调整降糖治疗方案为“磷酸西格列汀片0.1g口服qd，伏格列波糖片0.2mg口服tid，门冬胰岛素注射液(诺和锐笔芯)10iu皮下tid，甘精胰岛素34uqn”，自诉院外血糖控制可。 | 536 | [
{
"anatomy_list": [],
"character": [
"控制不佳"
],
"core_name": "血糖",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"2型"
],
"core_name": "糖尿病",
"tendency": ""
},
{
"anatomy_list": [
"肾"
],
"character": [
"糖尿病",
"v期"
],
"core_name": "肾病",
"tendency": ""
},
{
"anatomy_list": [
"视网膜"
],
"character": [
"糖尿病"
],
"core_name": "病变",
"tendency": ""
},
{
"anatomy_list": [
"周围血管"
],
"character": [
"糖尿病"
],
"core_name": "病变",
"tendency": ""
},
{
"anatomy_list": [
"肾"
],
"character": [
"慢性",
"尿毒症期"
],
"core_name": "肾功能衰竭",
"tendency": ""
},
{
"anatomy_list": [
"心脏"
],
"character": [
"冠状动脉性"
],
"core_name": "心脏病",
"tendency": ""
},
{
"anatomy_list": [
"心"
],
"character": [
"Ⅲ级"
],
"core_name": "心功能",
"tendency": ""
},
{
"anatomy_list": [
"双肺",
"胸膜"
],
"character": [
"转移"
],
"core_name": "癌",
"tendency": ""
},
{
"anatomy_list": [
"右上肺"
],
"character": [],
"core_name": "癌",
"tendency": ""
},
{
"anatomy_list": [
"肺"
],
"character": [
"慢性",
"阻塞性"
],
"core_name": "肺病",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"极高危",
"3极"
],
"core_name": "高血压",
"tendency": ""
},
{
"anatomy_list": [
"心脏"
],
"character": [
"高血压性"
],
"core_name": "心脏病",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"代谢异常"
],
"core_name": "血脂",
"tendency": ""
},
{
"anatomy_list": [
"胃"
],
"character": [
"慢性"
],
"core_name": "胃炎",
"tendency": ""
},
{
"anatomy_list": [
"颈动脉"
],
"character": [],
"core_name": "狭窄",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"控制可"
],
"core_name": "血糖",
"tendency": ""
}
] |
患儿近期精神食欲可，睡眠好，大小便正常。 | 1,728 | [
{
"anatomy_list": [],
"character": [
"可"
],
"core_name": "精神",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"可"
],
"core_name": "食欲",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"好"
],
"core_name": "睡眠",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"正常"
],
"core_name": "大小便",
"tendency": ""
}
] |
患者自发病以来， 精神可 ， 食欲尚可 ， 睡眠可 ， 大便如常 ， 小便如常 ， 体重无明显变化 。 | 513 | [
{
"anatomy_list": [],
"character": [
"好"
],
"core_name": "精神",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"尚可"
],
"core_name": "食欲",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"好"
],
"core_name": "睡眠",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"如常"
],
"core_name": "大便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"如常"
],
"core_name": "小便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"明显"
],
"core_name": "体重变化",
"tendency": "否定"
}
] |
<宫颈>hsil累及腺体。 | 633 | [
{
"anatomy_list": [
"宫颈"
],
"character": [
"累及腺体"
],
"core_name": "hsil",
"tendency": ""
}
] |
2.双肺多发结节影，多系转移，较前变化不明显。 | 760 | [
{
"anatomy_list": [
"双肺"
],
"character": [
"多发",
"较前变化不明显"
],
"core_name": "结节影",
"tendency": ""
},
{
"anatomy_list": [
"双肺"
],
"character": [
"多系"
],
"core_name": "转移",
"tendency": ""
}
] |
