id
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2.07k
| text
stringlengths 5
708
| event
listlengths 1
59
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|---|---|---|
744 |
今患者为求进一步化疗治疗，遂入我科，门诊以“非霍奇金淋巴瘤”收入我科。
|
[
{
"anatomy_list": [
"淋巴"
],
"character": [
"非霍奇金氏"
],
"core_name": "瘤",
"tendency": ""
}
] |
614 |
近期偶有咳嗽，为刺激性干咳，偶感左胸部游走样针刺样疼痛，向左侧腋下放射，不影响睡眠，可忍受。
|
[
{
"anatomy_list": [],
"character": [
"偶尔"
],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"刺激性",
"干"
],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [
"左胸部"
],
"character": [
"游走样",
"针刺样",
"不影响睡眠",
"可忍受",
"偶尔"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"左侧腋下"
],
"character": [
"放射性"
],
"core_name": "疼痛",
"tendency": ""
}
] |
558 |
无肛门坠胀感。
|
[
{
"anatomy_list": [
"肛门"
],
"character": [],
"core_name": "坠胀感",
"tendency": "否定"
}
] |
221 |
伴腹胀 ， 伴恶心、呕吐,呕吐物为胃内容物 ， 发病 以来肛门少量排气排便。
|
[
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "腹胀",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "恶心",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"呕吐物为胃内容物"
],
"core_name": "呕吐",
"tendency": ""
},
{
"anatomy_list": [
"肛门"
],
"character": [
"少量"
],
"core_name": "排便",
"tendency": ""
},
{
"anatomy_list": [
"肛门"
],
"character": [
"少量"
],
"core_name": "排气",
"tendency": ""
}
] |
1,796 |
出院后患者间断来院行抗溶骨及内分泌治疗，院外仍感全身多处骨痛。
|
[
{
"anatomy_list": [
"全身",
"骨"
],
"character": [
"多处"
],
"core_name": "疼痛",
"tendency": ""
}
] |
1,188 |
术后病检示：（右乳）浸润性导管癌（Ⅱ级，7分），免疫组化：er（±） pr（+）5%cerbb-2（－） ki-67散在（+）。
|
[
{
"anatomy_list": [
"右乳"
],
"character": [
"浸润性",
"Ⅱ级",
"7分"
],
"core_name": "导管癌",
"tendency": ""
}
] |
1,097 |
2月前，患者因“肺气肿”于我院呼吸科住院治疗，当时患者排尿困难加重，予以口服“坦索罗辛”治疗，治疗有缓解，后患者持续服用该药物。
|
[
{
"anatomy_list": [
"肺"
],
"character": [],
"core_name": "肺气肿",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"加重"
],
"core_name": "排尿困难",
"tendency": ""
}
] |
1,752 |
胆囊胆固醇沉积症，慢性胆囊炎。
|
[
{
"anatomy_list": [
"胆囊"
],
"character": [],
"core_name": "胆固醇沉积症",
"tendency": ""
},
{
"anatomy_list": [
"胆囊"
],
"character": [
"慢性"
],
"core_name": "胆囊炎",
"tendency": ""
}
] |
1,175 |
缘于2014年5月患者自行发现左腹部肋下包块，约苹果大小，无进行性增大表现，伴左腹部胀痛、乏力，偶解黑色大便，无血便，无反酸、恶心、呕吐及腹泻等不适。
|
[
{
"anatomy_list": [
"左腹部肋下"
],
"character": [
"约苹果大小",
"进行性增大"
],
"core_name": "包块",
"tendency": ""
},
{
"anatomy_list": [
"左腹部"
],
"character": [
"胀痛"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "乏力",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"发黑"
],
"core_name": "大便颜色",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "血便",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "返酸",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "恶心",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "呕吐",
"tendency": "否定"
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "腹泻",
"tendency": "否定"
}
] |
456 |
2.肝硬化，脾稍大，胃底静脉曲张。
|
[
{
"anatomy_list": [
"肝"
],
"character": [],
"core_name": "硬化",
"tendency": ""
},
{
"anatomy_list": [
"脾"
],
"character": [
"稍"
],
"core_name": "脾大",
"tendency": ""
},
{
"anatomy_list": [
"胃底静脉"
],
"character": [],
"core_name": "静脉曲张",
"tendency": ""
}
] |
89 |
患者自发病以来，精神可，食欲一般，睡眠可，大便如常，小便如常，体重无明显变化。
|
[
{
"anatomy_list": [],
"character": [
"可"
],
"core_name": "精神",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"一般"
],
"core_name": "食欲",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"可"
],
"core_name": "睡眠",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"如常"
],
"core_name": "大便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"如常"
],
"core_name": "小便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"明显"
],
"core_name": "体重变化",
"tendency": "否定"
}
] |
1,368 |
患者40+天于我院诊断为：原发性肝癌伴肝内转移，于2015-3-2行tace，术后恢复可，院外服用华蟾素抗肿瘤治疗。
|
[
{
"anatomy_list": [
"肝"
],
"character": [
"原发性",
"肝内转移"
],
"core_name": "癌",
"tendency": ""
}
] |
1,315 |
6月前，患者因“大便习惯改变半年余”入院，完善检查后诊断为直肠癌，遂行腹腔镜直肠癌根治术（dixon）+放射性粒子置入术，术后病理提示：（直肠）中分化腺癌（含粘液腺癌成份）浸及肠壁全层，未见明确血管、神经侵犯，切端未见癌累及，肠壁淋巴结见癌转移（1/14）。
|
[
{
"anatomy_list": [],
"character": [
"习惯改变"
],
"core_name": "大便",
"tendency": ""
},
{
"anatomy_list": [
"直肠"
],
"character": [],
"core_name": "癌",
"tendency": ""
},
{
"anatomy_list": [
"直肠",
"肠壁全层"
],
"character": [
"中分化",
"含粘液腺癌成份",
"浸及肠壁全层"
],
"core_name": "腺癌",
"tendency": ""
},
{
"anatomy_list": [
"血管",
"神经"
],
"character": [
"明确",
"侵犯"
],
"core_name": "癌",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"切端",
"累及"
],
"core_name": "癌",
"tendency": "否定"
},
{
"anatomy_list": [
"肠壁淋巴结"
],
"character": [
"转移"
],
"core_name": "癌",
"tendency": ""
}
] |
1,107 |
3+月前，患者自行发现颈部包块，直径约2cm，质硬，轻压痛，不活动，边界不清，表面无红肿溃烂，无咳嗽、咯痰，无活动后心累、气促，无胸闷、胸痛、咯血、呼吸困难，无畏寒、发热。
|
[
{
"anatomy_list": [
"颈部"
],
"character": [
"质硬",
"轻压痛",
"不活动",
"边界不清",
"表面无红肿溃烂"
],
"core_name": "包块",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "咳嗽",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "咳痰",
"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": [
"胸"
],
"character": [],
"core_name": "胸闷",
"tendency": "否定"
},
{
"anatomy_list": [
"胸"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "咯血",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "呼吸困难",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "畏寒",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "发热",
"tendency": "否定"
}
] |
6 |
在我院住院期间行“胸部ct示：慢支炎伴双下肺感染或间质性炎症,肺气肿征。
|
[
{
"anatomy_list": [
"支气管"
],
"character": [
"慢性"
],
"core_name": "支气管炎",
"tendency": ""
},
{
"anatomy_list": [
"双下肺"
],
"character": [],
"core_name": "感染",
"tendency": ""
},
{
"anatomy_list": [
"双下肺"
],
"character": [
"间质性"
],
"core_name": "炎症",
"tendency": ""
},
{
"anatomy_list": [
"肺"
],
"character": [],
"core_name": "肺气肿征",
"tendency": ""
}
] |
522 |
患者此次患病以来，精神状态尚可，小便正常，便秘。
|
[
{
