id
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2.07k
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stringlengths 5
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listlengths 1
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52 |
两切端未见癌累及。
|
[
{
"anatomy_list": [
"两切端"
],
"character": [
"累及"
],
"core_name": "癌",
"tendency": "否定"
}
] |
1,824 |
患者拒绝行第6周期化疗，此后正规复查，肿瘤处于sd，2月前患者无明显诱因出现喘累、气促，活动后明显，休息时稍缓解，于我院住院治疗，胸、腹腔b超提示胸腔积液、腹腔积液，予以胸腔穿刺置管引流后喘累缓解，予以腹腔穿刺置管引流后于2018-05-24行dp方案（多西他赛100mg iv+顺铂100mg腹腔灌注）化疗1周期，化疗后出现轻度恶心、呕吐，予以止吐对症治疗后好转，无明显骨髓抑制，喘累好转。
|
[
{
"anatomy_list": [],
"character": [
"sd"
],
"core_name": "肿瘤",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"活动后明显",
"休息时稍缓解"
],
"core_name": "喘累",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"活动后明显",
"休息时稍缓解"
],
"core_name": "气促",
"tendency": ""
},
{
"anatomy_list": [
"胸腔"
],
"character": [],
"core_name": "积液",
"tendency": ""
},
{
"anatomy_list": [
"腹腔"
],
"character": [],
"core_name": "积液",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"缓解"
],
"core_name": "喘累",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"轻度",
"化疗后"
],
"core_name": "恶心",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"轻度",
"化疗后"
],
"core_name": "呕吐",
"tendency": ""
},
{
"anatomy_list": [
"骨髓"
],
"character": [
"明显"
],
"core_name": "骨髓抑制",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"好转"
],
"core_name": "喘累",
"tendency": ""
}
] |
1,803 |
入院前 3+天 ，患者检修自家瓦房屋顶时不慎从3+米多高处跌落，致头部及左下肢受伤（具体受力方式不详），伤后昏迷约10+分钟，醒转后神萎嗜睡、少语，感头晕头痛及左小腿疼痛，无抽搐及大小便失禁，无口鼻腔及外耳道耳道出血，无呕吐，无肢体活动受限。
|
[
{
"anatomy_list": [
"头部",
"左下肢"
],
"character": [
"高处跌落"
],
"core_name": "受伤",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"伤后"
],
"core_name": "昏迷",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"醒转后"
],
"core_name": "神萎",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"醒转后"
],
"core_name": "嗜睡",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "少语",
"tendency": ""
},
{
"anatomy_list": [
"头"
],
"character": [],
"core_name": "头晕",
"tendency": ""
},
{
"anatomy_list": [
"头"
],
"character": [],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"左小腿"
],
"character": [],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "抽搐",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "大小便失禁",
"tendency": "否定"
},
{
"anatomy_list": [
"口鼻腔",
"外耳道"
],
"character": [],
"core_name": "出血",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "呕吐",
"tendency": "否定"
},
{
"anatomy_list": [
"肢体"
],
"character": [],
"core_name": "活动受限",
"tendency": "否定"
}
] |
1,466 |
40+年患者发现血压升高，最高血压为190/？mmhg，平时无头昏、头痛不适。
|
[
{
"anatomy_list": [],
"character": [
"升高"
],
"core_name": "血压",
"tendency": ""
},
{
"anatomy_list": [
"头"
],
"character": [],
"core_name": "头昏",
"tendency": "否定"
},
{
"anatomy_list": [
"头"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
}
] |
1,923 |
出院后患者感容易饱胀，多次于当地镇医院输液治疗（具体不详）。
|
[
{
"anatomy_list": [],
"character": [
"容易"
],
"core_name": "饱胀",
"tendency": ""
}
] |
1,400 |
无同房出血及性交痛，建议月经期后进一步检查及治疗。
|
[
{
"anatomy_list": [],
"character": [
"同房"
],
"core_name": "出血",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"性交"
],
"core_name": "疼痛",
"tendency": "否定"
}
] |
403 |
2月前，患者无明显诱因出现便血，为鲜血，伴少许粘液，无恶臭，伴大便困难，无明显肛门坠胀，无腹痛、腹泻，无发热、寒战等不适，患者自认为“痔疮”并自行使用外用药物处理（具体不详）后仍反复便血，患者遂就诊于某医院，行ct见直肠下段管壁改变，考虑占位性病变。
|
[
{
"anatomy_list": [],
"character": [
"鲜血",
"伴少许粘液",
"无恶臭"
],
"core_name": "便血",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "大便困难",
"tendency": ""
},
{
"anatomy_list": [
"肛门"
],
"character": [
"明显"
],
"core_name": "坠胀",
"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": "发热",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "寒颤",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "痔疮",
"tendency": "不确定"
},
{
"anatomy_list": [],
"character": [
"反复"
],
"core_name": "便血",
"tendency": ""
},
{
"anatomy_list": [
"直肠下段管壁"
],
"character": [],
"core_name": "改变",
"tendency": ""
},
{
"anatomy_list": [
"直肠下段管壁"
],
"character": [
"占位性"
],
"core_name": "病变",
"tendency": "不确定"
}
] |
304 |
15月前，患者因“胸腔积液”再次入院，请心胸外科会诊后考虑转移所致，遂于2014-07-17在我院心胸外科行“剖胸探查术+胸膜部分剥脱术+胸壁包块切除术”，术后患者胸壁切口裂开，切口出现大量渗液，于2014-08-27经引流管向伤口方向注入顺铂30mg，抑制胸膜腔液体渗出，2014-09-02行胸腔闭式引流术，2014-09-04探查切口见引流管脱出，予纱布填塞后纱布很快浸湿，考虑仍有胸腔积液，予重新安置胸腔闭式引流并定期给予换药，后因患者强烈要求拔管遂拔除引流管。
|
[
{
"anatomy_list": [
"胸腔"
],
"character": [],
"core_name": "积液",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "转移",
"tendency": "不确定"
},
{
"anatomy_list": [
"胸壁"
],
"character": [
"术后"
],
"core_name": "切口裂开",
"tendency": ""
},
{
"anatomy_list": [
"胸壁切口"
],
"character": [
"大量"
],
"core_name": "渗液",
"tendency": ""
},
{
"anatomy_list": [
"胸壁"
],
"character": [],
"core_name": "引流管脱出",
"tendency": ""
},
{
"anatomy_list": [
"胸腔"
],
"character": [],
"core_name": "积液",
"tendency": "不确定"
}
] |
1,208 |
5.子宫左侧软组织肿块，肿瘤？其它？请结合mri检查。
|
[
{
"anatomy_list": [
"子宫左侧软组织"
],
"character": [],
"core_name": "肿块",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "肿瘤",
"tendency": "不确定"
}
] |
1,609 |
胸部ct：1.右肺下叶前基底段实性结节。
|
[
{
"anatomy_list": [
"右肺下叶前基底段"
],
"character": [
"实性"
],
"core_name": "结节",
"tendency": ""
}
] |
1,461 |
2+年患者在某医院住院期间发现血糖升高，行ogtt提示“空腹血糖6.6mmol/l，餐后60分钟血糖15.1mmol/l，餐后120分钟血糖15.7mmol/l”，诊断为“2型糖尿病”，现使用“阿卡波糖50mg2次/日”降糖，平时未规律监测血糖。
|
[
{
"anatomy_list": [],
"character": [
"升高"
],
"core_name": "血糖",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"2型"
],
"core_name": "糖尿病",
"tendency": ""
}
] |
697 |
2.子宫实性占位（符合子宫肌瘤声像图）3.盆腔积液；hpv检查示：hpv11（+）；宫腔镜诊断性刮宫，刮出组织送病检，病检结果（123456）：（宫腔）子宫内膜癌。
|
[
{
"anatomy_list": [
"子宫"
],
"character": [
"实性"
],
"core_name": "占位",
"tendency": ""
},
{
"anatomy_list": [
"子宫"
],
"character": [],
"core_name": "肌瘤",
"tendency": ""
},
{
"anatomy_list": [
"盆腔"
],
"character": [],
"core_name": "积液",
"tendency": ""
},
{
"anatomy_list": [
"宫腔"
],
"character": [
"子宫内膜"
],
"core_name": "癌",
"tendency": ""
}
] |
1,200 |
多次测血压收缩压均高于150mm，最高时收缩压达210mm，平素规律服用“奈迪亚”、“非洛地平”、“倍他乐克”等降压药物，自诉血压控制不佳。
|
[
{
"anatomy_list": [],
"character": [
"控制不佳"
],
"core_name": "血压",
"tendency": ""
}
] |
