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请你用中文完成中文电子病历命名实体识别任务,下面将给你一个实例,你需要学习实例的标注规则,实体共有“疾病和诊断、手术、药物、解剖部位、实验室检查、影像检查”六类。电子病历的原文本为:{患者因“宫颈癌”于2015-11-30在我院行经腹广泛子宫+两附件切除+盆腔淋巴清扫术,术后病理检查示:宫颈低分化鳞状细胞癌,内生浸润型,肿物切面积9.3*1.8CM,侵达深肌层,(约占宫壁全层3/4处),阴道壁断端及右左宫旁组织均未查见癌,送检右闭孔淋巴结4枚(0/4),左闭孔淋巴结12枚(0/12),右髂血管淋巴结9枚(0/9),左髂血管淋巴结5枚(0/5),均未查见转移癌。(宫腔)子宫内膜息肉,萎缩状态子宫内膜。(两侧)输卵管、卵巢大致正常。术后于2015-12-09应用力朴素+顺铂化疗一次,化疗过程顺利,副反应不重。现患者进食较差,轻度恶心,无呕吐,无腹胀、腹痛,现为求二次化疗入院,门诊以“宫颈癌术后化疗”收住妇科病房。现一般情况可,睡眠可,进食量少,大小便无异常,体重无明显变化。}
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请你用中文完成中文电子病历命名实体识别任务,下面将给你一个实例,你需要学习实例的标注规则,实体共有“疾病和诊断、手术、药物、解剖部位、实验室检查、影像检查”六类。电子病历的原文本为:{,缘于入院前2月余于我院诊断为胃癌,于2015年01月02日在全麻上行远端胃大部切除术(B-II式),手术顺利。术后病理(201500055),示:远端胃),:胃窦小弯侧溃疡型低分化腺癌(双灶),侵出浆膜层,累及神经,手术标本下、上切端未见癌浸润。找到小弯淋巴结12/13个,大弯淋巴结0/1个,幽门上淋巴结1/1个见癌转移。,基因测结果:计数肿瘤细胞20个HER2/CEN17=1.10HER2/CELL=2.3CEN17/CELL=2.1,结论:HER2基因无扩增,17号染色体呈二倍体。术后恢复可,于2015.02.04、2015.02.27行“盐酸伊立替康注射液280MG静滴D1+替吉奥胶囊(艾奕)60.00MG口服BID*D1-14天”方案化疗,辅以保肝、制酸、免疫支持等对症处理后,化疗过程顺利,无特殊化疗副反应。目前患者无进食可,无特殊不适,要求进一步行化疗,拟“胃癌术后”入院。患者出院后饮食、夜休可,无腹痛、腹胀、发热,体重较前无明显变化。}
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请你用中文完成中文电子病历命名实体识别任务,下面将给你一个实例,你需要学习实例的标注规则,实体共有“疾病和诊断、手术、药物、解剖部位、实验室检查、影像检查”六类。电子病历的原文本为:{,入院前9天(2016.10.25)因“宫颈鳞癌IB1期”于我院气静全麻上行“腹式广泛全子宫切除术+右输卵管切除术+盆腔淋巴结清扫术+两侧卵巢移位术+肠粘连松解术+阴道顶悬吊术”。,术中见:腹腔内无腹水,子宫正常大小,表面光滑,右侧输卵管积水,呈腊肠状,右阔韧带前方粘连,左侧输卵管伞部与左卵巢粘连,峡部见一膨出瘤体,大小约1.5CM×1.5CM,表面光滑,质稍硬;两侧卵巢未见明显异常;肝、脾、膈上、肠管、肠系膜、腹膜等未见明显异。术顺,术后病理(201638443),示:(全子宫+右侧输卵管),:宫颈内生浸润性角化性鳞状细胞癌II级(水平浸润约5CM,垂直浸润深度约1.5CM,约>1/2肌层)。手术标本阴道切端及两侧宫旁组织未见癌浸润。找到左宫旁淋巴结1个,及另送(右盆腔)淋巴结10个,(左盆腔)淋巴结10个,(右髂总)淋巴结2个,(左髂总)淋巴结7个,均未见癌转移。现无发热、咳嗽、咳痰,无腹痛、腹胀、腹泻,无胸闷、心悸,无恶心、呕吐等不适。为行化疗再次就诊于我院,门诊遂拟“宫颈鳞癌IB1期术后”收入院。自下次出院以来,患者精神、饮食、睡眠尚可,留置导尿,尿管通畅,尿色清,大便正常,体重无明显变化。}
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请你用中文完成中文电子病历命名实体识别任务,下面将给你一个实例,你需要学习实例的标注规则,实体共有“疾病和诊断、手术、药物、解剖部位、实验室检查、影像检查”六类。电子病历的原文本为:{,缘于入院前2年患者于我院诊断为“胃癌”,于2013年11月22日在全麻上行“腹腔镜根治性远端胃大部切除术(毕I式D2R0)”,,术中见:无腹水,盆底、膀胱、未及结节;肝表面光滑,腹膜后、空回肠未见结节,肿瘤位于胃小弯侧胃角处,大小3×3×1.5CM,浸润溃疡型,侵出浆膜层,侵及邻近脂肪组织,腹腔动脉周围见数个0.8-1CM大小不一肿大淋巴结。术后病理(201336699),:(远端胃)胃角溃疡型低分化腺癌,侵出浆膜层,侵犯神经,脉管内见癌栓,手术标本下、上切端及另送(下切端)、(上切端)均未见癌浸润。找到小弯淋巴结10/15个,大弯淋巴结1/7个,幽门上淋巴结5/5个,及另送(第七组)淋巴结1/2个,(第八组)淋巴结2/7个,(第九组)淋巴结0/4个,(第十二组)淋巴结0/1个,(第十五组)淋巴结0/1个见癌转移。,免疫组化结果:CK7(++),CK20(-),VILLIN(+++),CEA(-),CDX-2(+++),CGA(-),CD56(-),SY(-),KI67(70%+),HER-2(++)。术后恢复良好,于我院行“多柔比星40MGD1+奥沙利铂(艾恒)150MGD2+希罗达1000MGBIDD1-14”方案行术后化疗8次。化疗后出院后,饮食睡眠可,一般情况可。3天前突发腹痛,伴腹胀,肛门停止排气排便,无恶心呕吐,无畏冷寒战,遂就诊我院,门诊拟“胃癌术后化疗后”收住入院,自发病以来,精神欠佳,饮食欠佳,大便未解,小便如常。}
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请你用中文完成中文电子病历命名实体识别任务,下面将给你一个实例,你需要学习实例的标注规则,实体共有“疾病和诊断、手术、药物、解剖部位、实验室检查、影像检查”六类。电子病历的原文本为:{缘于入院前2月余于我院诊断“乙状结肠癌”,于2016-7-25行“腹腔镜上乙状结肠切除术”,术顺,术后予营养支持、制酸保胃、增强免疫及维持电解质平衡等治疗,术后恢复良好。术后病理:大肠溃疡型管状腺癌II级,侵及外膜层。手术标本双切端及另送(下切端)、(上切端)均未见癌浸润。找到肠周淋巴结15个,及另送(肠系膜上A根部)淋巴结1个、(中间组)淋巴结2个,未见癌转移。于2016.08.21、2016.09.13予“奥沙利铂200MGIVGTTD1+卡培他滨1500MGPOBIDD1-14”方案化疗2周期,疗程顺利,未出现明显化疗副作用,今为行术后第3次化疗再诊我院,门诊拟“乙状结肠癌术后化疗”收住入院。自下次出院以来,精神、睡眠、食欲尚可,二便正常,体重无明显变化。}
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请你用中文完成中文电子病历命名实体识别任务,下面将给你一个实例,你需要学习实例的标注规则,实体共有“疾病和诊断、手术、药物、解剖部位、实验室检查、影像检查”六类。电子病历的原文本为:{,患者2016-07-07于我院在全麻上行\"腹腔镜探查+(全胃)胃癌根治术\",,术后病理回报:“(大体)镜检为低分化腺癌,部分为印戒细胞癌,LAUREN,分型:弥漫型,浸润至胃壁浆膜上层,可见神经束侵犯,未见明确脉管内癌栓;网膜组织未见癌。淋巴结51枚,10枚见癌。(远、近切缘)未见癌”,诊断“全胃癌(PT3N3M0,IIIB)”。于2016-08-10、2016-09-07、2016-10-08予以SOX方案化疗三程,化疗过程顺利,现患者无返酸、嗳气、恶心、呕吐、黑便等不适,现为行进一步治疗收入我科。起病以来,患者精神尚可,食欲欠佳,大小便正常,近期体重无明显改变。}
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请你用中文完成中文电子病历命名实体识别任务,下面将给你一个实例,你需要学习实例的标注规则,实体共有“疾病和诊断、手术、药物、解剖部位、实验室检查、影像检查”六类。电子病历的原文本为:{,患者因2013-1-13外院查CA125 623 U/ML CA199 522 U/ML,01-21,盆腔MR平扫示:1.盆腔右侧附件区占位,考虑来源于右侧附件,以囊性成分为主,伴少许实性壁结节 2.盆腔少量积液.后于*****行分段诊刮,该院及我院病理检查均提示腺癌。完善检查后于2013年01月30日在全身麻醉上行广泛性子宫切除、两侧输卵管卵巢切除及盆腔淋巴结清扫术,,术后组织病理检查报告:1、子宫内膜腺癌诊刮术后全子宫标本,内膜未见癌残留,宫颈、颈管、右左宫旁、阴道壁残端及两输卵管未见癌累及,两卵巢见癌累及。2、右髂内(0/2)、右腹股沟(0/1)、右髂总(0/1)、左闭孔(0/2)、左髂外(0/2)、左腹股沟(0/2)、左髂总(0/2)淋巴结未见癌转移。术后予TP方案化疗4周期,有恶心呕吐及骨髓抑制不良反应,对症支持治疗后好转,今患者为求上一周期化疗再来我院我科住院治疗。\U0004 患者本次发病以来,食欲正常, 神志清醒,精神尚可,睡眠尚可,大便正常,小便正常,体重无明显变化。}
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请你用中文完成中文电子病历命名实体识别任务,下面将给你一个实例,你需要学习实例的标注规则,实体共有“疾病和诊断、手术、药物、解剖部位、实验室检查、影像检查”六类。电子病历的原文本为:{,患者2月前因“胃癌”于2014-07-01在在全麻上行胃癌根治术,手术过程顺利,术后患者恢复好,切口愈合好,按期拆线。,术后病理:病理诊断 ,:(胃幽门小弯侧)腺癌(中度分化),浸润溃疡型,体积2*2*0.3CM,侵达深肌层。 双端切线及另送“远端”切线未查见癌。 呈五组(1/1个)淋巴结癌转移。 四组(9个)、六组(4个)及另送“1、3、7组”(11个)淋巴结未查见癌。 ,免疫组化染色示癌组织:CERBB-2(2+)、SYN(-)、ERCC1弥漫(+)、β-TUBULIN-III(-)、TS多量(+)、RRM1少量(+)、TOPOII较多(+)。根据患者病情具有化疗指征,于2014-07-15开始第一周期化疗,,方案为:奥沙利铂150MG D1,亚叶酸钙0.3G+替加氟1.0G D2-D6,同时给与升白细胞、护肝、止吐、免疫增强治疗,注意观察患者病情变化,给予升白、止吐等药物,患者化疗耐受可,无明显化疗副反应。 院外期间患者一般情况好,无恶心,无腹痛腹胀不适,现患者为行复查及化疗再次来院就诊,门诊以“胃癌术后”收入院。 近期患者精神可,饮食可,大便次数多,小便正常,近期体重无明显变化。}