"anatomy_list": [],
"character": [
"尚可"
],
"core_name": "精神",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"正常"
],
"core_name": "小便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "便秘",
"tendency": ""
}
] |
454 |
3月前来我院就诊，2017-8-1414Mmr检查报告：腹部mr增强 1.肝癌hifu术后改变，与前片（2017.02.15）比较，肝右叶后段段结节较前范围稍增大，未见明显强化；肝右叶后下段包膜下肿块较前稍增大，病灶内缘可见少许延迟强化；肝右叶膈顶顶区病灶较前无明显变化；肝左叶外侧段包膜下结节，较前无明显变化。
|
[
{
"anatomy_list": [
"肝"
],
"character": [
"肝癌",
"hifu"
],
"core_name": "术后改变",
"tendency": ""
},
{
"anatomy_list": [
"肝右叶后段"
],
"character": [
"较前范围稍增大",
"未见明显强化"
],
"core_name": "结节",
"tendency": ""
},
{
"anatomy_list": [
"肝右叶后下段包膜下"
],
"character": [
"较前稍增大",
"病灶内缘可见少许延迟强化"
],
"core_name": "肿块",
"tendency": ""
},
{
"anatomy_list": [
"肝右叶膈顶区"
],
"character": [
"较前无明显变化"
],
"core_name": "病灶",
"tendency": ""
},
{
"anatomy_list": [
"肝左叶外侧段包膜下"
],
"character": [
"较前无明显变化"
],
"core_name": "结节",
"tendency": ""
}
] |
1,045 |
20天前，患者无明显诱因出现大便次数增多，约3-4次/天，约50-80g/次，为黄色成形大便，无腹痛、腹泻，无里急后重，无恶心、呕吐，无畏寒、发热，患者未予重视，未治疗。
|
[
{
"anatomy_list": [],
"character": [
"次数增多"
],
"core_name": "大便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"黄色",
"成形"
],
"core_name": "大便",
"tendency": ""
},
{
"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": "里急后重",
"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"
}
] |
1,173 |
患者为求进一步治疗，遂来我院门诊就诊，彩超（2018-04-16我院）示：甲状腺右侧叶囊肿。
|
[
{
"anatomy_list": [
"甲状腺右侧叶"
],
"character": [],
"core_name": "囊肿",
"tendency": ""
}
] |
1,375 |
5月前患者再次出现气促，无咳嗽、咳痰，无胸痛，入我院肾内科，诊断为”1.慢性肾功能不全（肾衰竭期）ckd5期 糖尿病肾病 肾性贫血； 2.急性左心衰；3.2型糖尿病糖尿病糖尿病肾病 糖尿病周围神经病变 糖尿病视网膜病变；4.原发性高血压3级高血压3级极高危极高危组 高血压性心脏病 心脏增大 心功能iv级；5.脑梗塞后遗症”。
|
[
{
"anatomy_list": [],
"character": [],
"core_name": "气促",
"tendency": ""
},
{
"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": [
"肾"
],
"character": [
"慢性",
"肾衰竭期"
],
"core_name": "肾功能不全",
"tendency": ""
},
{
"anatomy_list": [
"肾"
],
"character": [
"糖尿病"
],
"core_name": "肾病",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"肾性"
],
"core_name": "贫血",
"tendency": ""
},
{
"anatomy_list": [
"左心"
],
"character": [
"急性"
],
"core_name": "心力衰竭",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"2型"
],
"core_name": "糖尿病",
"tendency": ""
},
{
"anatomy_list": [
"肾"
],
"character": [
"糖尿病"
],
"core_name": "肾病",
"tendency": ""
},
{
"anatomy_list": [
"周围神经"
],
"character": [
"糖尿病"
],
"core_name": "病变",
"tendency": ""
},
{
"anatomy_list": [
"视网膜"
],
"character": [
"糖尿病"
],
"core_name": "病变",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"原发性",
"3级",
"极高危"
],
"core_name": "高血压",
"tendency": ""
},
{
"anatomy_list": [
"心脏"
],
"character": [
"高血压性"
],
"core_name": "心脏病",
"tendency": ""
},
{
"anatomy_list": [
"心脏"
],
"character": [],
"core_name": "增大",
"tendency": ""
},
{
"anatomy_list": [
"心"
],
"character": [
"iv级"
],
"core_name": "心功能",
"tendency": ""
},
{
"anatomy_list": [
"脑"
],
"character": [],
"core_name": "脑梗塞",
"tendency": ""
}
] |
751 |
后患者上述症状较前呈进行性加重，行胸部ct检查(2015-01-14)提示右肺中央型占位病变，考虑肺癌可能行大。
|
[
{
"anatomy_list": [
"右肺"
],
"character": [
"中央型"
],
"core_name": "占位性病变",
"tendency": ""
},
{
"anatomy_list": [
"肺"
],
"character": [],
"core_name": "癌",
"tendency": "不确定"
}
] |
73 |
入院前2年患儿下楼梯摔倒后出现左侧髋关节疼痛，不伴肿胀，先后累及左膝、左踝、右髋关节、右膝，有活动障碍，未行特殊处理，可自行缓解，双侧非对称分布。
|
[
{
"anatomy_list": [
"左侧髋关节"
],
"character": [],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "肿胀",
"tendency": "否定"
},
{
"anatomy_list": [
"左膝",
"左踝",
"右髋关节",
"右膝"
],
"character": [],
"core_name": "累及",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"双侧非对称分布"
],
"core_name": "活动障碍",
"tendency": ""
}
] |
1,896 |
入院前5年，患者无明显诱因出现小便不能自解，于某医院行导尿处理，拔除尿管后自解小便尚通畅，其后间断口服坦索罗辛及非那雄胺治疗。
|
[
{
"anatomy_list": [],
"character": [
"不能自解"
],
"core_name": "小便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"通畅"
],
"core_name": "排尿",
"tendency": ""
}
] |
1,480 |
于2017.2.13环磷酰胺700mg d1+多柔比星 70mg d1+奈达铂 120mg d1 全身静脉化疗，行奈达铂全身静脉化疗时，输注约5-10分时患者自诉出现胸闷伴呼吸困难，面色潮红，皮肤瘙痒，考虑奈达铂化疗药引起等过敏反应，立即停药，并予以地塞米松5mg静推后症状立即缓解。
|
[
{
"anatomy_list": [
"胸"
],
"character": [],
"core_name": "胸闷",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "呼吸困难",
"tendency": ""
},
{
"anatomy_list": [
"面"
],
"character": [],
"core_name": "面色潮红",
"tendency": ""
},
{
"anatomy_list": [
"皮肤"
],
"character": [],
"core_name": "瘙痒",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"奈达铂化疗药"
],
"core_name": "过敏反应",
"tendency": "不确定"
}
] |
925 |
今为进一步诊治来我科，以“ 1.双侧输尿管梗阻伴双肾积水 ”收入我科。
|
[
{
"anatomy_list": [
"双侧输尿管"
],
"character": [],
"core_name": "梗阻",
"tendency": ""
},
{
"anatomy_list": [
"双肾"
],
"character": [],
"core_name": "积水",
"tendency": ""
}
] |
1,988 |
无嗳气、烧心、胸骨后疼痛，无腹痛、腹胀，无厌油、黄疸，大便无粘液及脓血，无畏寒、发热，无头昏、心悸、耳鸣、全身乏力。
|
[
{
"anatomy_list": [],
"character": [],
"core_name": "嗳气",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "烧心",
"tendency": "否定"
},
{
"anatomy_list": [
"胸骨后"
],
"character": [],
"core_name": "疼痛",
"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": "厌油",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "黄疸",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"粘液",
"脓血"
],
"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": [
"头"
],
"character": [],
"core_name": "头昏",
"tendency": "否定"
},
{
"anatomy_list": [
"心"
],
"character": [],
"core_name": "心悸",
"tendency": "否定"
},
{
"anatomy_list": [
"耳"
],
"character": [],
"core_name": "耳鸣",
"tendency": "否定"
},
{
"anatomy_list": [
"全身"
],
"character": [],
"core_name": "乏力",
"tendency": "否定"
}
] |
188 |
无发热、盗汗、咯血、胸闷、胸痛、心悸、双下肢水肿等，每次予以抗感染、止咳祛痰等治疗后可好转。
|
[
{
"anatomy_list": [],
"character": [],
"core_name": "发热",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "盗汗",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "咯血",
