id
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2.07k
| text
stringlengths 5
708
| event
listlengths 1
59
|
|---|---|---|
1,969 |
右手拇指及食指麻木。
|
[
{
"anatomy_list": [
"右手拇指",
"右手食指"
],
"character": [],
"core_name": "麻木",
"tendency": ""
}
] |
1,839 |
入院前1天，患者行走后出现，双下肢对称性凹陷性水肿，无心悸、气促，无端坐呼吸，无眼睑水肿，无尿频、尿急、尿痛等不适，未予特殊处理，今为进一步诊治来我院，门诊拟“系统性红斑狼疮”收入院。
|
[
{
"anatomy_list": [
"双下肢"
],
"character": [
"行走后",
"对称性",
"凹陷性"
],
"core_name": "水肿",
"tendency": ""
},
{
"anatomy_list": [
"心"
],
"character": [],
"core_name": "心悸",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "气促",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "端坐呼吸",
"tendency": "否定"
},
{
"anatomy_list": [
"眼睑"
],
"character": [],
"core_name": "水肿",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "尿频",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "尿急",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "尿痛",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"系统性"
],
"core_name": "红斑狼疮",
"tendency": "不确定"
}
] |
214 |
纤支镜（2020-03-23）：左上升支支气管开口被肿物完全阻塞，于此处行活检及刷检，病理诊断：左上升支磷状细胞ca，灌洗液未找到抗酸杆菌。
|
[
{
"anatomy_list": [
"左上升支支气管开口"
],
"character": [
"完全"
],
"core_name": "阻塞",
"tendency": ""
},
{
"anatomy_list": [
"左上升支支气管开口"
],
"character": [],
"core_name": "肿物",
"tendency": ""
},
{
"anatomy_list": [
"左上升支"
],
"character": [],
"core_name": "鳞癌",
"tendency": ""
}
] |
1,450 |
患者后于2014年09月15日入某医院行“剖腹探查术+肝癌切除术+放射离子植入术”（具体不详）；取肝组织病检示：肝脏微小癌癌结节，免疫组化支持腺癌。
|
[
{
"anatomy_list": [
"肝脏"
],
"character": [
"癌",
"微小"
],
"core_name": "结节",
"tendency": ""
},
{
"anatomy_list": [
"肝脏"
],
"character": [],
"core_name": "腺癌",
"tendency": ""
}
] |
120 |
患者于2016年9月08日我院行右乳房乳癌麦默通切除术，术中冰冻电话报告：（右乳）恶性肿瘤，于2016年9月12日已行右腋窝前哨淋巴结活检+术中冰冻+右乳癌改良根治术术后辅助化疗，化疗方案为（化疗方案为吡柔比星粉针40mg+多西他赛注射液100mg+环磷酰胺粉针0.8g）。
|
[
{
"anatomy_list": [
"右乳"
],
"character": [
"恶性"
],
"core_name": "肿瘤",
"tendency": ""
}
] |
863 |
入院前1+年患者无明显诱因开始出现颈部、咽喉部疼痛，为间断性，无咳嗽、咳痰，无咽喉疼痛、咯血、胸痛、呼吸困难、吞咽梗阻、吞咽疼痛等症状，自行口服药物（具体不详）治疗，效果欠佳。
|
[
{
"anatomy_list": [
"颈部"
],
"character": [
"间断性"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"咽喉部"
],
"character": [
"间断性"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "咳嗽",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "咳痰",
"tendency": "否定"
},
{
"anatomy_list": [
"咽喉部"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "咯血",
"tendency": "否定"
},
{
"anatomy_list": [
"胸部"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "呼吸困难",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"吞咽"
],
"core_name": "梗阻",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"吞咽"
],
"core_name": "疼痛",
"tendency": "否定"
}
] |
427 |
到某医院就诊， 胸部增强ct 提示 尘肺，双肺上叶团块病灶有强化 。
|
[
{
"anatomy_list": [
"肺"
],
"character": [],
"core_name": "尘肺",
"tendency": ""
},
{
"anatomy_list": [
"双肺上叶"
],
"character": [
"病灶有强化"
],
"core_name": "团块",
"tendency": ""
}
] |
1,176 |
患者遂于2014年7月1日就诊于某医院胃肠外科，入院查血常规提示：白细胞总数383.40×109/l，红细胞计数2.53×1012/l，血红蛋白79g/L，血小板492×109/l，幼稚细胞百分比45%；腹部超声：胆囊息肉样病变；脾大；左肾囊性占位性病变（囊肿）；左上腹上腹部“包块”处探及增大的脾脏。
|
[
{
"anatomy_list": [
"胆囊"
],
"character": [
"息肉样"
],
"core_name": "病变",
"tendency": ""
},
{
"anatomy_list": [
"脾"
],
"character": [],
"core_name": "增大",
"tendency": ""
},
{
"anatomy_list": [
"左肾"
],
"character": [
"囊性",
"占位性"
],
"core_name": "病变",
"tendency": ""
},
{
"anatomy_list": [
"左肾"
],
"character": [],
"core_name": "囊肿",
"tendency": ""
},
{
"anatomy_list": [
"左上腹部"
],
"character": [],
"core_name": "包块",
"tendency": ""
},
{
"anatomy_list": [
"脾脏"
],
"character": [],
"core_name": "增大",
"tendency": ""
}
] |
1,344 |
术后出现小肝综合征，予以静脉营养支持、保肝利胆、输注人血白蛋白、间断小剂量输注新鲜冰冻血浆后肝功能逐渐恢复正常，其后患者无胸闷和心悸，无腹胀和腹痛，无腹泻和便血，无畏寒和发热，无眼黄、身黄，无闷油、乏力、纳差。
|
[
{
"anatomy_list": [
"肝"
],
"character": [],
"core_name": "小肝综合征",
"tendency": ""
},
{
"anatomy_list": [
"肝"
],
"character": [
"逐渐恢复正常"
],
"core_name": "肝功能",
"tendency": ""
},
{
"anatomy_list": [
"胸"
],
"character": [],
"core_name": "胸闷",
"tendency": "否定"
},
{
"anatomy_list": [
"心"
],
"character": [],
"core_name": "心悸",
"tendency": "否定"
},
{
"anatomy_list": [
"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": [],
"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": [
"眼"
],
"character": [],
"core_name": "黄染",
"tendency": "否定"
},
{
"anatomy_list": [
"身"
],
"character": [],
"core_name": "黄染",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "乏力",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "闷油",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "纳差",
"tendency": "否定"
}
] |
906 |
为求进一步治疗，今来我院就诊，门诊以“右侧髋关节滑膜炎？”入院。
|
[
{
"anatomy_list": [
"右侧髋关节滑膜"
],
"character": [],
"core_name": "滑膜炎",
"tendency": "不确定"
}
] |
1,533 |
入院前20+年，患者无明显诱因出现咳嗽、咳痰，咳白色泡沫痰，并逐年加重，伴心累、气促，稍活动后明显，无胸痛、胸闷、无咯血等，于院外诊断为"慢性阻塞性肺疾病"，未规范治疗，8+月前，患者因受凉后出现声音嘶哑，患者遂于肿瘤医院行胸部ct、纤支镜+活检检查，诊断为"左肺鳞癌"；建议患者住院进一步治疗，患者回家安排后分别于06月02日、06月29日，在我科住院，予以"tp"方案化疗第1、2周期（药物总量：紫杉醇 400mg 顺铂 160mg），化疗过程中患者无明显恶心、呕吐、发热、身痛等不适，门诊随访血常规未见明显异常，建议其可规律化疗，但患者本人拒绝。
|
[
{
"anatomy_list": [],
"character": [],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"白色",
"泡沫",
"逐年加重"
],
"core_name": "咳痰",
"tendency": ""
},
{
"anatomy_list": [
"心"
],
"character": [
"稍活动后",
"明显"
],
"core_name": "心累",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"稍活动后",
"明显"
],
"core_name": "气促",
"tendency": ""
},
{
"anatomy_list": [
"胸"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [
"胸"
],
"character": [],
"core_name": "胸闷",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "咯血",
"tendency": "否定"
},
{
"anatomy_list": [
"肺"
],
"character": [
"慢性",
"阻塞性"
],
"core_name": "慢性阻塞性肺疾病",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"受凉后"
],
"core_name": "声音嘶哑",
"tendency": ""
},
{
"anatomy_list": [
"左肺"
],
"character": [],
"core_name": "鳞癌",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"明显"
],
"core_name": "恶心",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"明显"
],
"core_name": "呕吐",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"明显"
],
"core_name": "发热",
"tendency": "否定"
},
{
"anatomy_list": [
"身"
],
"character": [
"明显"
],
"core_name": "疼痛",
"tendency": "否定"
}
] |
1,136 |
患者本次发病以来，食欲下降，神志清醒，精神欠佳，睡眠尚可，大便正常，体重减少3kg。
|
[
{
"anatomy_list": [],
"character": [
"下降"
],
"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": [
"尚可"
],
"core_name": "睡眠",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"正常"