1,742 |
患者本次发病以来，食欲不振，神志清醒，精神尚可，睡眠尚可，大便正常，小便正常，体重无明显变化。
|
[
{
"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": [
"尚可"
],
"core_name": "睡眠",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"正常"
],
"core_name": "大便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"正常"
],
"core_name": "小便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"明显"
],
"core_name": "体重改变",
"tendency": "否定"
}
] |
641 |
随后予以“奥沙利铂+雷替曲塞”方案化疗5次，化疗后无恶心、呕吐等不适。
|
[
{
"anatomy_list": [],
"character": [
"化疗后"
],
"core_name": "恶心",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"化疗后"
],
"core_name": "呕吐",
"tendency": "否定"
}
] |
704 |
于院外行心电图示：窦性心律，室性期前收缩三联律，t波改变。
|
[
{
"anatomy_list": [
"心"
],
"character": [],
"core_name": "窦性心律",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"室性"
],
"core_name": "期前收缩",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "三联律",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "t波改变",
"tendency": ""
}
] |
499 |
患者男，53岁，2+月前因进行性进食吞咽困难行活组织检查提示贲门食管腺癌，并于08-29日于我院在全麻下行开胸探查+贲门腺癌根治术。
|
[
{
"anatomy_list": [],
"character": [
"进行性",
"进食"
],
"core_name": "吞咽困难",
"tendency": ""
},
{
"anatomy_list": [
"贲门",
"食管"
],
"character": [],
"core_name": "腺癌",
"tendency": ""
}
] |
358 |
入院前1+年，患者右膝疼痛再发加重，伴左膝关节胀痛，以长距离行走、爬楼后明显，于当地医院就诊，诊断“双膝关节骨性关节炎”。
|
[
{
"anatomy_list": [
"右膝"
],
"character": [
"再发加重"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"左膝关节"
],
"character": [
"胀痛",
"长距离行走、爬楼后明显"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"双膝关节"
],
"character": [
"骨性"
],
"core_name": "关节炎",
"tendency": ""
}
] |
1,776 |
尿黄、眼黄、身黄持续存在，半月前，患者反复出现畏寒、发热、寒战，伴尿频、尿量增多，无尿急、尿痛及肉眼血尿，无咳嗽、咳痰，无恶心、呕吐，无腹痛、腹泻，自行服用退热药后症状缓解。
|
[
{
"anatomy_list": [],
"character": [],
"core_name": "尿黄",
"tendency": ""
},
{
"anatomy_list": [
"眼"
],
"character": [],
"core_name": "黄染",
"tendency": ""
},
{
"anatomy_list": [
"身"
],
"character": [],
"core_name": "黄染",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"反复"
],
"core_name": "畏寒",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"反复"
],
"core_name": "发热",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"反复"
],
"core_name": "寒颤",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "尿频",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"量增多"
],
"core_name": "小便",
"tendency": ""
},
{
"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": "咳嗽",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "咳痰",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "恶心",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "呕吐",
"tendency": "否定"
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "腹泻",
"tendency": "否定"
}
] |
1,966 |
患者2月前在我科住院，诊断为急性上消化道出血，治愈后出院，出院后一直感心累，伴有胸骨后梗阻感，运动后加重，无肩背部放射痛，与饮食无关。
|
[
{
"anatomy_list": [
"上消化道"
],
"character": [
"急性"
],
"core_name": "出血",
"tendency": ""
},
{
"anatomy_list": [
"心"
],
"character": [
"一直"
],
"core_name": "心累",
"tendency": ""
},
{
"anatomy_list": [
"胸骨后"
],
"character": [
"运动后加重"
],
"core_name": "梗阻感",
"tendency": ""
},
{
"anatomy_list": [
"肩",
"背部"
],
"character": [
"放射性"
],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [
"胸骨后"
],
"character": [
"与饮食无关"
],
"core_name": "疼痛",
"tendency": ""
}
] |
563 |
患者2月前因体检发现脾脏内结节，遂就诊于我院查体发现颈部、腋窝淋巴结有肿大，左侧颈部可扪及一大小约2*2cm大小包块，质地中等，活动度可，无触痛，局部皮肤无红肿、破溃。
|
[
{
"anatomy_list": [
"脾脏内"
],
"character": [],
"core_name": "结节",
"tendency": ""
},
{
"anatomy_list": [
"颈部淋巴结",
"腋窝淋巴结"
],
"character": [],
"core_name": "肿大",
"tendency": ""
},
{
"anatomy_list": [
"左侧颈部"
],
"character": [
"质地中等",
"活动度可",
"无触痛"
],
"core_name": "包块",
"tendency": ""
},
{
"anatomy_list": [
"局部皮肤"
],
"character": [],
"core_name": "红肿",
"tendency": "否定"
},
{
"anatomy_list": [
"局部皮肤"
],
"character": [],
"core_name": "破溃",
"tendency": "否定"
}
] |
370 |
不伴有发热寒战，不伴有恶心呕吐，不伴有腹痛腹泻。
|
[
{
"anatomy_list": [],
"character": [],
"core_name": "发热",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "寒颤",
"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"
}
] |
700 |
1+月前，患者无明显诱因出现上腹胀，进食后加重，伴纳差，进食约为平素1/3，无腹痛，伴反酸、嗳气，无恶心、呕吐，无腹泻，无呕血，无黑便，无肛门停止排便排气，伴全身乏力，无厌油、眼黄、尿黄，有尿量减少（具体不详），无尿频、尿急、尿痛，无排尿困难，无心悸、胸闷，无咳嗽、咳痰，无发热，有头昏、头痛，无偏瘫、抽搐等不适。
|
[
{
"anatomy_list": [
"上腹"
],
"character": [
"进食后加重"
],
"core_name": "腹胀",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"进食约为平素1/3"
],
"core_name": "纳差",
"tendency": ""
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "反酸",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "嗳气",
"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": [],
"core_name": "呕血",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "黑便",
"tendency": "否定"
},
{
"anatomy_list": [
"肛门"
],
"character": [
"停止"
],
"core_name": "排便",
"tendency": "否定"
},
{
"anatomy_list": [
"肛门"
],
"character": [
"停止"
],
"core_name": "排气",
"tendency": "否定"
},
{
"anatomy_list": [
"全身"
],
"character": [],
"core_name": "乏力",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "厌油",
"tendency": "否定"
},
{
"anatomy_list": [
"眼"
],
"character": [],
"core_name": "黄染",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "尿黄",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"减少"
],
"core_name": "小便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "尿频",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "尿急",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "尿痛",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "排尿困难",
"tendency": "否定"
},
{
"anatomy_list": [
"心"
],
"character": [],
"core_name": "心悸",
"tendency": "否定"
},
{
"anatomy_list": [
"胸"
],
"character": [],
"core_name": "胸闷",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "咳嗽",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "咳痰",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "发热",
"tendency": "否定"
},
{
"anatomy_list": [
"头"
],
"character": [],
"core_name": "头昏",
"tendency": ""
},
{
"anatomy_list": [
"头"
],
"character": [],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "偏瘫",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "抽搐",
"tendency": "否定"
}
] |
1,011 |
2、脾脏下极异常密度，建议增强扫描进一步明确。
|
[
{
"anatomy_list": [
"脾脏下极"
],
