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1,982
入院前4年，患者无明显原因出现言语不清，无头痛、恶心、呕吐，无意识障碍、肢体活动障碍、肢体抽搐、大小便失禁，患者家属将患者送至当地医院就诊，予以他汀、抗血小板聚集及对症治疗后言语不清好转，但未恢复至发病前。
[ { "anatomy_list": [], "character": [], "core_name": "言语不清", "tendency": "" }, { "anatomy_list": [ "头" ], "character": [], "core_name": "疼痛", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "恶心", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "呕吐", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "意识障碍", "tendency": "否定" }, { "anatomy_list": [ "肢体" ], "character": [], "core_name": "活动障碍", "tendency": "" }, { "anatomy_list": [ "肢体" ], "character": [], "core_name": "抽搐", "tendency": "" }, { "anatomy_list": [], "character": [ "失禁" ], "core_name": "大小便失禁", "tendency": "" }, { "anatomy_list": [], "character": [ "好转" ], "core_name": "言语不清", "tendency": "" } ]
1,508
；精神食欲一般，睡眠好；大小便正常。
[ { "anatomy_list": [], "character": [ "一般" ], "core_name": "精神", "tendency": "" }, { "anatomy_list": [], "character": [ "一般" ], "core_name": "食欲", "tendency": "" }, { "anatomy_list": [], "character": [ "好" ], "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": "" } ]
1,821
遂急诊“卵巢囊肿蒂扭转？”收入我科。
[ { "anatomy_list": [ "卵巢" ], "character": [], "core_name": "囊肿蒂扭转", "tendency": "不确定" } ]
1,357
原发性肝癌，患者于2020-02-23在某医院在全麻下行腹腔镜探查+开腹左半肝切除术+胆囊切除术，术后病理组织检查报告示：“肝脏”中分化细胞肝癌，包膜见癌组织侵犯；切缘未见癌组织累及。
[ { "anatomy_list": [ "肝" ], "character": [ "原发性" ], "core_name": "癌", "tendency": "" }, { "anatomy_list": [ "肝脏", "包膜", "切缘" ], "character": [ "中分化细胞", "包膜见癌组织侵犯", "切缘未见癌组织累及" ], "core_name": "癌", "tendency": "" } ]
79
无发热、寒战，无双乳胀胀痛，无乳头溢液，无皮肤红肿，无皮肤破溃，无气促、呼吸困难等不适。
[ { "anatomy_list": [], "character": [], "core_name": "发热", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "寒颤", "tendency": "否定" }, { "anatomy_list": [ "双乳" ], "character": [ "胀痛" ], "core_name": "疼痛", "tendency": "否定" }, { "anatomy_list": [ "乳头" ], "character": [], "core_name": "溢液", "tendency": "否定" }, { "anatomy_list": [ "皮肤" ], "character": [], "core_name": "红肿", "tendency": "否定" }, { "anatomy_list": [ "皮肤" ], "character": [], "core_name": "破溃", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "气促", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "呼吸困难", "tendency": "否定" } ]
1,449
32月前（2014年5月）患者复查ct见肝内原结节处病灶，复查afp持续升高（最高达113.7ug/L），再次到重医附二院就诊，腹部mri示：肝癌介入术后改变，肝右前叶强化小结节小结节影，与2014年6月9日病灶稍增大；肝门区淋巴结淋巴结肿大。
[ { "anatomy_list": [ "肝内" ], "character": [ "原结节处" ], "core_name": "病灶", "tendency": "" }, { "anatomy_list": [ "肝" ], "character": [ "肝癌介入术后" ], "core_name": "改变", "tendency": "" }, { "anatomy_list": [ "肝右前叶" ], "character": [ "强化", "小" ], "core_name": "结节影", "tendency": "" }, { "anatomy_list": [], "character": [ "稍增大" ], "core_name": "病灶", "tendency": "" }, { "anatomy_list": [ "肝门区淋巴结" ], "character": [], "core_name": "肿大", "tendency": "" } ]
374
患者自起病以来，精神略差，胃纳略差，大便如常，小便如常，体重未见明显下降。
[ { "anatomy_list": [], "character": [ "略差" ], "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": [ "如常" ], "core_name": "小便", "tendency": "" }, { "anatomy_list": [], "character": [ "明显" ], "core_name": "体重下降", "tendency": "否定" } ]
1,383
无畏寒、发热，无咳嗽、咳痰、无心慌、胸闷，无头晕、头痛，无潮热、盗汗等不适。
[ { "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": [ "心" ], "character": [], "core_name": "心慌", "tendency": "否定" }, { "anatomy_list": [ "胸" ], "character": [], "core_name": "胸闷", "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": "潮热", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "盗汗", "tendency": "否定" } ]
1,928
为进一步诊治，门诊以“食管癌术后”收入我科。
[ { "anatomy_list": [ "食管" ], "character": [ "术后" ], "core_name": "癌", "tendency": "" } ]
1,979
出院后一直于当地医院输液治疗，后患者感上述症状无明显改善，7天前再次到某医院就诊，行胸部ct检查提示“左肺结节影”，并出现多次咯血，血为暗红色，每次量约2ml，多于晨起发生，予以抗炎等治疗后无明显改善，现到我院就诊。
[ { "anatomy_list": [ "左肺" ], "character": [], "core_name": "结节影", "tendency": "" }, { "anatomy_list": [], "character": [ "多次", "暗红色", "多于晨起发生" ], "core_name": "咯血", "tendency": "" } ]
371
在我院入院后予以止咳、化痰、解痉、平喘、抗感染等对症支持治疗，咳嗽、咳痰好转出院。
[ { "anatomy_list": [], "character": [ "好转" ], "core_name": "咳嗽", "tendency": "" }, { "anatomy_list": [], "character": [ "好转" ], "core_name": "咳痰", "tendency": "" } ]
711
于2018-11开始出现左下肢下肢骨骨痛，2019-1-4起开始于某医院随访及治疗，ca-1252951u/ml、he4256.1pmol/l，全腹ct提示：考虑右肺下叶结节影、腹腔及腹腔后多发淋巴结转移、左侧骶翼骨转移，2019-1-9予以“奥沙利铂+多西他赛”静脉化疗1次，并间断予以“唑来磷酸”改善骨质破坏治疗，治疗期间ca125持续上升，患者拒绝化疗，2019-5-15ca-1253238u/ml，全腹ct提示：考虑双侧骶翼骨转移，予以“多西他赛+奈达铂”静脉化疗1次，2019-7-11ca-1251733u/ml，2019-8-14ca-1254242u/ml，8-15予以“多西他赛+奈达铂”静脉化疗1次，2019-9-5ca-1252953u/ml，予以“多西他赛+奈达铂”静脉化疗1次，2019-9-9ca-1251755u/ml，2019-10-11ca-1251750u/ml，2019-12-10ca-1254193u/ml，予以“吉西他滨+奈达铂”静脉化疗1次，2020-1-3ca-1252228u/ml，予以“吉西他滨+奈达铂”静脉化疗1次，后失访3月。
[ { "anatomy_list": [ "左下肢", "肢骨" ], "character": [], "core_name": "疼痛", "tendency": "" }, { "anatomy_list": [ "右肺下叶" ], "character": [], "core_name": "结节影", "tendency": "不确定" }, { "anatomy_list": [ "腹腔淋巴结", "腹腔后淋巴结" ], "character": [ "多发" ], "core_name": "转移", "tendency": "不确定" }, { "anatomy_list": [ "左侧骶翼骨" ], "character": [], "core_name": "转移", "tendency": "不确定" }, { "anatomy_list": [ "左侧骶翼骨" ], "character": [ "改善" ], "core_name": "骨质破坏", "tendency": "" }, { "anatomy_list": [ "双侧骶翼骨" ], "character": [], "core_name": "转移", "tendency": "不确定" } ]
74
2+月前再次出现右侧髋关节关节阵发性疼痛，伴活动障碍，不伴肿胀，无皮肤发红，不伴皮疹、光过敏、面部蝶形红斑，遂于2017.05.11～2017.05.20我院住院治疗，住院期间行相关检查，结合外院淋巴细胞b27阳性，诊断为幼年特发性关节炎（与附着点炎症相关的关节炎）。
[ { "anatomy_list": [ "右侧髋关节" ], "character": [ "阵发性" ], "core_name": "疼痛", "tendency": "" }, { "anatomy_list": [], "character": [], "core_name": "活动障碍", "tendency": "" }, { "anatomy_list": [], "character": [], "core_name": "肿胀", "tendency": "否定" }, { "anatomy_list": [ "皮肤" ], "character": [], "core_name": "发红", "tendency": "否定" }, { "anatomy_list": [ "皮肤" ], "character": [], "core_name": "皮疹", "tendency": "否定" }, { "anatomy_list": [], "character": [ "光" ], "core_name": "过敏", "tendency": "否定" }, { "anatomy_list": [ "面部" ], "character": [ "蝶形" ], "core_name": "红斑", "tendency": "" }, { "anatomy_list": [ "关节" ], "character": [ "幼年", "特发性", "与附着点炎症相关的关节炎" ], "core_name": "关节炎", "tendency": "" } ]
962
2015-09-21于某医院行培美曲塞900mg（具体治疗不详）维持治疗，自诉有头晕、食欲下降，无骨髓抑制，予以对症处理后好转出院。
[ { "anatomy_list": [ "头" ], "character": [], "core_name": "头晕", "tendency": "" }, { "anatomy_list": [], "character": [ "下降" ], "core_name": "食欲", "tendency": "" }, { "anatomy_list": [ "骨髓" ], "character": [], "core_name": "骨髓抑制", "tendency": "否定" } ]
1,127
2015年04月患者出现肿瘤标志物进行性升高，遂于我院就诊，并于2015-4-21行一周期紫杉醇脂质体210mg ivgtt d1+奈达铂50mg d1、40mg2方案化疗，化疗后出现口腔及咽喉部溃疡及iv度骨髓抑制，予以对症处理后好转出院。