],
"core_name": "大便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"减轻"
],
"core_name": "体重",
"tendency": ""
}
] |
495 |
二便正常，体重无明显减轻。
|
[
{
"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"
}
] |
319 |
患者1+年前于我科在局部浸润麻醉下行前列腺活检穿刺，病检回示：前列腺癌。
|
[
{
"anatomy_list": [
"前列腺"
],
"character": [],
"core_name": "癌",
"tendency": ""
}
] |
2,032 |
现患者为求进一步治疗右肩背部肿物而来我院入我科。
|
[
{
"anatomy_list": [
"右肩背部"
],
"character": [],
"core_name": "肿物",
"tendency": ""
}
] |
1,549 |
起病前无受凉感冒。
|
[
{
"anatomy_list": [],
"character": [],
"core_name": "感冒",
"tendency": "否定"
}
] |
54 |
另送（腹主动脉旁及肠系膜下）淋巴结均见癌转移（均为1/1）。
|
[
{
"anatomy_list": [
"腹主动脉旁淋巴结",
"肠系膜下淋巴结"
],
"character": [
"转移"
],
"core_name": "癌",
"tendency": ""
}
] |
1,463 |
15+年患者出现心前区不适，呈紧缩感，发作时伴有呼吸困难，间断使用药物治疗（具体不详），但症状反复。
|
[
{
"anatomy_list": [
"心前区"
],
"character": [
"呈紧缩感"
],
"core_name": "心前区不适",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "呼吸困难",
"tendency": ""
}
] |
244 |
腰椎mri(我院，2016-07-26）提示：腰4-5水平椎管内占位性病变，其上方椎管内可见较多迂曲血管影，请结合增强mri检查。
|
[
{
"anatomy_list": [
"腰椎L4-5水平椎管内"
],
"character": [
"占位性"
],
"core_name": "病变",
"tendency": ""
},
{
"anatomy_list": [
"腰椎L4-5水平上方椎管内"
],
"character": [
"较多",
"迂曲"
],
"core_name": "血管影",
"tendency": ""
}
] |
393 |
术后患者胆漏，引流管无液体引出，于10月15日局麻下行了腹腔穿刺引流术，术后恢复可；未促进瘘口好转，于10月25日咽部局麻下行了ercp术，但患者瘘口偏外，支架自行脱出，患者胆汁引流少。
|
[
{
"anatomy_list": [
"胆"
],
"character": [
"术后"
],
"core_name": "胆漏",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"引流管"
],
"core_name": "液体引出",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"未促进",
"好转"
],
"core_name": "瘘口",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"偏外"
],
"core_name": "瘘口",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"自行"
],
"core_name": "支架脱出",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"胆汁",
"少"
],
"core_name": "引流",
"tendency": ""
}
] |
1,614 |
请我院妇科妇检会诊后诊断“宫颈鳞癌iia期”。
|
[
{
"anatomy_list": [
"宫颈"
],
"character": [
"iia期"
],
"core_name": "鳞癌",
"tendency": ""
}
] |
179 |
某医院行脊柱mri（2020-1-22）：颈33/4-6/7椎间盘变性、突出；腰33/4椎间盘变性、突出；胸椎部分黄韧带增厚；腰2、3椎体及腹膜后异常信号，考虑转移；左侧中下腹部腹部占位性病变，考虑恶性肿瘤并腹膜后淋巴结转移可能，左肾积水。
|
[
{
"anatomy_list": [
"颈椎C3/4-6/7椎间盘"
],
"character": [],
"core_name": "变性",
"tendency": ""
},
{
"anatomy_list": [
"颈椎C3/4-6/7椎间盘"
],
"character": [],
"core_name": "突出",
"tendency": ""
},
{
"anatomy_list": [
"腰椎L3/4椎间盘"
],
"character": [],
"core_name": "变性",
"tendency": ""
},
{
"anatomy_list": [
"腰椎L3/4椎间盘"
],
"character": [],
"core_name": "突出",
"tendency": ""
},
{
"anatomy_list": [
"胸椎部分黄韧带"
],
"character": [
"部分"
],
"core_name": "增厚",
"tendency": ""
},
{
"anatomy_list": [
"腰椎L2、3椎体",
"腹膜后"
],
"character": [],
"core_name": "信号异常",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "转移",
"tendency": "不确定"
},
{
"anatomy_list": [
"左侧中下腹部"
],
"character": [
"占位性"
],
"core_name": "病变",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"恶性"
],
"core_name": "肿瘤",
"tendency": "不确定"
},
{
"anatomy_list": [
"腹膜后淋巴结"
],
"character": [],
"core_name": "转移",
"tendency": "不确定"
},
{
"anatomy_list": [
"左肾"
],
"character": [],
"core_name": "积水",
"tendency": ""
}
] |
1,090 |
2.（直肠）溃疡型中-低分化管状腺癌，浸及肠壁深肌层，脉管内见癌栓。
|
[
{
"anatomy_list": [
"直肠",
"直肠壁深肌层"
],
"character": [
"溃疡型",
"管状",
"中-低分化",
"浸及肠壁深肌层"
],
"core_name": "腺癌",
"tendency": ""
},
{
"anatomy_list": [
"脉管内"
],
"character": [],
"core_name": "癌栓",
"tendency": ""
}
] |
1,766 |
入院1+年前，患者洗澡时扪及右侧腋窝腋窝下一大小约4x5cm大小包块，质硬，表面光滑，活动度差，无压痛、分泌物，就诊于某医院，诊断乳腺癌并行右乳癌改良根治术。
|
[
{
"anatomy_list": [
"右侧腋窝下"
],
"character": [
"质硬",
"表面光滑",
"活动度差",
"无压痛",
"分泌物"
],
"core_name": "包块",
"tendency": ""
},
{
"anatomy_list": [
"乳腺"
],
"character": [],
"core_name": "癌",
"tendency": ""
}
] |
797 |
患者于2012-3-30日在全麻下行剖腹探查+胰十二指肠切除术，手术顺利，术后病理提示：1.壶腹部中分化腺癌，浸及肌层，脉管、神经未见癌侵犯，十二指肠、胰腺、胃未见癌累及，胃大弯淋巴结未见癌转移（0/1）；2.（胆总管）未见癌累及；3.慢性胆囊炎急性发作，胆囊多发性胆固醇性息肉，胆囊腺肌症；4.（肝门部淋巴结）未见癌转移（0/1）。
|
[
{
"anatomy_list": [
"壶腹部"
],
"character": [
"中分化",
"浸及肌层"
],
"core_name": "腺癌",
"tendency": ""
},
{
"anatomy_list": [
"脉管",
"神经"
],
"character": [
"侵犯"
],
"core_name": "癌",
"tendency": "否定"
},
{
"anatomy_list": [
"十二指肠",
"胰腺",
"胃"
],
"character": [
"累及"
],
"core_name": "癌",
"tendency": "否定"
},
{
"anatomy_list": [
"胃大弯淋巴结"
],
"character": [
"转移"
],
"core_name": "癌",
"tendency": "否定"
},
{
"anatomy_list": [
"胆总管"
],
"character": [
"累及"
],
"core_name": "癌",
"tendency": "否定"
},
{
"anatomy_list": [
"胆囊"
],
"character": [
"慢性",
"急性发作"
],
"core_name": "胆囊炎",
"tendency": ""
},
{
"anatomy_list": [
"胆囊"
],
"character": [
"多发性",
"胆固醇性"
],
"core_name": "息肉",
"tendency": ""
},
{
"anatomy_list": [
"胆囊"
],
"character": [],
"core_name": "腺肌症",
"tendency": ""
},
{
"anatomy_list": [
"肝门淋巴结"
],
"character": [
"转移"
],
"core_name": "癌",
"tendency": "否定"
}
] |
550 |
入院前3+年，患者无明显有诱因出现全身多关节肿痛，偶有晨僵，无明显皮肤潮红、皮温升高，无面部蝶形红斑、光敏反应，无雷诺现象，无反复口腔溃疡，无明显脱发，无畏寒、发热、寒战，无胸闷、心悸，无活动后心累、气促、夜间阵发性呼吸困难，无腰痛、少尿、肉眼血尿，无肢体水肿等表现，患者遂间断口服中药调理，关节肿痛可缓解，但反复发作，关节肿痛逐渐加重。
|
[
{
"anatomy_list": [
"全身",
"关节"
],
"character": [
"多"
],
"core_name": "肿痛",
"tendency": ""
},
{
"anatomy_list": [
"全身",
"关节"
],
"character": [
"偶有"
],
"core_name": "晨僵",
"tendency": ""
},
{
"anatomy_list": [
"皮肤"
],
"character": [
"明显"
],
"core_name": "潮红",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"升高",
"明显"
],
"core_name": "皮温",
"tendency": "否定"
},
{
"anatomy_list": [
"面部"
],
"character": [
"蝶形"
],
"core_name": "红斑",
"tendency": "否定"
},
{
"anatomy_list": [
"面部"
],
"character": [],
"core_name": "光敏反应",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "雷诺现象",
"tendency": "否定"
},
{
"anatomy_list": [
"口腔"
],
"character": [
"反复"
],
"core_name": "溃疡",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"明显"
],
"core_name": "脱发",
"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": [
"胸"
],
"character": [],
"core_name": "胸闷",
"tendency": "否定"
},
{
"anatomy_list": [
"心"
],
"character": [],
"core_name": "心悸",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"活动后"
],
"core_name": "心累",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"活动后"
],
"core_name": "气促",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"夜间",
"阵发性"
],
"core_name": "呼吸困难",
"tendency": "否定"
},
{
"anatomy_list": [
"腰"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "少尿",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "血尿",
"tendency": "否定"
},
{
"anatomy_list": [
"肢体"
],
"character": [],