"character": [
"异常"
],
"core_name": "密度",
"tendency": ""
}
] |
1,842 |
患者本次发病以来，食欲不振， 神志清醒，精神尚可，睡眠尚可，大便正常，小便正常，体重无明显变化。
|
[
{
"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": [
"尚可"
],
"core_name": "睡眠",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"正常"
],
"core_name": "大便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"正常"
],
"core_name": "小便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"明显"
],
"core_name": "体重改变",
"tendency": "否定"
}
] |
1,201 |
8年间头痛反复发作，期间未于外院就诊。
|
[
{
"anatomy_list": [
"头"
],
"character": [
"反复"
],
"core_name": "疼痛",
"tendency": ""
}
] |
959 |
予以右肺中叶及右肺下叶楔形切除+胸壁包块活检术，术中冰冻提示右肺中叶及下叶腺癌，术后病理结果及免疫组化不详，术后分期为t4n2Mm1。
|
[
{
"anatomy_list": [
"右肺中叶及下叶"
],
"character": [],
"core_name": "腺癌",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"术后分期为t4n2Mm1"
],
"core_name": "腺癌",
"tendency": ""
}
] |
1,022 |
入院前10+年，患者无明显诱因出现阴道不规律出血，为鲜红色，每次量少，无血凝块，无腹痛、腹胀，无阴道阴道坠胀，无尿频、尿急、尿痛、血尿，无呕血、黑便，无头痛、头昏、乏力，无畏寒、发热，无明显体重下降，在某医院就诊，完善相关检查（具体不详），考虑"宫颈癌"，行子宫全切术，术中取活检，活检报告提示子宫颈癌（未见报告），术后予以6周期化疗（具体用药不详），化疗过程中患者有恶心、呕吐，腹痛、腹胀，全血下降等不适，给予对症处理后缓解。
|
[
{
"anatomy_list": [
"阴道"
],
"character": [
"不规律",
"鲜红色",
"量少",
"无血凝块"
],
"core_name": "出血",
"tendency": ""
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "腹胀",
"tendency": "否定"
},
{
"anatomy_list": [
"阴道"
],
"character": [],
"core_name": "坠胀",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "尿频",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "尿急",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "尿痛",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "血尿",
"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": [
"头"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [
"头"
],
"character": [],
"core_name": "头昏",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "乏力",
"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": [
"明显"
],
"core_name": "体重减轻",
"tendency": "否定"
},
{
"anatomy_list": [
"宫颈"
],
"character": [],
"core_name": "癌",
"tendency": "不确定"
},
{
"anatomy_list": [
"子宫颈"
],
"character": [],
"core_name": "癌",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "恶心",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "呕吐",
"tendency": ""
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "腹胀",
"tendency": ""
}
] |
1,943 |
患者9月前无明显诱因出现腰部疼痛，疼痛可忍受，患者未予重视。
|
[
{
"anatomy_list": [
"腰部"
],
"character": [],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"腰部"
],
"character": [
"可忍受"
],
"core_name": "疼痛",
"tendency": ""
}
] |
859 |
入院前1天患者有腹泻症状，解数次黄色水样便，伴排便时脐周及脐上隐痛，伴恶心，无畏寒、发热、心悸、呕吐、呕血、黑便，在家口服诺氟沙星治疗后未再腹泻。
|
[
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "腹泻",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"黄色",
"水样"
],
"core_name": "大便",
"tendency": ""
},
{
"anatomy_list": [
"脐上",
"脐周"
],
"character": [
"排便时",
"隐痛"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "恶心",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "畏寒",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "发热",
"tendency": "否定"
},
{
"anatomy_list": [
"心"
],
"character": [],
"core_name": "心悸",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "呕吐",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "呕血",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "黑便",
"tendency": "否定"
},
{
"anatomy_list": [
"腹"
],
"character": [
"口服诺氟沙星治疗后"
],
"core_name": "腹泻",
"tendency": "否定"
}
] |
734 |
患者自发病以来，精神尚可，食欲可，睡眠可，大便如常，小便如常，体重有减轻（具体不详）。
|
[
{
"anatomy_list": [],
"character": [
"尚可"
],
"core_name": "精神",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"可"
],
"core_name": "食欲",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"可"
],
"core_name": "睡眠质量",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"如常"
],
"core_name": "大便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"如常"
],
"core_name": "小便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "体重减轻",
"tendency": ""
}
] |
801 |
伴干咳，无痰液。
|
[
{
"anatomy_list": [],
"character": [
"干性"
],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "咳痰",
"tendency": "否定"
}
] |
1,350 |
入院前1+年，患者自行发现左侧乳腺1cm*1cm大小包块，质硬，无活动，无压痛，边界不清，乳头无溢液，无腋窝淋巴结肿大，患者未重视。
|
[
{
"anatomy_list": [
"左侧乳腺"
],
"character": [
"质硬",
"无活动",
"无压痛",
"边界不清"
],
"core_name": "包块",
"tendency": ""
},
{
"anatomy_list": [
"乳头"
],
"character": [],
"core_name": "溢液",
"tendency": "否定"
},
{
"anatomy_list": [
"腋窝淋巴结"
],
"character": [],
"core_name": "肿大",
"tendency": "否定"
}
] |
1,768 |
腋窝淋巴结见癌转移（6/22）。
|
[
{
"anatomy_list": [
"腋窝淋巴结"
],
"character": [
"转移"
],
"core_name": "癌",
"tendency": ""
}
] |
1,205 |
2.纵隔淋巴结增大。
|
[
{
"anatomy_list": [
"纵隔淋巴结"
],
"character": [],
"core_name": "增大",
"tendency": ""
}
] |
1,230 |
无腰背部放射痛。
|
[
{
"anatomy_list": [
"腰",
"背部"
],
"character": [
"放射性"
],
"core_name": "疼痛",
"tendency": "否定"
}
] |
1,872 |
今晨患者突然出现下腹部疼痛疼痛加重，仍排气排便，无返酸、嗳气，无恶心、呕吐、腹痛，无心慌气促、无畏寒、发热、无呕血等不适，为求治疗急诊来我院，腹部ct示：1、直乙交界区肠管壁增厚2、前列腺增大伴钙化。
|
[
{
"anatomy_list": [
"下腹部"
],
"character": [],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"下腹部"
],
"character": [
"加重"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "返酸",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "嗳气",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "恶心",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "呕吐",
"tendency": "否定"
},
{
"anatomy_list": [
"腹部"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [
"心"
],
"character": [],
"core_name": "心慌",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "气促",
"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": "呕血",
"tendency": "否定"
},
{
"anatomy_list": [
"直乙交界区肠管壁"
],
"character": [],
"core_name": "增厚",
"tendency": ""
},
{
"anatomy_list": [
"前列腺"
],
"character": [],
"core_name": "钙化",
"tendency": ""
},
{
"anatomy_list": [
"前列腺"
],
"character": [],
"core_name": "增大",
"tendency": ""
}
] |
1,807 |
（2020-10-24）患者于我院体检中心体检，行胸部ct：双肺多发结节影（未见具体报告），无明显发热、寒颤、咳嗽、咳痰、恶心、呕吐、头痛、头晕、腹痛等不适。
|
[
{
"anatomy_list": [
"双肺"
],
"character": [
"多发"
],
"core_name": "结节影",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"明显"
],