[ { "anatomy_list": [], "character": [ "进行性升高" ], "core_name": "肿瘤标志物", "tendency": "" }, { "anatomy_list": [ "口腔", "咽喉部" ], "character": [], "core_name": "溃疡", "tendency": "" }, { "anatomy_list": [ "骨髓" ], "character": [ "iv度" ], "core_name": "骨髓抑制", "tendency": "" } ]
293
患者10余年前无明显诱因出现尿频，白天约10-30分/次，尿急，夜尿次数增多，7-8次/夜，此后上述症状持续不缓解，无尿量、尿液颜色异常，无尿痛、排尿困难、尿不尽，无泡沫尿、肉眼血尿，无腰痛不适，未见皮疹、口腔溃疡、光敏、脱发及关节痛。患者未予以重视，未行任何治疗。
[ { "anatomy_list": [], "character": [ "白天约10-30分/次" ], "core_name": "尿频", "tendency": "" }, { "anatomy_list": [], "character": [], "core_name": "尿急", "tendency": "" }, { "anatomy_list": [], "character": [], "core_name": "夜尿次数增多", "tendency": "" }, { "anatomy_list": [], "character": [], "core_name": "尿量异常", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "尿液颜色异常", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "尿痛", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "排尿困难", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "尿不尽", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "泡沫尿", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "血尿", "tendency": "否定" }, { "anatomy_list": [ "腰" ], "character": [], "core_name": "疼痛", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "皮疹", "tendency": "否定" }, { "anatomy_list": [ "口腔" ], "character": [], "core_name": "溃疡", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "光敏", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "脱发", "tendency": "否定" }, { "anatomy_list": [ "关节" ], "character": [], "core_name": "疼痛", "tendency": "否定" } ]
1,436
入院2月前，患者因“右侧肩背部疼痛1周”于我院住院治疗，完善相关检查，肺癌肿瘤标志物：癌胚抗原(cea)110.00ng/ml↑，细胞角蛋白19片段(cyfra21-1)8.78ng/ml↑，神经元特异性烯醇化酶(nse)27.16ng/ml↑。
[ { "anatomy_list": [ "右侧肩", "右侧背部" ], "character": [], "core_name": "疼痛", "tendency": "" }, { "anatomy_list": [ "肺" ], "character": [], "core_name": "癌", "tendency": "" } ]
1,846
右侧输尿管及右肾盂积水。
[ { "anatomy_list": [ "右侧输尿管", "右肾盂" ], "character": [], "core_name": "积水", "tendency": "" } ]
1,754
10余天前，患者无明显诱因出现右上腹疼痛，为持续性隐痛，程度尚可忍受，无明显加重及缓解因素，与体位及进食无明显关系，无明显放射性疼痛，伴活动后气促，伴纳差，伴巩膜轻度黄染，无恶心、呕吐、呕血、黑便，无畏寒、发热、寒战，无白陶土样大便，无全身皮肤瘙痒。
[ { "anatomy_list": [ "右上腹" ], "character": [], "core_name": "疼痛", "tendency": "" }, { "anatomy_list": [], "character": [ "持续性隐痛", "程度尚可忍受", "无明显加重及缓解因素", "与体位及进食无明显关系" ], "core_name": "疼痛", "tendency": "" }, { "anatomy_list": [], "character": [ "明显放射性" ], "core_name": "疼痛", "tendency": "否定" }, { "anatomy_list": [], "character": [ "活动后" ], "core_name": "气促", "tendency": "" }, { "anatomy_list": [], "character": [], "core_name": "纳差", "tendency": "" }, { "anatomy_list": [ "巩膜" ], "character": [ "轻度" ], "core_name": "黄染", "tendency": "" }, { "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": "黑便", "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": "寒颤", "tendency": "否定" }, { "anatomy_list": [], "character": [ "白陶土样" ], "core_name": "大便", "tendency": "否定" }, { "anatomy_list": [ "全身皮肤" ], "character": [], "core_name": "瘙痒", "tendency": "否定" } ]
1,560
放疗结束后患者出现咳嗽，阵时咳痰，痰液为白色泡沫痰，感进食梗阻较前稍有缓解，无畏寒、发热，无饮水呛咳，无声嘶等不适，为进一步治疗，故来我院，以“左下肺鳞癌伴肺门、纵膈、锁骨上淋巴结转移、胸膜转移（ct3n3Mm1a iva期）、食管癌放疗后”收入我科。
[ { "anatomy_list": [], "character": [], "core_name": "咳嗽", "tendency": "" }, { "anatomy_list": [], "character": [ "阵时", "白色", "泡沫痰" ], "core_name": "咳痰", "tendency": "" }, { "anatomy_list": [], "character": [ "进食", "稍有缓解" ], "core_name": "梗阻", "tendency": "" }, { "anatomy_list": [], "character": [], "core_name": "畏寒", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "发热", "tendency": "否定" }, { "anatomy_list": [], "character": [ "饮水" ], "core_name": "呛咳", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "声嘶", "tendency": "否定" }, { "anatomy_list": [ "左下肺" ], "character": [ "转移", "ct3n3Mm1a iva期" ], "core_name": "鳞癌", "tendency": "" }, { "anatomy_list": [ "肺门淋巴结 " ], "character": [ "转移", "ct3n3Mm1a iva期" ], "core_name": "癌", "tendency": "" }, { "anatomy_list": [ "纵隔淋巴结" ], "character": [ "转移", "ct3n3Mm1a iva期" ], "core_name": "癌", "tendency": "" }, { "anatomy_list": [ "锁骨上淋巴结" ], "character": [ "转移", "ct3n3Mm1a iva期" ], "core_name": "癌", "tendency": "" }, { "anatomy_list": [ "胸膜" ], "character": [ "转移", "ct3n3Mm1a iva期" ], "core_name": "癌", "tendency": "" }, { "anatomy_list": [ "食管" ], "character": [ "放疗后" ], "core_name": "癌", "tendency": "" } ]
1,974
患者半月前无明显诱因出现无痛性肉眼血尿，呈全程血尿，未见血凝块，无畏寒、发热，无恶心、呕吐，无腰腹部疼痛，无尿频、尿痛等不适，就诊于某医院，行彩超提示：前列腺增生，双侧睾丸鞘膜积液（患者自诉，未见报告）。
[ { "anatomy_list": [], "character": [ "无痛性" ], "core_name": "血尿", "tendency": "" }, { "anatomy_list": [], "character": [], "core_name": "血尿", "tendency": "" }, { "anatomy_list": [], "character": [], "core_name": "血凝块", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "畏寒", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "发热", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "恶心", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "呕吐", "tendency": "否定" }, { "anatomy_list": [ "腰部", "腹部" ], "character": [], "core_name": "疼痛", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "尿频", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "尿痛", "tendency": "否定" }, { "anatomy_list": [ "前列腺" ], "character": [], "core_name": "增生", "tendency": "" }, { "anatomy_list": [ "双侧睾丸鞘膜" ], "character": [], "core_name": "积液", "tendency": "" } ]
161
患者患病以来精神一般，食欲可，睡眠可，大小便正常，近期无明显体重减轻。
[ { "anatomy_list": [], "character": [ "一般" ], "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": "体重减轻", "tendency": "否定" } ]
1,813
术后患者行基因检测提示egfr19号外显子缺失。
[ { "anatomy_list": [], "character": [], "core_name": "egfr19号外显子缺失", "tendency": "" } ]
827
3天前至我院就诊，查妇科彩超提示：右侧附件区见两枚囊性回声，较大者大小约22mm×19mm，左侧附件区见一大小约63mm×27mm囊性回声，考虑巧囊，要求手术。
[ { "anatomy_list": [ "右侧附件" ], "character": [ "两枚", "囊性" ], "core_name": "回声", "tendency": "" }, { "anatomy_list": [ "左侧附件" ], "character": [ "囊性" ], "core_name": "回声", "tendency": "" }, { "anatomy_list": [], "character": [], "core_name": "巧克力囊肿", "tendency": "不确定" } ]
1,795
入院前1年，患者因双肩部及双上臂疼痛，ect:右侧肱骨头异常放射性浓聚结合，融合图像考虑：转移性骨肿瘤。
[ { "anatomy_list": [ "双肩部", "双上臂" ], "character": [], "core_name": "疼痛", "tendency": "" }, { "anatomy_list": [ "右侧肱骨头" ], "character": [ "异常放射性" ], "core_name": "浓聚结合", "tendency": "" }, { "anatomy_list": [ "右侧肱骨头" ], "character": [ "转移性" ], "core_name": "肿瘤", "tendency": "" } ]
1,865
患者4+月前因“大便次数增多伴便血2月”到我院就诊，我院行肠镜及病检123456提示：直肠腺癌(距肛门8-14cm)，大肠多发息肉。