"core_name": "水肿",
"tendency": "否定"
},
{
"anatomy_list": [
"关节"
],
"character": [
"可缓解"
],
"core_name": "肿痛",
"tendency": ""
},
{
"anatomy_list": [
"关节"
],
"character": [
"逐渐加重",
"反复发作"
],
"core_name": "肿痛",
"tendency": ""
}
] |
1,069 |
为进一步诊疗，患者于某医院复核提示：（左腹股沟）非霍奇金淋巴瘤，结合免疫组化符合弥漫大b细胞淋巴瘤（生发中心型），免疫组化：ck（-）、plap（-）、cd3散（+）、bcl-6（-）、mum-1散在（+）、cd20（+）、ki676760%（+）、ema（-）、alk（-）、melana（-）、s100（-）、cd30（-）、cd10（+）、lca（+）。
|
[
{
"anatomy_list": [
"左腹股沟",
"淋巴"
],
"character": [
"非霍奇金"
],
"core_name": "瘤",
"tendency": ""
},
{
"anatomy_list": [
"左腹股沟",
"淋巴",
"大B细胞"
],
"character": [
"弥漫性",
"生发中心型"
],
"core_name": "瘤",
"tendency": ""
}
] |
884 |
于2020-03-07就诊于我院感染科，肿瘤标志物ca19-9、cea明显升高，考虑胃肠道肿瘤，进一步完善全胸腹部增强ct：1、升结肠占位，考虑肿瘤性病变可能性大：结肠癌？伴肝内多发转移、邻近右侧膈肌膈肌受侵可能，腹膜后多发淋巴结显示伴部分增大，盆腔积液。
|
[
{
"anatomy_list": [],
"character": [
"明显升高"
],
"core_name": "肿瘤标志物ca19-9",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
""
],
"core_name": "肿瘤标志物cea",
"tendency": ""
},
{
"anatomy_list": [
"胃肠道"
],
"character": [],
"core_name": "肿瘤",
"tendency": "不确定"
},
{
"anatomy_list": [
"升结肠"
],
"character": [],
"core_name": "占位",
"tendency": ""
},
{
"anatomy_list": [
"升结肠"
],
"character": [
"肿瘤性"
],
"core_name": "病变",
"tendency": "不确定"
},
{
"anatomy_list": [
"结肠"
],
"character": [],
"core_name": "癌",
"tendency": "不确定"
},
{
"anatomy_list": [
"肝内"
],
"character": [
"多发"
],
"core_name": "转移",
"tendency": ""
},
{
"anatomy_list": [
"近邻右侧膈肌"
],
"character": [],
"core_name": "受侵",
"tendency": "不确定"
},
{
"anatomy_list": [
"腹膜后淋巴结"
],
"character": [
"部分"
],
"core_name": "增大",
"tendency": ""
},
{
"anatomy_list": [
"盆腔"
],
"character": [],
"core_name": "积液",
"tendency": ""
}
] |
485 |
建议至我科就诊，今日门诊以“结外边缘区淋巴瘤”收住院。
|
[
{
"anatomy_list": [
"结外边缘区",
"淋巴"
],
"character": [],
"core_name": "瘤",
"tendency": ""
}
] |
1,019 |
一个多月前患者感时有头昏、视物模糊，活动时加重，3天前晚上患者发作眩晕，视物旋转，伴右耳痛，休息后眩晕好转，但活动后仍感行走不稳。
|
[
{
"anatomy_list": [
"头"
],
"character": [
"时有",
"活动时加重"
],
"core_name": "头昏",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"时有",
"活动时加重"
],
"core_name": "视物模糊",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "眩晕",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "视物旋转",
"tendency": ""
},
{
"anatomy_list": [
"右耳"
],
"character": [],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"休息后好转"
],
"core_name": "眩晕",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"不稳",
"活动后"
],
"core_name": "行走",
"tendency": ""
}
] |
476 |
患者平素日常活动后无明显气促、喘累，无夜间阵发性呼吸困难，不咳粉红色泡沫痰。
|
[
{
"anatomy_list": [],
"character": [
"活动后",
"明显"
],
"core_name": "气促",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"活动后",
"明显"
],
"core_name": "喘累",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"夜间",
"阵发性"
],
"core_name": "呼吸困难",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"粉红色",
"泡沫痰"
],
"core_name": "咳痰",
"tendency": "否定"
}
] |
341 |
伴肛门坠胀 ， 不伴肛门肿物脱出 ， 不伴眩晕、黑蒙 ， 患者不伴纳差、乏力 ， 不伴恶心、呕吐 ， 不伴畏寒、发热 ， 不伴反酸、嗳气 ， 无咳嗽、咳痰 ， 无胸闷、心悸 ， 无尿频、尿急、尿痛 ， 不伴腹胀等症状 。
|
[
{
"anatomy_list": [
"肛门"
],
"character": [],
"core_name": "坠胀",
"tendency": ""
},
{
"anatomy_list": [
"肛门"
],
"character": [],
"core_name": "肿物脱出",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "眩晕",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "黑朦",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "纳差",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "乏力",
"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": [],
"character": [],
"core_name": "反酸",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "嗳气",
"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": [],
"character": [],
"core_name": "尿痛",
"tendency": "否定"
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "腹胀",
"tendency": "否定"
}
] |
90 |
5年前患者于外院行辅助检查提示“肝硬化”诊断（具体不详），遵医嘱予以“替比夫定”抗病毒治疗，后患者于我院门诊复诊后调整为口服“恩替卡韦”抗病毒治疗。
|
[
{
"anatomy_list": [
"肝"
],
"character": [],
"core_name": "硬化",
"tendency": ""
}
] |
1,834 |
4月前患者感头昏症状加重，每日早晨及午睡后头昏较轻，此后1-2小时后头昏症状逐渐加重，感夜间头昏症状最明显，偶有自觉行走站立不稳，并诉头昏严重时自测血压159/95mmHg，头昏缓解时血压139/85mmHg，无恶心、呕吐、眩晕、耳鸣、头痛、单侧肢体乏力、黑蒙、手抖、饮水呛咳等，今日患者仍感上诉症状无明显缓解，未进一步治疗，遂入我科。
|
[
{
"anatomy_list": [
"头"
],
"character": [
"加重"
],
"core_name": "头昏",
"tendency": ""
},
{
"anatomy_list": [
"头"
],
"character": [
"早晨及午睡后较轻",
"此后1-2小时后逐渐加重"
],
"core_name": "头昏",
"tendency": ""
},
{
"anatomy_list": [
"头"
],
"character": [
"夜间最明显"
],
"core_name": "头昏",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"偶有"
],
"core_name": "站立不稳",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"偶有"
],
"core_name": "行走不稳",
"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": "眩晕",
"tendency": "否定"
},
{
"anatomy_list": [
"耳"
],
"character": [],
"core_name": "耳鸣",
"tendency": "否定"
},
{
"anatomy_list": [
"头"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [
"单侧肢体"
],
"character": [],
"core_name": "乏力",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "黑朦",
"tendency": "否定"
},
{
"anatomy_list": [
"手"
],
"character": [],
"core_name": "手抖",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"饮水"
],
"core_name": "呛咳",
"tendency": "否定"
}
] |
570 |
纤支镜检查：右上叶支气管被新生物完全阻塞，新生物表现血管迂曲、丰富，周围粘膜呈浸润样改变，累计右侧亚隆突、中间支气管，于镜下活检，病理活检及免疫组化：<右支气管>恶性肿瘤，结合组织学形态，倾向于小细胞癌，免疫组化：ck（+），ema（+），napsina（-），p63（-），p40（-），cga（+），syn（+），cd56（+），ki6790%（+），ttf-1（+）。
|
[
{
"anatomy_list": [
"右上叶支气管"
],
"character": [
"完全",
"被新生物"
],
"core_name": "阻塞",
"tendency": ""
},
{
"anatomy_list": [
"右上叶支气管"
],
"character": [
"血管迂曲",
"血管丰富",
"累及右侧亚隆突、中间支气管"
],
"core_name": "新生物",
"tendency": ""
},
{
"anatomy_list": [
"右上叶支气管周围粘膜"
],
"character": [
"浸润样"
],
"core_name": "改变",
"tendency": ""
},
{
"anatomy_list": [
"右支气管"
],
"character": [
"恶性"
],
"core_name": "肿瘤",
"tendency": ""
},
{
"anatomy_list": [
"右支气管",
"小细胞"
],
"character": [],
"core_name": "癌",
"tendency": "不确定"
}
] |
938 |
入院前2+年，患者无明显诱因出现右下肢不自主抖动、麻木、僵硬，无头痛、呕吐，无肢体活动障碍，无意识障碍、大小便失禁，无失语、幻听等不适，后患者觉上述症状加重，2018-6-6就诊于某医院，行头颅ct示左侧额、顶叶占位，2018-6-9就诊于某医院行胸部ct示：右肺上叶新生物，大小约2.0*2.4cm，纵膈内见稍大淋巴结。
|
[
{
"anatomy_list": [
"右下肢"
],
"character": [
"不自主"
],
"core_name": "抖动",
"tendency": ""
},
{
"anatomy_list": [
"右下肢"
],
"character": [],
"core_name": "麻木",
"tendency": ""
},
{
"anatomy_list": [
"右下肢"
],
"character": [],
"core_name": "僵硬",
"tendency": ""
},
{
"anatomy_list": [
"头"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "呕吐",
"tendency": "否定"
},
{