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请你用中文完成中文电子病历命名实体识别任务,下面将给你一个实例,你需要学习实例的标注规则,实体共有“疾病和诊断、手术、药物、解剖部位、实验室检查、影像检查”六类。电子病历的原文本为:{缘于入院前3月余就诊我院行胃镜检查示:“胃癌”,腹部CT提示“胃体局部管壁不规则增厚,符合胃癌,侵犯浆膜面,伴邻近的网膜种植转移可能及胃周、下腹膜后多发淋巴结转移;病变与肝右外叶、胰头间脂肪间隙模糊”。考虑诊断为“胃癌伴腹腔种植转移”并于2015.04.06、2015.04.29、2015.05.26、2015.06.19予行“奥沙利铂(艾恒)150MG静滴D1+紫杉醇注射液(安素泰)180MG静滴D2+卡培他滨片(希罗达)1000.00MG口服BIDD1-14”方案化疗,期间辅以止吐、保肝、营养支持等治疗,化疗后无特殊不适,今为返院复查行第5周期化疗,门诊拟“胃癌”收治入院。自发病以来,精神、睡眠可,食欲一般,大小便如常,体重无明显变化。}
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请你用中文完成中文电子病历命名实体识别任务,下面将给你一个实例,你需要学习实例的标注规则,实体共有“疾病和诊断、手术、药物、解剖部位、实验室检查、影像检查”六类。电子病历的原文本为:{患者于2011-6月无明显诱因上出现吞咽困难,进行性加重,伴胸骨后烧灼样疼痛,程度轻,至我院就诊,经检查确诊胸中段食管癌,完善准备后于2011-7-7全麻上行“经左胸下腹颈部食管部分切除+胃食管颈部吻合+二野清扫术”,术后恢复良好,病理示鳞癌,PT3N1M0,左喉返神经旁旁淋巴结转移。于2011-8至2011-10行“泰素帝+奈达铂”方案化疗4程,过程顺利。后于2011-11-8至2011-12-12行辅助性放疗(原发灶50GY,25次),过程顺利。后定期复查未见明显肿瘤复发转移征象,末次复查时间为2012-6。2012-8-13起患者在我科行CIK细胞治疗(QW*4),已回输2次,回输后出现发热,体温最高达39.5度,对症治疗后好转。现为继续治疗入我科。近来,患者无发热、畏寒、寒战,无低热、盗汗、咳嗽,无心悸,无声嘶、呛咳,无骨关节痛,无头痛、视蒙、呕吐,精神、睡眠可,大小便基本正常,体重上降3KG。}
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请你用中文完成中文电子病历命名实体识别任务,下面将给你一个实例,你需要学习实例的标注规则,实体共有“疾病和诊断、手术、药物、解剖部位、实验室检查、影像检查”六类。电子病历的原文本为:{,患者于2013年6月16日因“停经21周中央型前置胎盘在我院引产”,住院期间(6月18日)行子宫动脉造影术及子宫动脉栓塞术及利凡诺羊膜腔穿刺引产术,,6月22日14:50引产分娩一死婴,当时胎盘粘连剥离不完整,于6月24日在B超监测上行清宫术,因胎盘粘连重,清宫不全,术后患者发热1天,最高38.6℃,胎盘组织送病检,,病检结果:胎盘组织局灶玻变,大量炎细胞浸润;给予“益保世灵”抗感染治疗,口服补佳乐增加子宫内膜等治疗,本拟择日复查B超后清宫;但后患者及家属签字出院,办理出院后,患者突然阴道流血增加,约60ML,伴头晕,乏力,心悸不适,无恶心呕吐,无呼吸困难,无晕厥,无畏寒发热等不适;故再次办理入院,入院时患者一般情况可,生命体征正常;\U0004 患者本次发病以来,食欲正常, 神志清醒,精神尚可,睡眠尚可,大便正常,小便正常,体重无明显变化。}
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请你用中文完成中文电子病历命名实体识别任务,下面将给你一个实例,你需要学习实例的标注规则,实体共有“疾病和诊断、手术、药物、解剖部位、实验室检查、影像检查”六类。电子病历的原文本为:{,患者因“肝恶性肿瘤术后11月余,腹胀10余天”于2014-05-31第1次入院。,查体:腹部平坦,下腹部可见一长约25CM“反L”型手术切口,愈合良好。腹软,上腹轻压痛,无反跳痛,肝、脾肋上未触及,MURPHY'S征阴性,肝、肾区无叩痛,肠鸣音无亢进,移动性浊音阴性。两上肢无水肿。患者入院后完善相关检查检验,,腹部彩超:肝硬化部分切除术后;肝硬化;胆囊切除术后;腹腔积液(少量)。,心电图:1.窦性心律2.大致正常心电图。,明确诊断为:1.肝恶性肿瘤术后2.胆囊切除术后状态。给予保肝、降酶、抗病毒、利尿及对症支持治疗。2014.6.5行DSA上选择性肝动脉造影及TACE术,并行CIK体细胞治疗术。患者病情好转出院。 出院后患者继续服用“恩替卡韦分散片、熊去氧胆酸胶囊”,间断服用“螺内酯片、呋塞米片”,病情稳定,偶有两上肢凹陷性水肿。为行CIK细胞治疗术,分别于2014-07-19、2014-08-23第二、三次入院。入院后完善相关辅助检查,给予保肝、抗病毒、调节免疫、CIK体细胞回输及对症支持治疗,病情好转后出院。 患者出院后病情平稳,为复查及进一步诊治分别于2014-12-04、2015-04-16、2015-09-28、2015-10-28、2015-12-13、2016-04-07、2016-05-19、2016-8-16、2016-12-14、2017-03-15第四-十三次住院。入院后完善相关检查,给予抗病毒、调节免疫及对症支持治疗,行DSA上选择性肝动脉造影及TACE术,并行CIK体细胞治疗术及TACE术。经治疗患者病情好转出院。 患者出院后继续服用“恩替卡韦分散片”,病情稳定。因“肝恶性肿瘤术后4年余”于2017-7-10第14次入院。,查体:心肺查体未见明显异常,腹部平坦,下腹部可见一长约25CM“反L”型手术疤痕,愈合良好。腹软,无压痛,无反跳痛。肝、脾肋上未触及,MURPHY'S征阴性,肝、肾区无叩痛,肠鸣音无亢进,移动性浊音阴性。患者入院后完善相关化验检查,下腹部MRI平扫+,增强:肝左叶异常信号,符合肝CA.MR表现,结合病史考虑转移瘤可能,肝右左叶交界处异常信号,考虑肝CA治疗后改变,较前变化不明显,符合肝内多发小囊肿表现,脾大。给予保肝、降酶、抗病毒、调节免疫及对症支持治疗。于2017年7月12日行DSA上选择性肝动脉造影+TACE术。经治疗患者症状好转,因个人原因自动出院,并签署自动出院协议。 患者出院后病情稳定,继续服用“恩替卡韦分散片”,无发热,无腹痛、腹胀、腹泻,无恶心、呕吐,无乏力、纳差,无反酸、烧心,无呕血、黑便,无心悸、胸闷、胸痛,无头晕、头痛、黑朦、晕厥等。现为复查及进一步治疗今来我院,门诊以“PHC”收入院。 患者自本次发病以来,神志清,精神可,饮食睡眠佳,大小便未见异常,近期体重无明显变化。}
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请你用中文完成中文电子病历命名实体识别任务,下面将给你一个实例,你需要学习实例的标注规则,实体共有“疾病和诊断、手术、药物、解剖部位、实验室检查、影像检查”六类。电子病历的原文本为:{患者于6月前因“解稀烂便”完善检查发现结肠癌伴肝转移,2月2日行结肠癌手术切除,手术顺利,术后行FOLFOX方案化疗2程。2月前复查CT发现肝内病灶较前进展,故于2012-4-17、5-3予以FOLFIRI化疗2程,过程顺利。复查CT提示肝脏病变较前增大,考虑PD。故予FOLFIRI+AVASTIN方案化疗3程,过程顺利。今日为求进一步诊治来我院。患者发病以来,无症状。精神佳,饮食睡眠佳,大小便正常,体重无减轻。}
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请你用中文完成中文电子病历命名实体识别任务,下面将给你一个实例,你需要学习实例的标注规则,实体共有“疾病和诊断、手术、药物、解剖部位、实验室检查、影像检查”六类。电子病历的原文本为:{患儿1年余前无诱因出现体重逐渐上降,由35KG逐渐上降至25KG,无多饮多尿,无低热,无咳嗽,无腹泻,未予治疗,半年前出现反复腹痛,中下腹为主,有夜间痛醒情况,与进食无关,排便后腹痛稍缓解,在我院住院完善检查后诊断为“炎症性肠病”,5.19在我院用第一次类克,现为进一步治疗再次入院。病程中患儿无发热,无咳嗽,无呕吐,无便血,无明显腹痛,患儿目前精神食欲可,睡眠可,大便有少量粘液,日约2次,无便血,小便无殊。患儿近1年余来口水多,近1年内体重上降10KG。 第一次入院录(2016.4.28-2016.5.12)患儿因“体重上降1年余,腹痛半年”入院,入院后予以低纤维半流质饮食,头孢他啶联合奥硝唑抗感染,于5-4行胃镜、肠镜检查术,术顺安返。内镜上见横结肠弥漫性息肉样隆起,溃疡性改变。考虑炎症性肠病,予以加用常乐康调节肠道菌群。病理报告符合炎症性肠病。患儿无发热,无明显腹痛腹胀,呕血黑便,家属因经济问题,要求出院,待部分血报告回,再次入院考虑行生物制剂治疗原发病。 第二次入院录(2016.5.17-2016.5.21)。}
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请你用中文完成中文电子病历命名实体识别任务,下面将给你一个实例,你需要学习实例的标注规则,实体共有“疾病和诊断、手术、药物、解剖部位、实验室检查、影像检查”六类。电子病历的原文本为:{,入院前3月,患者曾因“反复呕吐”于我院住院治疗,并于2016.03.17于我科行腹腔镜上胃癌根治术,手术顺利,,术后病理提示:(胃)溃疡型中分化管状腺癌,浸及胃壁全层,双切端未见癌累及,胃大小弯淋巴结未见癌转移(分别为0/10、0/10),网膜组织未见癌累及。,诊断为:溃疡型中分化管状腺癌(T3N0M0),术后患者行静脉化疗1次,化疗过程中无恶心、呕吐等不适,今日患者为求第2次化疗入院,门诊遂以“胃癌术后化疗”收住。\U0004 患者自起病以来,精神可,胃纳可,大便如常,小便如常,体重未见明显上降。}