[ { "anatomy_list": [], "character": [ "次数增多" ], "core_name": "大便", "tendency": "" }, { "anatomy_list": [], "character": [], "core_name": "便血", "tendency": "" }, { "anatomy_list": [ "直肠" ], "character": [], "core_name": "腺癌", "tendency": "" }, { "anatomy_list": [ "大肠" ], "character": [ "多发" ], "core_name": "息肉", "tendency": "" } ]
1,056
患者于3年前无明显诱因出现排大便困难，排大便1次/3天,大便外观正常,成形便，无粘液脓血，无血便。
[ { "anatomy_list": [], "character": [ "1次/3天" ], "core_name": "排便困难", "tendency": "" }, { "anatomy_list": [], "character": [ "外观正常", "成形" ], "core_name": "大便", "tendency": "" }, { "anatomy_list": [], "character": [ "脓血", "粘液" ], "core_name": "大便", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "血便", "tendency": "否定" } ]
110
无身黄、眼黄，无呕血及黑便；体重未见明显消瘦。
[ { "anatomy_list": [ "身" ], "character": [], "core_name": "黄染", "tendency": "否定" }, { "anatomy_list": [ "眼" ], "character": [], "core_name": "黄染", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "呕血", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "黑便", "tendency": "否定" }, { "anatomy_list": [], "character": [ "明显" ], "core_name": "消瘦", "tendency": "否定" } ]
144
入院前1+年，患者因“1.右肾萎缩；2.左肾重度积水；3.双肾结石；4.左侧输尿管支架置入术后”于我科行“经输尿管镜左侧输尿管支架取出术+左侧输尿管镜检+经输尿管镜钬激光碎石术+左侧输尿管支架植入术”，术后患者带管回家，病程中患者无尿频、尿急、尿痛、血尿，无反酸、嗳气，无恶心、呕吐，无畏寒、发热，无明显腹胀、腹泻、转移性疼痛。
[ { "anatomy_list": [ "右肾" ], "character": [], "core_name": "萎缩", "tendency": "" }, { "anatomy_list": [ "左肾" ], "character": [ "重度" ], "core_name": "积水", "tendency": "" }, { "anatomy_list": [ "双肾" ], "character": [], "core_name": "结石", "tendency": "" }, { "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" }, { "anatomy_list": [], "character": [], "core_name": "反酸", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "嗳气", "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": "畏寒", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "发热", "tendency": "否定" }, { "anatomy_list": [ "腹" ], "character": [ "明显" ], "core_name": "腹胀", "tendency": "否定" }, { "anatomy_list": [ "腹" ], "character": [ "明显" ], "core_name": "腹泻", "tendency": "否定" }, { "anatomy_list": [], "character": [ "转移性" ], "core_name": "疼痛", "tendency": "否定" } ]
1,660
2017-02-08予以予以吡柔比星 70mg ivgtt qd+维a酸 10mg po tid+阿糖胞苷75mg q12h 微量泵入，辅以碱化尿液、水化、增强免疫力等对症治疗，阿糖胞苷50mg+地塞米松磷酸钠5mg+甲氨蝶呤15mg鞘内注射第3次化疗，化疗期间患者出现血象下降、感染，予以输入血小板、升血、抗感染等治疗好转出院。
[ { "anatomy_list": [], "character": [ "血象" ], "core_name": "感染", "tendency": "" }, { "anatomy_list": [], "character": [ "下降" ], "core_name": "血象", "tendency": "" } ]
44
3月前患者于我院复查彩超提示“左附件区大小约70×48×38mm的异常回声,考虑畸胎瘤可能”。
[ { "anatomy_list": [ "左附件" ], "character": [], "core_name": "异常回声", "tendency": "" }, { "anatomy_list": [], "character": [], "core_name": "畸胎瘤", "tendency": "不确定" } ]
213
随后咳嗽咳痰症状逐渐加重，为求进一步诊治，于某医院就诊，完善胸部增强ct检查（2020-03-09）：双肺肺气肿，左肺上叶支气管腔内稍低密度影，肿瘤性病变不完全除外，建议结合纤支镜检查。
[ { "anatomy_list": [], "character": [ "逐渐加重" ], "core_name": "咳嗽", "tendency": "" }, { "anatomy_list": [], "character": [ "逐渐加重" ], "core_name": "咳痰", "tendency": "" }, { "anatomy_list": [ "双肺" ], "character": [], "core_name": "肺气肿", "tendency": "" }, { "anatomy_list": [ "左肺上叶支气管腔内" ], "character": [ "稍低" ], "core_name": "密度影", "tendency": "" }, { "anatomy_list": [], "character": [ "肿瘤性" ], "core_name": "病变", "tendency": "不确定" } ]
103
患者于5年前，无意中发现左侧颈部包块，最初发现时包块约花生米大小， 无压痛 ， 无吞咽不适 ，未作特殊处理。
[ { "anatomy_list": [ "左侧颈部" ], "character": [], "core_name": "包块", "tendency": "" }, { "anatomy_list": [], "character": [ "花生米大小" ], "core_name": "包块", "tendency": "" }, { "anatomy_list": [], "character": [], "core_name": "压痛", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "吞咽不适", "tendency": "否定" } ]
1,426
患者于3天前无明显诱因感双下肢乏力、纳差，无咳嗽咳痰，无畏寒发热，无头痛头昏，无恶心呕吐，无反酸、烧心，无腹痛、腹泻、黑便，精神萎，时有谵语，期间未行相应治疗，以“乏力待查”收入院。
[ { "anatomy_list": [ "双下肢" ], "character": [], "core_name": "乏力", "tendency": "" }, { "anatomy_list": [], "character": [], "core_name": "纳差", "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": "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": "头昏", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "恶心", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "呕吐", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "反酸", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "烧心", "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": "黑便", "tendency": "否定" }, { "anatomy_list": [], "character": [ "萎" ], "core_name": "精神", "tendency": "否定" }, { "anatomy_list": [], "character": [ "时有" ], "core_name": "谵语", "tendency": "" }, { "anatomy_list": [], "character": [], "core_name": "乏力", "tendency": "不确定" } ]
1,260
左肺下叶少许炎症，左肺下叶外侧基底段小结节。随访。
[ { "anatomy_list": [ "左肺下叶" ], "character": [ "少许" ], "core_name": "炎症", "tendency": "" }, { "anatomy_list": [ "左肺下叶外侧基底段" ], "character": [ "小" ], "core_name": "结节", "tendency": "" } ]
580
入院前4天，患者为求进一步治疗，遂前往我院就诊，门诊行乳腺彩超示：左侧乳腺3点钟方向占位，超声bi-rads分类：3类，乳腺纤维腺瘤可能，建议6月后再次超声检查。
[ { "anatomy_list": [ "左侧乳腺3点钟方向" ], "character": [ "超声bi-rads分类：3类" ], "core_name": "占位", "tendency": "" }, { "anatomy_list": [ "乳腺" ], "character": [ "纤维" ], "core_name": "腺瘤", "tendency": "不确定" } ]
1,476
患者入院前1天无明显诱因出现视物双影，伴轻度倾斜。
[ { "anatomy_list": [], "character": [], "core_name": "视物双影", "tendency": "" }, { "anatomy_list": [], "character": [ "轻度" ], "core_name": "视物倾斜", "tendency": "" } ]
1,672
3天前，患者因再次受凉后感咳嗽、咳痰加重，痰为白色粘稠痰、量多，并出现活动后呼吸困难，休息及自服“铝碳酸镁片”后稍缓解，现患者仍存在咳嗽、咳痰，痰为白色粘稠痰，量多，不易咳出，轻微活动后即感呼吸困难，为进一步诊治，遂至我院，我科以“肺部感染、食道ca术后”收入院。
[ { "anatomy_list": [], "character": [ "受凉后", "加重" ], "core_name": "咳嗽", "tendency": "" }, { "anatomy_list": [], "character": [ "受凉后", "加重" ], "core_name": "咳痰", "tendency": "" }, { "anatomy_list": [], "character": [ "白色", "粘稠" ], "core_name": "咳痰", "tendency": "" }, { "anatomy_list": [], "character": [ "增多" ], "core_name": "咳痰", "tendency": "" }, { "anatomy_list": [], "character": [ "活动后" ], "core_name": "呼吸困难", "tendency": "" }, { "anatomy_list": [], "character": [], "core_name": "咳嗽", "tendency": "" }, { "anatomy_list": [], "character": [], "core_name": "咳痰", "tendency": "" }, { "anatomy_list": [], "character": [ "白色", "粘稠" ], "core_name": "咳痰", "tendency": "" }, { "anatomy_list": [], "character": [ "增多", "不易咳出" ], "core_name": "咳痰", "tendency": "" }, { "anatomy_list": [], "character": [ "轻微活动后" ], "core_name": "呼吸困难", "tendency": "" }, { "anatomy_list": [ "肺部" ], "character": [], "core_name": "感染", "tendency": "" }, { "anatomy_list": [ "食道" ], "character": [ "术后" ], "core_name": "癌", "tendency": "" } ]
28
入院前15月余因“唾液中带血”于我院耳鼻喉科就诊,查肾功示：尿素50.96mmol/L↑,肌酐1654.9umol/L↑,尿酸472.1umol/L↑,行彩超示：双肾减小,诊断为“尿毒症”,后转入我科,诊断为“慢性肾功不全 尿毒症期 高血压肾病 肾性贫血”,行左上肢动静脉造瘘术,并予以透析治疗。