4+年（2016-5-13）前因“卵巢肿瘤”于我科行“腹腔镜下卵巢癌肿瘤细胞减灭术+肠粘连松解术+右侧盆腔淋巴结切除术+大网膜切除术+阑尾切除术+肠修补术”，术前查ca-125>5000U/ml，术后病检结果：（双侧卵巢）高级别浆液性癌；（双侧输卵管）见癌累及；（左宫旁、右宫旁、阴道壁、宫颈、颈管、宫体、肌壁）均见癌累及，脉管内可见癌栓；（子宫浆膜下结节、网膜）见癌结节；（右侧宫旁、右侧髂内淋巴结）见癌转移；（直肠壁）见癌累及，肠周淋巴结见癌转移，术后复查ca-1251160U/ml，诊断分期为“卵巢高级别浆液性癌iiic期”，术后予以“tc方案”（紫杉醇静脉+卡铂腹腔）化疗八次，在第七次化疗前ca-125降至正常（2016-9-29），化疗期间出现iii~iv度骨髓抑制骨髓抑制（粒细胞缺乏），予以对症治疗，于2016-10-22结束第八次化疗，化疗后未遵医嘱定期复查，化疗结束后有全身轻微瘙痒不适，无畏寒、发热、恶心、呕吐、咳嗽、关节疼痛、心慌气短等不适，全身无淤血淤斑、皮疹、口腔溃疡、阴道流血流液等症状。 | 707 | [
{
"anatomy_list": [
"卵巢"
],
"character": [],
"core_name": "肿瘤",
"tendency": ""
},
{
"anatomy_list": [
"双侧卵巢"
],
"character": [
"高级别",
"浆液性"
],
"core_name": "癌",
"tendency": ""
},
{
"anatomy_list": [
"双侧输卵管"
],
"character": [
"累及"
],
"core_name": "癌",
"tendency": ""
},
{
"anatomy_list": [
"脉管"
],
"character": [],
"core_name": "癌栓",
"tendency": ""
},
{
"anatomy_list": [
"左宫旁",
"右宫旁",
"阴道壁",
"宫颈",
"颈管",
"宫体",
"肌壁"
],
"character": [
"累及"
],
"core_name": "癌",
"tendency": ""
},
{
"anatomy_list": [
"子宫浆膜下",
"网膜"
],
"character": [],
"core_name": "癌结节",
"tendency": ""
},
{
"anatomy_list": [
"右侧髂内淋巴结",
"子宫旁"
],
"character": [
"转移"
],
"core_name": "癌",
"tendency": ""
},
{
"anatomy_list": [
"直肠壁"
],
"character": [
"累及"
],
"core_name": "癌",
"tendency": ""
},
{
"anatomy_list": [
"肠周淋巴结"
],
"character": [
"转移"
],
"core_name": "癌",
"tendency": ""
},
{
"anatomy_list": [
"卵巢"
],
"character": [
"高级别",
"浆液性",
"iiic期"
],
"core_name": "癌",
"tendency": ""
},
{
"anatomy_list": [
"骨髓"
],
"character": [
"iii~iv度"
],
"core_name": "骨髓抑制",
"tendency": ""
},
{
"anatomy_list": [
"粒细胞"
],
"character": [],
"core_name": "缺乏",
"tendency": ""
},
{
"anatomy_list": [
"全身"
],
"character": [
"化疗结束后",
"轻微"
],
"core_name": "瘙痒",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "畏寒",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "发热",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "恶心",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "呕吐",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "咳嗽",
"tendency": "否定"
},
{
"anatomy_list": [
"关节"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [
"心"
],
"character": [],
"core_name": "心慌",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "气短",
"tendency": "否定"
},
{
"anatomy_list": [
"全身"
],
"character": [],
"core_name": "瘀血",
"tendency": "否定"
},
{
"anatomy_list": [
"全身"
],
"character": [],
"core_name": "瘀斑",
"tendency": "否定"
},
{
"anatomy_list": [
"全身"
],
"character": [],
"core_name": "皮疹",
"tendency": "否定"
},
{
"anatomy_list": [
"口腔"
],
"character": [],
"core_name": "溃疡",
"tendency": "否定"
},
{
"anatomy_list": [
"阴道"
],
"character": [],
"core_name": "出血",
"tendency": "否定"
},
{
"anatomy_list": [
"阴道"
],
"character": [],
"core_name": "流液",
"tendency": "否定"
}
] |
入院前两月，患者入某医院就甲状腺包快情况就诊，甲状腺彩超示：甲状腺右叶内囊实混合性结节（3.3*1.3cm）。 | 917 | [
{
"anatomy_list": [
"甲状腺"
],
"character": [],
"core_name": "包块",
"tendency": ""
},
{
"anatomy_list": [
"甲状腺右叶内"
],