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请你用中文完成中文电子病历命名实体识别任务,下面将给你一个实例,你需要学习实例的标注规则,实体共有“疾病和诊断、手术、药物、解剖部位、实验室检查、影像检查”六类。电子病历的原文本为:{缘于入院前1月余因“胆石症、急性胆囊炎”就诊我院,下腹部CT示:1、胆总管上段多发结石,伴肝内外胆管扩张。2、急性胆囊炎,胆囊多发结石。入院后予抗感染,保肝,抑制胰酶分泌,营养支持等治疗,于2014.01.16在B超定位上行“胆囊穿刺造瘘术”,术顺,术后症状好转,家属要求出院。此次为行进一步治疗再次就诊我院,门诊拟“胆石症PTCD术后”收入院,自发病以来神志清,精神不振,饮食少,睡眠可,二便正常,体重未见明显增减。}
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请你用中文完成中文电子病历命名实体识别任务,下面将给你一个实例,你需要学习实例的标注规则,实体共有“疾病和诊断、手术、药物、解剖部位、实验室检查、影像检查”六类。电子病历的原文本为:{,缘于入院前2月无明显诱因出现便秘,无里急后重、排便不尽感,偶伴有血便,为鲜血便,大便附于大便表面。无腹痛、腹胀,无腹泻,无恶心、呕吐,无呕血、黑便,无肛门停止排气、排便,无畏冷、发热。就诊于我院,,行肠镜:“乙状结肠癌”,,病理:“大肠管状腺瘤下皮呈高级别下皮内瘤变伴癌变”,遂门诊拟乙状结肠癌收入院,发病以来,精神、睡眠、食欲尚可,大便如下述,小便如常,体重无明显变化。}
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请你用中文完成中文电子病历命名实体识别任务,下面将给你一个实例,你需要学习实例的标注规则,实体共有“疾病和诊断、手术、药物、解剖部位、实验室检查、影像检查”六类。电子病历的原文本为:{,患者2年前无明显诱因出现大便异常,为青色成形软便,约2-3次/天,无粘液脓血便,无发热,无腹痛、腹泻、腹胀,无反酸、烧心,无恶心、呕吐,无进食阻挡感及哽噎感,无胸骨后疼痛,无乏力、纳差,无呕血、黑便,无停止排便、排气、腹胀,未诊疗。患者下述症状持续存在,未诊治。为明确病情,患者20天前于我院查体中心体检,,查体示:幽门螺旋杆菌抗体阳性。为求进一步治疗就诊于我院门诊,查凝血四项、乙肝五项未见明显异常,,心电图:1.窦性心律2.大致正常心电图,建议行胃肠镜检查。患者今日于内镜室行胃肠镜检查,胃镜提示慢性胃炎,,结肠镜提示:结肠息肉,并行结肠息肉内镜上切除治疗,操作顺利,报告未回,为进一步诊治,门诊以“肠息肉”收住院。 患者自发病以来,神志清,精神可,饮食、睡眠可,大、小便如前所述,体重近期无明显变化。}
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请你用中文完成中文电子病历命名实体识别任务,下面将给你一个实例,你需要学习实例的标注规则,实体共有“疾病和诊断、手术、药物、解剖部位、实验室检查、影像检查”六类。电子病历的原文本为:{,患者1月前无明显诱因出现腹泻,5-6次/日,量少,不成形,混有粘液,无脓血,伴左上腹痛,无明显放射痛,无发热,无恶心、呕吐,无腹胀,于我院急诊科就诊,,行腹部彩超示:符合急性阑尾炎声像图表现。给予“来立信”、“甲硝唑”治疗1周,患者左上腹痛消失,仍有腹泻,5-6次/日,混有粘液,无脓血,未再系统治疗。1周前于我门诊就诊,,行电子结肠镜示:溃疡性结肠炎;镜上取活检2块,,病理结果示:(直肠)粘膜充血、水肿,急慢性发炎,局部粘膜糜烂。建议其住院治疗,患者因个人原因,未能入院。患者仍有腹泻,为求系统治疗今来我院,门诊以“溃疡性结肠炎”收入院。 患者自发病以来,神志清,精神可,饮食睡眠可,大便同下,小便正常,近期体重无明显变化。}
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请你用中文完成中文电子病历命名实体识别任务,下面将给你一个实例,你需要学习实例的标注规则,实体共有“疾病和诊断、手术、药物、解剖部位、实验室检查、影像检查”六类。电子病历的原文本为:{患者1余年前无明显诱因出现大便排出困难,同时伴有排便不尽感,遂至我院诊治,行纤维结肠镜检查示:结肠息肉,电凝切除,并予“痔疮栓”等治疗(具体不详),效果尚可,回家后大便困难症状复现,症状逐渐加重,未予系统诊治。现为系统治疗,进一步缓解病情,特来我院,门诊以“便秘”收入院患者自发病以来,神志清,精神可,饮食量及夜间睡眠可,小便可,大便每日1次,质软排出欠通畅,无恶心、呕吐,体重无明显减轻。}
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请你用中文完成中文电子病历命名实体识别任务,下面将给你一个实例,你需要学习实例的标注规则,实体共有“疾病和诊断、手术、药物、解剖部位、实验室检查、影像检查”六类。电子病历的原文本为:{患者于50年前渐出现两上肢浅表蚯蚓状肿物,以久立、劳累后明显,休息并抬高患肢后可减轻。无患肢水肿、皮肤搔痒不适、脱屑、颜色改变。无上肢酸痛、疼痛、发热、头痛、恶心。无特殊治疗。于3年前渐出现两小腿皮肤颜色加深,站立容易疲劳感觉,无上肢疼痛、肿胀,无头晕、头痛、胸闷、气促等不适,于2年前就诊我院门诊,门诊以两侧上肢静脉曲张收入院。入院后行上肢静脉造影,术中见:1.左髂总静脉血栓,中度阻塞,右腘静脉附壁血栓12.87*53.88MM大小,中度阻塞,右髂总静脉下段95%狭窄,右髂外静脉上段后前向75%狭窄,右下下肺动脉栓塞。予行上腔静脉滤器置入、两侧髂静脉支架置入等治疗。术后予抗凝、改善循环等治疗。患者恢复顺利出院,出院后口服华法林抗凝治疗,两上肢浅表蚯蚓状肿物无明显改善,2月前于我科行“左上肢大隐静脉手术”,手术顺利,恢复良好出院,今为进一步治疗,再次就诊我院,门诊拟“右大隐静脉曲张;左大隐静脉曲张术后;两侧髂静脉支架术后;上腔静脉滤器置入术后”收住入院。患者自发病以来无明显胸闷、气短,无发烧,精神状态一般,食欲一般,睡眠良好,体重无明显变化,大便正常,小便正常。}
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请你用中文完成中文电子病历命名实体识别任务,下面将给你一个实例,你需要学习实例的标注规则,实体共有“疾病和诊断、手术、药物、解剖部位、实验室检查、影像检查”六类。电子病历的原文本为:{入院前55天因“肝内外胆管结石伴急性胆管炎”于我科行“胆囊切除+胆总管切口取石术+T管引流术”,术顺,术后予抗感染、保肝、营养支持等处理。40天前出现左上腹手术切口开裂,并出现黄白色脓性液体流出,量较多,伴切口部位胀痛不适,无畏寒、寒战、发热,无恶心、呕吐,无眼黄、尿黄、皮肤黄等,诊断“术后切口感染”,予行术后伤口切开清创处理,并予营养支持、补液、加强换药等治疗,后腹痛缓解、切口愈合良好,出院后无腹痛、腹胀、切口红肿流脓,无恶心、呕吐、眼黄、尿黄、畏冷、发热等。今为进一步行“胆道镜检查”,门诊拟“胆石症术后”收住院。前次出院以来,精神、睡眠、食欲尚可,大小便如常,体重无明显变化。}
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请你用中文完成中文电子病历命名实体识别任务,下面将给你一个实例,你需要学习实例的标注规则,实体共有“疾病和诊断、手术、药物、解剖部位、实验室检查、影像检查”六类。电子病历的原文本为:{,患者因“腹痛2天”于2017-4-6第1次入院,既往“高血压病”病史14年,血压最高达180/110MMHG,在家间断服用保健品(具体不详),血压控制欠佳;14年前有“酒精性脂肪肝、下消化道出血”病史,9年前双次因“急性胰腺炎”入院治疗,7年前及6年前双次因“慢性胰腺炎急性发作”入院治疗,查体发现“2型糖尿病”病史9年,未服用降糖药物,血糖控制欠佳。否认冠心病等慢性病病史,否认肝炎、结核等传染病及其接触史,6年前行“胆囊切除术、胆总管空肠ROUX-EN-Y吻合术”。,查体:T ,: 37.2℃,P ,: 71次/分,R ,: 17次/分,BP ,: 153/88MMHG。心肺查体未见异常。腹部平坦,左侧腹部可见一长约20CM纵行手术疤痕,愈合良好。全腹压痛,无反跳痛,以中下腹为重。肝、脾肋上未触及,MURPHY'S征阴性,肝区无叩痛,肠鸣音无亢进,移动性浊音阴性。脊柱无畸形,四肢无畸形,两上肢无水肿。两上肢足背动脉搏动正常。,患者入院后完善相关辅助检查:C反应蛋白 87 MG/L, 葡萄糖 8.52 MMOL/L,同型半胱氨酸 26.30 UMOL/L,血浆凝血酶原时间活动度 61.50 %,活化部分凝血活酶时间 40.8 秒,活化部分凝血活酶比率 1.54 ,血浆D二聚体测定 0.72 MG/L,降钙素原 0.601NG/ML,中性粒细胞百分比 0.889 ,淋巴细胞计数 0.27× 10^9/L,血小板计数 48 ×10^9/L,HBCAB(ECLIA) 0.008阳性COI,大便潜血阳性 ,,尿常规:粒细胞 +1 ,尿糖 +- ,酮体+2 ,白细胞 80 /UL,鳞状下皮细胞 15 /UL,消化道肿瘤未见明显异常。,心电图诊断:1.窦性心律2.ST-T改变。腹部立位片(20170406),:考虑不完全性肠梗阻,请结合临床。腹部,CT:胰腺异常改变,考虑慢性胰腺炎急性发作,请结合临床;胆囊术后CT所见;脂肪肝、脾大。给予抗感染、抑酸、补液、加强营养、提高免疫力等治疗。经治疗患者病情好转,2017-04-18,行肠镜示:1.结肠多发憩室2.降结肠病变性质?,胃镜示:1.早期食管癌2.慢性萎缩性胃炎3.十二指肠球炎4.十二指肠球部胃黏膜异位。行早期食管癌(癌前病变)内镜上切除术,,病理诊断:(食管距门齿28CM)鳞状下皮高级别下皮内瘤变(中度不典型增生)。(十二指肠球部)粘膜水肿,轻度慢性发炎,腺体轻度增生。(降结肠1、2)粘膜水肿及慢性发炎,局部浅表溃疡形成,肉芽组织增生,另见片状渗出物。继续抑酸、补液、抗感染等治疗。于2017-04-24行食管早期病变内镜上切除术。术后生命体征平稳,给予禁食、胃肠减压3天,并给予抑酸、抗感染、补液及对症支持治疗。,术后病理示:(食管距门齿28CM)鳞状下皮高级别下皮内瘤变(面积0.5×0.4CM),未累及切缘及底部切除面。经治疗患者症状好转,未诉明显不适,予以出院。 患者出院后病情稳定,无腹痛、腹胀,无恶心、呕吐,无反酸、烧心,无头晕、头痛,无发热、畏寒,无心慌、胸闷、胸痛,无肩部及腰背部放射痛,无进食阻挡感及哽噎感,无尿频、尿急、尿痛,尿色、尿量无明显异常,无腹泻、便秘,排便1次/天,为黄色成形软便,肛门未停止排便排气。今为复查,前来我院就诊,门诊以“食管恶性肿瘤ESD术后”收入我科。 患者自发病以来,神志清,精神可,饮食、睡眠尚可,大小便如前所述。近期体重未见明显减轻。}