[ { "anatomy_list": [], "character": [ "带血" ], "core_name": "唾液", "tendency": "" }, { "anatomy_list": [ "双肾" ], "character": [ "减小" ], "core_name": "肾减小", "tendency": "" }, { "anatomy_list": [], "character": [], "core_name": "尿毒症", "tendency": "" }, { "anatomy_list": [ "肾" ], "character": [ "慢性" ], "core_name": "肾功能不全", "tendency": "" }, { "anatomy_list": [ "肾" ], "character": [ "高血压" ], "core_name": "高血压肾病", "tendency": "" }, { "anatomy_list": [ "肾" ], "character": [ "肾性" ], "core_name": "贫血", "tendency": "" } ]
1,001
4年余前,患者于某医院体检,行b超检查发现肝右前叶异常回声结节,脾大。
[ { "anatomy_list": [ "肝右前叶" ], "character": [ "异常回声" ], "core_name": "结节", "tendency": "" }, { "anatomy_list": [ "脾" ], "character": [ "大" ], "core_name": "脾大", "tendency": "" } ]
1,249
患者自发病以来， 精神差 ， 食欲差 ， 睡眠差 ， 大便如常 ， 小便如常 ， 体重无明显变化 。
[ { "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", "tendency": "" }, { "anatomy_list": [], "character": [ "如常" ], "core_name": "大便", "tendency": "" }, { "anatomy_list": [], "character": [ "如常" ], "core_name": "小便", "tendency": "" }, { "anatomy_list": [], "character": [ "明显" ], "core_name": "体重改变", "tendency": "否定" } ]
279
期间自诉口服中药治疗，未特殊诊治，10+天前，患者因感冒后感咳嗽、咳痰症状加重，伴左侧胸背部胸背部疼痛，与体位、呼吸无相关性，偶有痰中带血丝，无鼻塞、流涕、头昏、头痛，无心悸、胸闷、气促，无腹痛、腹泻，就诊于某医院复查胸部ct（2018年12月29日）：1.左肺上叶舌段示软组织块块影，考虑肺ca可能，建议进一步行增强检查。
[ { "anatomy_list": [], "character": [], "core_name": "感冒", "tendency": "" }, { "anatomy_list": [], "character": [ "感冒后", "加重" ], "core_name": "咳嗽", "tendency": "" }, { "anatomy_list": [], "character": [ "感冒后", "加重" ], "core_name": "咳痰", "tendency": "" }, { "anatomy_list": [ "左侧胸背部" ], "character": [ "与体位、呼吸无相关性" ], "core_name": "疼痛", "tendency": "" }, { "anatomy_list": [], "character": [ "偶有", "痰中带血" ], "core_name": "咳痰", "tendency": "" }, { "anatomy_list": [ "鼻" ], "character": [], "core_name": "鼻塞", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "流涕", "tendency": "否定" }, { "anatomy_list": [ "头" ], "character": [], "core_name": "头昏", "tendency": "否定" }, { "anatomy_list": [ "头" ], "character": [], "core_name": "疼痛", "tendency": "否定" }, { "anatomy_list": [ "心" ], "character": [], "core_name": "心悸", "tendency": "否定" }, { "anatomy_list": [ "胸" ], "character": [], "core_name": "胸闷", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "气促", "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": [ "左肺上叶舌段", "软组织" ], "character": [], "core_name": "块影", "tendency": "" }, { "anatomy_list": [ "肺" ], "character": [], "core_name": "癌", "tendency": "不确定" } ]
926
患者自发病以来， 精神可 ， 食欲可 ， 睡眠可 ， 大便如常 ，小便如上述，体力、体重无明显变化。
[ { "anatomy_list": [], "character": [ "可" ], "core_name": "精神", "tendency": "" }, { "anatomy_list": [], "character": [ "可" ], "core_name": "食欲", "tendency": "" }, { "anatomy_list": [], "character": [ "可" ], "core_name": "睡眠质量", "tendency": "" }, { "anatomy_list": [], "character": [ "如常" ], "core_name": "大便", "tendency": "" }, { "anatomy_list": [], "character": [ "如常" ], "core_name": "小便", "tendency": "" }, { "anatomy_list": [], "character": [ "明显" ], "core_name": "体力改变", "tendency": "否定" }, { "anatomy_list": [], "character": [ "明显" ], "core_name": "体重改变", "tendency": "否定" } ]
1,999
第二次入院记录（2012年2月13日-2012年3月8日） 患者于1年前于我院再次复查，腹部mri提示：肝右叶小结节，给予保肝对症治疗，于2012.2.21行介入治疗，手术顺利。
[ { "anatomy_list": [ "肝右叶" ], "character": [ "小" ], "core_name": "结节", "tendency": "" } ]
785
入院1+年 前 ，患者无明显诱因出现头昏，伴有头闷胀不适，呈持续性，以双侧颞部及额部为主，伴有四肢麻木，无视物旋转、恶心、呕吐，耳鸣、听力下降等，无肢体偏瘫、失语、吞咽困难、饮水呛咳等，无意识障碍、四肢抽搐、口吐白沫、大小便失禁等，无胸闷、气促、心前区压榨感等，无畏寒、发热、咳嗽、咳痰等，患者自行在个体医师处治疗（具体不详），患者症状无明显缓解，入院3月前，患者感头昏、头胀较前加重，并伴有双眼胀痛，为进一步治疗，遂来我科，门诊以“后循环缺血”收入我院。
[ { "anatomy_list": [ "头" ], "character": [], "core_name": "头昏", "tendency": "" }, { "anatomy_list": [ "头", "双侧颞部", "额部" ], "character": [ "持续性" ], "core_name": "闷胀", "tendency": "" }, { "anatomy_list": [ "四肢" ], "character": [], "core_name": "麻木", "tendency": "" }, { "anatomy_list": [], "character": [], "core_name": "视物旋转", "tendency": "" }, { "anatomy_list": [], "character": [], "core_name": "呕吐", "tendency": "" }, { "anatomy_list": [ "耳" ], "character": [], "core_name": "耳鸣", "tendency": "" }, { "anatomy_list": [], "character": [], "core_name": "听力下降", "tendency": "" }, { "anatomy_list": [ "肢体" ], "character": [], "core_name": "偏瘫", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "失语", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "吞咽困难", "tendency": "否定" }, { "anatomy_list": [], "character": [ "饮水" ], "core_name": "呛咳", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "意识障碍", "tendency": "否定" }, { "anatomy_list": [ "四肢" ], "character": [], "core_name": "抽搐", "tendency": "否定" }, { "anatomy_list": [ "口" ], "character": [], "core_name": "口吐白沫", "tendency": "否定" }, { "anatomy_list": [], "character": [ "失禁" ], "core_name": "大小便", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "憋闷", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "气促", "tendency": "否定" }, { "anatomy_list": [ "心前区" ], "character": [], "core_name": "压榨感", "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": [ "明显缓解" ], "core_name": "症状", "tendency": "否定" }, { "anatomy_list": [ "头" ], "character": [ "加重" ], "core_name": "头昏", "tendency": "" }, { "anatomy_list": [ "头" ], "character": [ "加重" ], "core_name": "发胀", "tendency": "" }, { "anatomy_list": [ "双眼" ], "character": [ "胀痛" ], "core_name": "疼痛", "tendency": "" }, { "anatomy_list": [ "后循环" ], "character": [], "core_name": "缺血", "tendency": "" } ]
352
病程中患者无腹痛、腹胀、腹泻,无恶心、呕吐,无畏寒、发热，无阴道阴道流血流液，无同房接触性出血，无排便习惯及性状改变，无头晕、头痛，无胸闷、心悸，无尿频、尿急等不适,考虑盆腔包块，建议住院手术治疗，今日患者为求手术就诊我院，故门诊以“盆腔包块性质待查”收入院。
[ { "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": [], "character": [], "core_name": "恶心", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "呕吐", "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": [ "阴道" ], "character": [], "core_name": "出血", "tendency": "否定" }, { "anatomy_list": [ "阴道" ], "character": [], "core_name": "流液", "tendency": "否定" }, { "anatomy_list": [], "character": [ "同房接触性" ], "core_name": "出血", "tendency": "否定" }, { "anatomy_list": [], "character": [ "习惯及性状改变" ], "core_name": "排便", "tendency": "" }, { "anatomy_list": [ "头" ], "character": [], "core_name": "头晕", "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" }, { "anatomy_list": [ "心" ], "character": [], "core_name": "心悸", "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": [ "盆腔" ], "character": [], "core_name": "包块", "tendency": "不确定" }, { "anatomy_list": [ "盆腔" ], "character": [], "core_name": "包块", "tendency": "不确定" } ]