"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": [
"双下肢"
],
"character": [],
"core_name": "水肿",
"tendency": "否定"
}
] |
1,300 |
入院前8+年，患者在某医院体检发现右肺占位，无咳嗽、咯血，无呼吸困难，无胸痛，无潮热、盗汗、疲乏、消瘦，无畏寒、发热，行纤支镜及病检提示肺鳞癌（未见报告），行肺癌根治术及辅助化疗（具体情况不详），于7+年前复查胸部ct提示肿瘤复发，建议手术治疗，但患者本人拒绝，在某医院行姑息性放疗及化疗（情况不详），此后一直在家休养。
|
[
{
"anatomy_list": [
"右肺"
],
"character": [],
"core_name": "占位",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "咳嗽",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "咯血",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "呼吸困难",
"tendency": "否定"
},
{
"anatomy_list": [
"胸"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "潮热",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "盗汗",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "疲乏",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "消瘦",
"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": [
"肺"
],
"character": [],
"core_name": "鳞癌",
"tendency": ""
},
{
"anatomy_list": [
"肺"
],
"character": [
"复发"
],
"core_name": "肿瘤",
"tendency": ""
}
] |
1,123 |
并于2012-6-2以“卡铂500mg d1+紫杉醇240mg d1"方案行第四周期化疗，化疗后复查血常规提示贫血，行骨穿后诊断为“巨幼红细胞性贫血”，考虑为卡铂所致，随后将卡铂改为奥沙利铂。
|
[
{
"anatomy_list": [],
"character": [
"化疗后"
],
"core_name": "贫血",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"巨幼红细胞"
],
"core_name": "贫血",
"tendency": ""
}
] |
1,454 |
遂入我科，予以全脑姑息性放疗，以2.2G/f照射4次后，患者头痛加重，予以对症处理后，症状无明显缓解，考虑患者颅内病灶多且较分散，颅脑单次剂量过高，经全科讨论后，改为全脑放疗2.0G/f照射16次+2.2G/f照射2次，患者头痛、呕吐症状明显缓解，院外休息，自服索拉菲尼，未诉特殊不适。
|
[
{
"anatomy_list": [
"头"
],
"character": [
"加重"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"颅内病灶"
],
"character": [
"多",
"较分散"
],
"core_name": "病灶",
"tendency": ""
},
{
"anatomy_list": [
"头"
],
"character": [
"明显缓解"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"明显缓解"
],
"core_name": "呕吐",
"tendency": ""
}
] |
1,668 |
院后饮食、睡眠、精神均可。
|
[
{
"anatomy_list": [],
"character": [
"可"
],
"core_name": "饮食",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"可"
],
"core_name": "睡眠",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"可"
],
"core_name": "精神",
"tendency": ""
}
] |
1,676 |
患者于30余年前，因感冒受凉后出现咳嗽咳痰、痰为白色泡沫痰、量多、无脓臭味，无咯血，无畏寒发热、无潮热盗汗等不适；于外院经抗感染、止咳祛痰等对症处理后症状好转。
|
[
{
"anatomy_list": [],
"character": [],
"core_name": "感冒",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"受凉后"
],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"白色",
"泡沫痰",
"量多",
"无脓臭味"
],
"core_name": "咳痰",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "咯血",
"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": "潮热",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "盗汗",
"tendency": "否定"
}
] |
1,538 |
经肿瘤科、肝胆外科、胸外科多科会诊后，结论：患者直肠癌诊断明确，且肝转移可能性大，建议先行新辅助化疗，后期评估后再行手术，遂于2016-01-22、2016-02-04、2016-02-19日分别以“奥沙利铂+5-氟尿嘧啶（folfox4）”行新辅助化疗3次；复查胸腹部ct(2016-03-14 某医院): 1.符合慢支炎、肺气肿改变； 2.主动脉弓钙化； 3.肝左叶内侧段钙化灶；肝内低密度结节影 请随访复查。
|
[
{
"anatomy_list": [
"直肠"
],
"character": [],
"core_name": "癌",
"tendency": ""
},
{
"anatomy_list": [
"肝"
],
"character": [
"转移"
],
"core_name": "癌",
"tendency": "不确定"
},
{
"anatomy_list": [
"支气管"
],
"character": [
"慢性"
],
"core_name": "支气管炎",
"tendency": ""
},
{
"anatomy_list": [
"肺"
],
"character": [],
"core_name": "肺气肿",
"tendency": ""
},
{
"anatomy_list": [
"主动脉弓"
],
"character": [],
"core_name": "钙化",
"tendency": ""
},
{
"anatomy_list": [
"肝左叶内侧段"
],
"character": [],
"core_name": "钙化灶",
"tendency": ""
},
{
"anatomy_list": [
"肝内"
],
"character": [
"低密度"
],
"core_name": "结节影",
"tendency": ""
}
] |
2,044 |
3天前患者中腹部阵发隐痛不适，伴黄色稀便，2次/天，每次量少，今日为进一步治疗入我院，急诊以"白血病"收入我科住院治疗。
|
[
{
"anatomy_list": [
"中腹部"
],
"character": [
"阵发",
"隐痛"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"中腹部"
],
"character": [],
"core_name": "腹部不适",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"黄色",
"每次量少",
"稀"
],
"core_name": "大便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "白血病",
"tendency": ""
}
] |
1,574 |
无禁忌症，于01月17日开始给予folfox方案（奥沙利铂200mg d1，氟尿嘧啶.075g1-d5）化疗1周期，过程顺利，患者出现恶心i度及手足麻木麻木不适，无明显骨髓抑制，给予营养神经、对症等治疗后腹痛及手足麻木好转。
|
[
{
"anatomy_list": [],
"character": [
"i度"
],
"core_name": "恶心",
"tendency": ""
},
{
"anatomy_list": [
"手",
"足"
],
"character": [],
"core_name": "麻木",
"tendency": ""
},
{
"anatomy_list": [
"手",
"足"
],
"character": [],
"core_name": "手足不适",
"tendency": ""
},
{
"anatomy_list": [
"骨髓"
],
"character": [
"明显"
],
"core_name": "骨髓抑制",
"tendency": "否定"
},
{
"anatomy_list": [
"腹"
],
"character": [
"好转"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"手",
"足"
],
"character": [
"好转"
],
"core_name": "麻木",
"tendency": ""
}
] |
999 |
入院前8天，患者无明显诱因右上腹疼痛，为“压榨样”疼痛，无肩背部放射痛，间断发作，弯腰屈膝位可缓解，无明显加重因素，伴发热，最高高体温不详，无畏寒、寒战，无胸痛、胸闷，无恶心、呕吐、腹泻，无咳嗽、咳痰，无皮肤、黏膜黄染，小便未见明显异常，未予重视，自行口服药物（具体不详）治疗无效。
|
[
{
"anatomy_list": [
"右上腹"
],
"character": [],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"右上腹"
],
"character": [
"压榨样",
"间歇发作",
"弯腰屈膝位可缓解",
"无明显加重因素"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"肩背部"
],
"character": [
"放射性"
],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "发热",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "畏寒",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "寒颤",
"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": [],
"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": [],
"core_name": "咳嗽",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "咳痰",
"tendency": "否定"
},
{
"anatomy_list": [
"皮肤",
"黏膜"
],
"character": [],
"core_name": "黄染",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"明显"
],
"core_name": "小便异常",
"tendency": "否定"
}
] |
1,891 |
病程中患者无头痛及头晕，患者长期于院外复查，患者为复查了解机体情况，今日以“鼻咽癌”收入我科。
|
[
{
"anatomy_list": [
"头"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [
"头"
],
"character": [],
"core_name": "头晕",
"tendency": "否定"
},
{