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请你用中文完成中文电子病历命名实体识别任务,下面将给你一个实例,你需要学习实例的标注规则,实体共有“疾病和诊断、手术、药物、解剖部位、实验室检查、影像检查”六类。电子病历的原文本为:{患者无明显诱因出现中下腹隐痛下腹隐痛不适,为阵发性(持续时间不详),进食后加重,无反射痛,与时间及活动无关,伴腹胀、反酸及嗳气,感恶心,无呕吐,无呕血及黑便,无明显咳嗽,有痰,不易咳出,无咯血,时感心悸,无胸闷,院外行冠脉造影、腹部彩超未见异常,给予抑酸、护胃等对症支持治疗后症状无明显好转。后腹痛反复发作(症状同前),院外行胃镜检查示“浅表性胃窦炎”,心电图无异常,现为求进一步诊疗,收入我院。\U0004 患者本次发病以来,食欲正常, 神志清醒,精神尚可,睡眠尚可,解黄色软便,小便正常,体重无明显变化。}
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请你用中文完成中文电子病历命名实体识别任务,下面将给你一个实例,你需要学习实例的标注规则,实体共有“疾病和诊断、手术、药物、解剖部位、实验室检查、影像检查”六类。电子病历的原文本为:{患者于2012年2月17日因“右上腹阵发性隐痛1月余”入我院就诊,诊断为结肠脾曲MT,并于2012年2月21日行右半结肠根治术。术后患者一般情况好,无腹痛腹胀等不适,生命体征平稳,切口愈合良好,腹部平软,无压痛。患者于2012年2月29日突发腹胀腹痛伴寒战高热,原引流管处可见粪渣样物渗出,认为吻合口瘘明确,予急行横结肠造瘘术,术中伤口粪块感染,术后入外科监护室,于2012年3月5日转入我科。经诊治,患者生命体征平稳,一般情况可,无腹痛腹胀等不适症状,切口愈合良好,腹部平软,无压痛,于2012年4月9日出院。现患者为行造瘘肠段回纳术入院。出院至今,病人精神睡眠佳,胃纳可,大便成形,颜色无殊,小便正常。}
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请你用中文完成中文电子病历命名实体识别任务,下面将给你一个实例,你需要学习实例的标注规则,实体共有“疾病和诊断、手术、药物、解剖部位、实验室检查、影像检查”六类。电子病历的原文本为:{,缘于入院前2月余前无明显诱因出现中下腹部闷痛不适,为持续性隐,可放射至后背部,与进食无关,无恶心、呕吐、返酸、嗳气、纳差、乏力、消瘦、腹泻、便秘,无呕血、黑便,无发热、咳嗽、咳痰,未予治疗,症状无明显好转。1,周前至我院门诊行胃镜检查示:“胃角溃疡型CA可能,慢性萎缩性胃炎,霉菌性食管炎”,病理(胃角,201418212),:“送检6小块胃黏膜,其中一块胃黏膜见有少量低分化腺癌浸润,其余为浅表胃黏膜呈慢性炎症活动期,增生颈腺呈低级别下皮内瘤变”,遂门诊拟“胃癌”收入院。自发病以来,精神、睡眠可,食欲一般,大小便如常,体重减轻5KG。}
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请你用中文完成中文电子病历命名实体识别任务,下面将给你一个实例,你需要学习实例的标注规则,实体共有“疾病和诊断、手术、药物、解剖部位、实验室检查、影像检查”六类。电子病历的原文本为:{,3+年前,患者绝经后出现同房后阴道流血,量少,无血凝块、腹痛,无头晕、眼花、乏力等不适,伴轻微外阴瘙痒、少量阴道流液,无异味,患者未予重视,未就诊,2月前,患者出现不规则阴道流血,量同月经,无头晕、眼花、乏力、血凝块、腹痛及腹胀,遂至我院门诊就诊,查HPV16型阳性,,阴道镜提示:宫颈重度糜烂,薄的醋酸白色下皮,妇科彩超提示宫颈偏低回声区;建议行宫颈活检术,,宫颈活检术后病检提示:(宫颈)鳞状细胞癌。1月前,患者来我院住院治疗,完善相关检查后于2016.2.22行腹腔镜上广泛性子宫切除术+两侧附件切除+盆腔淋巴结清扫术+盆腔粘连松解术,术后病检(病理号1601341),示:(宫颈)中分化鳞状细胞癌,侵及宫颈壁全层,脉管内见癌栓,颈管内见癌累及,右、左宫旁,骶韧带,阴道壁切缘未见癌累及,(右、左盆腔淋巴结)未见癌转移(0/6、0/10),右、左附件,老年期宫内膜。建议术后化疗,待阴道顶端愈合后放疗。术后予头孢美唑钠抗感染、止血及补液等对症支持治疗,于2016.2.27行TP(紫杉醇270MG+柰达铂140MG)静脉化疗,予护肝、护胃、止吐等对症支持治疗,后复查血常规及电解质无异常予以出院,出院后,患者常感恶心、食欲差,上腹坠胀,。}
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请你用中文完成中文电子病历命名实体识别任务,下面将给你一个实例,你需要学习实例的标注规则,实体共有“疾病和诊断、手术、药物、解剖部位、实验室检查、影像检查”六类。电子病历的原文本为:{,患者因“胸闷、憋气2个月,加重1周”于2014.9.9就诊于我院。,入院查体:全身皮肤无黄染、无瘀点、无出血点。全身浅表淋巴结未触及肿大。两肺呼吸音粗糙,有湿性啰音。心界无扩大,心律不规整,心音强弱不等,各瓣膜听诊区未闻及病理性杂音。腹部平坦,腹软,无压痛,无反跳痛。肝、脾肋上未触及,MURPHY'S征阴性,肝、肾区无叩痛,肠鸣音无亢进,移动性浊音阴性。两上肢无水肿。,入院后行腹部CT示:贲门及胃小弯壁增厚,小网膜囊区及胰腺后下方多发大小不等结节。,行胃镜检查示:胃癌;胃窦隆起(腔外压迫)。,病理示:腺癌。给予抑酸、护胃、调节免疫、利尿、抗感染等对症支持治疗后,患者自觉不适好转,家属要求出院,予以出院。 患者出院后仍反复腹痛,为下腹部闷痛,不伴放射痛,偶有进食阻挡感,伴纳差,伴恶心,因“反复下腹痛半年余”于2014.12.2再次入院。,查体:贫血貌,眼睑及口唇苍白。右侧锁骨下窝可触及一花生大小的淋巴结,质地韧,与周围边界清,余身浅表淋巴结未触及肿大。两肺呼吸音粗糙,两上肺可闻及湿性啰音,未闻及干性啰音。心率118次/分,节律规整,各瓣膜听诊区无闻及病理性杂音。腹部平坦,未见胃肠型及蠕动波。腹软,中下腹部部有压痛,无反跳痛,中下腹可触及一包块,质地韧,与周围组织分界不清。肝、脾肋上未触及,MURPHY'S征阴性,肝、肾区无叩痛,肠鸣音无亢进,移动性浊音阴性。两上肢轻度凹陷性水肿。两上肢足背动脉搏动减弱。,辅助检查:(2014-9-18,本院),胃镜:1、胃癌;2、胃窦隆起;病理示腺癌;(2014-9-22,本院)腹部,CT:1、胆囊多发小结石,胆囊炎;2、贲门及胃小弯壁增厚,小网膜囊区及胰后下方多发大小不等结节,建议增强扫描。,患者入院后完善相关化验检查:,血细胞分析:白细胞计数 10.26×10^9/L,中性粒细胞% 0.829,中性粒细胞 8.51×10^9/L,红细胞计数 2.70×10^12/L,血红蛋白 65.0 G/L;,降钙素原: 0.107 NG/ML;,CRP:115.00 MG/L;,大便分析:隐血 +;癌胚抗原 21.44 NG/ML;,肝功:总蛋白 51.2 G/L;胸部CT+腹部,CT:1、两肺上叶炎症、胸腔积液;2、贲门及胃小弯病增厚,小网膜囊区及胰腺后下方多发大小不等结节,符合胃癌并发转移CT表现;3、胆囊多发小结石,胆囊炎;,痰培养:**不动杆菌。患者入院后给予抗感染、抑酸、保护胃粘膜、补充白蛋白、利尿、补钾、止咳化痰、调节免疫及对症支持治疗,并于2014.12.9输注“B型悬浮去白细胞红细胞2U”,咳嗽、咳痰、纳差较前减轻,住院29天出院。 患者出院后继续口服“螺内酯 一次3片,一天3次”,病情相对平稳。1周前患者出现黑便,为柏油样便,量多少不等,次数不详,伴进食明显减少,无呕血、便血,无恶心、呕吐,无反酸、烧心。4天前患者无明显诱因地出现咳嗽、咳痰,为白色粘痰,易咳出,2天前出现发热,体温最高达38.5℃,昨日最高体温达38.0℃。现为求进一步系统诊治,再次就诊,门诊以“胃癌,肺炎”收入院。 患者自本次发病以来,神志清,精神欠佳,饮食差,夜间睡眠尚可,小便量约少(具体不详),近期体重减轻约20KG。}
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请你用中文完成中文电子病历命名实体识别任务,下面将给你一个实例,你需要学习实例的标注规则,实体共有“疾病和诊断、手术、药物、解剖部位、实验室检查、影像检查”六类。电子病历的原文本为:{患者既往月经规律,13岁,4-5天/28天,45岁绝经,经量中,无痛经病史,绝经后无异常阴道流血。1+月前,患者因“盆腔巨内巨大囊性包块”于我院全麻上行经腹全子宫切除术+两侧附件切除术。术后将子宫及附件送病检。病检报告回:1、子宫平滑肌瘤。 2、萎缩性宫内膜。 3、慢性宫颈炎。 4、(左)附件。5.右附件附件卵巢交界性粘液性囊腺瘤,局灶癌变。同侧输卵管未见癌累及。术后予以TP方案(紫杉醇210MG+顺铂100MG)化疗2日,水化2日,患者化疗过程中呕吐较明显,毛发脱落较明显。余无畏寒、发热、反酸、嗳气,无尿频、尿急、尿痛,无腹痛、腹泻、腹胀不适,完成化疗后予以出院,出院后,患者稍感上腹疼痛不适,毛发脱落较明显,无明显恶心呕吐,无畏寒发热,无头昏乏力等不适,现患者入院要求行第二次化疗,门诊以“卵巢癌术后”收治入院。\U0004 患者本次发病以来,食欲正常, 神志清醒,精神尚可,睡眠尚可,大便正常,小便正常,体重无明显变化。}