65
入院前35天，患者于当地常规体检时发现转氨酶增高（具体值不详），不伴发热、畏寒、寒战、咳嗽、咳痰、恶心、呕吐、腹痛、腹泻、皮肤瘙痒、尿黄、眼黄、身黄等不适。
[ { "anatomy_list": [], "character": [ "增高" ], "core_name": "转氨酶", "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": "寒颤", "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": "恶心", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "呕吐", "tendency": "否定" }, { "anatomy_list": [ "腹" ], "character": [], "core_name": "疼痛", "tendency": "否定" }, { "anatomy_list": [ "腹" ], "character": [], "core_name": "腹泻", "tendency": "否定" }, { "anatomy_list": [ "皮肤" ], "character": [], "core_name": "瘙痒", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "尿黄", "tendency": "" }, { "anatomy_list": [ "眼" ], "character": [], "core_name": "黄染", "tendency": "否定" }, { "anatomy_list": [ "身" ], "character": [], "core_name": "黄染", "tendency": "否定" } ]
255
患者于3天前无明显诱因右眼突发眼胀胀痛不适，无视力下降、视物变形、视物重影，无眼红、分泌物增多，至我院就诊，双眼视神经萎缩，建议完善检查。
[ { "anatomy_list": [ "右眼" ], "character": [ "突发", "胀痛不适" ], "core_name": "疼痛", "tendency": "" }, { "anatomy_list": [], "character": [], "core_name": "视力下降", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "视物变形", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "视物重影", "tendency": "否定" }, { "anatomy_list": [ "眼" ], "character": [], "core_name": "眼红", "tendency": "否定" }, { "anatomy_list": [ "眼" ], "character": [], "core_name": "分泌物增多", "tendency": "否定" }, { "anatomy_list": [ "双眼视神经" ], "character": [], "core_name": "萎缩", "tendency": "" } ]
879
2天前，患者上诉症状再发，夜间高枕卧位，伴夜间阵发性呼吸困难，无双下肢水肿，伴有咳嗽、咳痰,为白色泡沫痰,无畏寒、发热，无胸闷、胸痛、心悸，无恶心、呕吐，无出汗等不适，为进一步诊治入我院，门诊以“心力衰竭”收入我科。
[ { "anatomy_list": [], "character": [ "夜间", "阵发性" ], "core_name": "呼吸困难", "tendency": "" }, { "anatomy_list": [ "双下肢" ], "character": [], "core_name": "水肿", "tendency": "否定" }, { "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": "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": [ "胸" ], "character": [], "core_name": "疼痛", "tendency": "否定" }, { "anatomy_list": [ "心" ], "character": [], "core_name": "心悸", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "恶心", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "呕吐", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "出汗", "tendency": "否定" }, { "anatomy_list": [ "心" ], "character": [], "core_name": "心力衰竭", "tendency": "" } ]
1,911
1周前，患者诉骶尾部疼痛，影响夜间睡眠，未诊治入我科，门诊以"右肺腺癌”收入我科。
[ { "anatomy_list": [ "骶尾部" ], "character": [ "影响夜间睡眠" ], "core_name": "疼痛", "tendency": "" }, { "anatomy_list": [ "右肺" ], "character": [], "core_name": "腺癌", "tendency": "" } ]
51
5+月前患者因“大便习惯改变”于我院就诊,经检查后诊断为乙状结肠肿瘤,于07.16在全麻下行腹腔镜下乙状结肠肿瘤根治术,手术顺利,术后病检：（乙状结肠）溃疡型中-低分化管状腺癌,浸及肠壁深肌层,癌侵犯神经。
[ { "anatomy_list": [], "character": [ "习惯改变" ], "core_name": "大便", "tendency": "" }, { "anatomy_list": [ "乙状结肠" ], "character": [], "core_name": "肿瘤", "tendency": "" }, { "anatomy_list": [ "乙状结肠" ], "character": [ "溃疡型", "浸及肠壁深肌层", "侵犯神经" ], "core_name": "管状腺癌", "tendency": "" } ]
1,446
患者发病以来，神志 清晰，精神可，胃纳可，大便次数增多，小便如常，体重未见明显下降。
[ { "anatomy_list": [], "character": [ "清晰" ], "core_name": "神志", "tendency": "" }, { "anatomy_list": [], "character": [ "可" ], "core_name": "精神", "tendency": "" }, { "anatomy_list": [ "胃" ], "character": [ "可" ], "core_name": "胃纳", "tendency": "" }, { "anatomy_list": [], "character": [ "次数增多" ], "core_name": "大便", "tendency": "" }, { "anatomy_list": [], "character": [ "如常" ], "core_name": "小便", "tendency": "" }, { "anatomy_list": [], "character": [ "明显" ], "core_name": "体重下降", "tendency": "否定" } ]
1,570
入院前5+月，患者无明显诱因出现大便次数增加，由1次/天，增加至10次/天，为稀糊样大便，大便无明显变细、变形，大便表面或大便中混有暗红色血液，伴轻度肛门坠胀坠胀不适，偶有下腹部隐痛不适，发作无规律，可自行解除或排除后缓解，无脓性便、果酱样便，无腹胀、恶心、呕吐等不适。
[ { "anatomy_list": [], "character": [ "次数增加" ], "core_name": "大便", "tendency": "" }, { "anatomy_list": [], "character": [ "稀糊样" ], "core_name": "大便", "tendency": "" }, { "anatomy_list": [], "character": [ "明显变细" ], "core_name": "大便", "tendency": "" }, { "anatomy_list": [], "character": [ "明显变形" ], "core_name": "大便", "tendency": "" }, { "anatomy_list": [], "character": [ "表面或大便中暗红色血液" ], "core_name": "大便", "tendency": "" }, { "anatomy_list": [ "肛门" ], "character": [ "轻度" ], "core_name": "坠胀", "tendency": "" }, { "anatomy_list": [ "下腹部" ], "character": [ "发作无规律", "偶有", "隐痛", "自行解除", "排除后缓解" ], "core_name": "疼痛", "tendency": "" }, { "anatomy_list": [], "character": [ "脓性" ], "core_name": "大便", "tendency": "否定" }, { "anatomy_list": [], "character": [ "果酱样" ], "core_name": "大便", "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" } ]
1,391
自患病以来，患者精神、食欲、睡眠可，大小便基本正常，体重无明显变化。
[ { "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": [ "基本正常" ], "core_name": "大便", "tendency": "" }, { "anatomy_list": [], "character": [ "基本正常" ], "core_name": "小便", "tendency": "" }, { "anatomy_list": [], "character": [ "明显" ], "core_name": "体重改变", "tendency": "否定" } ]
391
患者本次发病以来，食欲减退， 神志清醒，精神尚可，睡眠尚可，大便正常，小便正常，1月余体重减少约2Kg。
[ { "anatomy_list": [], "character": [ "减退" ], "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": [], "core_name": "体重减少", "tendency": "" } ]
1,419
该次入院前3月发现左侧锁骨上锁骨上肿块约花生米粒大小，伴有胸痛，咳嗽，粘痰，无发热、无痰血、及头痛、头晕、恶心、呕吐及骨关节关节疼痛。
[ { "anatomy_list": [ "左侧锁骨上" ], "character": [ "花生米粒大小" ], "core_name": "肿块", "tendency": "" }, { "anatomy_list": [ "胸" ], "character": [], "core_name": "疼痛", "tendency": "" }, { "anatomy_list": [], "character": [], "core_name": "咳嗽", "tendency": "" }, { "anatomy_list": [], "character": [ "粘痰" ], "core_name": "咳痰", "tendency": "" }, { "anatomy_list": [], "character": [], "core_name": "发热", "tendency": "否定" }, { "anatomy_list": [], "character": [ "痰血" ], "core_name": "咳痰", "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": "恶心", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "呕吐", "tendency": "否定" }, { "anatomy_list": [ "骨关节" ], "character": [], "core_name": "疼痛", "tendency": "否定" } ]
840
患者自起病以来，精神可，睡眠可，胃纳可，大便如常，小便如常，体重未见明显下降。
[ { "anatomy_list": [], "character": [ "可" ], "core_name": "精神", "tendency": "" }, { "anatomy_list": [], "character": [ "可" ], "core_name": "睡眠", "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" } ]
64
患者自起病以来，精神可，胃纳可，大便如常，尿急，体重未见明显下降。
[ { "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": [], "core_name": "尿急", "tendency": "" }, { "anatomy_list": [], "character": [ "明显" ], "core_name": "体重下降", "tendency": "否定" } ]
873
予以护肾、降尿酸、抑酸、改善循环、营养神经、营养心肌、降压等处理后好转出院；4年前患者在体检时发现血肌酐肌酐升高（约100+umol/l），但患者未予重视，院外不规律服用“金水宝、尿毒清颗粒”护肾治疗，不定期随访肾功，均提示血肌酐呈上升趋势，伴夜尿增多，不伴尿量减少、浮肿，不伴恶心、呕吐等不适。