"character": [
"囊实性",
"混合性"
],
"core_name": "结节",
"tendency": ""
}
] |
腋窝淋巴结未见癌转移（0/7）。 | 491 | [
{
"anatomy_list": [
"腋窝淋巴结"
],
"character": [
"转移"
],
"core_name": "癌",
"tendency": "否定"
}
] |
积极行右侧胸腔穿刺置管引流术，引流出暗红色血性液体，考虑癌性胸水可能性大，胸水送常规、细胞检查符合渗出液特征，送检体液tct(2019-07-22):送检胸水细胞学：血凝块样组织中见少许炎症细胞。 | 764 | [
{
"anatomy_list": [],
"character": [
"暗红色血性液体"
],
"core_name": "引流",
"tendency": ""
},
{
"anatomy_list": [
"胸"
],
"character": [
"癌性"
],
"core_name": "胸水",
"tendency": "不确定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "渗出液",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"血凝块样组织中见",
"少许"
],
"core_name": "炎症细胞",
"tendency": ""
}
] |
咳嗽无减轻，咳嗽较重时伴前胸疼痛。 | 1,718 | [
{
"anatomy_list": [],
"character": [
"减轻"
],
"core_name": "咳嗽",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [
"前胸"
],
"character": [],
"core_name": "疼痛",
"tendency": ""
}
] |
4月前患者因“腹胀、纳差”再次入我院，予以诊断“食管恶性肿瘤术后、胃肠功能紊乱、严重营养不良、急性腹膜炎、肺部感染”。 | 1,924 | [
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "腹胀",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "纳差",
"tendency": ""
},
{
"anatomy_list": [
"食管"
],
"character": [
"术后",
"恶性"
],
"core_name": "肿瘤",
"tendency": ""
},
{
"anatomy_list": [
"胃",
"肠"
],
"character": [],
"core_name": "功能紊乱",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"严重"
],
"core_name": "营养不良",
"tendency": ""
},
{
"anatomy_list": [
"腹膜"
],
"character": [
"急性"
],
"core_name": "腹膜炎",
"tendency": ""
},
{
"anatomy_list": [
"肺部"
],
"character": [],
"core_name": "感染",
"tendency": ""
}
] |
室间隔间隔增厚。 | 599 | [
{
"anatomy_list": [
"室间隔"
],
"character": [],
"core_name": "增厚",
"tendency": ""
}
] |
无发热、黄染；无反酸、嗳气；我院行上腹部ct增强提示：胰头癌可能。 | 1,406 | [
{
"anatomy_list": [],
"character": [],
"core_name": "发热",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "黄染",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "反酸",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "嗳气",
"tendency": "否定"
},
{
"anatomy_list": [
"胰头"
],
"character": [],
"core_name": "癌",
"tendency": "不确定"
}
] |
糖类抗原125：591.10U/ml、人附睾蛋白:186.30pmol/l，请肿瘤多学科会诊后，明确患者为卵巢癌复发伴直肠转移，转我科继续治疗。 | 1,035 | [
{
"anatomy_list": [
"卵巢"
],
"character": [
"复发"
],
"core_name": "癌",
"tendency": ""
},
{
"anatomy_list": [
"直肠"
],
"character": [
"转移"
],
"core_name": "癌",
"tendency": ""
}
] |
第三次入院记录（2012年12月4日-2012年12月24日） 患者2月余前无明显诱因出现乏力，但不影响正常工作，无纳差、身黄，无发热、畏寒，无腹痛、腹胀，无黑便等不适。 | 2,001 | [
{
"anatomy_list": [],
"character": [],
"core_name": "乏力",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "影响正常工作",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "纳差",
"tendency": "否定"
},
{
"anatomy_list": [
"身"
],
"character": [],
"core_name": "黄染",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "发热",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "畏寒",
"tendency": "否定"
},
{
"anatomy_list": [
"腹部"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "腹胀",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "黑便",