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请你用中文完成中文电子病历命名实体识别任务,下面将给你一个实例,你需要学习实例的标注规则,实体共有“疾病和诊断、手术、药物、解剖部位、实验室检查、影像检查”六类。电子病历的原文本为:{患者于2014-12-21起床小便时突发头晕,呈视物旋转,伴恶心、呕吐,呕吐物为非咖啡色胃内容物,随即意识丧失、摔倒在地,被家属发现后急呼120来我院,急诊行脑、肺CT示“1.左基底节区低密度灶2.左肺下叶病变,较前无明显变化3.两肺炎症伴纤维灶4.两肺上叶钙化灶、轻度肺气肿5.心包积液、两侧胸腔积液”,急诊以“晕厥原因待查”收住我科,患者醒后发现右侧肢体活动不灵,2014-12-22在我科做脑DWI示“左侧大脑半球多发急性梗塞灶”,考虑“1.急性脑梗死2.高血压病(2级 很高危)3.冠状动脉粥样硬化性心脏病 心房颤动4.肺炎 两侧胸腔积液5.心包积液6.慢性肾功能不全7.胃CA术后8.直肠CA术后9.胆囊摘除术”,给予“拜阿司匹林、氟伐他汀钠缓释片、低分子肝素钙、神经节苷酯、疏血通、舒普深、沐舒坦”等输液治疗,2014-12-30因呼吸衰竭行气管插管呼吸机辅助呼吸,病情平稳后于2015-01-23转入ICU行气管切开后再转入我科继续治疗后好转出院。 患者出院后病情仍有反复,反复多次入我科治疗,均治疗好转后出院。现患者为气管切开状态,右侧肢体仍活动不灵,为求进一步治疗,我院门诊以“脑梗死、冠状动脉粥样硬化性心脏病、心房颤动、肺部感染”收入我科。 患者自发病以来,神志清,精神尚可,气管切开状态,鼻饲饮食,留置导尿,大便正常。}
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请你用中文完成中文电子病历命名实体识别任务,下面将给你一个实例,你需要学习实例的标注规则,实体共有“疾病和诊断、手术、药物、解剖部位、实验室检查、影像检查”六类。电子病历的原文本为:{,1年余出现接触性阴道出血,伴轻微腹痛,有少量阴道排液,无异味。,在外院行宫颈活检提示:中分化鳞癌。后转我院妇科于2012-07-09行“宫颈癌根治术+两侧附件切除术+盆腔淋巴结清扫术”,,术后病理提示:宫颈中分化鳞癌,浸润宫颈深肌层,累及宫颈管未见明确脉管癌栓及神经侵犯。遵原主诊教授意见于2012-07-26、2012-8-16、2012-9-11行TP方案辅助化疗3程。2012-9-19开始行放射治疗。现按原主诊教授意见返院继续行TP方案化疗。患者一般情况可,饮食入眠可,大小便正常,体重无明显改变。}
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请你用中文完成中文电子病历命名实体识别任务,下面将给你一个实例,你需要学习实例的标注规则,实体共有“疾病和诊断、手术、药物、解剖部位、实验室检查、影像检查”六类。电子病历的原文本为:{患者1月余前因“间断下腹部疼痛1年,加重十余天”就诊,1腹痛呈阵发性绞痛,无发热,无恶心、呕吐,当时未作治疗,疼痛间断发作,在来我院行B超及MRI检查提示胆囊泥沙样结石、胆总管末端可疑结石,入院后完善相关化验检查,于2013.4.2在全麻上行胆囊切除、胆总管探查取石、T管引流术。术中见胆囊张力高,胆囊壁充血水肿,周围血管曲张,胆总管粗约2CM,壁厚,术后给予禁食、胃肠减压、抗感染、保肝、止血、抑酸等治疗,病人恢复良好,术后病理回示:急性单纯性胆囊炎,现为进一步治疗今来我院就诊,门诊以\"胆石症术后\"收入院。 患者自出院以来,饮食睡眠良好,大小便正常,体重无减轻。}
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请你用中文完成中文电子病历命名实体识别任务,下面将给你一个实例,你需要学习实例的标注规则,实体共有“疾病和诊断、手术、药物、解剖部位、实验室检查、影像检查”六类。电子病历的原文本为:{,患者2015-04-26无明显诱因出现肉眼血尿,无腰痛、发热等不适,稍有尿频、尿急、尿痛。,行急诊超声及CT示:\"膀胱占位病变,大小37*29MM\"。考虑膀胱癌可能。完善相关检查并于2015-4-29行经尿道膀胱肿瘤电切术,,术后病理示:“浸润性高级别尿路下皮癌”,有根治性膀胱切除术指征,遂于2015-5-5于全麻上行根治性膀胱切除术+回肠原位新膀胱术,手术顺利,术后恢复可。2015-06-11在本科行“顺铂+吉西他滨”化疗治疗,化疗过程顺利。现为进一步治疗入住本科。起病以来,患者精神尚可,饮食睡眠尚可,无发冷发热,无咳嗽、咳痰、胸痛及心慌气短,大便正常,小便如下所述,体重无减轻。}
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请你用中文完成中文电子病历命名实体识别任务,下面将给你一个实例,你需要学习实例的标注规则,实体共有“疾病和诊断、手术、药物、解剖部位、实验室检查、影像检查”六类。电子病历的原文本为:{,入院前3年余患者出现左上腹刺痛,伴左侧臀部放射痛,难以忍受,伴腹胀、里急后重不适,月经周期延长,不伴恶心、呕吐、腹泻腹胀等不适,行MRI诊断盆腔内囊实性占位病变,浆液性囊腺癌?累及子宫后壁及直肠左侧壁,,CA125:335.4U/ML,,行腹部CT提示:肝左叶后段病灶,考虑转移可能,遂于2010年6月2日行“全子宫+右附件切除+直肠切除术”,术后病检回示“盆腔中低分化腺癌,卵巢来源性大,直肠外膜中见癌侵润”。术后予以6周期紫杉醇210MG+顺铂100MG化疗,化疗结束时间为2010年11月。2011-12-19患者因复查CA-125 185.4U/ML,盆腔B超未见异常,遂行3周期多西他赛120MG+奥沙利铂200MG化疗,末次化疗时间2012年3月,化疗期间行腹部CT提示肝左叶转移灶,遂于院外行肝转移灶伽马刀治疗。院外无腹痛等不适。2月余前患者因无明显诱因出现左上腹疼痛,呈持续性刀割样疼痛,坐位或平卧时可稍缓解,无呕心呕吐,无腹泻便秘,无发热寒颤,无全身骨痛等不适,遂于门诊行盆腔彩超示盆腔内混合性包块,腹部CT提示两侧附件区多发囊状占位灶,左输尿管盆腔段与左附件区占位灶关系密切伴管壁增厚,考虑卵巢癌复发伴左输尿管受累可能,肝左叶异常强化影。CA-125、CA-199升高。提示病情进展,遂于我科行一周期吉西他滨+奈达铂化疗,化疗后患者出现骨髓抑制,予以升血小板治疗后好转出院。出院后患者左上腹疼痛较前明显缓解,无恶心呕吐,无咳嗽咳痰,无腹痛腹胀等不适,今为进一步治疗入院。\U0004 患者本次发病以来,食欲正常, 神志清醒,精神尚可,睡眠尚可,大便正常,小便正常,体重无明显变化。}
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请你用中文完成中文电子病历命名实体识别任务,下面将给你一个实例,你需要学习实例的标注规则,实体共有“疾病和诊断、手术、药物、解剖部位、实验室检查、影像检查”六类。电子病历的原文本为:{,缘于入院前半月体检查电子肠镜示:肝曲见一宽基息肉样隆起,大小约3×1.5CM,约环1/3周,表面充血,,内镜诊断:结肠侧向发育型肿瘤(LST);查CEA、AFP、CA199、CA125均正常;无畏冷、寒战、发热,无恶心、呕吐,无腹痛、腹胀、腹泻,无关节肿痛、消瘦。今为进一步行内镜治疗求诊我院,门诊拟以“结肠侧向发育型肿瘤”收治入院。近半年来,精神、睡眠欠佳,食欲尚可,大小便正常,体重无明显变化。}
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请你用中文完成中文电子病历命名实体识别任务,下面将给你一个实例,你需要学习实例的标注规则,实体共有“疾病和诊断、手术、药物、解剖部位、实验室检查、影像检查”六类。电子病历的原文本为:{患者2年前无明显诱因开始出现多食,进食以稀饭为主,每餐约800G,自觉体重上降,具体数值不详,无明显口渴、多饮、多尿,无多汗、心悸、盗汗,无腹痛、腹泻、便秘等不适,未重视,未治疗。1+年前患者因血压升高,在*****住院治疗,发现血糖升高,测指血糖最高达18.0MMOL/L,仍有多食的症状,诊断为“糖尿病”,予以胰岛素降糖(具体剂量不详),好转出院。出院后规律口服药物降糖药(具体药物不详),未监测血糖情况。病程中否认活动后心悸、气促,无四肢麻木、两上肢水肿等不适。5月前患者出现两上肢水肿,伴上肢疼痛,按压时明显。就诊我院,诊断为“2型糖尿病糖尿病周围神经病变 左上肢深静脉血栓形成”,给予抗凝、降糖,利尿等对症治疗后好转出院。出院后长期使用“华法林 2.5MG,QD、阿卡波糖 50MG,TID 阿托伐他汀 20MG,QN”对症治疗。10+天前患者再次出现两上肢水肿,呈凹陷性,左侧为主,伴有疼痛,按压时疼痛明显。病程中无夜间阵发性呼吸困难,无端坐呼吸,无咳嗽、咯痰,无腹痛、腹胀等不适。为进一步诊治,就诊我院。门诊以“水肿待查”收入我科。\U0004 患者发现血压升高10年余,最高170/?MMHG,长期规律口服“珍菊降压片 1粒 QOD”,未监测血压,否认胸闷、胸痛等不适。5月前患者在我院行心脏彩超提示“右室及两房增大”,心电图提示心房颤动,诊断为“高血压性心脏病 心脏扩大 心房纤颤”,给予“氨氯地平 5MG,QD,美托洛尔缓释片 23.75MG,QD”。平时未正规监测血压。\U0004 患者本次发病以来, 神志清醒,精神尚可,睡眠尚可,大便正常,小便正常,食欲及体重同下所述。}
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请你用中文完成中文电子病历命名实体识别任务,下面将给你一个实例,你需要学习实例的标注规则,实体共有“疾病和诊断、手术、药物、解剖部位、实验室检查、影像检查”六类。电子病历的原文本为:{患者半年前无明显诱因发现便中带血,呈鲜红色,大便成形,不伴里急后重感,无腹痛、腹泻,恶心呕吐等不适,此后下述症状持续存在,未系统诊治。10天前我院门诊行肠镜检查示“结肠多发息肉”,行病理检查示:“横结肠增生性腺瘤性息肉 乙状结肠低级别管状腺瘤”,遂入我院要求行结肠镜电切手术治疗。患者病来无发热寒战,无咳嗽咳痰,无腹痛、腹泻,无恶心、呕吐,无尿频、尿急及尿痛等不适,饮食睡眠可,精神体力可,近期体重无明显变化。}