"anatomy_list": [
"肢体"
],
"character": [],
"core_name": "活动障碍",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "意识障碍",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"失禁"
],
"core_name": "大小便",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "失语",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "幻听",
"tendency": "否定"
},
{
"anatomy_list": [
"左侧额叶"
],
"character": [],
"core_name": "占位",
"tendency": ""
},
{
"anatomy_list": [
"左侧顶叶"
],
"character": [],
"core_name": "占位",
"tendency": ""
},
{
"anatomy_list": [
"右肺上叶"
],
"character": [],
"core_name": "新生物",
"tendency": ""
},
{
"anatomy_list": [
"纵膈内"
],
"character": [
"稍大"
],
"core_name": "淋巴结大",
"tendency": ""
}
] |
753 |
完善ect检查提示骨转移，征得患者及其家属同意后，分别于2015-01-22、2015-02-12、2015-03-11、2015-04-01、2015-04-22、2015-05-13、2015-06-10、2015-07-08予以tp方案化疗8周期，期间曾复查提示肿瘤较前缩小，但未达cr，评估为sd，8期化疗结束后复查ct(2015-07-12):1.右下肺肺门肿块影，考虑肿瘤性病变，伴阻塞性肺炎。
|
[
{
"anatomy_list": [
"骨"
],
"character": [
"转移"
],
"core_name": "转移",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"较前缩小",
"未达cr",
"评估为sd"
],
"core_name": "肿瘤",
"tendency": ""
},
{
"anatomy_list": [
"右下肺门"
],
"character": [],
"core_name": "肿块影",
"tendency": ""
},
{
"anatomy_list": [
"右下肺门"
],
"character": [
"肿瘤性"
],
"core_name": "病变",
"tendency": "不确定"
},
{
"anatomy_list": [
"肺"
],
"character": [
"阻塞性"
],
"core_name": "肺炎",
"tendency": ""
}
] |
1,875 |
15天前，患者无明显诱因出现中上腹上腹痛，为阵发性隐痛，疼痛程度较轻，患者尚可忍受，疼痛持续时间约1分1分钟后自行缓解，与体位变化、进食无关，伴后背部放射痛，伴恶心、嗳气，无呕吐、呃逆，无胸痛、胸闷、心前区压榨感，无烧心、反酸、腹胀，无呕血、黑便、血便，无畏寒、发热、黄疸等症状，患者未重视。
|
[
{
"anatomy_list": [
"中上腹"
],
"character": [],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"中上腹"
],
"character": [
"阵发性",
"隐痛"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"腹部"
],
"character": [
"程度较轻",
"可忍受"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"腹部"
],
"character": [
"约1分钟后自行缓解",
"与体位变化、进食无关"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"后背部"
],
"character": [
"放射性"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "恶心",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "嗳气",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "呕吐",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "打嗝",
"tendency": "否定"
},
{
"anatomy_list": [
"胸"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [
"胸"
],
"character": [],
"core_name": "胸闷",
"tendency": "否定"
},
{
"anatomy_list": [
"心前区"
],
"character": [],
"core_name": "压榨感",
"tendency": "否定"
},
{
"anatomy_list": [
"心"
],
"character": [],
"core_name": "烧心",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "返酸",
"tendency": "否定"
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "腹胀",
"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": "血便",
"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": "黄疸",
"tendency": "否定"
}
] |
489 |
术后病检（123456）结果回报：（左乳）浸润性癌，非特殊类型，Ⅱ级7分。
|
[
{
"anatomy_list": [
"左乳"
],
"character": [
"浸润性",
"非特殊类型",
"Ⅱ级7分"
],
"core_name": "癌",
"tendency": ""
}
] |
1,340 |
<门静脉右支血管壁>未见癌组织。
|
[
{
"anatomy_list": [
"门静脉右支血管壁"
],
"character": [],
"core_name": "癌组织",
"tendency": "否定"
}
] |
1,799 |
自发病以来，患者精神、食欲尚可，嗜睡，大便、大便正常，小便夜尿次数多，约4~5次。
|
[
{
"anatomy_list": [],
"character": [
"尚可"
],
"core_name": "精神",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"尚可"
],
"core_name": "食欲",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "嗜睡",
"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": "夜尿次数多",
"tendency": ""
}
] |
1,235 |
急诊科请我科会诊后以“肠扭转”收入我科。
|
[
{
"anatomy_list": [
"肠"
],
"character": [],
"core_name": "扭转",
"tendency": ""
}
] |
921 |
无明显腰腹部疼痛，无畏寒、发热，无尿频、尿急、尿痛，无血尿，无恶心、呕吐，无腹胀、腹泻等临床表现。
|
[
{
"anatomy_list": [
"腰",
"腹"
],
"character": [],
"core_name": "疼痛",
"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": "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": "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": "腹泻",
"tendency": "否定"
}
] |
1,133 |
2、肝内外胆管多发结石，胆囊增大伴胆囊底部结石可能。
|
[
{
"anatomy_list": [
"肝内外胆管"
],
"character": [
"多发"
],
"core_name": "结石",
"tendency": ""
},
{
"anatomy_list": [
"胆囊"
],
"character": [],
"core_name": "增大",
"tendency": "不确定"
},
{
"anatomy_list": [
"胆囊底部"
],
"character": [],
"core_name": "结石",
"tendency": "不确定"
}
] |
1,878 |
入院前10年，患者无明显诱因出现烦渴、多饮、多尿，每日饮水量3000ml，饮水量与尿量相当，伴全身乏力乏力不适，无双下肢麻木，无易饥多食，无视物模糊，无腹痛、腹泻，无心前区疼痛、活动后心累、气促，大便正常，患者于某医院就诊，查得血糖高（具体不详），诊断为2型糖尿病（具体不详），给予二甲双胍、消渴丸等降糖治疗(具体方案及剂量不详），服药期间未规律监测血糖，期间患者偶测得血糖偏高。
|
[
{
"anatomy_list": [],
"character": [],
"core_name": "烦渴",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "多饮",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "多尿",
"tendency": ""
},
{
"anatomy_list": [
"全身"
],
"character": [],
"core_name": "乏力",
"tendency": ""
},
{
"anatomy_list": [
"全身"
],
"character": [],
"core_name": "全身不适",
"tendency": ""
},
{
"anatomy_list": [
"双下肢"
],
"character": [],
"core_name": "麻木",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "易饥多食",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "视物模糊",
"tendency": "否定"
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "腹泻",
"tendency": "否定"
},
{
"anatomy_list": [
"心前区"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [
"心"
],
"character": [
"活动后"
],
"core_name": "心累",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"活动后"
],
"core_name": "气促",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"正常"
],
"core_name": "大便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"偏高"
],
"core_name": "血糖",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"2型"
],
"core_name": "糖尿病",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"高"
],
"core_name": "血糖",
"tendency": ""
}
] |
1,496 |
入院前6+月，患者无明显诱因出现头昏、乏力，伴活动后心累、气促，伴视物模糊，无头痛、晕厥，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，于某医院就诊，完善血常规考虑诊断为“重度贫血原因待查”，予以输血等对症治疗（具体不详）后患者头昏、乏力症状稍好转，但贫血原因未明确，建议转上级医院治疗。
|
[
{
"anatomy_list": [
"头"
],
"character": [],
"core_name": "头昏",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "乏力",
"tendency": ""
},
{
"anatomy_list": [
"心"
],
"character": [
"活动后"
],
"core_name": "心累",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"活动后"
],
"core_name": "气促",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "视物模糊",
"tendency": ""
},
{
"anatomy_list": [
"头"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "晕厥",
"tendency": "否定"
},
{
"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": [