"core_name": "发热",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "寒颤",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "咳嗽",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "咳痰",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "恶心",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "呕吐",
"tendency": "否定"
},
{
"anatomy_list": [
"头"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [
"头"
],
"character": [],
"core_name": "头晕",
"tendency": "否定"
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
}
] |
766 |
建议可继续口服奥西替尼（印度版），但鉴于右侧胸腔恶性积液，病情缓慢进展，建议患者可更换为正版奥西替尼，患者及家属拒绝；后征得患者及家属同意后分别于7-22、7-26、7-29、8-01行胸腔灌注注射用重组改构人肿瘤坏死因子300万iu。
|
[
{
"anatomy_list": [
"右侧胸腔"
],
"character": [
"恶性"
],
"core_name": "积液",
"tendency": ""
}
] |
1,591 |
自述双乳有肿痛，与月经有关。
|
[
{
"anatomy_list": [
"双乳"
],
"character": [
"月经有关",
"肿痛"
],
"core_name": "疼痛",
"tendency": ""
}
] |
1,007 |
患者入院8月前无明显诱因出现全腹痛，主要表现为右下腹痛，呈阵发性隐痛，发作无规律性，与进食无关，无放射痛，可忍受，偶有打嗝，完善相关检查诊断为“结肠肿块”，于2016-05-07行剖腹探查+右半结肠根治术，术后病理示：右半结肠圆形细胞恶性肿瘤，两切端及阑尾均未见肿瘤累及。肠壁上淋巴结未见肿瘤转移（0/15）。
|
[
{
"anatomy_list": [
"全腹"
],
"character": [],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"右下腹"
],
"character": [
"阵发性隐痛",
"发作无规律性",
"与进食无关",
"可忍受"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"放射性"
],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"偶有"
],
"core_name": "打嗝",
"tendency": ""
},
{
"anatomy_list": [
"结肠"
],
"character": [],
"core_name": "肿块",
"tendency": ""
},
{
"anatomy_list": [
"右半结肠"
],
"character": [
"圆形细胞",
"恶性"
],
"core_name": "肿瘤",
"tendency": ""
},
{
"anatomy_list": [
"右半结肠"
],
"character": [],
"core_name": "癌",
"tendency": ""
},
{
"anatomy_list": [
"右半结肠两切端",
"阑尾"
],
"character": [
"累及"
],
"core_name": "肿瘤",
"tendency": "否定"
},
{
"anatomy_list": [
"肠壁上淋巴结"
],
"character": [
"转移"
],
"core_name": "肿瘤",
"tendency": "否定"
}
] |
392 |
患者于5+月前，因腹痛就诊于我院，我院诊断为“原发性肝癌破裂出血”，于2019年09月29日病人于全麻下行了腹腔镜肝中叶切除术+大网膜淋巴结清扫+胆囊切除术，术后给予静脉滴注护胃、静脉滴注维生素改善患者围手术期营养状况、促进机体能量代谢、抗感染、改善肝内胆道淤积症状、预防并发症、补钾、维持电解质平衡等对症治疗。
|
[
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"肝"
],
"character": [
"原发性肝癌"
],
"core_name": "破裂出血",
"tendency": ""
}
] |
1,281 |
于2016-03-04行全麻下腹腔镜全子宫双附件切除术+盆腔淋巴结清扫术+腹主动脉旁淋巴结清扫术+盆腔粘连松解术，镜下见：乙状结肠及肠系膜与左侧盆壁致密粘连；子宫体前位，正常大小，表面光滑：双侧附件萎缩、纤维化；盆腹腔内其他脏器表面未见明显异常。
|
[
{
"anatomy_list": [
"乙状结肠",
"肠系膜",
"左侧盆壁"
],
"character": [
"致密"
],
"core_name": "粘连",
"tendency": ""
},
{
"anatomy_list": [
"子宫体"
],
"character": [],
"core_name": "子宫体前位",
"tendency": ""
},
{
"anatomy_list": [
"双侧附件"
],
"character": [],
"core_name": "萎缩",
"tendency": ""
},
{
"anatomy_list": [
"双侧附件"
],
"character": [],
"core_name": "纤维化",
"tendency": ""
},
{
"anatomy_list": [
"盆腹腔内其他脏器表面"
],
"character": [
"明显"
],
"core_name": "异常",
"tendency": "否定"
}
] |
1,674 |
入院1年余前，患者无明显诱因出现下腹疼痛，左下腹明显，呈阵发性隐痛，无放射痛，无加重缓解因素，大便1-3次/日，为黄色成型软便，无畏寒、发热、盗汗、消瘦，无便秘、腹泻等伴随，遂至我院门诊，于2015年7月查肠镜提示：结肠多发息肉，病检："结肠"腺瘤型息肉，遂在我科住院行肠息肉治疗术，治疗后病情好转出院；2016-06因体检发现癌胚抗原异常升高，遂至我科住院治疗，完善肠镜提示：结肠多发性息肉，同时行了射频治疗；今日患者住院，要求复查肠镜，同时评估有无肠道息肉，故门诊以"慢性肠炎、结肠息肉？"收治入院。
|
[
{
"anatomy_list": [
"下腹"
],
"character": [],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"左下腹"
],
"character": [
"明显"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"下腹"
],
"character": [
"阵发性",
"隐痛"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"放射性"
],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [
"下腹"
],
"character": [
"无加重缓解因素"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"黄色",
"成型",
"软"
],
"core_name": "大便",
"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": "盗汗",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "消瘦",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "便秘",
"tendency": "否定"
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "腹泻",
"tendency": "否定"
},
{
"anatomy_list": [
"结肠"
],
"character": [
"多发"
],
"core_name": "息肉",
"tendency": ""
},
{
"anatomy_list": [
"结肠"
],
"character": [
"腺瘤型"
],
"core_name": "息肉",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"异常升高"
],
"core_name": "癌胚抗原",
"tendency": ""
},
{
"anatomy_list": [
"肠"
],
"character": [],
"core_name": "肿物",
"tendency": ""
},
{
"anatomy_list": [
"结肠"
],
"character": [
"多发性"
],
"core_name": "息肉",
"tendency": ""
},
{
"anatomy_list": [
"肠道"
],
"character": [],
"core_name": "息肉",
"tendency": "不确定"
},
{
"anatomy_list": [
"肠"
],
"character": [
"慢性"
],
"core_name": "肠炎",
"tendency": ""
},
{
"anatomy_list": [
"结肠"
],
"character": [],
"core_name": "息肉",
"tendency": "不确定"
}
] |
1,709 |
复查颅脑ct及骨盆平片见颅骨、骨盆、双股骨多发骨质异常，符合多发性骨髓瘤。
|
[
{
"anatomy_list": [
"颅骨",
"骨盆",
"双股骨"
],
"character": [
"多发"
],
"core_name": "骨质异常",
"tendency": ""
},
{
"anatomy_list": [
"骨髓"
],
"character": [
"多发性"
],
"core_name": "瘤",
"tendency": ""
}
] |
635 |
门诊以“宫颈高级别鳞状上皮内病变”收住入院。
|
[
{
"anatomy_list": [
"宫颈"
],
"character": [
"高级别",
"鳞状上皮"
],
"core_name": "病变",
"tendency": ""
}
] |
395 |
患者自发病以来，精神可，食欲可，睡眠可，大便如常，小便如常，体重减轻8kg。
|
[
{
"anatomy_list": [],
"character": [
""
],
"core_name": "精神",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
""
],
"core_name": "食欲",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
""
],
"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": [],
"core_name": "体重减轻",
"tendency": ""
}
] |
124 |
入院4天前，患者于我院体检，行胸部ct提示：“左肺下叶后基底段团块影，考虑肿瘤性病变可能（周围型肺癌？），纵隔、双肺门多发肿大淋巴结，建议进一步检查明确”。
|
[
{
"anatomy_list": [
"左肺下叶后基底段"
],
"character": [],
"core_name": "团块影",
"tendency": ""
},
{
"anatomy_list": [
"肺"
],
"character": [
"肿瘤性"
],
"core_name": "病变",
"tendency": "不确定"
},
{
"anatomy_list": [
"肺"
],
"character": [
"周围型"
],
"core_name": "癌",
"tendency": "不确定"
},
{
"anatomy_list": [
"纵隔淋巴结",
"双肺门淋巴结"
],
"character": [
"多发"
],
"core_name": "肿大",
"tendency": ""
}
] |
469 |
患者于30年前体检时发现血压升高（具体不详），未予重视，此后多次测血压均高于正常值，最高达180/120mmHg，长期口服降压药，血压控制不理想，血压波动于160-130/100-70mmHg。
|
[
{
"anatomy_list": [],
"character": [
"升高"
],
"core_name": "血压",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"控制不理想"
],
"core_name": "血压",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"波动"
],
"core_name": "血压",
"tendency": ""
}
] |
1,648 |
于全麻下行“左侧乳腺癌改良根治术”，免疫组化提示:左侧乳腺浸润性导管癌，er(-),pr(-)her-2（3+），ki676710%。
|
[
{