"tendency": "否定"
}
] |
pet/ct90检查(123456)提示：1.右肺下叶内基底段段结节影，fdg代谢增高，考虑肿瘤。 | 1,902 | [
{
"anatomy_list": [
"右肺下叶内基底段"
],
"character": [],
"core_name": "结节影",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"增高"
],
"core_name": "fdg代谢",
"tendency": ""
},
{
"anatomy_list": [
"右肺下叶内基底段"
],
"character": [],
"core_name": "肿瘤",
"tendency": "不确定"
}
] |
入院前5月于我院行右肩背部肿物彩超检查提示：右肩部肩部皮下皮下脂肪层内可见范围约56mm*13mm中等回声团，考虑脂肪瘤。 | 2,031 | [
{
"anatomy_list": [
"右肩背部"
],
"character": [],
"core_name": "肿物",
"tendency": ""
},
{
"anatomy_list": [
"右肩部皮下皮下脂肪层"
],
"character": [
"中等"
],
"core_name": "回声团",
"tendency": ""
},
{
"anatomy_list": [
"脂肪"
],
"character": [],
"core_name": "瘤",
"tendency": "不确定"
}
] |
为求进一步治疗，今日来我院就诊，门诊以“尿频原因待查”收入院。 | 1,698 | [
{
"anatomy_list": [],
"character": [],
"core_name": "尿频",
"tendency": "不确定"
}
] |
半天前患者自觉头昏、双下肢乏力伴耳鸣，轻微活动后心累、气促等不适，无牙龈出血、鼻出血，无恶心、呕吐，无呕血、便血，无畏寒、发热，无咳嗽、咳痰，无血尿等不适，现患者为求进一步诊疗，遂就诊于我科门诊，门诊以“慢性粒单核细胞白血病；化疗后骨髓抑制”收入我科住院治疗。 | 1,504 | [
{
"anatomy_list": [
"头"
],
"character": [],
"core_name": "头昏",
"tendency": ""
},
{
"anatomy_list": [
"双下肢"
],
"character": [],
"core_name": "乏力",
"tendency": ""
},
{
"anatomy_list": [
"耳"
],
"character": [],
"core_name": "耳鸣",
"tendency": ""
},
{
"anatomy_list": [
"心"
],
"character": [
"轻微活动后"
],
"core_name": "心累",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"轻微活动后"
],
"core_name": "气促",
"tendency": ""
},
{
"anatomy_list": [
"牙龈"
],
"character": [],
"core_name": "出血",
"tendency": "否定"
},
{
"anatomy_list": [
"鼻"
],
"character": [],
"core_name": "出血",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "恶心",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "呕吐",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "呕血",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "便血",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "畏寒",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "发热",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "咳嗽",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "咳痰",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "血尿",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"慢性",
"粒单核细胞"
],
"core_name": "白血病",
"tendency": ""
},
{
"anatomy_list": [
"骨髓"
],
"character": [
"化疗后"
],
"core_name": "骨髓抑制",
"tendency": ""
}
] |
胸部ct：1.右肺上叶后段占位伴空洞形成，由肺动脉供血，考虑肿瘤性病变；2.纵隔淋巴结肿大，考虑t3椎体转移可能；腰椎磁共振：右髂骨软组织占位，结合病史，考虑转移可能大。 | 1,437 | [
{
"anatomy_list": [
"右肺上叶后段"
],
"character": [
"占位性"
],
"core_name": "病变",
"tendency": ""
},
{
"anatomy_list": [
"右肺上叶后段"
],
"character": [],
"core_name": "空洞形成",
"tendency": ""
},
{
"anatomy_list": [
"右肺上叶后段"
],
"character": [
"肿瘤性"
],
"core_name": "病变",
"tendency": "不确定"
},
{
"anatomy_list": [
"纵隔淋巴结"
],
"character": [],
"core_name": "肿大",
"tendency": ""
},
{
"anatomy_list": [
"t3椎体"
],
"character": [],
"core_name": "转移",
"tendency": "不确定"
},
{
"anatomy_list": [