"anatomy_list": [
"鼻咽"
],
"character": [],
"core_name": "癌",
"tendency": ""
}
] |
1,606 |
2020-7-28行宫颈活检（123456）示：（宫颈上唇、下唇）浸润性鳞状细胞癌；（阴道壁组织）鳞状上皮高级别异型增生，不除外鳞状细胞癌。
|
[
{
"anatomy_list": [
"宫颈上唇、下唇"
],
"character": [
"浸润性"
],
"core_name": "鳞癌",
"tendency": ""
},
{
"anatomy_list": [
"阴道壁组织"
],
"character": [
"鳞状上皮",
"高级别",
"异型"
],
"core_name": "增生",
"tendency": ""
},
{
"anatomy_list": [
"阴道壁"
],
"character": [],
"core_name": "鳞癌",
"tendency": "不确定"
}
] |
257 |
1月前患者无明显诱因出现间断中上腹隐痛上腹隐痛不适，感腹胀，解可疑成形黑便，精神欠佳，无明显反酸、烧心、嗳气，无恶心、呕吐、呕血，无头晕、黑曚，无胸闷、胸痛、心悸，无咳嗽、气促，无腹泻。
|
[
{
"anatomy_list": [
"中上腹"
],
"character": [
"间断",
"隐痛"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"上腹"
],
"character": [
"隐痛不适"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "腹胀",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "黑便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"欠佳"
],
"core_name": "精神",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"明显"
],
"core_name": "返酸",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"明显"
],
"core_name": "烧心",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"明显"
],
"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": "呕血",
"tendency": "否定"
},
{
"anatomy_list": [
"头"
],
"character": [],
"core_name": "头晕",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "黒朦",
"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": "咳嗽",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "气促",
"tendency": "否定"
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "腹泻",
"tendency": "否定"
}
] |
1,960 |
患病以来，患者精神、食欲、睡眠可，二便基本正常，体重无明显改变。
|
[
{
"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": "大小便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"明显"
],
"core_name": "体重改变",
"tendency": "否定"
}
] |
767 |
2019-11-20患者为求进一步治疗入院，复查ct提示患者病情进展，前期患者胸水基因检测提示egfr基因T790M和19-del突变，积极与患者及家属沟通，建议可申购正版奥西替尼或行化疗，患者及家属经商议后决定于11月27日行培美曲塞0.7g+奈达铂100mg化疗，化疗结束后出院。
|
[
{
"anatomy_list": [
"胸"
],
"character": [],
"core_name": "胸水",
"tendency": ""
}
] |
1,113 |
患者无明显头痛、胸痛，无视物模糊、视物旋转，无畏寒发热、喘累气促、呼吸困难等不适。
|
[
{
"anatomy_list": [
"头"
],
"character": [
"明显"
],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [
"胸"
],
"character": [
"明显"
],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "视物模糊",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "视物旋转",
"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": "呼吸困难",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "气促",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "喘累",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "呼吸困难",
"tendency": "否定"
}
] |
1,784 |
术后病理示<直肠>中分化腺癌，侵及肠壁全层及肠周脂肪组织中，脂肪中见癌结节1枚。
|
[
{
"anatomy_list": [
"直肠"
],
"character": [
"中分化"
],
"core_name": "腺癌",
"tendency": ""
},
{
"anatomy_list": [
"肠壁全层",
"肠周脂肪组织"
],
"character": [],
"core_name": "侵及",
"tendency": ""
},
{
"anatomy_list": [
"肠周脂肪组织中"
],
"character": [
"癌"
],
"core_name": "结节",
"tendency": ""
}
] |
373 |
今为求进一步诊治，入我科就诊，门诊以“间质性肺炎”收入我院。
|
[
{
"anatomy_list": [
"肺"
],
"character": [
"间质性"
],
"core_name": "肺炎",
"tendency": ""
}
] |
424 |
患者于入院前10余年前反复无明显诱因出现腹痛伴大便不通，腹痛部位不定，为间歇性隐痛，大便次数约3
|
[
{
"anatomy_list": [
"腹"
],
"character": [
"反复"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"不通"
],
"core_name": "大便",
"tendency": ""
},
{
"anatomy_list": [
"腹"
],
"character": [
"部位不定",
"间歇性",
"隐痛"
],
"core_name": "疼痛",
"tendency": ""
}
] |
400 |
患者于入院2个月前（2015.11.19）于我院在全麻下行左乳包块切除+术中冰冻活检+左腋窝前哨淋巴结探查活检+左乳癌改良根治术，术后病理诊断：（左）乳浸润性癌；免疫组化示：er（++）70%pr（+）10%cerbb-2（±） ki-67（－）；腋窝淋巴结癌转移12/16。
|
[
{
"anatomy_list": [
"左乳"
],
"character": [
"浸润性"
],
"core_name": "癌",
"tendency": ""
},
{
"anatomy_list": [
"腋窝淋巴结"
],
"character": [
"转移"
],
"core_name": "癌",
"tendency": ""
}
] |
1,464 |
2+年患者自觉心前区不适症状加重，就诊于某医院，行冠脉造影后于前降支植入支架2枚，右冠植入支架1枚。
|
[
{
"anatomy_list": [
"心前区"
],
"character": [
"加重"
],
"core_name": "心前区不适",
"tendency": ""
}
] |
798 |
1月前患者来我科行第一次化疗，化疗后患者一般清况尚可，无畏寒发热、无皮肤巩膜黄染、无恶心呕吐、无腹胀腹痛、无头晕气促、无食欲减退等不适，现患者为行第二次化疗来我院收住我科。
|
[
{
"anatomy_list": [],
"character": [],
"core_name": "畏寒",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "发热",
"tendency": "否定"
},
{
"anatomy_list": [
"皮肤",
"巩膜"
],
"character": [],
"core_name": "黄染",
"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": [
"头"
],
"character": [],
"core_name": "头晕",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "气促",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "食欲减退",
"tendency": "否定"
}
] |
1,977 |
入院前7月余，患者无明显诱因出现胸痛、咳嗽，胸痛为阵发性牵扯样疼痛，咳嗽为阵发性，白昼无明显差别，伴有少量白色泡沫痰，易咳出，伴有乏力、喘息、胸闷，无夜间阵发性呼吸困难、夜间端坐呼吸、无双下肢水肿，无发热、盗汗、纳差，无心悸、反酸、嗳气等不适。患者未予重视，后患者感上述症状无明显改善。
|
[
{
"anatomy_list": [
"胸"
],
"character": [],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [
"胸"
],
"character": [
"阵发性",
"牵扯样"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"阵发性"
],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"少量",
"白色",
"泡沫痰",
"易咳出"
],
"core_name": "咳痰",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "乏力",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "喘息",
"tendency": ""
},
{
"anatomy_list": [
"胸"
],
"character": [],
"core_name": "胸闷",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"阵发性",
"夜间"
],
"core_name": "呼吸困难",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"夜间"
],
"core_name": "端坐呼吸",
"tendency": "否定"
},
{
"anatomy_list": [
"双下肢"
],
"character": [],
"core_name": "水肿",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "发热",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "盗汗",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "纳差",
"tendency": "否定"
},
{
"anatomy_list": [
"心"
],
"character": [],
"core_name": "心悸",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "反酸",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "嗳气",