"anatomy_list": [
"左侧乳腺"
],
"character": [
"浸润性"
],
"core_name": "导管癌",
"tendency": ""
}
] |
15 |
入院前5月,患儿因发热,头痛伴反复呕吐入院治疗,ct提示右侧小脑占位性病变、梗阻性脑积水,住院期间先后行了左侧脑室外引流术（储液囊）、后颅窝肿瘤切除术、腰大池引流术,术后恢复可,顺利出院,出院后定期神经外科门诊随访。
|
[
{
"anatomy_list": [],
"character": [],
"core_name": "发热",
"tendency": ""
},
{
"anatomy_list": [
"头"
],
"character": [],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"反复"
],
"core_name": "呕吐",
"tendency": ""
},
{
"anatomy_list": [
"右侧小脑"
],
"character": [
"占位性"
],
"core_name": "病变",
"tendency": ""
},
{
"anatomy_list": [
"脑"
],
"character": [
"梗阻性"
],
"core_name": "积水",
"tendency": ""
}
] |
574 |
入院前1+月，患者因右下腹痛就诊于某医院，行急诊剖腹探查术，术后病理切片提示：（右卵巢）卵黄囊瘤，术后予以抗感染等对症处理后好转出院。
|
[
{
"anatomy_list": [
"右下腹"
],
"character": [],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"右卵巢"
],
"character": [
"卵黄囊"
],
"core_name": "瘤",
"tendency": ""
}
] |
956 |
入院前半年，患者重体力劳动中出现胸骨后疼痛，呈压榨感，伴大汗淋漓，无放射痛，无黑蒙、晕厥，无呼吸困难，持续约3分3分钟，休息后缓解，患者未予以重视，未就医治疗。
|
[
{
"anatomy_list": [
"胸骨后"
],
"character": [
"重体力劳动中",
"压榨感"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "大汗淋漓",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"放射性"
],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "黑朦",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "晕厥",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"休息后缓解"
],
"core_name": "呼吸困难",
"tendency": "否定"
}
] |
194 |
半月前患者再次症状反复，出现痰中带血，再次于当地医院治疗咳嗽、咳痰明显缓解，未见痰中带血，患者仍感活动后气促、喘累，1天前患者就诊于某医院，行胸部ct检查提示右肺门增大，见增多软组织，考虑肿瘤性病变可能大。
|
[
{
"anatomy_list": [],
"character": [
"反复",
"带血"
],
"core_name": "咳痰",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"明显缓解"
],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"明显缓解"
],
"core_name": "咳痰",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"带血"
],
"core_name": "咳痰",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"活动后"
],
"core_name": "气促",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"活动后"
],
"core_name": "喘累",
"tendency": ""
},
{
"anatomy_list": [
"右肺门"
],
"character": [],
"core_name": "增大",
"tendency": ""
},
{
"anatomy_list": [
"软组织"
],
"character": [],
"core_name": "软组织增多",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"肿瘤性"
],
"core_name": "病变",
"tendency": "不确定"
}
] |
832 |
入院前11月患者复查胸部ct示气管占位并双肺多发结节，于某医院就诊，诊断气道狭窄，行活检后诊断为“气管鳞癌”，于某医院行介入治疗（冷冻冻取、电圈套、激光消融、apc，坏死及新生物清理），2019年1月及4月在某医院分别行气道介入治疗 活检钳清理、冷冻冻取清理新生物。
|
[
{
"anatomy_list": [
"气管"
],
"character": [],
"core_name": "占位",
"tendency": ""
},
{
"anatomy_list": [
"双肺"
],
"character": [
"多发"
],
"core_name": "结节",
"tendency": ""
},
{
"anatomy_list": [
"气道"
],
"character": [],
"core_name": "狭窄",
"tendency": ""
},
{
"anatomy_list": [
"气管"
],
"character": [],
"core_name": "鳞癌",
"tendency": ""
}
] |
684 |
6.右侧肾上腺病灶，考虑肿瘤性病变，腺瘤或其它；右肾小囊肿。
|
[
{
"anatomy_list": [
"右侧肾上腺"
],
"character": [],
"core_name": "病灶",
"tendency": ""
},
{
"anatomy_list": [
"右侧肾上腺"
],
"character": [
"肿瘤性"
],
"core_name": "病变",
"tendency": "不确定"
},
{
"anatomy_list": [
"右侧肾上腺"
],
"character": [],
"core_name": "腺瘤",
"tendency": "不确定"
},
{
"anatomy_list": [
"右肾"
],
"character": [
"小"
],
"core_name": "囊肿",
"tendency": ""
}
] |
104 |
包块 逐渐增大 ， 无局部红、肿、热、痒 ， 无烦躁 ， 无失眠 ， 无声痛 ， 无怕热多汗 ， 无心慌气短 ， 无吞咽困难 ， 无呼吸困难 。
|
[
{
"anatomy_list": [],
"character": [
"逐渐增大，无局部红，无局部肿，无局部热，无局部痒"
],
"core_name": "包块",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "烦躁",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "失眠",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "声痛",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "怕热",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"增多"
],
"core_name": "出汗",
"tendency": "否定"
},
{
"anatomy_list": [
"心"
],
"character": [],
"core_name": "心慌",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "气短",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "吞咽困难",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "呼吸困难",
"tendency": "否定"
}
] |
447 |
5月前患者无明显诱因出现夜间睡眠时憋醒，伴有多梦、偶有梦魇，醒后偶有嗜睡，自诉平时记忆力欠佳，伴有晨起后咽干、咽痒、咽痛、口苦、口干，偶有咽喉部异物感等不适。
|
[
{
"anatomy_list": [],
"character": [
"夜间睡眠时"
],
"core_name": "憋醒",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "多梦",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"偶有"
],
"core_name": "梦魇",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"醒后偶有"
],
"core_name": "嗜睡",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"欠佳"
],
"core_name": "记忆力",
"tendency": ""
},
{
"anatomy_list": [
"咽"
],
"character": [
"晨起后"
],
"core_name": "咽干",
"tendency": ""
},
{
"anatomy_list": [
"咽"
],
"character": [
"晨起后"
],
"core_name": "咽痒",
"tendency": ""
},
{
"anatomy_list": [
"咽"
],
"character": [
"晨起后"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"口"
],
"character": [
"晨起后"
],
"core_name": "口苦",
"tendency": ""
},
{
"anatomy_list": [
"口"
],
"character": [
"晨起后"
],
"core_name": "口干",
"tendency": ""
},
{
"anatomy_list": [
"咽喉部"
],
"character": [
"偶有"
],
"core_name": "异物感",
"tendency": ""
}
] |
67 |
２.肝癌肿瘤滋养动脉超选择性插管化疗栓塞术。
|
[
{
"anatomy_list": [
"肝"
],
"character": [],
"core_name": "癌",
"tendency": ""
}
] |
786 |
入院前30年，患者受凉后出现频繁咳嗽，为非高调金属声样咳嗽及鸡鸣样咳嗽，伴咳痰，为白色泡沫痰，以晨起明显，与体位改变无明显相关。
|
[
{
"anatomy_list": [],
"character": [
"受凉后",
"频繁"
],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"非高调金属声样"
],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"鸡鸣样"
],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"白色",
"泡沫痰",
"以晨起明显",
"与体位改变无明显相关"
],
"core_name": "咳痰",
"tendency": ""
}
] |
1,611 |
3.双肺门肺门及纵隔淋巴结淋巴结钙化。
|
[
{
"anatomy_list": [
"双肺门淋巴结",
"纵隔淋巴结"
],
"character": [],
"core_name": "钙化",
"tendency": ""
}
] |
510 |
（食管旁淋巴结）未见癌转移（0/1），(胃周脂肪组织内淋巴结)未见癌转移（0/4），8组组淋巴结未见癌转移（0/1），（右喉返神经旁淋巴结）未见癌转移（0/3），术后诊断：1.食管胸中段腺鳞癌pT3n0M3 iib期；2.双肺结节；3.慢性非萎缩性胃炎；4.右肾囊肿。
|
[
{
"anatomy_list": [
"食管旁淋巴结"
],
"character": [
"转移"
],
"core_name": "癌",
"tendency": "否定"
},
{
"anatomy_list": [
"胃周脂肪组织内淋巴结"
],
"character": [
"转移"
],
"core_name": "癌",
"tendency": "否定"
},
{
"anatomy_list": [
"8组淋巴结"
],
"character": [
"转移"
],
"core_name": "癌",
"tendency": "否定"
},
{
"anatomy_list": [
"右喉返神经旁淋巴结"
],
"character": [
"转移"
],
"core_name": "癌",
"tendency": "否定"