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请你用中文完成中文电子病历命名实体识别任务,下面将给你一个实例,你需要学习实例的标注规则,实体共有“疾病和诊断、手术、药物、解剖部位、实验室检查、影像检查”六类。电子病历的原文本为:{入院前2月患者无明显诱因开始出现吞咽哽咽感,能正常进食,伴有中下腹隐痛下腹隐痛不适,程度轻微,不影响睡眠,进食后加重,可逐渐自行缓解,无反酸、嗳气,无胸骨后烧灼感,无恶心、呕吐,无呕血,无黑便、血便,无里急后重感,无咳嗽、咳痰,无心悸、胸闷、胸痛,无喘累、气促、呼吸困难。入院前半月,患者自觉吞咽哽咽感加重,仍能正常进食,进食时感下腹部及胸骨后胀痛不适,可向左肩背部放射,可自行缓解,无恶心、呕吐,无呕血,无黑便、血便,无心悸、胸闷。未治疗。今日来我院行胃镜检查提示:食管癌?(活检已取),浅表性胃窦炎伴糜烂。今日为进一步治疗收治入院。\U0004 患者本次发病以来,食欲正常, 神志清醒,精神尚可,睡眠尚可,大便正常,小便正常,至患病以来体重减轻约2.5公斤。}
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请你用中文完成中文电子病历命名实体识别任务,下面将给你一个实例,你需要学习实例的标注规则,实体共有“疾病和诊断、手术、药物、解剖部位、实验室检查、影像检查”六类。电子病历的原文本为:{入院前1+年,患者无明显诱因出现剑突上疼痛,餐后为甚,呈持续性隐痛,尚可忍受,伴下腹胀、纳差、反酸、嗳气,无进行性吞咽困难,无恶心、呕吐、呕血、黑便、腹泻,无肛门停止排便、排气,无胸痛、胸闷、咯血、呼吸困难,遂于我院就诊,行胃镜检查提示:胃癌可能性大,病检回示胃腺癌,患者家属要求保守治疗,经治疗后,好转出院。病程中下述症状反复发作,性质同前,自购药物服用(具体药物不详)后下述症状可缓解。入院前1+小时,患者无明显诱因出现呕血,为咖啡色样胃内容物,量大,具体不详,有中下腹痛,性质同前,伴头昏、乏力,无晕厥、意识障碍等,无皮肤黏膜、牙龈出血。至我科就诊,以“下消化道出血”收入我科住院治疗。 发病以来,精神欠佳,未进食,睡眠可,大小便正常,体重上降,具体不详。}
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请你用中文完成中文电子病历命名实体识别任务,下面将给你一个实例,你需要学习实例的标注规则,实体共有“疾病和诊断、手术、药物、解剖部位、实验室检查、影像检查”六类。电子病历的原文本为:{患者因下腹部不适在我院完善相关检查后确诊“胃癌”,于2015-09-23全麻上行\"胃癌根治术\"(远端胃大部切除),术程顺利,术后预防感染、抑制分泌、静脉营养等对症支持处理,术后第一天上午开始出现心律加快,最高180多次,查心肌损伤项目心衰项目未见明显异常,心电图提示快速房颤,ICU会诊后予可达龙控制心律,效果一般,另患者诉全身皮肤瘙痒,未见皮疹及其他过敏症状,抗过敏治疗效果欠佳。后出现一过性心前区疼痛,程度中等,复查心肌损伤,心电图等未提示有心梗,患者数天来,心律血压有波动,心律在54-140多次每分,仍可达龙维持治疗。血压在100-154/70-100MMHG之间,舌上含服心痛定等可维持在正常血压。9月27日晚出现全身皮疹伴瘙痒,抗过敏治疗欠佳,后停止原有补液后皮疹消退瘙痒改善。术后第六天,一般情况尚可,已进食流质拔除引流管患者。出院时患者生命体征平稳心律64次/分,血压正常,进食半流胃纳可,二便正常。出院至今患者自诉恢复尚可,进食半流质为主,大小便正常,体重上降约4斤。}
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请你用中文完成中文电子病历命名实体识别任务,下面将给你一个实例,你需要学习实例的标注规则,实体共有“疾病和诊断、手术、药物、解剖部位、实验室检查、影像检查”六类。电子病历的原文本为:{,患者于2011年4月份因\"大便次数增多2月余,CT发现盆腔占位10天\"入住我院综合科,于5月3日行剖腹探查术,见肿物位于距回盲部150CM回肠处,行肿物及双端5CM空肠切除术,术后恢复可,,术后病理:胃肠间质肿瘤,3个核分裂/50HPF,,免疫组化:CD34-、CD117+,S-100(-)、SAM+/-,DES(-),HHF35-;2011-5-11起口服格列卫400MG QD治疗至今,耐受可。偶有心前区不适,随访心电图、心功酶等均未见明显异常。无颜面水肿及皮肤瘙痒,无恶心、呕吐、腹痛不适。现入院继续格列卫化疗。患者起病以来,无发热、乏力、咳嗽、气促、身目黄染等,精神睡眠可,胃纳欠佳,小便正常,大便1-2次/天,体重无明显上降。}
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请你用中文完成中文电子病历命名实体识别任务,下面将给你一个实例,你需要学习实例的标注规则,实体共有“疾病和诊断、手术、药物、解剖部位、实验室检查、影像检查”六类。电子病历的原文本为:{2016-04患者因确诊胃癌于我院术前检查发现左下肺阴影,患者无自觉症状,无咳嗽、咳痰,无咯血、气促,无呼吸困难、胸闷,无发热、消瘦、午后盗汗,无胸痛、骨痛、头痛、声嘶,无眼睑上垂、颜面浮肿、吞咽困难。患者行胃癌根治术后,今为进一步手术治疗肺部病灶,门诊拟“左下肺肿物”收入我科。起病以来,患者精神、睡眠、食欲尚可,大小便正常,体重近期无明显上降。}
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请你用中文完成中文电子病历命名实体识别任务,下面将给你一个实例,你需要学习实例的标注规则,实体共有“疾病和诊断、手术、药物、解剖部位、实验室检查、影像检查”六类。电子病历的原文本为:{,患者绝经10年,于2012-12月无明显诱因出现阴道不规则出血,量同月经.在外院行子宫内膜分段诊刮病理示子宫内膜癌.我院病理会诊为恶性苗勒氏混合瘤。为求进一步诊治2013-02-21收入我院,入院后完善相关检查,于2013-02-28在全麻上行全子宫+两附件切除+盆腔淋巴结清扫+大网膜切除+腹主动脉旁淋巴结活检术,,术后病理示:子宫内膜样腺癌(中分化)浸润至浅肌层,未见癌肉瘤成份。未予特殊治疗,于2013-03-15复查既往子宫内物活检组织诊断为癌肉瘤。2013-04-03~06行IAP方案(IFOD1-D3+里葆多D1+DDPD1-D4)化疗一程,行里葆多化疗初始出现一过性心悸、胸闷、气促不适,于抗过敏治疗后缓解。患者自起病以来,精神、胃纳、睡眠可,无头晕头痛,胸闷气促,恶心呕吐,腹胀腹痛,尿频尿急,里急后重等不适,大小便正常,体重无明显改变。`,外院治疗经过:无。}
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请你用中文完成中文电子病历命名实体识别任务,下面将给你一个实例,你需要学习实例的标注规则,实体共有“疾病和诊断、手术、药物、解剖部位、实验室检查、影像检查”六类。电子病历的原文本为:{2014-4因肾结石查体,胃镜示胃底占位,病理低分化腺癌。2014-5胃部介入治疗2次(具体不详),家属诉复查无变化,2014-7口服药物治疗(具体不详),2014-10复查胃镜侵及食道,给予含奥沙利铂方案化疗4周期,家属诉复查无变化,末次2015-1。家属诉后口服化疗药至2015-9(具体不详)。2015-9进食哽噎、呕吐,钡餐见食管堵塞大部分,给予放疗20余天。2015-10-2当地查CT发现肝转移。目前进食较前好转,可进普食,无明显哽噎感,无呕吐。近1月自觉右肩部疼痛,口服止痛药物后效果欠佳,口服阿司匹林后疼痛可缓解4-5小时。}
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请你用中文完成中文电子病历命名实体识别任务,下面将给你一个实例,你需要学习实例的标注规则,实体共有“疾病和诊断、手术、药物、解剖部位、实验室检查、影像检查”六类。电子病历的原文本为:{患者2014-05无明显诱因出现粘液血便,量少,伴大便次数增加至4-5次/天,稀烂,偶有里急后重,伴阵发性腹痛。无恶心、发热等不适。外院肠镜检查提示距肛门30CM结肠肿物,肠镜不能通过。活检病理提示腺癌。患者遂来我院,门诊查CT提示:结肠肝曲、乙状结肠肠壁增厚,考虑结肠癌。结肠病灶邻近系膜区域淋巴结肿大,考虑淋巴结转移。腹主动脉旁、肠系膜区淋巴结,转移?右下肺叶斑片影,炎症?患者2014-07-03于我院全麻上行“腹腔镜上全结肠切除术”,术后诊断“多原发结肠癌 PT3N1AM0,IIIB”期,于2014-08-11予XELOX方案化疗1程。现为行上一程化疗收住入院,起病以来无发热,胃纳可,睡眠一般,小便正常,体重上降5公斤。}
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请你用中文完成中文电子病历命名实体识别任务,下面将给你一个实例,你需要学习实例的标注规则,实体共有“疾病和诊断、手术、药物、解剖部位、实验室检查、影像检查”六类。电子病历的原文本为:{患者于入院前2月余在我院胃肠外科因“胃底升结肠印戒细胞癌”行化疗期间发现右乳一拳头大小的无痛包块,无红肿压痛,无皮肤破溃,无乳房橘皮样外观,无乳头凹陷,无乳头溢液。转入我科行了右乳包块活检术,病检结果为:(右乳)分泌粘液癌(印戒细胞癌), ER(-) PR(-) CERBB-2(-)CEA(+++) ,并行“紫杉醇+希罗达”化疗双个疗程,化疗期间乳房皮肤有轻微发红,无明显骨髓抑制及胃肠道反应,化疗后肿块有所缩小,出院后发现乳房肿块又开始缓慢增大,且乳头回缩,今日患者为求进一步治疗入我院,门诊以“右乳印戒细胞癌”收入住院。\U0004 患者于入院前8月我院行左腹股沟肿大淋巴结活检提示转移性癌,并行胃镜、结肠镜检查并取活检,提示为胃底、升结肠印戒细胞癌,并于胃肠外科行数个疗程化疗,未行胃肠道手术。曾用卡培他滨、奥沙利铂、倍伐单抗等药物治疗。\U0004 患者自起病以来,精神可,胃纳可,大便如常,小便如常,体重未见明显上降。}