"重度"
],
"core_name": "贫血",
"tendency": "不确定"
},
{
"anatomy_list": [
"头"
],
"character": [
"稍好转"
],
"core_name": "头昏",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"稍好转"
],
"core_name": "乏力",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "贫血",
"tendency": ""
}
] |
2,023 |
症状未见明显好转，于今日来我院就诊，门诊以“前列腺癌”收入我科治疗。
|
[
{
"anatomy_list": [
"前列腺"
],
"character": [],
"core_name": "癌",
"tendency": ""
}
] |
1,619 |
胸部ct平扫：1.右肺下叶前基底段实性结节，右肺中叶血管旁及胸膜下、右肺下叶背段微结节，建议随诊。
|
[
{
"anatomy_list": [
"右肺下叶前基底段"
],
"character": [
"实性"
],
"core_name": "结节",
"tendency": ""
},
{
"anatomy_list": [
"右肺旁下下叶背段"
],
"character": [
"微"
],
"core_name": "结节",
"tendency": ""
},
{
"anatomy_list": [
"右肺中叶血管旁"
],
"character": [
"微"
],
"core_name": "结节",
"tendency": ""
},
{
"anatomy_list": [
"胸膜下"
],
"character": [
"微"
],
"core_name": "结节",
"tendency": ""
}
] |
1,696 |
否认关节疼痛、脱发、皮疹病史。
|
[
{
"anatomy_list": [
"关节"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "脱发",
"tendency": "否定"
},
{
"anatomy_list": [
"皮"
],
"character": [],
"core_name": "皮疹",
"tendency": "否定"
}
] |
1,666 |
常规病理检查报告：肝组织内恶性肿瘤，待免疫组化进一步检查确诊。周围肝组织部分区域脂肪变。
|
[
{
"anatomy_list": [
"肝组织内"
],
"character": [
"恶性"
],
"core_name": "肿瘤",
"tendency": ""
},
{
"anatomy_list": [
"周围肝组织"
],
"character": [
"部分区域"
],
"core_name": "脂肪变",
"tendency": ""
}
] |
1,505 |
入院前2+月患儿因出血、贫血及发热在我院经骨髓micm分型确诊为确诊急性普通b淋巴细胞淋巴细胞白血病l11型（tel/aml1阳性，低危）。
|
[
{
"anatomy_list": [],
"character": [],
"core_name": "出血",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "贫血",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "发热",
"tendency": ""
},
{
"anatomy_list": [
"b淋巴细胞"
],
"character": [
"急性",
"普通",
"l11型",
"tel/aml1阳性",
"低危"
],
"core_name": "白血病",
"tendency": ""
}
] |
84 |
术后病理示：左乳浸润性导管癌（Ⅲ级，8分）腋窝淋巴结未见癌转移（0/13）。
|
[
{
"anatomy_list": [
"左乳"
],
"character": [
"浸润性"
],
"core_name": "导管癌",
"tendency": ""
},
{
"anatomy_list": [
"腋窝淋巴结"
],
"character": [
"转移"
],
"core_name": "癌",
"tendency": "否定"
}
] |
127 |
入院前3月，患者因“发现左乳包块2+年”入院。
|
[
{
"anatomy_list": [
"左乳"
],
"character": [],
"core_name": "包块",
"tendency": ""
}
] |
158 |
3+年患者无明显诱因出现腰臀部阵发性胀痛，久行、弯腰可诱发疼痛加重，休息后减轻，无双下肢麻木、疼痛和乏力，无尿频、尿急及肉眼血尿，当时曾在我科就诊，经行腰椎mri等检查后，诊断为“腰椎间盘突出症”，自行在外理疗后缓解，7天前，患者上述症状无明显诱因加重，并伴左下肢疼痛，于今日来我科诊治，门诊以"胸背部疼痛待查"收入住院。
|
[
{
"anatomy_list": [
"腰部",
"臀部"
],
"character": [
"阵发性",
"胀痛",
"久行弯腰可诱发加重",
"休息后减轻"
],
"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": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [
"双下肢"
],
"character": [],
"core_name": "乏力",
"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": "血尿",
"tendency": "否定"
},
{
"anatomy_list": [
"腰椎间盘"
],
"character": [],
"core_name": "突出",
"tendency": ""
},
{
"anatomy_list": [
"左下肢"
],
"character": [],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"胸背部"
],
"character": [],
"core_name": "疼痛",
"tendency": "不确定"
}
] |
1,374 |
后患者双下肢水肿反复发作。
|
[
{
"anatomy_list": [
"双下肢"
],
"character": [
"反复发作"
],
"core_name": "水肿",
"tendency": ""
}
] |
1,210 |
7.双侧盆壁、腹股沟区淋巴结肿大。
|
[
{
"anatomy_list": [
"双侧盆壁淋巴结",
"腹股沟区淋巴结"
],
"character": [],
"core_name": "肿大",
"tendency": ""
}
] |
1,388 |
入院前3+月患者因受凉后开始出现声嘶，为间断性，伴咽喉部不适、咽喉部异物感，无咳嗽、咳痰，无咽喉疼痛、咯血、胸痛、呼吸困难、吞咽梗阻、吞咽疼痛等症状，声嘶在长时间说话加重，休息后声嘶可稍缓解。
|
[
{
"anatomy_list": [],
"character": [
"间断性"
],
"core_name": "声嘶",
"tendency": ""
},
{
"anatomy_list": [
"咽喉部"
],
"character": [],
"core_name": "咽喉部不适",
"tendency": ""
},
{
"anatomy_list": [
"咽喉部"
],
"character": [],
"core_name": "异物感",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "咳嗽",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "咳痰",
"tendency": "否定"
},
{
"anatomy_list": [
"咽喉"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "咯血",
"tendency": "否定"
},
{
"anatomy_list": [
"胸"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "呼吸困难",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"吞咽"
],
"core_name": "梗阻",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"吞咽"
],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"休息后稍缓解",
"长时间说话加重"
],
"core_name": "声嘶",
"tendency": ""
}
] |
332 |
患者昨日已解出大便4次。
|
[
{
"anatomy_list": [],
"character": [
"4次"
],
"core_name": "大便",
"tendency": ""
}
] |
799 |
3天前，患者无明显诱因出现腰背部疼痛，呈持续性胀痛，疼痛明显，翻身、起床、睡下困难。
|
[
{
"anatomy_list": [
"腰背部"
],
"character": [],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"持续性",
"胀痛"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"明显"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "翻身困难",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "起床困难",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "睡下困难",
"tendency": ""
}
] |
1,451 |
2016年6月患者随访复查ct提示局部病灶增大，afp异常升高（具体不详），遂入某医院，行肝右叶肿瘤切除术（具体不详），术后病检提示原发性肝细胞性腺癌（未见原报告）。
|
[
{
"anatomy_list": [],
"character": [
"局部",
"增大"
],
"core_name": "病灶",
"tendency": ""
},
{
"anatomy_list": [
"肝"
],
"character": [
"原发性",
"肝细胞性"
],
"core_name": "腺癌",
"tendency": ""
}
] |
1,535 |
2+月前，患者出现胸痛，为持续性胀痛，无明显加重及缓解因素，伴咳嗽、咳痰，考虑诊断为“左肺鳞癌4周期化疗后伴纵膈淋巴结、肺内、骨转移”，给予口服“羟考酮”对症处理，患者仍诉胸痛明显，“羟考酮”剂量逐日增加至240mg q12h，其胸痛仍缓解不明显，后于我院住院治疗给予皮下注射“盐酸吗啡注射液 50mg q12h”后疼痛缓解。
|
[
{
"anatomy_list": [
"胸"
],
"character": [
"持续性胀痛",
"无明显加重及缓解因素"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "咳痰",
"tendency": ""
},
{
"anatomy_list": [
"左肺"
],
"character": [
"化疗后"
],
"core_name": "鳞癌",
"tendency": "不确定"
},
{
"anatomy_list": [
"纵膈淋巴结",
"肺内",
"骨"
],
"character": [
"转移"
],
"core_name": "癌",
"tendency": "不确定"
},
{
"anatomy_list": [
"胸"
],
"character": [
"明显"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"胸"
],
"character": [
"明显缓解"
],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [
"胸"
],
"character": [
"缓解"
],
"core_name": "疼痛",
"tendency": ""
}
] |
845 |
病程中否认四肢麻木、疼痛、感觉异常、腹泻与便秘交替，间断足靴区溃疡，无意识丧失，无头晕、头痛、胡言乱语，无胸闷、胸痛、心悸等不适。
|
[
{
"anatomy_list": [
"四肢"
],
"character": [],
"core_name": "麻木",
"tendency": "否定"
},
{
"anatomy_list": [
"四肢"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [
"四肢"
],
"character": [
"异常"
],
"core_name": "感觉",
"tendency": "否定"
},
{
"anatomy_list": [
"腹"
],
"character": [
"与便秘交替"
],
"core_name": "腹泻",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"与腹泻交替"
],
"core_name": "便秘",
"tendency": "否定"
},
{
"anatomy_list": [
"足靴区"
],
"character": [
"间断"
],
"core_name": "溃疡",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "意识丧失",
"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": "胡言乱语",