},
{
"anatomy_list": [
"食管胸中段"
],
"character": [
"pT3n0M3",
"iib期"
],
"core_name": "腺鳞癌",
"tendency": ""
},
{
"anatomy_list": [
"双肺"
],
"character": [],
"core_name": "结节",
"tendency": ""
},
{
"anatomy_list": [
"胃"
],
"character": [
"慢性",
"非萎缩性"
],
"core_name": "胃炎",
"tendency": ""
},
{
"anatomy_list": [
"右肾"
],
"character": [],
"core_name": "囊肿",
"tendency": ""
}
] |
523 |
入院前3年，患者活动后出现呼吸困难（爬楼梯时），无胸痛，无左肩部放射痛，无咯血，无端坐呼吸及咯粉红泡沫样痰，无咳嗽、咳痰，患者未予重视，未治疗。
|
[
{
"anatomy_list": [],
"character": [
"活动后",
"爬楼梯时"
],
"core_name": "呼吸困难",
"tendency": ""
},
{
"anatomy_list": [
"胸"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [
"左肩部"
],
"character": [
"放射性"
],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "咯血",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "端坐呼吸",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"粉红泡沫样"
],
"core_name": "咳痰",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "咳嗽",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "咳痰",
"tendency": "否定"
}
] |
1,978 |
1月前，患者无明显诱因出现痰中带血，量少，后到某医院就诊，给予抗炎等对症支持治疗后未再出现咯血，胸痛、咳嗽、喘累、乏力稍有好转。
|
[
{
"anatomy_list": [],
"character": [
"带血",
"量少"
],
"core_name": "咳痰",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "咯血",
"tendency": "否定"
},
{
"anatomy_list": [
"胸"
],
"character": [
"稍有好转"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"稍有好转"
],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"稍有好转"
],
"core_name": "喘累",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"稍有好转"
],
"core_name": "乏力",
"tendency": ""
}
] |
168 |
右肺下叶胸膜旁小结节影，fdg代谢未见异常增高。
|
[
{
"anatomy_list": [
"右肺下叶胸膜旁"
],
"character": [
"小"
],
"core_name": "结节影",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"代谢异常增高"
],
"core_name": "fdg",
"tendency": "否定"
}
] |
1,196 |
3天前患者因车祸伤在我院骨科住院，住院期间彩超示：左肾下极实质稍低回声，肿瘤性病变待排。
|
[
{
"anatomy_list": [],
"character": [],
"core_name": "车祸伤",
"tendency": ""
},
{
"anatomy_list": [
"左肾下极实质"
],
"character": [
"稍低"
],
"core_name": "回声",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"肿瘤性"
],
"core_name": "病变",
"tendency": "不确定"
}
] |
648 |
为求进一步诊治，今晨急诊以“低血糖症”收治住院。
|
[
{
"anatomy_list": [],
"character": [],
"core_name": "低血糖症",
"tendency": ""
}
] |
769 |
入院半年前，患者无明显诱因出现头昏、乏力，以站立及活动时明显，平卧及休息可缓解，伴纳差，无畏寒、发热、咳嗽、咳痰、咯血，无腹胀、腹痛、黄疸、恶心、呕吐、呕血、黑便，无血尿、皮肤粘膜瘀斑，无胸痛、心前区压榨感，无晕厥、意识障碍等伴随。
|
[
{
"anatomy_list": [
"头"
],
"character": [
"活动时明显",
"平卧及休息可缓解"
],
"core_name": "头昏",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"活动时明显",
"平卧及休息可缓解"
],
"core_name": "乏力",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "纳差",
"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": "咳嗽",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "咳痰",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "咯血",
"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": "黄疸",
"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": "黑便",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "血尿",
"tendency": "否定"
},
{
"anatomy_list": [
"皮肤黏膜"
],
"character": [],
"core_name": "瘀斑",
"tendency": "否定"
},
{
"anatomy_list": [
"胸"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [
"心前区"
],
"character": [],
"core_name": "压榨感",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "晕厥",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "意识障碍",
"tendency": "否定"
}
] |
947 |
1天前，患者出现颠顶部阵发性疼痛疼痛不适，为阵发性钝痛，疼痛轻度影响睡眠，持续时间长短不等后缓解，无双目凝视及精神意识障碍，无恶心、呕吐，无视物旋转等，今日为进一步治疗来院，遂以“1.肺部感染；2.肺癌脑转移、骨多处转移”收住我科。
|
[
{
"anatomy_list": [
"颠顶部"
],
"character": [
"阵发性",
"钝痛",
"轻度影响睡眠",
"持续时间长短不等后缓解"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"双目"
],
"character": [],
"core_name": "凝视",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "精神障碍",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "意识障碍",
"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": "视物旋转",
"tendency": "否定"
},
{
"anatomy_list": [
"肺部"
],
"character": [],
"core_name": "感染",
"tendency": ""
},
{
"anatomy_list": [
"肺"
],
"character": [
"脑转移",
"骨多处转移"
],
"core_name": "癌",
"tendency": ""
}
] |
1,500 |
考虑诊断为：“慢性粒单核细胞白血病”，予以调节免疫、输血、补液支持等治疗后好转出院。
|
[
{
"anatomy_list": [
"粒单核细胞"
],
"character": [
"慢性"
],
"core_name": "白血病",
"tendency": ""
}
] |
1,620 |
2.双肺散在钙化结节。
|
[
{
"anatomy_list": [
"双肺"
],
"character": [
"散在",
"钙化"
],
"core_name": "结节",
"tendency": ""
}
] |
565 |
胸部ct平扫+增强：1.双侧肺门、纵隔多发淋巴结显示，双侧腋窝淋巴结肿大。
|
[
{
"anatomy_list": [
"双侧腋窝淋巴结"
],
"character": [],
"core_name": "肿大",
"tendency": ""
}
] |
150 |
入院前2月，患者在某医院体检，腹部彩超示肝内实质性占位病变，肝囊性占位；肝左叶形态饱满，肝实质回声增粗增强，不均匀，胆囊息肉样病变，脾大。
|
[
{
"anatomy_list": [
"肝内"
],
"character": [
"占位",
"实质性"
],
"core_name": "病变",
"tendency": ""
},
{
"anatomy_list": [
"肝"
],
"character": [
"囊性"
],
"core_name": "占位",
"tendency": ""
},
{
"anatomy_list": [
"肝实质"
],
"character": [
"增粗",
"增强",
"不均匀"
],
"core_name": "回声",
"tendency": ""
},
{
"anatomy_list": [
"胆囊"
],
"character": [
"息肉样"
],
"core_name": "病变",
"tendency": ""
},
{
"anatomy_list": [
"脾"
],
"character": [],
"core_name": "脾大",
"tendency": ""
}
] |
291 |
现患者为进一步诊治来我院，门诊以“ 右上肺肺团块影待查”收入我院我科。
|
[
{
"anatomy_list": [
"右上肺"
],
"character": [],
"core_name": "团块影",
"tendency": "不确定"
}
] |
231 |
患者本次发病以来，食欲减退， 神志清醒，精神尚可，睡眠尚可，大便正常，小便正常，体重减少。
|
[
{
"anatomy_list": [],
"character": [
"减退"
],
"core_name": "食欲",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"清醒"
],
"core_name": "神志",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"尚可"
],
"core_name": "精神",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"尚可"
],
"core_name": "睡眠",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"正常"
],
"core_name": "大便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"正常"
],
"core_name": "小便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "体重减少",
"tendency": ""
}
] |
758 |
院外不规律随访，疗效sd。
|
[
{
"anatomy_list": [],
"character": [],
"core_name": "SD",
"tendency": ""
}
] |
1,909 |
综上诊断为:右肺腺癌 iv期 骨转移，予以口服吉非替尼治疗4个多月后，患者诉自行ct复查提示：肋骨转移病灶较之前有所缩小，肺部病灶稳定。
|
[
{
"anatomy_list": [
"右肺"
],
"character": [
"iv期"
],
"core_name": "腺癌",
"tendency": ""
},
{
"anatomy_list": [
"骨"
],
"character": [
"转移"
],
"core_name": "腺癌",