"右髂骨软组织"
],
"character": [],
"core_name": "占位",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"转移"
],
"core_name": "肿瘤",
"tendency": "不确定"
}
] |
患者因“间断头昏伴呕吐40天，发现颅内占位病变20天”于2012-8-25入院，mri：右侧顶枕叶囊实性占位，于2012-8-31在全麻下行开颅肿瘤切除术，术后病检示：（右枕叶）室管膜母细胞瘤。 | 606 | [
{
"anatomy_list": [
"头"
],
"character": [
"间断"
],
"core_name": "头昏",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "呕吐",
"tendency": ""
},
{
"anatomy_list": [
"颅内"
],
"character": [
"占位性"
],
"core_name": "病变",
"tendency": ""
},
{
"anatomy_list": [
"右侧顶枕叶"
],
"character": [
"囊实性"
],
"core_name": "占位",
"tendency": ""
},
{
"anatomy_list": [
"右枕叶室管膜",
"母细胞"
],
"character": [],
"core_name": "瘤",
"tendency": ""
}
] |
入院前1周，患者无明显诱因出现咳嗽、咳痰，伴乏力，不伴发热、头昏、心悸、呼吸困难、恶心、呕吐、腹胀、腹痛等，今为求下一疗程化疗来我院住院。 | 1,484 | [
{
"anatomy_list": [],
"character": [],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "咳痰",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "乏力",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "发热",
"tendency": "否定"
},
{
"anatomy_list": [
"头"
],
"character": [],
"core_name": "头昏",
"tendency": "否定"
},
{
"anatomy_list": [
"心"
],
"character": [],
"core_name": "心悸",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "呼吸困难",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "恶心",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "呕吐",
"tendency": "否定"
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "腹胀",
"tendency": "否定"
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
}
] |
1+月前，患者因中上腹疼痛疼痛不适于外院求诊，行电子胃镜示：1、食道赘生物性质待定？2、慢性浅表性胃炎。 | 1,190 | [
{
"anatomy_list": [
"中上腹"
],
"character": [],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"食道"
],
"character": [],
"core_name": "赘生物",
"tendency": "不确定"
},
{
"anatomy_list": [
"胃"
],
"character": [
"慢性",
"浅表性"
],
"core_name": "胃炎",
"tendency": ""
}
] |
遂于今日就诊于我院神经内科门诊，门诊以“血管性头痛？”收入我科。 | 1,550 | [
{
"anatomy_list": [
"头"
],
"character": [
"血管性"
],
"core_name": "疼痛",
"tendency": "不确定"
}
] |
患者本次发病以来，食欲下降， 神志清醒，精神尚可，睡眠欠佳，大便正常，小便正常，体重无明显变化。 | 251 | [
{
"anatomy_list": [],
"character": [
"下降"
],
"core_name": "食欲",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"清醒"
],
"core_name": "神志",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"尚可"
],
"core_name": "精神",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"欠佳"
],
"core_name": "睡眠",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"正常"
],
"core_name": "大便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"正常"
],
"core_name": "小便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"明显"
],
"core_name": "体重变化",
"tendency": "否定"
}
] |
膀胱两侧多发结节，考虑转移。 | 1,222 | [
{
"anatomy_list": [
"膀胱两侧"
],
"character": [
"多发"
],
"core_name": "结节",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "转移",
"tendency": "不确定"
}
] |
4+年前，患者无明显诱因出现咳嗽，干咳为主，偶有痰中带血，伴活动后气促，无发热，无盗汗，无明显消瘦，无胸痛，无头晕、头痛，无视物改变，无恶心、呕吐，患者自以为“感冒”，自购药物治疗无明显好转。 | 750 | [
{
"anatomy_list": [],