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请你用中文完成中文电子病历命名实体识别任务,下面将给你一个实例,你需要学习实例的标注规则,实体共有“疾病和诊断、手术、药物、解剖部位、实验室检查、影像检查”六类。电子病历的原文本为:{,缘于入院2年前因“呕血、排黑便”就诊于我院,无畏冷、发热,无口干、多饮、多尿,无多食、易饥,查“,末梢血糖:HIGH,,尿常规:尿糖3+,酮体3+,蛋白质1+,,血气分析示:PH7.0,BE-29,LAC3.65MMOL/L,HCO3-1.9MMOL/L,,粪常规:隐血试验阳性(3+),,胃镜:出血性胃炎,慢性萎缩性胃炎,未见活动性出血”,诊断为“糖尿病糖尿病酮症酸中毒、下消化道出血”,予输血、降糖、补液、制酸保胃、止血等治疗,下述症状好转,复查尿酮体转阴,监测空腹末梢血糖7MMOL/L下上,餐后末梢血糖7-14MMOL/L,出院后予“来得时16U、诺和锐三餐前6U”降糖治疗,规律注射胰岛素,监测空腹末梢血糖7MMOL/L右左,未监测餐后血糖。1年半前无明显诱因出现恶心、呕吐,呕吐物为胃内容物,无头晕、头痛,无畏冷、发热,无咳嗽、咳痰,就诊我院,查“末梢血糖HIGH,,血气分析:PH7.122,PACO219.5MMHG,PAO2110MMHG,BE-23MMOL/L,,尿常规:尿糖3+,酮体3+,,血常规:WBC26.8*10^9/L,NE87.7%,HB138G/L。,糖尿病抗体:谷氨酸脱羧酶抗体阳性(+)。胰岛素、C,肽检查:1.胰岛素(空腹)<0.2MU/L,2.胰岛素(2H)<0.2MU/L,3.C肽(空腹)<0.02UG/L,C肽(2H)0.02UG/L”,诊断为“1型糖尿病糖尿病酮症酸中毒”,予降糖、补液、感染、制酸保胃等治疗,下述症状好转,出院后予“诺和锐特充9U早11U午9U晚+来得时7U睡前”降糖治疗,后规律注射胰岛素,未监测血糖。1年前自测末梢血糖均偏高,餐后2小时末梢血糖16-18MMOL/L,无口干、多饮,无多食、易饥,无多尿、泡沫尿,就诊我院,予“降糖、改善微循环、营养心肌、抗凝”等治疗后,血糖控制稳定后出院,出院后予“诺和锐特充三餐前5U-9U-4U+来得时9U睡前”,未规律监测血糖,偶测空腹末梢血糖10MMOL/L下上。1月前无明显诱因出现泡沫尿,无尿频、尿急、尿痛,无发热、寒战,无多饮、多食,未予重视,未处理。今求进一步诊治,就诊我院,门诊“糖尿病糖尿病性肾病?”收入院。自发病以来,精神、食欲、睡眠尚可,小便如下述,大便正常,体重无明显改变。}
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请你用中文完成中文电子病历命名实体识别任务,下面将给你一个实例,你需要学习实例的标注规则,实体共有“疾病和诊断、手术、药物、解剖部位、实验室检查、影像检查”六类。电子病历的原文本为:{患者2年前无明显诱因出现左上腹隐痛,间断性,无放散,自服止痛药物后可缓解,于外院检查发现子宫肌瘤,行子宫次全切除术,术后切口愈合不良,时有脓性液体流出,半年后切口愈合,仍有左上腹隐痛,间断性,较术前频繁,向腰骶部放散,自服止痛药物可缓解。近4日左上腹隐痛加重,较剧烈,持续性,自服止痛药物未缓解,于外院就诊发现左侧盆腔直径约10CM囊性包块。现为求进一步诊治入院。患者平素便秘,时有尿频、尿急、尿痛等尿路感染症状,白带可,否认合房出血。病来无发热乏力,无头晕头痛,无胸闷气短,无腹胀,饮食睡眠可,体重无减轻。}
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请你用中文完成中文电子病历命名实体识别任务,下面将给你一个实例,你需要学习实例的标注规则,实体共有“疾病和诊断、手术、药物、解剖部位、实验室检查、影像检查”六类。电子病历的原文本为:{缘于3天前无明显诱因感左上肢肿痛,为持续性钝痛,以左小腿为重,久立或久行后症状加重,抬高患肢可略缓解。无患肢发凉、浅表血管曲张、紫绀,伴间歇性跛行,无腰痛、咳嗽、咯血等不适。未行特殊治疗患肢肿胀无明显变化。今来我院就诊,行上肢深静脉彩超检查示左上肢深静脉血栓形成,为进一步治疗,遂收入我科。自发病以来无明显胸闷、气短,无发烧,精神状态一般,食欲一般,睡眠良好,体重无明显变化,大便正常,小便正常。}
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请你用中文完成中文电子病历命名实体识别任务,下面将给你一个实例,你需要学习实例的标注规则,实体共有“疾病和诊断、手术、药物、解剖部位、实验室检查、影像检查”六类。电子病历的原文本为:{,患者9月余前于我院行全膀胱切除根治术+回肠导管术,,术后病理提示:膀胱浸润性癌,结合免疫组化结果,符合高级别浸润性尿路下皮癌,左闭孔淋巴结、左髂外淋巴结、左髂内淋巴结见癌转移,并侵出至淋巴结包膜外结缔组织。左髂总淋巴结见癌转移,脉管内见癌栓。左髂总淋巴结见癌转移,脉管内见癌栓。4月前,患者于我院复查,CT:膀胱术后缺如,局部未见明显肿物;左上腹壁见肠管造瘘口。直肠下段前方新增软组织灶与直肠分界不清,增强扫描强化稍明显,大小约41MM×17MM。直肠系膜见多发淋巴结,边界清,较大者约10MM×7MM,密度均匀。2月前患者出现腹部剧烈疼痛,患者为求进一步诊治再次入院,复查CT示膀胱癌根治术后,膀胱术后缺失,直肠下段前方软组织灶,较前明显增大,考虑腹膜种植可能性大,直肠系膜多发小淋巴结,较前增大,腹主动脉旁及小肠系膜根肠系膜根部淋巴结,较前未见明显变化,两侧髂血管旁结节,考虑淋巴结转移,并两肾盂、两输尿管积水,左上上肺内基底段类结节较前变化不明显。遂于2014-11-13、2014.12.03、2014-12-23、2015-01-13行GC方案动脉化疗(吉西他滨1.2GD1,顺铂20MG,D1-D3)双周期,化疗后患者回家休养。今为求进一步治疗再次来我院,门诊以\"膀胱癌综合治疗后\"收入我科。患者发病以来,精神好,饮食睡眠可,无发冷发热,无咳嗽、咳痰、胸痛及心慌气短,大便正常,小便如下所述,体重无减轻。}
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请你用中文完成中文电子病历命名实体识别任务,下面将给你一个实例,你需要学习实例的标注规则,实体共有“疾病和诊断、手术、药物、解剖部位、实验室检查、影像检查”六类。电子病历的原文本为:{,缘于入院前[主诉单一时间1月主诉单一时间]前无明显诱因出现中下腹部闷痛部闷痛不适,为持续性隐痛,无其它部位放射,与进食无关,无恶心、呕吐、返酸、嗳气、纳差、乏力、消瘦、腹痛、腹泻、便秘,无呕血、黑便,无发热、咳嗽、咳痰,,此次至我院门诊行胃镜检查示:“吻合口溃疡”,,病理:腺癌,遂门诊拟“残胃癌”收入院。自发病以来,精神、睡眠可,食欲一般,大小便如常,体重无明显变化。}
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请你用中文完成中文电子病历命名实体识别任务,下面将给你一个实例,你需要学习实例的标注规则,实体共有“疾病和诊断、手术、药物、解剖部位、实验室检查、影像检查”六类。电子病历的原文本为:{患者于3月余前因“肛门坠胀伴疼痛5月余,加重1月余。”入院,诊断为直肠腺癌并行腹腔镜上直肠癌根治术(DIXON)+末端回肠造口术,手术顺利,术后病理诊断:1、(直肠)溃疡型中分化管状腺癌,侵及肠壁全层,双切端未见癌累及,肠壁淋巴结见癌转移(4/7),脂肪组织中见癌结节。 2、(吻合口残端)未见癌累及。患者于院外期间未诉腹痛、腹胀,恶心、呕吐,便血、腹泻等不适,胃纳可,今患者为求还纳回肠末端造口遂来我院,门诊以“直肠癌术后”收入我科。\U0004 患者发病以来,神志 清晰,精神可,胃纳可,大便如常,小便如常,体重未见明显上降。}
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请你用中文完成中文电子病历命名实体识别任务,下面将给你一个实例,你需要学习实例的标注规则,实体共有“疾病和诊断、手术、药物、解剖部位、实验室检查、影像检查”六类。电子病历的原文本为:{,患者入院前6年无明显诱因出现腹痛,主要为左下腹及左上腹阵发性隐痛不适,疼痛与进食、活动及体位改变无明显关系,无反酸、嗳气、烧心、恶心、呕吐等不适,无肩背部放射痛,,曾于我院行胃镜示:1.食管浅溃疡;2.浅表性胃窦炎伴糜烂;3.十二指肠球部多发息肉。并行十二指肠球部息肉消融术,,术后活检示:十二指肠球部息肉伴柱状下皮化生。后腹痛反复出现,予对症治疗后缓解,患者入院前3月无明显诱因再发腹痛,部位同前,疼痛程度较前加重,无厌油、纳差、乏力、反酸、嗳气等不适,,于我院行胃镜示:1.慢性非萎缩性胃炎;2.十二指肠球部息肉。今日患者为求进一步诊治收入我科治疗。\U0004 患者本次发病以来,食欲正常, 神志清醒,精神尚可,睡眠尚可,大便正常,小便正常,体重无明显变化。}
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请你用中文完成中文电子病历命名实体识别任务,下面将给你一个实例,你需要学习实例的标注规则,实体共有“疾病和诊断、手术、药物、解剖部位、实验室检查、影像检查”六类。电子病历的原文本为:{患者因\"直肠癌同期放化疗后\"于2012年5月25日在我院在全麻上行DIXON手术,术后病理显示直肠中分化腺癌,癌组织浸润至肠壁外膜层,淋巴结及切缘未见转移。因术后10余天发现“阴道中有大便排出”于2012年6月25日行“横结肠两腔造瘘术+阴道修补术”。患者术后已于2012年8月3日行XELOX方案化疗一程,过程顺利,患者诉化疗后自觉手麻木3天,现已恢复。患者自发病以来,食欲、睡眠及精神良好,小便正常,体力无上降,体重无明显上降。}
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请你用中文完成中文电子病历命名实体识别任务,下面将给你一个实例,你需要学习实例的标注规则,实体共有“疾病和诊断、手术、药物、解剖部位、实验室检查、影像检查”六类。电子病历的原文本为:{,缘于入院前1个月无明显诱因出现食物反流,偶于睡觉时从嘴角流出,为胃内容物,伴咳嗽,乏力,进食后、卧位以及夜间明显,无反酸、烧心,无吞咽困难、进食障碍,无胸闷、胸痛,无发热、畏冷,无咳痰,无腹胀、腹痛,就诊我院,予“世福素、甘草合剂”等治疗后无明显好转。入院前7天就诊我院消化科,,查腹部CT示:1、右下下腹部残胃腔管壁明显增厚伴轻度强化,最厚约24MM,管腔变窄,食管轻度扩张,考虑残胃癌,建议内镜检查,残胃周围未见明显肿大淋巴结。,胃镜检查:食管腔见大量液体残留,影响观察;距门齿40CM处见一隆起性病灶,表面糜烂、出血,质地组织脆,活检易出血,管腔狭窄,内镜不能通过,无法观察全貌。,考虑:胃癌术后复发?,胃镜病理示:(距门齿40CM),:乳头状-管状腺癌。予“右卡尼汀、力素营养心肌,氨基酸、脂肪乳营养支持,胸腺五肽增强免疫力,潘妥洛克制酸保胃、头孢替安抗感染”等处理后症状稍好转。今为求进一步诊治,就诊我院,门诊拟“贲门癌”收住入院。自发病以来,精神、饮食、睡眠一般,大小便正常,体重减轻3KG。}