"tendency": "否定"
}
] |
1,453 |
67天前，患者无明显诱因出现头痛，为持续性隐痛，伴呕吐，非喷射性，呕吐物为胃内容物，呕吐后症状无明显好转，伴头晕、视物模糊，伴厌油，无腹痛、腹泻，无畏寒、发热等不适，于我院门诊行颅脑ct示颅内多发占位，考虑转移。
|
[
{
"anatomy_list": [
"头"
],
"character": [
"持续性",
"隐痛"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"非喷射性",
"呕吐物为胃内容物",
"呕吐后症状无明显好转"
],
"core_name": "呕吐",
"tendency": ""
},
{
"anatomy_list": [
"头"
],
"character": [],
"core_name": "头晕",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "视物模糊",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "厌油",
"tendency": ""
},
{
"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": "畏寒",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "发热",
"tendency": "否定"
},
{
"anatomy_list": [
"颅内"
],
"character": [
"多发"
],
"core_name": "占位",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"转移"
],
"core_name": "转移",
"tendency": "不确定"
}
] |
346 |
术后患者出现排尿困难，二次导尿后好转，经积极治疗，于2020年01月20日出院。
|
[
{
"anatomy_list": [],
"character": [],
"core_name": "排尿困难",
"tendency": ""
}
] |
380 |
入院前1+年，患者受凉后出现咳嗽，为刺激性咳嗽，痰量少，不易咳出，无胸闷、胸痛、咯血、呼吸困难，无潮热、盗汗、疲乏、消瘦，无畏寒、发热。
|
[
{
"anatomy_list": [],
"character": [
"受凉后"
],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"刺激性"
],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"量少",
"不易咳出"
],
"core_name": "咳痰",
"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": "咯血",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "呼吸困难",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "潮热",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "盗汗",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "疲乏",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "消瘦",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "畏寒",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "发热",
"tendency": "否定"
}
] |
687 |
随后于停经58天（2020-5-18）就诊于我院，查血hcg23126.3m/ml，孕酮：21.13ng/ml。
|
[
{
"anatomy_list": [],
"character": [],
"core_name": "停经",
"tendency": ""
}
] |
540 |
病程中，患者逐渐出现手足麻木、疼痛，间断泡沫尿及间断性跛行，多次于我院就诊，诊断为“2型糖尿病、糖尿病周围神经病变、糖尿病肾病”，予以皮下注射胰岛素（诺和锐30早12iu 晚12iu qd）、服用瑞格列奈 1mg午餐前qd。
|
[
{
"anatomy_list": [
"手",
"足"
],
"character": [],
"core_name": "麻木",
"tendency": ""
},
{
"anatomy_list": [
"手",
"足"
],
"character": [],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"间断"
],
"core_name": "泡沫尿",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"间断性"
],
"core_name": "跛行",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"2型"
],
"core_name": "糖尿病",
"tendency": ""
},
{
"anatomy_list": [
"周围神经"
],
"character": [
"糖尿病"
],
"core_name": "病变",
"tendency": ""
},
{
"anatomy_list": [
"肾"
],
"character": [
"糖尿病"
],
"core_name": "肾病",
"tendency": ""
}
] |
72 |
2天前患者于体检时行胸部ct检查提示：左肺占位性病变伴阻塞性肺炎，无低热盗汗、畏寒寒战、咯血、痰中带血、胸闷胸痛、恶心呕吐等不适，患者为求进一步诊治，遂入我院，门诊以“左肺占位”收治入科。
|
[
{
"anatomy_list": [
"左肺"
],
"character": [
"占位性"
],
"core_name": "病变",
"tendency": ""
},
{
"anatomy_list": [
"肺"
],
"character": [
"阻塞性"
],
"core_name": "肺炎",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"低"
],
"core_name": "发热",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "盗汗",
"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": "咯血",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"带血"
],
"core_name": "咳痰",
"tendency": "否定"
},
{
"anatomy_list": [
"胸"
],
"character": [],
"core_name": "胸闷",
"tendency": "否定"
},
{
"anatomy_list": [
"胸"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "恶心",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "呕吐",
"tendency": "否定"
},
{
"anatomy_list": [
"左肺"
],
"character": [],
"core_name": "占位",
"tendency": ""
}
] |
203 |
病程中有反酸、进粗食哽噎感，目前患者无畏寒、发热，无恶心、呕吐，无腹痛、腹泻，无鼻塞、流涕表现，近1周来，患者感进食梗阻较前频繁，2016年3月23日来我院门诊检查胃镜示：食管癌术后；食管吻合口炎吻合口炎伴糜烂；食管吻合口狭窄。
|
[
{
"anatomy_list": [],
"character": [],
"core_name": "反酸",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"进粗食"
],
"core_name": "哽噎感",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "畏寒",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "发热",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "恶心",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "呕吐",
"tendency": "否定"
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "腹泻",
"tendency": "否定"
},
{
"anatomy_list": [
"鼻"
],
"character": [],
"core_name": "鼻塞",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "流涕",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"较前频繁"
],
"core_name": "进食梗阻",
"tendency": ""
},
{
"anatomy_list": [
"食管"
],
"character": [
"术后"
],
"core_name": "癌",
"tendency": ""
},
{
"anatomy_list": [
"食管吻合口"
],
"character": [],
"core_name": "食管吻合口炎",
"tendency": ""
},
{
"anatomy_list": [
"吻合口"
],
"character": [],
"core_name": "吻合口炎",
"tendency": ""
},
{
"anatomy_list": [
"食管吻合口"
],
"character": [],
"core_name": "糜烂",
"tendency": ""
},
{
"anatomy_list": [
"食管吻合口"
],
"character": [],
"core_name": "狭窄",
"tendency": ""
}
] |
408 |
患者于2018年12月24日转诊某医院，腹部ct提示直肠新生物伴周围淋巴结淋巴结增大，行pet/ct提示：直肠下段管壁增厚，fdg代谢增高，倾向肿瘤；盆腔淋巴结肿大，fdg代谢增高，倾向转移；左肾上腺增大，fdg代谢增高，可疑转移；右肾上腺增大，fdg代谢增高，建议随访；双肺小结节，fdg代谢未见异常增高，倾向良性病变。
|
[
{
"anatomy_list": [
"直肠"
],
"character": [],
"core_name": "新生物",
"tendency": ""
},
{
"anatomy_list": [
"直肠周围淋巴结"
],
"character": [],
"core_name": "淋巴结增大",
"tendency": ""
},
{
"anatomy_list": [
"直肠下段管壁"
],
"character": [],
"core_name": "增厚",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"代谢增高"
],
"core_name": "fdg",
"tendency": ""
},
{
"anatomy_list": [
"直肠下段"
],
"character": [],
"core_name": "肿瘤",
"tendency": "不确定"
},
{
"anatomy_list": [
"盆腔淋巴结"
],
"character": [],
"core_name": "肿大",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"代谢增高"
],
"core_name": "fdg",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "转移",
"tendency": "不确定"
},
{
"anatomy_list": [
"左肾上腺"
],