"tendency": ""
},
{
"anatomy_list": [
"肋骨"
],
"character": [
"较之前有所缩小",
"转移"
],
"core_name": "病灶",
"tendency": ""
},
{
"anatomy_list": [
"肺部"
],
"character": [
"稳定"
],
"core_name": "病灶",
"tendency": ""
}
] |
1,516 |
患者肾上腺良性肿瘤、原发性醛固酮增多症、低钾血症10+年，平时反复全身乏力、恶心、纳差等症状，患者因手术风险高未行手术治疗，多次于当地医院就诊予以补钾治疗后好转。
|
[
{
"anatomy_list": [
"肾上腺"
],
"character": [
"良性"
],
"core_name": "肿瘤",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"原发性"
],
"core_name": "醛固酮增多症",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "低钾血症",
"tendency": ""
},
{
"anatomy_list": [
"全身"
],
"character": [
"反复"
],
"core_name": "乏力",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "恶心",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "纳差",
"tendency": ""
}
] |
1,053 |
4年前患者我院常规体检发现cea达正常值高限，未做特殊处理，无乏力、纳差、腹痛、黑便等不适，无咳嗽、咳痰、胸痛等。
|
[
{
"anatomy_list": [],
"character": [],
"core_name": "乏力",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "纳差",
"tendency": "否定"
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "黑便",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "咳嗽",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "咳痰",
"tendency": "否定"
},
{
"anatomy_list": [
"胸"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
}
] |
1,695 |
无尿急、肉眼血尿。
|
[
{
"anatomy_list": [],
"character": [],
"core_name": "尿急",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "血尿",
"tendency": "否定"
}
] |
1,418 |
患者入院前因“咳嗽、咳痰8月，加重伴声嘶、消瘦10余天”于2009年6月住我院呼吸内科就诊，后经检查诊断为“左肺中央型肺癌伴纵膈膈胸膜、骨转移”。
|
[
{
"anatomy_list": [],
"character": [
"加重"
],
"core_name": "咳嗽",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"加重"
],
"core_name": "咳痰",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "声嘶",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "消瘦",
"tendency": ""
},
{
"anatomy_list": [
"左肺"
],
"character": [
"中央型"
],
"core_name": "癌",
"tendency": ""
},
{
"anatomy_list": [
"纵膈",
"胸膜",
"骨"
],
"character": [
"转移"
],
"core_name": "癌",
"tendency": ""
}
] |
1,323 |
结合曾患乳癌病史及免疫组化gata-2阳性，考虑乳腺癌转移。
|
[
{
"anatomy_list": [
"乳腺"
],
"character": [
"转移"
],
"core_name": "癌",
"tendency": "不确定"
}
] |
911 |
半月前，患者诉进食油腻食物后出现上腹疼痛，伴恶心，无腹胀、腹泻、发热等不适，服用消炎利胆片后缓解，1周前，患者再次出现右上腹不适，无腹痛、腹胀、腹泻、发热，现患者为求进一步治疗来我院就诊，门诊以“胆囊结石伴急性胆囊炎”收入我科。
|
[
{
"anatomy_list": [
"上腹"
],
"character": [
"进食油腻食物后"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "恶心",
"tendency": ""
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "腹胀",
"tendency": "否定"
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "腹泻",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "发热",
"tendency": "否定"
},
{
"anatomy_list": [
"右上腹"
],
"character": [],
"core_name": "不适",
"tendency": ""
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "腹胀",
"tendency": "否定"
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "腹泻",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "发热",
"tendency": "否定"
},
{
"anatomy_list": [
"胆囊"
],
"character": [],
"core_name": "结石",
"tendency": ""
},
{
"anatomy_list": [
"胆囊"
],
"character": [
"急性"
],
"core_name": "胆囊炎",
"tendency": ""
}
] |
1,177 |
行骨髓穿刺提示：慢性髓细胞白血病。
|
[
{
"anatomy_list": [
"髓细胞"
],
"character": [
"慢性"
],
"core_name": "白血病",
"tendency": ""
}
] |
1,240 |
入院前3天，患者出现上述症状加重，为求进一步治疗，今日来我科门诊就诊，完善“血常规：红细胞计数 2.91*10^12/L、血红蛋白 98g/L、白细胞计数 13.1*10^12/L、n% 83%；肝功：门冬氨酸氨基转移酶:133U/L、丙氨酸氨基转移酶75U/L、γ谷氨酰基转移酶:570U/L、胆碱脂酶:1731U/L、清蛋白:26.6g/L、球蛋白:49.7g/L、直接胆红素:20umol/L、总胆红素:34.5umol/L；乙肝标志物定量、hcv报告未回；腹部彩超：肝脏弥漫性病变，肝内多发实性占位（考虑肝ca）伴门静脉栓子形成，胆囊壁水肿，脾大（中度），腹腔积液”，门诊以“原发性肝癌？”收入我科住院治疗。
|
[
{
"anatomy_list": [
"肝脏"
],
"character": [
"弥漫性"
],
"core_name": "病变",
"tendency": ""
},
{
"anatomy_list": [
"肝内"
],
"character": [
"多发",
"实性"
],
"core_name": "占位",
"tendency": ""
},
{
"anatomy_list": [
"肝"
],
"character": [],
"core_name": "癌",
"tendency": "不确定"
},
{
"anatomy_list": [
"门静脉"
],
"character": [],
"core_name": "栓子形成",
"tendency": ""
},
{
"anatomy_list": [
"胆囊壁"
],
"character": [],
"core_name": "水肿",
"tendency": ""
},
{
"anatomy_list": [
"脾"
],
"character": [
"中度"
],
"core_name": "增大",
"tendency": ""
},
{
"anatomy_list": [
"腹腔"
],
"character": [],
"core_name": "积液",
"tendency": ""
},
{
"anatomy_list": [
"肝"
],
"character": [
"原发性"
],
"core_name": "癌",
"tendency": "不确定"
}
] |
616 |
患者自发病以来， 精神可 ， 食欲尚可 ， 睡眠可 ， 大便如常 ， 小便如常 ， 体重近1月下降明显 。
|
[
{
"anatomy_list": [],
"character": [
"可"
],
"core_name": "精神",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"尚可"
],
"core_name": "食欲",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"可"
],
"core_name": "睡眠质量",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"如常"
],
"core_name": "大便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"如常"
],
"core_name": "小便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"明显"
],
"core_name": "体重下降",
"tendency": ""
}
] |
524 |
病程中，患者反复活动后呼吸困难，活动耐量逐渐下降，伴间断双下肢水肿，均当地诊所予以对症治疗后好转。
|
[
{
"anatomy_list": [],
"character": [
"反复",
"活动后"
],
"core_name": "呼吸困难",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"逐渐下降"
],
"core_name": "活动耐量",
"tendency": ""
},
{
"anatomy_list": [
"双下肢"
],
"character": [
"间断"
],
"core_name": "水肿",
"tendency": ""
}
] |
1,888 |
入院前3+年，患者出现头昏、头痛，无鼻衄，无耳鸣及听力减退，无视物旋转及视物模糊，无恶心、呕吐，无反酸、嗳气，无腹痛、腹泻，无全身酸痛及骨痛，无畏寒、发热，无潮热、盗汗等，无体重明显下降。
|
[
{
"anatomy_list": [
"头"
],
"character": [],
"core_name": "头昏",
"tendency": ""
},
{
"anatomy_list": [
"头"
],
"character": [],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"鼻"
],
"character": [],
"core_name": "鼻衄",
"tendency": "否定"
},
{
"anatomy_list": [
"耳"
],
"character": [
"减退"
],
"core_name": "耳鸣",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "听力减退",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "视物旋转",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "视物模糊",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "恶心",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "呕吐",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "返酸",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "嗳气",
"tendency": "否定"
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "腹泻",
"tendency": "否定"
},
{
"anatomy_list": [
"全身"
],