"character": [],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"干性"
],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"带血",
"偶有"
],
"core_name": "咳痰",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"活动后"
],
"core_name": "气促",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "发热",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "盗汗",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"明显"
],
"core_name": "消瘦",
"tendency": "否定"
},
{
"anatomy_list": [
"胸"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [
"头"
],
"character": [],
"core_name": "头晕",
"tendency": "否定"
},
{
"anatomy_list": [
"头"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "视物改变",
"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": "感冒",
"tendency": ""
}
] |
自患者起病以来，精神一般，食欲减退为正常时60%，睡眠欠佳，大便费力，尿量从1500ml左右逐渐减少为300ml左右，体重减少。 | 292 | [
{
"anatomy_list": [],
"character": [
"一般"
],
"core_name": "精神",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"减退"
],
"core_name": "食欲",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"欠佳"
],
"core_name": "睡眠",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"费力"
],
"core_name": "大便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "尿量减少",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "体重减少",
"tendency": ""
}
] |
进一步就诊我院，门诊查肾功示“尿素15.65mmol/L，肌酐508.5umol/L，腹部彩超：1.肝右叶钙化灶，肝囊肿；2.胆囊切除术后；3.双肾实质回声增强；4.右肾囊肿；5.胆管、胰、脾未见异常。 | 1,487 | [
{
"anatomy_list": [
"肝右叶"
],
"character": [],
"core_name": "钙化灶",
"tendency": ""
},
{
"anatomy_list": [
"肝"
],
"character": [],
"core_name": "囊肿",
"tendency": ""
},
{
"anatomy_list": [
"胆囊"
],
"character": [
"术后"
],
"core_name": "切除",
"tendency": ""
},
{
"anatomy_list": [
"双肾实质"
],
"character": [
"增强"
],
"core_name": "回声",
"tendency": ""
},
{
"anatomy_list": [
"右肾"
],
"character": [],
"core_name": "囊肿",
"tendency": ""
},
{
"anatomy_list": [
"胆管",
"胰",
"脾"
],
"character": [],
"core_name": "异常",
"tendency": "否定"
}
] |
发现血压升高13+年，最高血压达170/？mmhg，既往患者规律服用丹参片降压，平素血压维持在140/？mmhg，平素无头晕、耳鸣、视物模糊，无脑溢血病史，无明显语言肢体活动障碍。 | 2,063 | [
{
"anatomy_list": [],
"character": [
"升高"
],
"core_name": "血压",
"tendency": ""
},
{
"anatomy_list": [
"头"
],
"character": [],
"core_name": "头晕",
"tendency": "否定"
},
{
"anatomy_list": [
"耳"
],
"character": [],
"core_name": "耳鸣",
"tendency": "否定"
},
{
"anatomy_list": [
"眼"
],
"character": [],
"core_name": "视物模糊",
"tendency": "否定"
},
{
"anatomy_list": [
"脑"
],
"character": [],
"core_name": "脑溢血",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"明显"
],
"core_name": "语言障碍",
"tendency": "否定"
},
{
"anatomy_list": [
"肢体"
],
"character": [
"明显"
],
"core_name": "活动障碍",
"tendency": "否定"
}
] |
查体扪及右乳乳晕区约4.0×3.0cm大小质硬肿块，皮肤受累。 | 1,184 | [
{
"anatomy_list": [
"右乳乳晕"
],
"character": [
"质硬"
],
"core_name": "肿块",
"tendency": ""
},
{
"anatomy_list": [
"皮肤"
],
"character": [],
"core_name": "受累",
"tendency": ""
}
] |
Subsets and Splits