"character": [],
"core_name": "增大",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"代谢增高"
],
"core_name": "fdg",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "转移",
"tendency": "不确定"
},
{
"anatomy_list": [
"右肾上腺"
],
"character": [],
"core_name": "增大",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"代谢增高"
],
"core_name": "fdg",
"tendency": ""
},
{
"anatomy_list": [
"双肺"
],
"character": [
"小"
],
"core_name": "结节",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"代谢异常增高"
],
"core_name": "fdg",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"良性"
],
"core_name": "病变",
"tendency": "不确定"
}
] |
1,218 |
2017.06，患者无明显诱因出现阴道大量流血，呈鲜红色，一天可浸湿三张卫生巾，伴下腹部疼痛，难以忍受，遂至某医院就诊，给予止血、止痛等对症治疗后（具体治疗不详）症状未缓解，患者为进一步治疗到我院妇科门诊就诊，行妇科检查提示宫颈表面可见大量菜花样组织，有活动性出血，妇科彩超提示：1.宫颈偏低回声，考虑宫颈ca。
|
[
{
"anatomy_list": [
"阴道"
],
"character": [
"大量",
"呈鲜红色",
"一天可浸湿三张卫生巾"
],
"core_name": "出血",
"tendency": ""
},
{
"anatomy_list": [
"下腹部"
],
"character": [
"难以忍受"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"宫颈表面"
],
"character": [
"大量",
"有活动性出血"
],
"core_name": "菜花样组织",
"tendency": ""
},
{
"anatomy_list": [
"宫颈"
],
"character": [
"偏低"
],
"core_name": "回声",
"tendency": ""
},
{
"anatomy_list": [
"宫颈"
],
"character": [],
"core_name": "癌",
"tendency": "不确定"
}
] |
1,193 |
患者于2016-07-18在局麻超声引导下行右乳包块麦默通旋切术+快速冰冻活检术，术后病理提示：（右乳）浸润性小叶癌，免疫组化提示：er（－） pr（－） cerbb-2（－） ki-67（++）。
|
[
{
"anatomy_list": [
"右乳小叶"
],
"character": [
"浸润性"
],
"core_name": "癌",
"tendency": ""
}
] |
1,855 |
术后病理报告（123456）：（直肠）中分化腺癌，侵及深肌层。
|
[
{
"anatomy_list": [
"直肠"
],
"character": [
"中分化"
],
"core_name": "腺癌",
"tendency": ""
},
{
"anatomy_list": [
"深肌层"
],
"character": [
"侵及"
],
"core_name": "腺癌",
"tendency": ""
}
] |
135 |
术后病理示：（右乳）浸润性癌（倾向小叶癌合并小管癌），免疫组化：er（+）10%pr（－） ck（++） cr（－） cerbb-2（+） ki-67（+）＜10%。
|
[
{
"anatomy_list": [
"右乳"
],
"character": [
"浸润性"
],
"core_name": "癌",
"tendency": ""
},
{
"anatomy_list": [
"右乳"
],
"character": [],
"core_name": "小叶癌",
"tendency": "不确定 "
},
{
"anatomy_list": [
"右乳"
],
"character": [],
"core_name": "小管癌",
"tendency": "不确定 "
}
] |
1,362 |
患者感左侧胸痛进行性加重，夜间影响睡眠，于2016-09-23于某医院完善骨扫描：右前第2肋、左侧髋关节髋关节异常放射性增多。
|
[
{
"anatomy_list": [
"左侧胸"
],
"character": [
"进行性加重",
"夜间影响睡眠"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"右前2肋",
"左侧髋关节"
],
"character": [
"异常放射性"
],
"core_name": "增多",
"tendency": ""
}
] |
66 |
遂于我院就诊，完善相关检查示：hcv-dna定量为1.1*107IU/ml,甲胎蛋白示163.10ug/L，上腹部mr提示肝右叶肝癌可能，肝硬化。
|
[
{
"anatomy_list": [
"肝右叶"
],
"character": [],
"core_name": "癌",
"tendency": "不确定"
},
{
"anatomy_list": [
"肝"
],
"character": [],
"core_name": "硬化",
"tendency": ""
}
] |
1,144 |
子宫颈管见癌累及。建议住院行进一步诊治。
|
[
{
"anatomy_list": [
"子宫颈管"
],
"character": [],
"core_name": "癌",
"tendency": ""
}
] |
688 |
妇科超声提示宫内早孕，卵黄囊可见，直径3.1mm，胎芽可见，长径约3mm，原始心管搏动可见。
|
[
{
"anatomy_list": [
"宫内"
],
"character": [],
"core_name": "早孕",
"tendency": ""
},
{
"anatomy_list": [
"宫内"
],
"character": [
"可见"
],
"core_name": "卵黄囊",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"可见"
],
"core_name": "胎芽",
"tendency": ""
},
{
"anatomy_list": [
"心管"
],
"character": [
"原始",
"可见"
],
"core_name": "搏动",
"tendency": ""
}
] |
1,191 |
给予药物治疗（具体用药不详），中上腹疼痛症状稍缓解。
|
[
{
"anatomy_list": [
"中上腹"
],
"character": [
"稍缓解"
],
"core_name": "疼痛",
"tendency": ""
}
] |
438 |
今日再次来我院就诊，门诊以“左侧输尿管扩张”收住入院。
|
[
{
"anatomy_list": [
"左侧输尿管"
],
"character": [],
"core_name": "扩张",
"tendency": ""
}
] |
159 |
患“糖尿病”1+年，现仍在皮下注射胰岛素，血糖控制可。
|
[
{
"anatomy_list": [],
"character": [],
"core_name": "糖尿病",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"控制可"
],
"core_name": "血糖",
"tendency": ""
}
] |
156 |
入院前2天，患者到我院门诊随访，胸部+上腹部ct平扫+增强示：左肺上叶尖后段及下叶外基底段胸膜下类圆形结节结节影，考虑转移可能，较前比较，左肺上叶尖后段胸膜下结节结节影稍增大，肝ca介入术后改变。
|
[
{
"anatomy_list": [
"左肺上叶尖后段胸膜下",
"左肺下叶外基底段胸膜下"
],
"character": [
"类圆形"
],
"core_name": "结节影",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "转移",
"tendency": "不确定"
},
{
"anatomy_list": [
"左肺上叶尖后段胸膜下"
],
"character": [
"稍增大"
],
"core_name": "结节影",
"tendency": ""
},
{
"anatomy_list": [
"肝"
],
"character": [],
"core_name": "癌",
"tendency": ""
},
{
"anatomy_list": [
"肝"
],
"character": [
"介入术后"
],
"core_name": "改变",
"tendency": ""
}
] |
1,381 |
3.左冠状动脉壁钙化。
|
[
{
"anatomy_list": [
"左冠状动脉壁"
],
"character": [],
"core_name": "钙化",
"tendency": ""
}
] |
480 |
至某口腔医院就诊，因肺部检查异常（具体不详）无法麻醉，未行手术切除。
|
[
{
"anatomy_list": [
"肺部"
],
"character": [],
"core_name": "异常",
"tendency": ""
}
] |
1,566 |
入院前4月，患者进食后出现胸骨后哽咽感，无腹痛，无恶心、呕吐，无咯血、黑便，无腹胀，近期无异物吞咽史，病后于某医院行食管钡餐及喉镜检查，结果提示“未见明显实质性病变”，未行特殊治疗；入院前2月，患者出现进食哽咽加重伴吞咽困难，进食干硬及大块食物时明显，大量进食后呕吐，呕吐物为食物残渣，患者未重视，未行特殊治疗；现患者吞咽困难仍明显，为进一步诊治于某医院行胃镜检查，结果提示“食管上段鳞癌”，为进一步治疗入我院，门诊以“食管癌”收入我科。
|
[
{
"anatomy_list": [
"胸骨后"
],
"character": [
"进食后"
],
"core_name": "哽噎感",
"tendency": ""
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "恶心",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "呕吐",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "咯血",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "黑便",
"tendency": "否定"
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "腹胀",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "异物吞咽",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"明显实质性"
],
"core_name": "病变",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"进食加重",
"进食干硬大块食物明显"
],
"core_name": "哽噎感",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"进食干硬大块食物明显"
],
"core_name": "吞咽困难",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"大量进食后",
"呕吐物为食物残渣"
],
"core_name": "呕吐",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"明显"
],
"core_name": "吞咽困难",
"tendency": ""
},
{
"anatomy_list": [
"食管上段"
],
"character": [],
"core_name": "鳞癌",
"tendency": ""
},
{
"anatomy_list": [
"食管"