[ { "anatomy_list": [], "character": [], "core_name": "血肌酐肌酐升高", "tendency": "" }, { "anatomy_list": [], "character": [], "core_name": "血肌酐上升趋势", "tendency": "" }, { "anatomy_list": [], "character": [], "core_name": "夜尿增多", "tendency": "" }, { "anatomy_list": [], "character": [ "量减少" ], "core_name": "小便", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "浮肿", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "恶心", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "呕吐", "tendency": "否定" } ]
1,098
3天前，出现上述症状进行性加重，表现为：排尿费力，尿分叉，尿线变细，排尿滴沥，尿不尽感。
[ { "anatomy_list": [], "character": [], "core_name": "排尿费力", "tendency": "" }, { "anatomy_list": [], "character": [], "core_name": "尿分叉", "tendency": "" }, { "anatomy_list": [], "character": [], "core_name": "尿线变细", "tendency": "" }, { "anatomy_list": [], "character": [], "core_name": "排尿滴沥", "tendency": "" }, { "anatomy_list": [], "character": [], "core_name": "尿不尽感", "tendency": "" } ]
1,431
两次手术病检分别为：<膀胱>高级别尿路上皮癌，膀胱肿瘤及基底部高级别乳头状尿路上皮癌；<左输尿管近膀胱处>高级别浸润性尿路上皮癌，侵及浅肌层，<左侧>肾脏组织未见癌累及，<左肾门>淋巴结未见癌转移（0/12）。
[ { "anatomy_list": [ "膀胱", "尿路上皮" ], "character": [ "高级别" ], "core_name": "癌", "tendency": "" }, { "anatomy_list": [ "膀胱" ], "character": [], "core_name": "肿瘤", "tendency": "" }, { "anatomy_list": [ "膀胱基底部", "尿路上皮" ], "character": [ "高级别", "乳头状" ], "core_name": "癌", "tendency": "" }, { "anatomy_list": [ "左输尿管近膀胱处", "尿路上皮" ], "character": [ "左侧肾脏组织未见癌累及", "高级别", "浸润性", "侵及浅肌层" ], "core_name": "癌", "tendency": "" }, { "anatomy_list": [ "左肾门淋巴结" ], "character": [ "转移" ], "core_name": "癌", "tendency": "否定" } ]
1,384
今患者为行进一步诊治来我院，门诊以“双肺多发结节待查？”收入我科住院治疗。
[ { "anatomy_list": [ "双肺" ], "character": [ "多发" ], "core_name": "结节", "tendency": "不确定" } ]
1,691
4月前于我科诊断为“双眼糖尿病视网膜病变，右眼黄斑水肿”，后先后于我科行右眼玻璃体腔注药术（康柏西普），后患者觉视物模糊较前缓解。
[ { "anatomy_list": [ "双眼", "视网膜" ], "character": [ "糖尿病" ], "core_name": "病变", "tendency": "" }, { "anatomy_list": [ "右眼" ], "character": [], "core_name": "水肿", "tendency": "" }, { "anatomy_list": [ "右眼" ], "character": [], "core_name": "黄斑", "tendency": "" }, { "anatomy_list": [], "character": [ "较前缓解" ], "core_name": "视物模糊", "tendency": "" } ]
1,903
2.右肺门、纵膈、右侧锁骨锁骨区淋巴结淋巴结增大，fdg代谢增高，考虑转移。
[ { "anatomy_list": [], "character": [], "core_name": "转移", "tendency": "不确定" }, { "anatomy_list": [ "右肺门淋巴结", "纵膈淋巴结", "右侧锁骨淋巴结" ], "character": [], "core_name": "肿大", "tendency": "" }, { "anatomy_list": [], "character": [ "增高" ], "core_name": "fdg代谢", "tendency": "" } ]
1,801
患者4月前，开始出现进食后哽咽感，有进食停顿感，有胸骨后疼痛疼痛不适，无胸骨后烧灼感，无恶心，无呕吐，无返酸，无嗳气，无呕血，无黑便，无心悸、胸闷等不适，无发热、抽搐等症。
[ { "anatomy_list": [], "character": [ "进食后" ], "core_name": "哽噎感", "tendency": "" }, { "anatomy_list": [], "character": [ "进食" ], "core_name": "停顿感", "tendency": "" }, { "anatomy_list": [ "胸骨后" ], "character": [], "core_name": "疼痛", "tendency": "" }, { "anatomy_list": [ "胸骨后" ], "character": [], "core_name": "胸骨后不适", "tendency": "" }, { "anatomy_list": [ "胸骨后" ], "character": [], "core_name": "烧灼感", "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": "返酸", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "嗳气", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "呕血", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "黑便", "tendency": "否定" }, { "anatomy_list": [ "心" ], "character": [], "core_name": "心悸", "tendency": "否定" }, { "anatomy_list": [ "胸" ], "character": [], "core_name": "胸闷", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "发热", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "抽搐", "tendency": "否定" } ]
307
其后分别于2015-8-15、2015-9-18、2015-10-17行伊立替康 320mg1化疗，术后好转出院，现患者为行复查来我院，门诊以“左肺癌术后”收入我科。
[ { "anatomy_list": [ "左肺" ], "character": [ "术后" ], "core_name": "癌", "tendency": "" } ]
1,748
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，小便如上述，体重无明显变化。
[ { "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": "体重改变", "tendency": "否定" } ]
423
现患者遵嘱来我院化疗，门诊以“颅底颅眶沟通腺样性癌”收住我科。
[ { "anatomy_list": [], "character": [ "颅底颅眶沟通", "腺样性" ], "core_name": "癌", "tendency": "" } ]
823
1年前于某中医院体检，行妇科彩超检查提示：左附件区包块，直径约6cm，考虑巧囊可能（未见报告），建议手术，患者未做。
[ { "anatomy_list": [ "左附件" ], "character": [], "core_name": "包块", "tendency": "" }, { "anatomy_list": [], "character": [], "core_name": "巧克力囊肿", "tendency": "不确定" } ]
1,116
7天前患者无明显诱因出现双下肢水肿，呈进行性加重，最初水肿局限在双侧脚背，后逐渐扩大到双侧小腿，其余部位暂无明显水肿。
[ { "anatomy_list": [ "双下肢" ], "character": [ "进行性加重" ], "core_name": "水肿", "tendency": "" }, { "anatomy_list": [ "双侧脚背" ], "character": [ "局限" ], "core_name": "水肿", "tendency": "" }, { "anatomy_list": [ "双侧小腿" ], "character": [ "扩大" ], "core_name": "水肿", "tendency": "" }, { "anatomy_list": [], "character": [ "明显" ], "core_name": "水肿", "tendency": "否定" } ]
762
予以抗感染、增强免疫、辅助抗肿瘤等处理，患者发热等症状逐渐好转，患者及家属不考虑化疗等其他特殊治疗，自动出院。
[ { "anatomy_list": [], "character": [ "逐渐好转" ], "core_name": "发热", "tendency": "" } ]
1,000
6天前，患者在上述症状基础上出现恶心、呕吐非咖啡色胃内容物，遂就诊于某医院，予以糖尿病饮食、抗感染、护肝、改善循环、对症等治疗，患者未再发热，腹痛无明显改善，遂完善上腹部ct提示：1.肝右叶占位性病变，性质待定，肝脓肿？新生物？2.肝大；3.左肾小囊肿；4.右下肺炎症；5.右侧胸腔积液；诊断为：1.肝右叶占位：肝脓肿？肝癌?2.肺部感染；3.肝功能异常；4.急性冠脉综合征；5.急性胃黏膜病变；6.2型糖尿病；7.颈椎骨质增生，遂于今日转入我院，就诊于我院急诊科，请我科会诊后以“肝脏占位待查”收入我科住院治疗。
[ { "anatomy_list": [], "character": [], "core_name": "恶心", "tendency": "" }, { "anatomy_list": [], "character": [ "非咖啡色胃内容物" ], "core_name": "呕吐", "tendency": "" }, { "anatomy_list": [], "character": [], "core_name": "发热", "tendency": "否定" }, { "anatomy_list": [ "腹" ], "character": [ "明显改善" ], "core_name": "疼痛", "tendency": "否定" }, { "anatomy_list": [ "肝右叶" ], "character": [ "占位性" ], "core_name": "病变", "tendency": "" }, { "anatomy_list": [ "肝" ], "character": [], "core_name": "脓肿", "tendency": "不确定" }, { "anatomy_list": [ "肝" ], "character": [], "core_name": "新生物", "tendency": "不确定" }, { "anatomy_list": [ "肝" ], "character": [ "大" ], "core_name": "肝大", "tendency": "" }, { "anatomy_list": [ "左肾" ], "character": [ "小" ], "core_name": "囊肿", "tendency": "" }, { "anatomy_list": [ "右下肺" ], "character": [], "core_name": "炎症", "tendency": "" }, { "anatomy_list": [ "右侧胸腔" ], "character": [], "core_name": "积液", "tendency": "" }, { "anatomy_list": [ "肝右叶" ], "character": [], "core_name": "占位", "tendency": "" }, { "anatomy_list": [ "肝" ], "character": [], "core_name": "脓肿", "tendency": "不确定" }, { "anatomy_list": [ "肝" ], "character": [], "core_name": "癌", "tendency": "不确定" }, { "anatomy_list": [ "肺部" ], "character": [], "core_name": "感染", "tendency": "" }, { "anatomy_list": [ "肝" ], "character": [], "core_name": "肝功能异常", "tendency": "" }, { "anatomy_list": [], "character": [ "急性" ], "core_name": "冠脉综合征", "tendency": "" }, { "anatomy_list": [ "胃部" ], "character": [ "急性", "粘膜" ], "core_name": "病变", "tendency": "" }, { "anatomy_list": [], "character": [ "2型" ], "core_name": "糖尿病", "tendency": "" }, { "anatomy_list": [ "颈椎" ], "character": [], "core_name": "骨质增生", "tendency": "" }, { "anatomy_list": [ "肝脏" ], "character": [], "core_name": "占位", "tendency": "" } ]