"character": [
"酸痛"
],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [
"骨"
],
"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": "潮热",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "盗汗",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"明显"
],
"core_name": "体重减轻",
"tendency": "否定"
}
] |
1,052 |
期间包块一直存在，大小如前，有触痛，不伴纳差、腹痛、体重下降，不伴咳嗽、咳痰、胸痛等。
|
[
{
"anatomy_list": [],
"character": [
"一直存在",
"有触痛",
"大小如前"
],
"core_name": "包块",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "纳差",
"tendency": "否定"
},
{
"anatomy_list": [
"腹"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "体重下降",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "咳嗽",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "咳痰",
"tendency": "否定"
},
{
"anatomy_list": [
"胸"
],
"character": [],
"core_name": "疼痛",
"tendency": "否定"
}
] |
1,838 |
继之出现双侧掌指、近端指间关节关节肿胀，伴疼痛，肿胀可于数小时内缓解，诉夜间双肩、双肘、双膝等全身多处关节及腰背部疼痛明显，无明显晨僵，否认光过敏、皮疹、反复口腔溃疡、双手遇冷后变白变紫变红，为进一步诊治于我院我科住院治疗，予以甲强龙40mg qd静滴（2017.01.06-2017.01.20），羟氯喹 200mg bid（2017.01.06-2017.01.28）、帕夫林0.6g qd控制狼疮（2017.01.22-2017.01.28），服用碳酸钙、骨化三醇抗骨质疏松及护胃治疗，熊去氧胆酸250mg tid治疗原发性胆汁性肝硬化，及输白蛋白、血浆等对症支持治疗，疼痛症状明显好转后出院。
|
[
{
"anatomy_list": [
"双侧掌关节",
"指关节",
"近端指间关节关节"
],
"character": [],
"core_name": "肿胀",
"tendency": ""
},
{
"anatomy_list": [
"双侧掌关节",
"指关节",
"近端指间关节关节"
],
"character": [],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"可于数小时内缓解"
],
"core_name": "肿胀",
"tendency": ""
},
{
"anatomy_list": [
"双肩、双肘、双膝等全身多处关节"
],
"character": [
"夜间",
"明显"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [
"腰背部"
],
"character": [
"明显"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"明显"
],
"core_name": "晨僵",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"光"
],
"core_name": "过敏",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "皮疹",
"tendency": "否定"
},
{
"anatomy_list": [
"口腔"
],
"character": [
"反复"
],
"core_name": "溃疡",
"tendency": "否定"
},
{
"anatomy_list": [
"双手"
],
"character": [
"遇冷后"
],
"core_name": "变白",
"tendency": "否定"
},
{
"anatomy_list": [
"双手"
],
"character": [
"遇冷后"
],
"core_name": "变紫",
"tendency": "否定"
},
{
"anatomy_list": [
"双手"
],
"character": [
"遇冷后"
],
"core_name": "变红",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "狼疮",
"tendency": ""
},
{
"anatomy_list": [
"肝"
],
"character": [
"原发性",
"胆汁性"
],
"core_name": "硬化",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"明显",
"好转"
],
"core_name": "疼痛",
"tendency": ""
}
] |
1,733 |
2019年5月复查骨髓形态学示“与2018.11.5比，粒红两系无明显变化，巨核增多”。
|
[
{
"anatomy_list": [
"巨核"
],
"character": [
"增多"
],
"core_name": "增多",
"tendency": ""
}
] |
1,037 |
术后病理：（部分直肠）组织中见浸润，结合病史，免疫表型符合卵巢高级别浆液性癌侵犯直肠。
|
[
{
"anatomy_list": [
"直肠"
],
"character": [
"组织"
],
"core_name": "浸润",
"tendency": ""
},
{
"anatomy_list": [
"卵巢"
],
"character": [
"高级别",
"浆液性",
"侵犯直肠"
],
"core_name": "癌",
"tendency": ""
}
] |
1,265 |
因患者住院期间有心房纤颤病史，故未行纤支镜检查，予以强心、利尿纠正心衰，抗凝、对症等治疗后病情好转后出院。
|
[
{
"anatomy_list": [
"心房"
],
"character": [],
"core_name": "心房纤颤",
"tendency": ""
},
{
"anatomy_list": [
"心"
],
"character": [],
"core_name": "心力衰竭",
"tendency": ""
}
] |
106 |
今日为进一步治疗入我院，门诊以“甲状腺肿物”收入我科。
|
[
{
"anatomy_list": [
"甲状腺"
],
"character": [],
"core_name": "肿物",
"tendency": ""
}
] |
1,137 |
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": ""
}
] |
728 |
患者为进一步复查遂入我院，门诊以“直肠癌术后化疗后”收治入我科。
|
[
{
"anatomy_list": [
"直肠"
],
"character": [
"术后化疗后"
],
"core_name": "癌",
"tendency": ""
}
] |
382 |
因无手术指征，遂给予 ‘紫杉醇脂质体240mg+卡铂400mg+贝伐珠单抗400mg’方案姑息性化疗 8周期，化疗期间及化疗后无明显胃肠道反应、神经毒性、骨髓抑制等毒副症状。
|
[
{
"anatomy_list": [
"胃肠道"
],
"character": [
"化疗期间及化疗后",
"明显"
],
"core_name": "胃肠道反应",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [
"化疗期间及化疗后",
"明显",
"神经毒性"
],
"core_name": "毒副症状",
"tendency": "否定"
},
{
"anatomy_list": [
"骨髓"
],
"character": [
"化疗期间及化疗后",
"明显"
],
"core_name": "骨髓抑制",
"tendency": "否定"
}
] |
1,168 |
患者５天前无明显诱因下出现持续性右上腹痛，程度不剧烈，可忍受，伴恶心、呕吐，呕吐物为胃内容物或胆汁，不伴肩、背部放射痛、发热、畏寒、心慌、胸闷、眼黄、身黄等。
|
[
{
"anatomy_list": [
"右上腹"
],
"character": [
"持续性",
"不剧烈",
"可忍受"
],
"core_name": "疼痛",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "恶心",
"tendency": ""
},
{
"anatomy_list": [],
"character": [],
"core_name": "呕吐",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"呕吐物为胃内容物或胆汁"
],
"core_name": "呕吐",
"tendency": ""
},
{
"anatomy_list": [
"肩部",
"背部"
],
"character": [
"放射性"
],
"core_name": "疼痛",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "发热",
"tendency": "否定"
},
{
"anatomy_list": [],
"character": [],
"core_name": "畏寒",
"tendency": "否定"
},
{
"anatomy_list": [
"心"
],
"character": [],
"core_name": "心慌",
"tendency": "否定"
},
{
"anatomy_list": [
"胸"
],
"character": [],
"core_name": "胸闷",
"tendency": "否定"
},
{
"anatomy_list": [
"眼"
],
"character": [],
"core_name": "眼黄",
"tendency": "否定"
},
{
"anatomy_list": [
"身"
],
"character": [],
"core_name": "黄染",
"tendency": "否定"
}
] |
1,472 |
近期患儿精神、食欲可，睡眠好，大小便未见异常。
|
[
{
"anatomy_list": [],
"character": [
"可"
],
"core_name": "精神",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"可"
],
"core_name": "食欲",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"好"
],
"core_name": "睡眠",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"未见异常"
],
"core_name": "小便",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"未见异常"
],
"core_name": "大便",
"tendency": ""
}
] |
1,820 |
就诊于某医院阴道彩超示：子宫大小月8.6*6.2*5.6cm，肌层回声欠均质，前部较后壁增厚，宫内膜厚约0.6cm，子宫后方见一无回声，大小约6.1*4.9cm,提示：1.子宫后方囊性占位占位性病变 2.子宫稍增大，肌层回声欠均质：腺肌症？阑尾彩超、血常规未见明显异常，血hcg＜2.0m/ml,给予止痛治疗未见明显效果。
|
[
{
"anatomy_list": [
"子宫肌层"
],
"character": [
"欠均质"
],
"core_name": "回声",
"tendency": ""
},
{
"anatomy_list": [],
"character": [
"前部较后壁"
],
"core_name": "增厚",
"tendency": ""
},
{
"anatomy_list": [
"子宫后方"
],
"character": [
"囊性",
"占位性"
],
"core_name": "病变",
"tendency": ""
},
{
"anatomy_list": [
"子宫"
],
"character": [
"稍"
],
"core_name": "增大",
"tendency": ""
},
{
"anatomy_list": [
"子宫肌层"
],
"character": [
"欠均质"
],
"core_name": "回声",
"tendency": ""
},
{
"anatomy_list": [
"腺肌"
],
"character": [],
"core_name": "腺肌症",
"tendency": "不确定"
}
] |
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