],
"character": [],
"core_name": "癌",
"tendency": ""
}
] |
1,939 |
因无手术指征，于2017.04.02、04.26以tp方案（药物总量：紫杉醇480mg+奈达铂260mg）姑息性化疗2周期，化疗期间感全身酸痛，后自行缓解，患者因第三周期化疗时出现奈达铂过敏，于6月1日行tp方案（紫杉醇210mg+卡铂450mg）化疗第3周期，病程中因患者腰部胀痛明显，于2017年4月-66月行腰55椎体转移肿瘤放射治疗，放疗后患者腰部胀痛较前缓解，现口服盐酸吗啡缓释片4片q12h口服止痛治疗，现疼痛评分：2分。
|
[
{
"anatomy_list": [
"全身"
],
"character": [
"化疗期间",
"后自行缓解",
"酸痛"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"奈达铂"
],
"core_name": "过敏",
"tendency": ""
},
{
"anatomy_list": [
"腰部"
],
"character": [
"明显",
"胀痛"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"腰部"
],
"character": [
"较前缓解",
"放疗后",
"胀痛"
],
"core_name": "疼痛",
"tendency": ""
}
] |
1,522 |
2月前患者受凉后喘累明显，平路活动即感气促，间断白色粘痰，间断可咳暗红色血，稍活动伴心悸、心累，有纳差，剑突下隐痛，反酸、嗳气，不消化感，大便干结，6-7天/次，颗粒大便，给予抗感染、止咳平喘、护胃治疗好转出院。
|
[
{
"anatomy_list": [],
"character": [
"明显",
"受凉后"
],
"core_name": "喘累",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"平路活动"
],
"core_name": "气促",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"间断",
"白色",
"粘"
],
"core_name": "咳痰",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"间断",
"暗红色"
],
"core_name": "咳血",
"tendency": ""
},
{
"anatomy_list": [
"心"
],
"character": [
"稍活动"
],
"core_name": "心悸",
"tendency": ""
},
{
"anatomy_list": [
"心"
],
"character": [
"稍活动"
],
"core_name": "心累",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "纳差",
"tendency": ""
},
{
"anatomy_list": [
"剑突下"
],
"character": [
"隐痛"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "反酸",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "嗳气",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "不消化感",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"干结",
"颗粒",
"6-7天/次"
],
"core_name": "大便",
"tendency": ""
}
] |
783 |
急诊以“眩晕待诊”收入我院。
|
[
{
"anatomy_list": [],
"character": [],
"core_name": "眩晕",
"tendency": ""
}
] |
539 |
患者于入院前10+年无明显诱因出现口干、多尿、体重减轻（具体数值不详），晕厥1次，遂于“某医院”就诊，查随机血糖大于30mmol/L，诊断为“糖尿病”，予以胰岛素泵强化治疗后好转出院，院外使用一段时间胰岛素后改为口服“达美康”及“中药”（具体不详）等治疗，血糖控制情况不详。
|
[
{
"anatomy_list": [
"口"
],
"character": [],
"core_name": "口干",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "多尿",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "体重减轻",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"1次"
],
"core_name": "晕厥",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "糖尿病",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"控制不详"
],
"core_name": "血糖",
"tendency": ""
}
] |
1,377 |
2天前患者出现咳嗽、咳痰，咳黄白色粘稠痰，无咯血及痰中带血，无发热，未予重视治疗，入院前2小时突发呼吸困难，伴大汗淋漓，无畏寒、发热、头痛、胸痛、恶心、呕吐、抽搐等。
|
[
{
"anatomy_list": [],
"character": [],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"黄白色",
"粘稠"
],
"core_name": "咳痰",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "咯血",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"带血"
],
"core_name": "咳痰",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "发热",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"突发"
],
"core_name": "呼吸困难",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"大汗"
],
"core_name": "出汗",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "畏寒",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "发热",
"tendency": "否定"
},
{
"anatomy_list": [
"头"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [
"胸"
],
"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": "抽搐",
"tendency": "否定"
}
] |
1,407 |
患者与某医院肝胆外科，行全面下行开腹保留十二指肠的胰头切除术、胆囊切除术和胆总管探查术，术后6天患者出现低血容量性休克，考虑腹腔出血可能性大，予以扩容、输血等对症，无明显好转，局麻下行肝动脉分支假性动脉瘤栓塞止血术，术后经过泰能抗感染、生长抑素泵入、补液、腹腔引流及对症治疗，患者病情平稳后，带腹腔2根引流管+t管引流出院。
|
[
{
"anatomy_list": [],
"character": [
"低血容量性"
],
"core_name": "休克",
"tendency": ""
},
{
"anatomy_list": [
"腹腔"
],
"character": [],
"core_name": "出血",
"tendency": "不确定"
}
] |
955 |
患者本次发病以来，食欲减退，神志清醒，精神尚可，睡眠尚可，大便如上所诉，小便正常，体重无明显变化。
|
[
{
"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": "小便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"明显"
],
"core_name": "体重改变",
"tendency": ""
}
] |
908 |
追问病史，无结核接触史，有卡介苗接种史。
|
[
{
"anatomy_list": [],
"character": [
"接触史"
],
"core_name": "结核",
"tendency": "否定"
}
] |
581 |
门诊建议手术治疗，遂以“左侧乳腺肿瘤”收治入院。
|
[
{
"anatomy_list": [
"左侧乳腺"
],
"character": [],
"core_name": "肿瘤",
"tendency": ""
}
] |
492 |
患者于2016.06.14、2016.07.07、2016.07.29、2016.08.19、2016.09.12、2016.10.10于我院行共6次tac（吡柔比星60mg d1+紫杉醇240mg d2+环磷酰胺800mg d3）方案化疗，化疗过程顺利，化疗后患者出现肢端麻木、感觉异常，给予对症治疗后症状好转。
|
[
{
"anatomy_list": [
"肢端"
],
"character": [
"化疗后"
],
"core_name": "麻木",
"tendency": ""
},
{
"anatomy_list": [
"肢端"
],
"character": [
"化疗后"
],
"core_name": "感觉异常",
"tendency": ""
}
] |
1,042 |
入院前3+月，患者感上腹胀于我科门诊随访完善腹部ct提示肝右叶多发强化病灶，考虑肝转移瘤可能。
|
[
{
"anatomy_list": [
"上腹"
],
"character": [],
"core_name": "腹胀",
"tendency": ""
},
{
"anatomy_list": [
"肝右叶"
],
"character": [
"多发",
"强化"
],
"core_name": "病灶",
"tendency": ""
},
{
"anatomy_list": [
"肝"
],
"character": [
"转移"
],
"core_name": "瘤",
"tendency": "不确定"
}
] |
1,866 |
积极术前准备，于2019年11月10日在手术室全麻下行了腹腔镜辅助下直肠癌直肠前切除术，术后恢复良好出院，术后诊断：直肠腺癌t3n0M0。
|
[
{
"anatomy_list": [
"直肠"
],
"character": [
"t3n0M0"
],
"core_name": "腺癌",
"tendency": ""
}
] |
568 |
2016-12-16行第二次r-chop（长春瑞滨40mg1，吡柔比星30mg1，环磷酰胺1g1，泼尼松100mg1-d5，美罗华500mg6)，化疗顺利，今日为进一步就诊，门诊以“非霍奇金淋巴瘤”收治入院。
|
[
{
"anatomy_list": [
"淋巴"
],
"character": [
"非霍奇金氏"
],
"core_name": "瘤",
"tendency": ""
}
] |
18 |
术后病理诊断（123456）:<右乳>浸润性癌,非特殊类型（iii级,8分）；<右腋窝>淋巴结见癌转移（14/14）；乳头未见癌累及；免疫组化：er(+)70%,pr(+)10%,cerbb-2(0-1+),e-ca(+),p120(+),34βe12(+),p53(-),p63(-),ck5/6(-),calponin部分(+),ki67(+)5%。
|
[
{
"anatomy_list": [
"右乳"
],
"character": [
"浸润性",
"非特殊类型",
"8分"
],
"core_name": "癌",
"tendency": ""
},
{
"anatomy_list": [
"右腋窝淋巴结"
],
"character": [
"转移"
],
"core_name": "癌",
"tendency": ""
},
{
"anatomy_list": [
"乳头"
],
"character": [
"累及"
],
"core_name": "癌",
"tendency": "否定"
}
] |
1,085 |