1,023
4年前，患者于我院复查时发现腹腔包块，包块接近血管部位，考虑宫颈癌复发，故再次予以包块部分切除术，术后予以4周期化疗（具体不详），化疗中患者出现恶心、呕吐、腹痛、腹胀，全血下降等不适，给予对症处理后缓解。
[ { "anatomy_list": [ "腹腔" ], "character": [ "接近血管部位" ], "core_name": "包块", "tendency": "" }, { "anatomy_list": [ "宫颈" ], "character": [ "复发" ], "core_name": "癌", "tendency": "不确定" }, { "anatomy_list": [], "character": [], "core_name": "恶心", "tendency": "" }, { "anatomy_list": [], "character": [], "core_name": "呕吐", "tendency": "" }, { "anatomy_list": [ "腹" ], "character": [], "core_name": "疼痛", "tendency": "" }, { "anatomy_list": [ "腹" ], "character": [], "core_name": "腹胀", "tendency": "" } ]
71
病程中反复出现咳嗽、咳痰症状，程度及频次较前均减少，未再咯血，患者均予以对症治疗，未行进一步处理及治疗。
[ { "anatomy_list": [], "character": [ "反复", "程度及频次较前均减少" ], "core_name": "咳嗽", "tendency": "" }, { "anatomy_list": [], "character": [ "反复", "程度及频次较前均减少" ], "core_name": "咳痰", "tendency": "" }, { "anatomy_list": [], "character": [], "core_name": "咯血", "tendency": "否定" } ]
449
今为求进一步治疗，遂于我院就诊，门诊以“鼾症”收拾入院。
[ { "anatomy_list": [], "character": [], "core_name": "鼾症", "tendency": "" } ]
1,330
入院前 5年 ，患者渐感劳力性呼吸困难，以上楼、上坡或剧烈活动后明显，不伴夜间阵发性呼吸困难及端坐呼吸，不伴双下肢肿。
[ { "anatomy_list": [], "character": [ "劳力性", "以上楼、上坡或剧烈活动后明显" ], "core_name": "呼吸困难", "tendency": "" }, { "anatomy_list": [], "character": [ "夜间", "阵发性" ], "core_name": "呼吸困难", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "端坐呼吸", "tendency": "否定" }, { "anatomy_list": [ "双下肢" ], "character": [], "core_name": "肿", "tendency": "否定" } ]
1,353
21月前患者无明显诱因出现咽痛，服用抗生素（具体不详）后无明显缓解，未予重视，其后患者反复出现咽痛，伴间断发热，最高高体温达39℃，伴乏力，至某医院，查血图：hb67g/L，wbc3.34*10＾9/L，plt15*10＾9/L，d-二聚体最高时>5.0mg/L，凝血象：凝血酶原标准化比值1.14，凝血酶原时间12.5秒，活化部分凝血活酶时间>190秒,鱼精蛋白试验：阳性，铁蛋白：1942ng/ml，本周氏蛋白、甲功、贫血组合、抗人球蛋白试验正常，考虑为“急性髓系白血病（m3型），弥漫性血管内凝血（dic）”，因凝血功能极差未完善骨髓涂片及骨髓活检 ,予以输注红细胞、人纤维蛋白原等对症支持治疗，治疗过程中，患者全身乏力症状未见明显缓解，并伴发牙龈出血及全身皮肤瘀斑，后患者入我院。
[ { "anatomy_list": [ "咽" ], "character": [], "core_name": "疼痛", "tendency": "" }, { "anatomy_list": [ "咽" ], "character": [ "反复" ], "core_name": "疼痛", "tendency": "" }, { "anatomy_list": [], "character": [ "间断" ], "core_name": "发热", "tendency": "" }, { "anatomy_list": [], "character": [], "core_name": "乏力", "tendency": "" }, { "anatomy_list": [], "character": [ "急性", "髓系", "m3型" ], "core_name": "白血病", "tendency": "不确定" }, { "anatomy_list": [], "character": [], "core_name": "弥漫性血管内凝血", "tendency": "不确定" }, { "anatomy_list": [], "character": [], "core_name": "凝血功能极差", "tendency": "" }, { "anatomy_list": [ "全身" ], "character": [ "明显缓解" ], "core_name": "乏力", "tendency": "否定" }, { "anatomy_list": [ "牙龈" ], "character": [], "core_name": "出血", "tendency": "" }, { "anatomy_list": [ "全身皮肤" ], "character": [], "core_name": "瘀斑", "tendency": "" } ]
661
出院时患者出现心累气促，遂到某职工医院输液3天，经抗炎治疗（具体不详）后，心累气促减轻后出院。
[ { "anatomy_list": [], "character": [], "core_name": "心累", "tendency": "" }, { "anatomy_list": [], "character": [], "core_name": "气促", "tendency": "" }, { "anatomy_list": [], "character": [ "减轻" ], "core_name": "心累", "tendency": "" }, { "anatomy_list": [], "character": [ "减轻" ], "core_name": "气促", "tendency": "" } ]
1,468
患者本次发病以来，食欲正常，神志清醒，精神欠佳，睡眠欠佳，大便不成形，小便正常，体重无明显变化。
[ { "anatomy_list": [], "character": [ "正常" ], "core_name": "食欲", "tendency": "" }, { "anatomy_list": [], "character": [ "清醒" ], "core_name": "神志", "tendency": "" }, { "anatomy_list": [], "character": [ "欠佳" ], "core_name": "精神", "tendency": "" }, { "anatomy_list": [], "character": [ "欠佳" ], "core_name": "睡眠", "tendency": "" }, { "anatomy_list": [], "character": [ "不成形" ], "core_name": "大便", "tendency": "" }, { "anatomy_list": [], "character": [ "正常" ], "core_name": "小便", "tendency": "" }, { "anatomy_list": [], "character": [ "明显" ], "core_name": "体重改变", "tendency": "否定" } ]
1,901
2018.07.16于某医院，行肋骨螺旋ct检查：1.右肺下叶内基底段新生物可能；2.右肺中叶及左下肺小结节肺小结节影，转移不除外；3.纵膈内肿大淋巴结；4.右侧第4及左侧第9、10肋骨转移。
[ { "anatomy_list": [ "右肺下叶内基底段" ], "character": [], "core_name": "新生物", "tendency": "不确定" }, { "anatomy_list": [ "右肺中叶" ], "character": [ "转移不除外", "小" ], "core_name": "结节影", "tendency": "" }, { "anatomy_list": [ "左下肺" ], "character": [ "转移不除外", "小" ], "core_name": "结节影", "tendency": "" }, { "anatomy_list": [ "纵膈内淋巴结" ], "character": [], "core_name": "肿大", "tendency": "" }, { "anatomy_list": [ "右侧第4肋骨", "左侧第9、10肋骨" ], "character": [ "骨" ], "core_name": "转移", "tendency": "" } ]
353
患者于2个多月前（2013.02.28）因诊断为右乳浸润性导管癌，在我院行右乳癌改良根治术，受体情况为er(++) pr（++） cerbb-2(+++)。
[ { "anatomy_list": [ "右乳" ], "character": [ "浸润性" ], "core_name": "导管癌", "tendency": "" } ]
623
查hpv：16型阳性；妇科彩超未见明显异常，今日患者至我院就诊，门诊以“宫颈鳞状细胞癌”收治入院。
[ { "anatomy_list": [], "character": [ "阳性" ], "core_name": "hpv16型", "tendency": "" }, { "anatomy_list": [ "宫颈" ], "character": [], "core_name": "鳞癌", "tendency": "" } ]
157
故门诊以“肝癌”收入我科室。
[ { "anatomy_list": [ "肝" ], "character": [], "core_name": "癌", "tendency": "" } ]
416
门诊以“乳腺癌术后”收入我科。
[ { "anatomy_list": [ "乳腺" ], "character": [ "术后" ], "core_name": "癌", "tendency": "" } ]
421
之后患者于2015年10月5日于某医院行放射治疗（pgtvnx 69.96G/33f；pgtv2 66G/33f），2015年10月14日、2015年11月16日于华西医院行2周期化疗（化疗方案为顺铂30mg d1-?），出院后回家休养，间断出现呕吐，呈喷射状，呕吐物为胃内容物，自感颈部僵硬，无明显头痛，无四肢乏力等症状。
[ { "anatomy_list": [], "character": [ "间断出现", "呈喷射状", "呕吐物为胃内容物" ], "core_name": "呕吐", "tendency": "" }, { "anatomy_list": [ "颈部" ], "character": [], "core_name": "僵硬", "tendency": "" }, { "anatomy_list": [ "头" ], "character": [ "明显" ], "core_name": "疼痛", "tendency": "否定" }, { "anatomy_list": [ "四肢" ], "character": [], "core_name": "乏力", "tendency": "否定" } ]
1,204
右侧胸膜增厚。
[ { "anatomy_list": [ "右侧胸膜" ], "character": [], "core_name": "增厚", "tendency": "" } ]
1,423
2余月前（2019年4月）患者因院外查血糖高就诊于我院内分泌科，反复头晕，偶有耳鸣，无头痛，无肢体偏瘫，无意识障碍、视物旋转、视力下降，无畏寒、发热，无咳嗽、咳痰，无胸闷、心慌，无恶心、呕吐，无腹痛、腹胀、腹泻，无肢体麻木、肢体活动障碍。