"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": [
"心"
],
"character": [],
"core_name": "心悸",
"tendency": "否定"
}
] |
1,413 |
左右淋巴结未见癌转移。
|
[
{
"anatomy_list": [
"左右淋巴结"
],
"character": [
"转移"
],
"core_name": "癌",
"tendency": "否定"
}
] |
1,622 |
4.双肺门肺门及纵隔淋巴结淋巴结钙化。较2020-07-39片变化不明显。
|
[
{
"anatomy_list": [
"双肺门淋巴结",
"纵隔淋巴结"
],
"character": [],
"core_name": "钙化",
"tendency": ""
}
] |
654 |
起病以来，患者精神、食欲、睡眠可，大便正常，小便量少，体重未见明显下降。
|
[
{
"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": [
"正常"
],
"core_name": "大便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"量少"
],
"core_name": "小便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"明显"
],
"core_name": "体重下降",
"tendency": "否定"
}
] |
1,422 |
入院前5余月，患者无明显诱因出现左侧牙龈疼痛，伴左侧一颗下磨牙松动，患者自行拔除，疼痛缓解，但疼痛反复，于当地医院间断输液治疗，疗效差，期间逐渐出现张口受限，仍未重视。
|
[
{
"anatomy_list": [
"左侧牙龈"
],
"character": [],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"左侧下磨牙"
],
"character": [
"一颗"
],
"core_name": "松动",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"缓解",
"反复"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"逐渐出现"
],
"core_name": "张口受限",
"tendency": ""
}
] |
1,723 |
遂至我院就诊，行上腹部ct提示“小肝癌”，遂于2017-12-12行肝肿瘤射频消融术，术后予以保肝、止血、抑酸等治疗，患者恢复可，遂出院。出院期间患者未出现何不适。
|
[
{
"anatomy_list": [
"肝"
],
"character": [
"小"
],
"core_name": "癌",
"tendency": ""
}
] |
1,084 |
半余年前患者无明显诱因下开始出现活动后胸痛、心悸、胸闷不适症状，爬坡、爬楼、快走、劳动等中等量体力活动后出现上述不适加重，每次持续约5-10分钟，休息后可缓解；当时无肩背部放射痛、乏力、端坐呼吸，无头晕、头痛，无恶心、呕吐、反酸、烧心等不适症状；患者未重视，未正规治疗。
|
[
{
"anatomy_list": [
"胸"
],
"character": [
"活动后加重",
"爬坡、爬楼、快走、劳动等中等量体力活动后加重",
"休息后缓解",
"每次持续约5-10分钟"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"心"
],
"character": [
"活动后加重",
"爬坡、爬楼、快走、劳动等中等量体力活动后加重",
"休息后缓解",
"每次持续约5-10分钟"
],
"core_name": "心悸",
"tendency": ""
},
{
"anatomy_list": [
"胸"
],
"character": [
"活动后加重",
"爬坡、爬楼、快走、劳动等中等量体力活动后加重",
"休息后缓解",
"每次持续约5-10分钟"
],
"core_name": "胸闷",
"tendency": ""
},
{
"anatomy_list": [
"肩背部"
],
"character": [
"放射性"
],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "乏力",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "端坐呼吸",
"tendency": "否定"
},
{
"anatomy_list": [
"头"
],
"character": [],
"core_name": "头晕",
"tendency": "否定"
},
{
"anatomy_list": [
"头"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "恶心",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "呕吐",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "反酸",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "烧心",
"tendency": "否定"
}
] |
652 |
肝功示：谷丙转氨酶71U/L，谷草转氨酶88U/L，谷酰转肽酶94U/L，总胆汁酸80.6umol/L，总胆红素46.5umol/L，白蛋白28.9g/L；泌尿系彩超：左侧输尿管上段结石伴左肾重度积水。
|
[
{
"anatomy_list": [
"左侧输尿管上段"
],
"character": [],
"core_name": "结石",
"tendency": ""
},
{
"anatomy_list": [
"左肾"
],
"character": [
"重度"
],
"core_name": "积水",
"tendency": ""
}
] |
1,793 |
于2013年9月13日入我院泌尿外科行下腹部增强ct:前列腺右侧外腺区肿块考虑前列腺癌并精囊腺侵犯，盆腔淋巴结转移；全身骨骨扫描spect/ct图像融合提示：右肱骨上段放射性浓聚区见局部骨密度明显增强，局部骨皮质中断；胸椎及肋骨放射性浓聚区见局部骨密度明显增强。
|
[
{
"anatomy_list": [
"前列腺右侧外腺区"
],
"character": [],
"core_name": "肿块",
"tendency": ""
},
{
"anatomy_list": [
"前列腺"
],
"character": [],
"core_name": "癌",
"tendency": "不确定"
},
{
"anatomy_list": [
"精囊腺"
],
"character": [],
"core_name": "侵犯",
"tendency": "不确定"
},
{
"anatomy_list": [
"盆腔淋巴结"
],
"character": [],
"core_name": "转移",
"tendency": ""
},
{
"anatomy_list": [
"右肱骨上段放射性浓聚区"
],
"character": [
"明显",
"局部"
],
"core_name": "骨密度增强",
"tendency": ""
},
{
"anatomy_list": [
"右肱骨上段局部骨皮质"
],
"character": [
"局部"
],
"core_name": "骨皮质中断",
"tendency": ""
},
{
"anatomy_list": [
"胸椎放射性浓聚区",
"肋骨放射性浓聚区"
],
"character": [
"放射性浓聚区",
"明显增强",
"局部"
],
"core_name": "骨密度增强",
"tendency": ""
}
] |
448 |
近期患者自觉症状明显，并伴有右侧耳前耳前疼痛疼痛不适，可触及肿大包块，不伴有面颊部麻木，口角歪斜，无发热、咳嗽，无口角流涎等不适。
|
[
{
"anatomy_list": [
"右侧耳前"
],
"character": [],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"右侧耳前"
],
"character": [],
"core_name": "肿大包块",
"tendency": ""
},
{
"anatomy_list": [
"面颊"
],
"character": [],
"core_name": "麻木",
"tendency": "否定"
},
{
"anatomy_list": [
"口角"
],
"character": [],
"core_name": "歪斜",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "发热",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "咳嗽",
"tendency": "否定"
},
{
"anatomy_list": [
"口角"
],
"character": [],
"core_name": "流涎",
"tendency": "否定"
}
] |
904 |
无明确外伤史，右下肢稍肿，无关节红肿。
|
[
{
"anatomy_list": [
"右下肢"
],
"character": [
"稍"
],
"core_name": "肿",
"tendency": ""
},
{
"anatomy_list": [
"关节"
],
"character": [],
"core_name": "红肿",
"tendency": "否定"
}
] |
1,832 |
入院前10+年患者无明显诱因反复感头昏不适，头部昏沉感，发作时伴有肢体乏力表现，自诉既往于重医诊断为“腔隙性脑梗死”，平素口服“强力定眩片”等药物治疗。
|
[
{
"anatomy_list": [
"头"
],
"character": [
"反复"
],
"core_name": "头昏",
"tendency": ""
},
{
"anatomy_list": [
"头"
],
"character": [
"反复"
],
"core_name": "头不适",
"tendency": ""
},
{
"anatomy_list": [
"头部"
],
"character": [],
"core_name": "昏沉感",
"tendency": ""
},
{
"anatomy_list": [
"肢体"
],
"character": [
"发作时"
],
"core_name": "乏力",
"tendency": ""
},
{
"anatomy_list": [
"脑"
],
"character": [
"腔隙性"
],
"core_name": "梗死",
"tendency": ""
}
] |
1,149 |
为进一步明确诊治患者就诊于某医院行“化疗”，此后半年间患者先后3次就诊于某医院进行相关化疗（具体不详），吞咽困难逐渐加重，现仅能进流质，今日患者因自身原因就诊我院门诊，门诊以“食道癌”收入我科。
|
[
{
"anatomy_list": [],
"character": [
"逐渐加重"
],
"core_name": "吞咽困难",
"tendency": ""
},
{
"anatomy_list": [
"食道"
],
"character": [],
"core_name": "癌",
"tendency": ""
}
] |
669 |
患者本次发病以来，食欲欠佳，神志、精神可，睡眠欠佳，大便如常，夜尿次数增多，体重无明显改变。
|
[
{
"anatomy_list": [],
"character": [
"欠佳"
],
"core_name": "食欲",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"可"
],
"core_name": "神志",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"可"
],
"core_name": "精神",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"欠佳"
],
"core_name": "睡眠质量",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"如常"
],
"core_name": "大便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "夜尿次数增多",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"明显"
],
"core_name": "体重改变",
"tendency": "否定"
}
] |
716 |
患者目前病情稳定，患者出院后无明显恶心呕吐、胃寒发热，患者拟行第一次术后化疗入院。
|
[
{
"anatomy_list": [],
"character": [
"明显"
],
"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"
}
] |
1,363 |
患者本人及家属要求回当地医院治疗，故来我院，以“左肺非小细胞癌”收入我科。
|
[
{
"anatomy_list": [
"左肺"
],
"character": [
"非小细胞"
],
"core_name": "癌",
"tendency": ""
}
] |
1,087 |
入院前1月患者于无明显诱因出现进食辛辣食物后不适，表现为上腹轻微胀痛，伴反酸烧心，偶有黑便，无恶心、呕吐，无腹泻及大便次数改变,无畏寒发热，无咯血胸痛、无胸闷心悸、气促，无双下肢水肿，入院前2天，患者受凉出现咳嗽、咳痰，可咳出少量白色粘液痰，伴双下肢水肿，伴纳差乏力，无四肢酸痛，无消瘦乏力，无咯血胸痛，于今日来我院就诊，为进一步治疗，门诊以"上腹不适待查"收入我科住院治疗。