10天患者自感活动后胸痛、心悸、胸闷较前加重，表现为少于之前活动量即可发作，症状持续时间较前延长；伴有咳嗽、咳痰不适，痰液为黄色，较粘稠；为进一步治疗来我院门诊，查血脂：甘油三酯(tg)1.09mmol/l，总胆固醇(cho)6.51mmol/l↑，高密度脂蛋白胆固醇(hdl-c)1.63mmol/l，低密度脂蛋白胆固醇(ldl-c)3.46mmol/l↑；门诊诊断”“冠心病、高脂血症”，予以“阿托伐他钙片20mg、富马酸比索洛尔片2.5mg、阿司匹林肠溶片100mg”口服；患者仍有反复的活动后胸痛、心悸、胸闷发作。
|
[
{
"anatomy_list": [
"胸"
],
"character": [
"活动后",
"较前加重",
"少于之前活动量即可发作",
"症状持续时间较前延长"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"心"
],
"character": [
"活动后",
"较前加重",
"少于之前活动量即可发作",
"症状持续时间较前延长"
],
"core_name": "心悸",
"tendency": ""
},
{
"anatomy_list": [
"胸"
],
"character": [
"活动后",
"较前加重",
"少于之前活动量即可发作",
"症状持续时间较前延长"
],
"core_name": "胸闷",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"黄色",
"较粘稠"
],
"core_name": "咳痰",
"tendency": ""
},
{
"anatomy_list": [
"冠状动脉",
"心脏"
],
"character": [
"粥样",
"硬化性"
],
"core_name": "心脏病",
"tendency": ""
},
{
"anatomy_list": [
"全身"
],
"character": [],
"core_name": "高脂血症",
"tendency": ""
},
{
"anatomy_list": [
"胸"
],
"character": [
"反复",
"活动后"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"心"
],
"character": [
"反复",
"活动后"
],
"core_name": "心悸",
"tendency": ""
},
{
"anatomy_list": [
"胸"
],
"character": [
"反复",
"活动后"
],
"core_name": "胸闷",
"tendency": ""
}
] |
1,433 |
3月前患者复查完善膀胱镜检，膀胱镜检发现左侧输尿管输尿管口瘢痕组织旁及膀胱左侧顶顶壁见膀胱粘膜炎症、水肿、滤泡样增生，异物钳钳夹左侧输尿管输尿管口附近及左侧顶顶壁粘膜送检后病检示：<左输尿管口附近>低级别非浸润性尿路上皮癌，<左顶壁粘膜>息肉。
|
[
{
"anatomy_list": [
"左侧输尿管口",
"膀胱左侧顶壁",
"膀胱粘膜"
],
"character": [
"瘢痕组织旁"
],
"core_name": "炎症",
"tendency": ""
},
{
"anatomy_list": [
"左侧输尿管口",
"膀胱左侧顶壁",
"膀胱粘膜"
],
"character": [
"瘢痕组织旁性"
],
"core_name": "水肿",
"tendency": ""
},
{
"anatomy_list": [
"左侧输尿管口",
"膀胱左侧顶壁",
"膀胱粘膜"
],
"character": [
"滤泡样"
],
"core_name": "增生",
"tendency": ""
},
{
"anatomy_list": [
"左侧输尿管口附近",
"尿路上皮"
],
"character": [
"低级别",
"非浸润性"
],
"core_name": "癌",
"tendency": ""
},
{
"anatomy_list": [
"左顶壁粘膜"
],
"character": [
"粘膜"
],
"core_name": "息肉",
"tendency": ""
}
] |
1,944 |
4月余前，患者自觉腰背部疼痛疼痛加重，伴咳嗽、咳痰、乏力多汗等不适。
|
[
{
"anatomy_list": [
"腰背部"
],
"character": [],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"腰背部"
],
"character": [
"加重"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "咳痰",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "疲劳",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "多汗",
"tendency": ""
}
] |
1,252 |
就诊于A医院、B医院予以抗炎等治疗后腹痛无明显缓解。
|
[
{
"anatomy_list": [
"腹"
],
"character": [
"无明显缓解"
],
"core_name": "疼痛",
"tendency": ""
}
] |
2,049 |
取活检示：1、（十二指肠球部）送检粘膜下方见少许异型细胞团，恶性肿瘤可能。
|
[
{
"anatomy_list": [
"十二指肠球粘膜下方"
],
"character": [
"少许"
],
"core_name": "异形细胞团",
"tendency": ""
},
{
"anatomy_list": [
"十二指肠球粘膜下方"
],
"character": [
"恶性"
],
"core_name": "肿瘤",
"tendency": "不确定"
}
] |
1,991 |
入院前1月，患者无明显诱因出现咳嗽、咳痰，咳白色粘液痰，无痰中带血、胸痛，于诊所就医后予“硫磺解毒丸、头痛粉”治疗后无好转。
|
[
{
"anatomy_list": [],
"character": [],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "咳痰",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"白色",
"粘液"
],
"core_name": "咳痰",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"带血"
],
"core_name": "咳痰",
"tendency": "否定"
},
{
"anatomy_list": [
"胸"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
}
] |
2,005 |
2.腋窝淋巴结见癌转移（2/20）。
|
[
{
"anatomy_list": [
"腋窝淋巴结"
],
"character": [
"转移"
],
"core_name": "癌",
"tendency": ""
}
] |
1,319 |
2013年患者无明显诱因触及左侧腋窝腋窝包块，大小约2*2cm,质硬,无压痛,无发热等不适，于某医院行包块穿刺活检提示:乳腺转移转移性癌,er(+),pr(+),her-2(++),遂行新辅助化疗两个周期ta方案（吡柔比星60mg1+多西他赛120mg2）后于2013年8月22日行左侧乳腺癌改良根治术，术后病理提示：左侧乳腺浸润性导管癌iii期,er(+),pr(+),her-2(+)，腋窝淋巴结6/6。
|
[
{
"anatomy_list": [
"左侧腋窝"
],
"character": [
"质硬",
"无压痛"
],
"core_name": "包块",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "发热",
"tendency": "否定"
},
{
"anatomy_list": [
"乳腺"
],
"character": [
"转移"
],
"core_name": "癌",
"tendency": ""
},
{
"anatomy_list": [
"左侧乳腺"
],
"character": [
"浸润性",
"iii期"
],
"core_name": "导管癌",
"tendency": ""
}
] |
414 |
化疗期间有骨髓抑制，骨髓毒性程度为Ⅰ度；有胃肠道反应，消化系统毒性程度为Ⅰ度。
|
[
{
"anatomy_list": [
"骨髓"
],
"character": [
"化疗期间"
],
"core_name": "骨髓抑制",
"tendency": ""
},
{
"anatomy_list": [
"骨髓"
],
"character": [
"程度为Ⅰ度"
],
"core_name": "骨髓毒性",
"tendency": ""
},
{
"anatomy_list": [
"胃肠道"
],
"character": [],
"core_name": "胃肠道反应",
"tendency": ""
},
{
"anatomy_list": [
"消化系统"
],
"character": [
"程度为Ⅰ度"
],
"core_name": "消化系统毒性",
"tendency": ""
}
] |
2,062 |
患病以来，患者精神、食欲、睡眠差，大便正常，尿频，近期体重无明显改变。
|
[
{
"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": [
"正常"
],
"core_name": "大便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "尿频",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"明显"
],
"core_name": "体重改变",
"tendency": "否定"
}
] |
915 |
为求进一步改善右侧腕部瘢痕及活动情况，今日以“右腕部溃疡25年余”收入我科。
|
[
{
"anatomy_list": [
"右侧腕部"
],
"character": [],
"core_name": "瘢痕",
"tendency": ""
},
{
"anatomy_list": [
"右腕部"
],
"character": [],
"core_name": "溃疡",
"tendency": ""
}
] |
865 |
患者于12天前无明显诱因出现便血，为鲜红色，约2-3次/天，每次量约几十毫升，伴肛门坠胀感，大便次数及性状正常，表面附着少量鲜血。
|
[
{
"anatomy_list": [],
"character": [
"鲜红色",
"约2-3次/天",
"每次量约几十毫升"
],
"core_name": "便血",
"tendency": ""
},
{
"anatomy_list": [
"肛门"
],
"character": [],
"core_name": "坠胀",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"次数正常"
],
"core_name": "大便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"性状正常"
],
"core_name": "大便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"表面附着少量鲜血"
],
"core_name": "大便",
"tendency": ""
}
] |
826 |
近2月外院2次妇科彩超均提示双侧附件区巧囊可能。
|
[
{
"anatomy_list": [
"双侧附件"
],
"character": [],
"core_name": "巧克力囊肿",
"tendency": "不确定"
}
] |
1,397 |
宫颈6、9、12点慢性炎症伴鳞状上皮增生，上皮内可见挖空细胞。
|
[
{
"anatomy_list": [
"宫颈6、9、12点"
],
"character": [
"慢性"
],
"core_name": "炎症",
"tendency": ""
},
{
"anatomy_list": [
"宫颈6、9、12点"
],
"character": [
"鳞状上皮"
],
"core_name": "增生",
"tendency": ""
}
] |
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