[ { "anatomy_list": [], "character": [ "高" ], "core_name": "血糖", "tendency": "" }, { "anatomy_list": [ "头" ], "character": [ "反复" ], "core_name": "头晕", "tendency": "" }, { "anatomy_list": [ "耳" ], "character": [], "core_name": "耳鸣", "tendency": "" }, { "anatomy_list": [ "头" ], "character": [], "core_name": "疼痛", "tendency": "否定" }, { "anatomy_list": [ "肢体" ], "character": [], "core_name": "偏瘫", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "意识障碍", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "视物旋转", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "视力下降", "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": [ "胸" ], "character": [], "core_name": "胸闷", "tendency": "否定" }, { "anatomy_list": [ "心" ], "character": [], "core_name": "心慌", "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": [ "肢体" ], "character": [], "core_name": "麻木", "tendency": "否定" }, { "anatomy_list": [ "肢体" ], "character": [], "core_name": "活动障碍", "tendency": "否定" } ]
978
8月前，患者到某医院就诊，行胸片：1.双肺尖改变，考虑陈旧性肺结核可能，建议胸部ct+查痰；2.双肺慢性感染；3.两肋膈角变钝，考虑双侧胸腔积液；4.胸腰椎骨质增生。
[ { "anatomy_list": [ "双肺尖" ], "character": [], "core_name": "改变", "tendency": "" }, { "anatomy_list": [ "肺" ], "character": [ "陈旧性" ], "core_name": "结核", "tendency": "不确定" }, { "anatomy_list": [ "双肺" ], "character": [ "慢性" ], "core_name": "感染", "tendency": "" }, { "anatomy_list": [ "两肋膈角" ], "character": [], "core_name": "变钝", "tendency": "" }, { "anatomy_list": [ "双侧胸腔" ], "character": [], "core_name": "积液", "tendency": "不确定" }, { "anatomy_list": [ "胸椎", "腰椎" ], "character": [], "core_name": "骨质增生", "tendency": "" } ]
2,070
病后患者精神、饮食、睡眠尚可，大小便基本正常，体重无明显变化。
[ { "anatomy_list": [], "character": [ "尚可" ], "core_name": "精神", "tendency": "" }, { "anatomy_list": [], "character": [ "尚可" ], "core_name": "进食", "tendency": "" }, { "anatomy_list": [], "character": [ "尚可" ], "core_name": "睡眠", "tendency": "" }, { "anatomy_list": [], "character": [ "基本正常" ], "core_name": "大小便", "tendency": "" }, { "anatomy_list": [], "character": [ "明显" ], "core_name": "体重改变", "tendency": "否定" } ]
657
现为行进一步诊治，遂来我院就诊，门诊以“双侧乳房肿物”收入住院。
[ { "anatomy_list": [ "双侧乳房" ], "character": [], "core_name": "肿物", "tendency": "" } ]
842
病程中患者无明显颈部疼痛、颈部异物感、咽痛、发热，无怕热、多汗、心悸、凸眼，无食欲改变、明显脱发、颜面部及下肢水肿，无大便性状及频率改变等不适。此次患者为进一步诊治入院。
[ { "anatomy_list": [ "颈部" ], "character": [ "明显" ], "core_name": "疼痛", "tendency": "否定" }, { "anatomy_list": [ "颈部" ], "character": [], "core_name": "异物感", "tendency": "否定" }, { "anatomy_list": [ "咽" ], "character": [], "core_name": "疼痛", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "发热", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "怕热", "tendency": "否定" }, { "anatomy_list": [], "character": [ "增多" ], "core_name": "出汗", "tendency": "否定" }, { "anatomy_list": [ "心" ], "character": [], "core_name": "心悸", "tendency": "否定" }, { "anatomy_list": [ "眼" ], "character": [], "core_name": "凸眼", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "食欲改变", "tendency": "否定" }, { "anatomy_list": [], "character": [ "明显" ], "core_name": "脱发", "tendency": "否定" }, { "anatomy_list": [ "颜面部" ], "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": "大便性状改变", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "大便频率改变", "tendency": "否定" } ]
1,586
于3月前（07-22）行第一次tp方案化疗，化疗期间患者感轻微恶心，有明显脱发，无腹痛、腹泻等不适。
[ { "anatomy_list": [], "character": [ "轻微" ], "core_name": "恶心", "tendency": "" }, { "anatomy_list": [], "character": [ "明显" ], "core_name": "脱发", "tendency": "" }, { "anatomy_list": [ "腹" ], "character": [], "core_name": "疼痛", "tendency": "否定" }, { "anatomy_list": [ "腹" ], "character": [], "core_name": "腹泻", "tendency": "否定" } ]
1,160
患者入院前10天，无明显诱因下出现干咳，伴发热、气促，发热时大汗淋漓，无胸闷胸痛，无呼吸困难，自服川贝止咳糖浆后无好转。
[ { "anatomy_list": [], "character": [ "干性" ], "core_name": "咳嗽", "tendency": "" }, { "anatomy_list": [], "character": [], "core_name": "发热", "tendency": "" }, { "anatomy_list": [], "character": [], "core_name": "气促", "tendency": "" }, { "anatomy_list": [], "character": [], "core_name": "发热", "tendency": "" }, { "anatomy_list": [], "character": [ "大汗" ], "core_name": "出汗", "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": "呼吸困难", "tendency": "否定" } ]
741
为进一步，门诊以“意识丧失待查”收入我科。
[ { "anatomy_list": [], "character": [], "core_name": "意识丧失", "tendency": "" } ]
437
2、左肾积水伴左输尿管全程扩张，不除外输尿管末段狭窄。
[ { "anatomy_list": [ "左肾" ], "character": [], "core_name": "积水", "tendency": "" }, { "anatomy_list": [ "左输尿管全程" ], "character": [], "core_name": "扩张", "tendency": "" }, { "anatomy_list": [ "输尿管末段" ], "character": [], "core_name": "狭窄", "tendency": "不确定" } ]
43
入院前1年,患者体检超声发现“左侧附件区7.2×5.5cm混合性包块”,考虑畸胎瘤可能,无畏寒、发热,无恶心、呕吐,无腹胀、腹痛、腹泻,无大便隐血,无肛门坠胀,无尿频、尿急、尿痛,无阴道阴道流血、流液等不适,嘱患者密切随访,随后患者多次行腹部b超检查,包块未见明显增大,患者未予重视、未做特殊处理。
[ { "anatomy_list": [ "左侧附件" ], "character": [ "混合性" ], "core_name": "包块", "tendency": "" }, { "anatomy_list": [], "character": [], "core_name": "畸胎瘤", "tendency": "不确定" }, { "anatomy_list": [], "character": [], "core_name": "畏寒", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "发热", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "恶心", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "呕吐", "tendency": "否定" }, { "anatomy_list": [ "腹" ], "character": [], "core_name": "腹胀", "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": [ "无隐血" ], "core_name": "大便", "tendency": "" }, { "anatomy_list": [ "肛门" ], "character": [], "core_name": "坠胀", "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": [ "阴道" ], "character": [], "core_name": "出血", "tendency": "否定" }, { "anatomy_list": [ "阴道" ], "character": [], "core_name": "流液", "tendency": "否定" }, { "anatomy_list": [ "左侧附件" ], "character": [ "明显" ], "core_name": "包块增大", "tendency": "否定" } ]
1,815
右肺中叶结节。
[ { "anatomy_list": [ "右肺中叶" ], "character": [], "core_name": "结节", "tendency": "" } ]
1,628
患者近期无发热、咳嗽、咳痰、呼吸困难病史，无疫区接触史，无新冠肺炎患者及疑似患者接触史。
[ { "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": "呼吸困难", "tendency": "否定" }, { "anatomy_list": [ "肺" ], "character": [], "core_name": "新冠肺炎", "tendency": "否定" } ]
2,008
自患病以来，患者精神、食欲尚可，睡眠欠佳，大小便正常，近期体重无明显改变。
[ { "anatomy_list": [], "character": [ "尚可" ], "core_name": "精神", "tendency": "" }, { "anatomy_list": [], "character": [ "尚可" ], "core_name": "食欲", "tendency": "" }, { "anatomy_list": [], "character": [ "欠佳" ], "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" } ]
1,055
近期无恶心、呕吐，腹痛、腹胀，无咳嗽、咳痰，胸痛、咯血等，患者为求进一步诊治遂来我院，以“右下颌下颌包块待查”收入我科。
[ { "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": [], "character": [], "core_name": "咳嗽", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "咳痰", "tendency": "否定" }, { "anatomy_list": [ "胸" ], "character": [], "core_name": "疼痛", "tendency": "否定" }, { "anatomy_list": [], "character": [], "core_name": "咯血", "tendency": "否定" }, { "anatomy_list": [ "右下颌" ], "character": [], "core_name": "包块", "tendency": "不确定" } ]