|
[
{
"anatomy_list": [
"上腹"
],
"character": [
"轻微",
"胀痛"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "反酸",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "烧心",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"偶有"
],
"core_name": "黑便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "恶心",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "呕吐",
"tendency": "否定"
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "腹泻",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"次数改变"
],
"core_name": "大便",
"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": "咯血",
"tendency": "否定"
},
{
"anatomy_list": [
"胸"
],
"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": "气促",
"tendency": "否定"
},
{
"anatomy_list": [
"双下肢"
],
"character": [],
"core_name": "水肿",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"受凉"
],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"白色",
"少量",
"粘液",
"受凉"
],
"core_name": "咳痰",
"tendency": ""
},
{
"anatomy_list": [
"双下肢"
],
"character": [],
"core_name": "水肿",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "纳差",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "乏力",
"tendency": ""
},
{
"anatomy_list": [
"四肢"
],
"character": [
"酸痛"
],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "消瘦",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "乏力",
"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": [
"上腹"
],
"character": [],
"core_name": "上腹不适",
"tendency": ""
}
] |
1,853 |
入院前20天，患者因“大便习惯改变伴大便带血6月，加重2月。
|
[
{
"anatomy_list": [],
"character": [],
"core_name": "大便习惯改变",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"带血"
],
"core_name": "大便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"加重"
],
"core_name": "大便习惯改变",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"带血",
"加重"
],
"core_name": "大便",
"tendency": ""
}
] |
866 |
无粘液血便、呕血，无恶心、呕吐，无反酸、嗳气，无腹胀、腹痛，无黑朦、乏力等不适。
|
[
{
"anatomy_list": [],
"character": [
"粘液"
],
"core_name": "血便",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "呕血",
"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": "反酸",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "嗳气",
"tendency": "否定"
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "腹胀",
"tendency": "否定"
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "黑朦",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "乏力",
"tendency": "否定"
}
] |
864 |
4+天患者自诉上述症状加重，伴声嘶不适，患者为进一步诊治遂就诊我科门诊行电子鼻咽喉镜检查提示：鼻中隔偏曲/鼻咽部膨隆待查/慢性咽喉炎/双侧声带息肉，建议住院治疗，患者因自身原因未住院，今日患者再次就诊我科要求住院，门诊即以"喉新生物、鼻咽部新生物"收入院治疗。
|
[
{
"anatomy_list": [],
"character": [],
"core_name": "声嘶",
"tendency": ""
},
{
"anatomy_list": [
"鼻中隔"
],
"character": [],
"core_name": "偏曲",
"tendency": ""
},
{
"anatomy_list": [
"鼻咽部"
],
"character": [],
"core_name": "膨隆",
"tendency": ""
},
{
"anatomy_list": [
"咽",
"喉"
],
"character": [
"慢性"
],
"core_name": "咽喉炎",
"tendency": ""
},
{
"anatomy_list": [
"双侧声带"
],
"character": [],
"core_name": "息肉",
"tendency": ""
},
{
"anatomy_list": [
"喉"
],
"character": [],
"core_name": "新生物",
"tendency": ""
},
{
"anatomy_list": [
"鼻咽部"
],
"character": [],
"core_name": "新生物",
"tendency": ""
}
] |
557 |
今晨院外自行使用“开塞露”，能解少量大便，无黑便、血便、粘液便。
|
[
{
"anatomy_list": [],
"character": [
"少量"
],
"core_name": "大便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "黑便",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "血便",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"粘液性"
],
"core_name": "大便",
"tendency": "否定"
}
] |
1,916 |
5+月前，患者上述症状反复出现并加重，并出现喘息、咳痰，痰不易咳出，遂到我科就诊，ct检查（123456):右侧枕叶结节，结合病史，考虑转移性肿瘤；左肺门区占位性病变，考虑肺癌伴左肺阻塞性肺不张、左肺门淋巴结肿大；左侧胸腔积液；右肺上叶局部肺气肿（小叶中心型）；右肺细小结节，尘肺？；右肺上叶及斜裂结节，转移性肿瘤可能；肝脏多发环形强化强化结节，系转移性肿瘤；右肾占位性病变，考虑肿瘤性病变，肾癌？；左肾小结石；左侧肾上腺结节，结合病史，考虑转移性肿瘤。
|
[
{
"anatomy_list": [],
"character": [],
"core_name": "气喘",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "咳痰",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"不易咳出"
],
"core_name": "咳痰",
"tendency": ""
},
{
"anatomy_list": [
"右侧枕叶"
],
"character": [],
"core_name": "结节",
"tendency": ""
},
{
"anatomy_list": [
"右侧枕叶"
],
"character": [
"转移性"
],
"core_name": "肿瘤",
"tendency": "不确定"
},
{
"anatomy_list": [
"左肺门区"
],
"character": [
"占位性"
],
"core_name": "病变",
"tendency": ""
},
{
"anatomy_list": [
"肺"
],
"character": [],
"core_name": "癌",
"tendency": ""
},
{
"anatomy_list": [
"左肺"
],
"character": [
"阻塞性"
],
"core_name": "肺不张",
"tendency": ""
},
{
"anatomy_list": [
"左肺门淋巴结"
],
"character": [],
"core_name": "肿大",
"tendency": ""
},
{
"anatomy_list": [
"左侧胸腔"
],
"character": [],
"core_name": "积液",
"tendency": ""
},
{
"anatomy_list": [
"右肺上叶"
],
"character": [
"小叶中心型",
"局部"
],
"core_name": "肺气肿",
"tendency": ""
},
{
"anatomy_list": [
"右肺"
],
"character": [
"细小"
],
"core_name": "结节",
"tendency": ""
},
{
"anatomy_list": [
"右肺"
],
"character": [],
"core_name": "尘肺",
"tendency": "不确定"
},
{
"anatomy_list": [
"右肺上叶",
"右肺上叶斜裂"
],
"character": [],
"core_name": "结节",
"tendency": ""
},
{
"anatomy_list": [
"右肺上叶",
"右肺上叶斜裂"
],
"character": [
"转移性"
],
"core_name": "肿瘤",
"tendency": "不确定"
},
{
"anatomy_list": [
"肝脏"
],
"character": [
"多发",
"环形",
"强化"
],
"core_name": "结节",
"tendency": ""
},
{
"anatomy_list": [
"肝脏"
],
"character": [
"转移性"
],
"core_name": "肿瘤",
"tendency": ""
},
{
"anatomy_list": [
"右肾"
],
"character": [
"占位性"
],
"core_name": "病变",
"tendency": ""
},
{
"anatomy_list": [
"右肾"
],
"character": [
"肿瘤性"
],
"core_name": "病变",
"tendency": "不确定"
},
{
"anatomy_list": [
"右肾"
],
"character": [],
"core_name": "癌",
"tendency": "不确定"
},
{
"anatomy_list": [
"左肾"
],
"character": [
"小"
],
"core_name": "结石",
"tendency": ""
},
{
"anatomy_list": [
"左侧肾上腺"
],
"character": [],
"core_name": "结节",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"转移性"
],
"core_name": "肿瘤",
"tendency": "不确定"
}
] |
88 |
3天前，患者受凉后出现流清涕，伴胸闷及耳鸣，活动后心累、气促症状较前加重，无明显咳嗽咳痰，无畏寒寒战，无腹痛腹泻，无尿频尿急尿痛，无皮下出血及皮肤瘀点瘀斑，患者于小渡中心卫生院差血常规提示白细胞高及血红蛋白低，今日拟输血及进一步治疗来院，遂以“骨髓增生异常综合症”收住入院。
|
[
{
"anatomy_list": [],
"character": [
"受凉后",
"清"
],
"core_name": "流涕",
"tendency": ""
},
{
"anatomy_list": [
"胸"
],
"character": [],
"core_name": "胸闷",
"tendency": ""
},
{
"anatomy_list": [
"耳"
],
"character": [],
"core_name": "耳鸣",
"tendency": ""
},
{
"anatomy_list": [
"心"
],
"character": [
"活动后",
"症状较前加重"
],
"core_name": "心累",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"活动后",
"症状较前加重"
],
"core_name": "气促",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"明显"
],
"core_name": "咳嗽",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"明显"
],
"core_name": "咳痰",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "畏寒",
"tendency": "否定"
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "寒颤",
"tendency": "否定"
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "腹泻",
"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": [
"皮下"
],
"character": [],
"core_name": "出血",
"tendency": "否定"
},
{
"anatomy_list": [
"皮肤"
],
"character": [],
"core_name": "瘀点",
"tendency": "否定"
},
{
"anatomy_list": [
"皮肤"
],
"character": [],
"core_name": "瘀斑",
"tendency": "否定"
},
{
"anatomy_list": [
"白细胞"
],
"character": [],
"core_name": "白细胞高",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"低"
],
"core_name": "血红蛋白",
"tendency": ""
},
{
"anatomy_list": [
"骨髓"
],
"character": [],
"core_name": "骨髓增生异常综合症",
"tendency": ""
}
] |
169 |
脂肪肝、肝右叶钙化灶；左肾肾盂肾盏及左侧输尿管上段稍积水扩张；脊柱退行性变。
|
[
{
"anatomy_list": [
"肝"
],
"character": [],
"core_name": "脂肪肝",
"tendency": ""
},
{
"anatomy_list": [
"肝右叶"
],
"character": [],
"core_name": "钙化灶",
"tendency": ""
},
{
"anatomy_list": [
"左肾肾盂",
"左肾肾盏",
"左侧输尿管上段"
],
"character": [
"稍"
],
"core_name": "积水扩张",
"tendency": ""
},
{
"anatomy_list": [
"脊柱"
],
"character": [
"退行性"
],
"core_name": "改变",
"tendency": ""
}
] |
950 |
其后上述症状反复发作，后逐渐出现食欲减退。
|
[
{
"anatomy_list": [],
"character": [
"减退"
],
"core_name": "食欲",
"tendency": ""
}
] |
526 |
入院前5月前，患者受凉后呼吸困难加重，伴双下肢水肿，于某医院治疗后好转出院（具体诊疗不详）。
|
[
{
"anatomy_list": [],
"character": [
"受凉后加重"
],
"core_name": "呼吸困难",
"tendency": ""
},
{
"anatomy_list": [
"双下肢"
],
"character": [],
"core_name": "水肿",
"tendency": ""
}
] |
467 |
遂于我院就诊，查超声示“子宫周围探及异常回声，范围约98×46mm的异常无回声区，主要位于子宫右后方，边界不清，形态不规则，以低回声为主，cdfi:其周边未探及血流信号；腹腔探及片状无回声区，最深处约56mm；盆腔内可见片状的不规则无回声区，最深处位于子宫后方，约7mm，内透声差，可见点状弱回声浮动”。
|
[
{
"anatomy_list": [
"子宫周围"
],
"character": [
"异常"
],
"core_name": "回声",
"tendency": ""
},
{
"anatomy_list": [
"子宫右后方"
],
"character": [
"边界不清",
"形态不规则"
],
"core_name": "异常无回声",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"周边探及"
],
"core_name": "血流信号",
"tendency": "否定"
},
{
"anatomy_list": [
"腹腔"
],
"character": [
"片状"
],
"core_name": "无回声区",
"tendency": ""
},
{
"anatomy_list": [
"盆腔内"
],
"character": [
"最深处位于子宫后方",
"片状",
"不规则",
"内透声差",
"可见点状弱回声浮动",
"弱"
],
"core_name": "回声",
"tendency": ""
}
] |
628 |
于“某医院”就诊，诊断为copd急性加重期，经治疗（具体不详）后症状无明显好转，为求进一步治疗遂于我院就诊，我院门诊以“慢性阻塞性肺疾病急性加重期”收入我科。
|
[
{
"anatomy_list": [],
"character": [
"急性加重期"
],
"core_name": "copd",
"tendency": ""
},
{
"anatomy_list": [
"肺"
],
"character": [
"慢性",
"阻塞性",
"急性加重期"
],
"core_name": "肺疾病",
"tendency": ""
}
] |
1,782 |
盆腹腔内未见明显转移结节。
|
[
{
"anatomy_list": [
"盆腹腔内"
],
"character": [
"明显",
"转移"
],
"core_name": "结节",
"tendency": "否定"
}
] |
1,071 |
4月前，患者因“左臀部臀部包块”于某医院就诊，行左臀部包块切除+病检术，术后病检提示：（左臀部）恶性肿瘤，结合临床病史考虑恶性淋巴瘤转移可能。
|
[
{
"anatomy_list": [
"左臀部"
],
"character": [],
"core_name": "包块",
"tendency": ""
},
{
"anatomy_list": [
"左臀部"
],
"character": [
"恶性"
],
"core_name": "肿瘤",
"tendency": ""
},
{
"anatomy_list": [
"淋巴"
],
"character": [
"恶性",
"转移"
],
"core_name": "瘤",
"tendency": "不确定"
}
] |
1,514 |
患者本次发病后外院住院期间发生肺部感染、Ⅰ型呼吸衰竭、肺气肿、菌血症，予以抗感染，止咳化痰等对症治疗后病情逐渐平稳。
|
[
{
"anatomy_list": [
"肺部"
],
"character": [],
"core_name": "感染",
"tendency": ""
},
{
"anatomy_list": [
"肺"
],
"character": [
"Ⅰ型"
],
"core_name": "呼吸衰竭",
"tendency": ""
},
{
"anatomy_list": [
"肺"
],
"character": [],
"core_name": "肺气肿",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "菌血症",
"tendency": ""
}
] |
891 |
不咯黄脓痰及铁锈色痰，不伴畏寒、寒战、高热，不伴潮热、盗汗及午后低热，无明显喘累。
|
[
{
"anatomy_list": [],
"character": [
"黄",
"脓痰"
],
"core_name": "咳痰",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"铁锈色"
],
"core_name": "咳痰",
"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": [
"高"
],
"core_name": "发热",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "潮热",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "盗汗",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"午后",
"低"
],
"core_name": "发热",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"明显"
],
"core_name": "喘累",
"tendency": "否定"
}
] |
1,750 |
神经见癌侵犯。
|
[
{
"anatomy_list": [
"神经"
],
"character": [
"侵犯"
],
"core_name": "癌",
"tendency": ""
}
] |
488 |
入院前6+月，患者发现左乳包块来我院就诊，完善相关检查后，于2016-06-03全麻下行左乳包块切除术+术中冰冻+左乳癌改良根治术。
|
[
{
"anatomy_list": [
"左乳"
],
"character": [],
"core_name": "包块",
"tendency": ""
}
] |
1,074 |
院外口服药物治疗（具体不详），患者 但仍感咳嗽明显，为进一步治疗入我院门诊， 胸部ct 提示：1、双肺内多发团片状、结节状状高密度高密度影，考虑结核可能。
|
[
{
"anatomy_list": [],
"character": [
"明显"
],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [
"双肺"
],
"character": [
"多发",
"团片状",
"结节状",
"高"
],
"core_name": "密度影",
"tendency": ""
},
{
"anatomy_list": [
"肺"
],
"character": [],
"core_name": "结核",
"tendency": "不确定"
}
] |
220 |
患者 10+天 前无明显诱因下开始出现 中上腹 疼痛 ， 疼痛呈胀痛伴阵发性加重 ， 无放射痛 。
|
[
{
"anatomy_list": [
"中上腹"
],
"character": [
"呈胀痛",
"阵发性加重",
"无放射痛"
],
"core_name": "疼痛",
"tendency": ""
}
] |
898 |
反复前因上述症状加重再次于我院住院，检查后提示多浆膜腔积液，予以血液透析、改善心功能，穿刺抽胸腔积液后症状缓解；因肺癌转入呼吸肿瘤科，予以ct引导下行肺穿刺活检术，术后病检提示（右肺）恶性肿瘤，完善头颅mri未见转移征象，与患者及家属沟通后表示不愿行介入治疗等，予以经皮动脉栓塞术（肿瘤）；院外长期在我院规律血液透析。
|
[
{
"anatomy_list": [
"浆膜腔"
],
"character": [
"多"
],
"core_name": "积液",
"tendency": ""
},
{
"anatomy_list": [
"胸腔"
],
"character": [],
"core_name": "积液",
"tendency": ""
},
{
"anatomy_list": [
"肺"
],
"character": [],
"core_name": "癌",
"tendency": ""
},
{
"anatomy_list": [
"右肺"
],
"character": [
"恶性"
],
"core_name": "肿瘤",
"tendency": ""
},
{
"anatomy_list": [
"头颅"
],
"character": [],
"core_name": "转移",
"tendency": "否定"
},
{
"anatomy_list": [
"右肺"
],
"character": [],
"core_name": "肿瘤",
"tendency": ""
}
] |
714 |
患者近1月以来，食欲不振，神志清醒，精神尚可，睡眠欠佳，体重减少2kg。
|
[
{
"anatomy_list": [],
"character": [
"不振"
],
"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": "睡眠质量",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "体重减轻",
"tendency": ""
}
] |
195 |
病程中患者有头晕，无头痛、视物旋转、晕厥。
|
[
{
"anatomy_list": [
"头"
],
"character": [],
"core_name": "头晕",
"tendency": ""
},
{
"anatomy_list": [
"头"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "视物旋转",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "晕厥",
"tendency": "否定"
}
] |
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