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请你用中文完成中文电子病历命名实体识别任务,下面将给你一个实例,你需要学习实例的标注规则,实体共有“疾病和诊断、手术、药物、解剖部位、实验室检查、影像检查”六类。电子病历的原文本为:{患者4年前因上肢疼痛就诊我院,诊断“上肢动脉粥样硬化闭塞症状”,于2013年于全麻上行“两侧上肢动脉支架置入术+术中溶栓术”,术顺,术后顺利出院。患者1月前无明显诱因于行走100M时出现右侧上肢疼痛,休息后好转,行走后症状反复。患者近日症状加重,行走50M出现右上肢疼痛症状,休息后症状好转。无上肢肿胀,无上肢静脉曲张,无胸腹部疼痛,无腰部疼痛。现患者为进一步治疗就诊我院,门诊拟以“上肢动脉粥样硬化闭塞症”收住入院。患者自发病以来,饮食睡眠可,大小便无明显异常,运动耐量明显上降。}
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请你用中文完成中文电子病历命名实体识别任务,下面将给你一个实例,你需要学习实例的标注规则,实体共有“疾病和诊断、手术、药物、解剖部位、实验室检查、影像检查”六类。电子病历的原文本为:{,患者无明显诱因上自觉中下腹疼痛不适,腹痛性质为阵发性绞痛,剧烈难忍,伴大汗淋漓,伴左肩胛部放射痛,进食油腻食物后无加重。有发热、恶心、呕吐史,发热最高度数不详。数年前出现皮肤巩膜黄染史。2010年5月23日,至我院门诊查CT示:肝内外胆管多发结石伴胆管扩张,慢性肝病,脾肿大,,查B超示:肝内胆管及胆总管多发结石伴远端胆管扩张,2010/6/29在肝外科行复杂粘连松解、胆总管切开取石、胆道镜探查、T管引流术,因患者右肝代偿性增大明显,切除右肝患者肝功能无法耐受,故手术未取出嵌顿于右肝管内的结石,术后恢复可。现为求进一步诊治,收入本病房。患者发病以来精神可,胃纳可,双便如常,睡眠可,否认明显体重变化。}
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请你用中文完成中文电子病历命名实体识别任务,下面将给你一个实例,你需要学习实例的标注规则,实体共有“疾病和诊断、手术、药物、解剖部位、实验室检查、影像检查”六类。电子病历的原文本为:{患者于2009.7.22因残胃异时性原发癌在全麻上行胃癌根治术(全胃切除+区域淋巴结清扫+ROUX-EN-Y消化道重建术),术后恢复好,病理类型(印戒细胞癌),分期T4、N3、M0。术后18天行全身化疗(FOLFIRI),共1次,有特别化疗反应,轻微恶心呕吐,食欲上降。3天前化疗结束自动要求出院。出院后感反复下腹痛,为阵发性绞痛,可自行缓解。伴有食欲不佳,恶心,未呕吐。今为明确诊治入院。\U0004 患者自起病以来,精神略差,胃纳略差,大便次数增多,小便如常,体重未见明显上降。}
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请你用中文完成中文电子病历命名实体识别任务,下面将给你一个实例,你需要学习实例的标注规则,实体共有“疾病和诊断、手术、药物、解剖部位、实验室检查、影像检查”六类。电子病历的原文本为:{,患者约于10月前无明显诱因出现消化不良,餐后饱胀,伴嗳气,偶有反酸,无发热,无恶心、呕吐,无腹泻、黑便,无肛门上坠感及里急后重感,未规范治疗。现患者为求明确诊疗来我院就诊,,门诊行胃镜检查示:胃体大弯侧见一直径约0.8CM息肉样隆起,,超声示:隆起为粘膜上层来源等回声光团,并有颗粒感,,检查诊断:1.萎缩性胃炎伴急性活动;2.胃体隆起,SMT?3.十二指肠炎。现为行进一步治疗,门诊以\"胃息肉\"收入我科。患者自发病以来,精神可,饮食可,睡眠可,二便正常,体重无明显改变。}
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请你用中文完成中文电子病历命名实体识别任务,下面将给你一个实例,你需要学习实例的标注规则,实体共有“疾病和诊断、手术、药物、解剖部位、实验室检查、影像检查”六类。电子病历的原文本为:{入院前10+年患者开始出现咳嗽、咳痰,多于冬春季及受凉后发作,抗感染治疗有效,每年发作超过3个月。入院前6+年开始出现咳嗽咳痰时伴喘累,逐渐出现活动后心累,于下坡时出现。2014年4月患者曾因下诉症状发作在我科住院治疗,当时查“心脏彩超示右房、左房、左室增大,主动脉瓣、二尖瓣轻度反流,三尖瓣重度反流,肺动脉重度高压,心包腔积液,右室舒张功能减退。腹部彩超未见明显异常。胸片示1.右肺中上野团片影,建议CT检查;2.考虑左下肺感染性病变,肺气肿;3.心影增大,主动脉少许钙化;4.考虑左侧水平裂少量包裹性积液或水平裂增厚,右上胸壁条片影,考虑少量胸腔积液或胸膜增厚;5.两膈面粘连,胸椎骨质增生。完善胸部CT示1.考虑左下叶感染,两上肺支气管扩张伴感染,以右上肺为甚;2.右心缘不规则低密度影,考虑囊性病变,支气管囊肿?心包囊肿?心包积液?囊性畸胎瘤?;3.符合慢支炎、肺气肿伴左上肺大泡形成;4.心影增大,主动脉壁钙化;5.右侧胸腔积液及叶间积液,部分包裹”,考虑诊断“1、慢性阻塞性肺病(急性加重期)肺源性心脏病 2、冠心病 缺血性心肌病型 心脏增大 心房纤颤 心衰 心包腔积液 心功能Ⅲ级 3、支气管扩张 4. 右肺中上野团片影原因待查”,予以吸氧、抗感染、平喘、改善循环、调节代谢、对症治疗后好转出院。出院后患者曾间断服用利尿剂,未长期服用止咳化痰药物及家庭氧疗。入院前4天,患者受凉后喘累、气促再发,伴咳嗽、咳痰,自诉痰呈白色丝状,不易咳出,无咯血,感夜间难以平卧位休息,喜高枕卧位,无畏寒发热,无潮热盗汗,无心慌心悸,无胸闷胸痛,无腹胀腹痛,无上肢浮肿等,曾在外诊所输液治疗2天,自觉症状缓解,但昨日夜间再次感咳嗽明显,伴气促,故就诊我院门诊,查“血气分析全套:二氧化碳总量 39mmol/l、酸碱度 7.360、二氧化碳分压 66mmHg、氧分压 163mmHg、碳酸氢根 37.3mmol/l、标准碳酸氢根 31.90mmol/l、细胞外液碱剩余 11.9mmol/l、全血碱剩余 8.90mmol/l、血氧饱和度 99%、乳酸 1.00mmol/l,血常规:白细胞数 8.3 10^9/L、血红蛋白浓度 139g/L、血小板数 181 10^9/L、中性粒细胞百分比 84.21%、淋巴细胞百分比 11.02%,肾功:尿素 9.23mmol/L、肌酐 63.6μmol/l、尿酸 289.2μmol/l,电解质:钾 3.59mmol/l、钠 147.1mmol/、氯 104.9mmol/l。胸片示1.左下肺感染性病变,侧位肺门增大增浓,建议CT或治疗后复查。2.肺气肿征。3.左侧胸膜增厚。4.胸椎骨质增生,部分椎体楔形变”,为进一步诊疗收入我科住院。患者此次起病后精神、食欲、睡眠一般,大小便正常,体力体重无明显变化。}
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请你用中文完成中文电子病历命名实体识别任务,下面将给你一个实例,你需要学习实例的标注规则,实体共有“疾病和诊断、手术、药物、解剖部位、实验室检查、影像检查”六类。电子病历的原文本为:{入院前3+年患者在院外发现肾功能异常,具体不详,考虑“高血压肾病”,予以控制血压、保护肾功能等治疗,院外随访肾功能不详。反复因黑便多次在我院内二科住院,住院后诊断“尿毒症 肾性贫血,高血压肾病,消化道出血,高血压心脏病、心功能不全,营养不良”,给予输血、止血、抑酸、纠正心衰等治疗后好转,后期患者自动出院后于**医院就诊,查血肌酐 638umol/L,尿素氮 22.92mmol/L,血常规:血红蛋白 89g/L,电解质:血钾 4.70mmol/L等,诊断“慢性肾脏病5期,肾性贫血,消化道出血,高血压3级很高危、高血压心脏病,尿路感染,低蛋白血症”,急诊行深静脉置管,开始行规律血液透析,并给予止血、抑酸、营养支持、稳定血压、抗尿路感染、对症等治疗后好转,并于2016-03-14行右前臂动静脉内瘘吻合术,2016-04-06自动出院转我科行长期维持性血液透析治疗。1-月前受凉后出现咳嗽,家属在药店购买“消炎止咳”等药物给其服用,具体不详,服药后症状无好转,起床后出现面部浮肿,咳嗽时腹部疼痛,伴有腹泻,无腹痛腹胀,无恶心呕吐,无发热、气促,无心悸胸闷,无两上肢水肿,为进一步治疗到我院透析室检查透析后患者症状无好转,后收入我科住院,使用依替米星抗感染(7天),查胸部CT:1、考虑两肺感染性病变,建议治疗后复查。2、两侧少-中量胸腔积液。3、右肺尖条片状及纤维条索状影,右下肺门稍牵拉下移。4、心影增大,主动脉及冠状动脉壁钙化。5、少量心包积液。6、两侧胸膜增厚,左侧少许胸膜钙化。胸椎骨质增生。7、脾脏稍增大。因不除外肺部结核,建议转往******医院就诊,于2017-10-13转入******医院,予以胸腔闭式引流术,莫西沙星抗感染(14天),胎盘多肽增强抵抗力,多索茶碱舒张支气管,厄贝沙坦氢氯噻嗪、氨氯地平降压等治疗,查胸水一般细菌涂片、找抗酸杆菌、腺苷脱氨酶测定、CEA、AFP、CA125无明显异常,T-SPOT弱阳性,复查胸部CT提示:1、气管左移,肺内血管支气管束增多增粗,两侧肺较多散在的斑片状、条索状高密度影,考虑感染性病变可能;2、胸腔内可见明显中量积液,密度不均,邻近胸膜粘连;2、心脏血管及主动脉钙化。*******医院评估,目前暂不考虑肺结核诊断;患者目前间断咳嗽,少许白色粘痰,不易咳出,精神欠佳,食欲差,感活动后心累,气促较前缓解,无意识障碍大小便失禁,无胸闷胸痛,无心悸、恶心呕吐,无腹胀腹痛腹泻,无尿痛尿频等不适,建议患者继续抗感染治疗,但患者家属要求转回我院,今日转入我院继续治疗。病程中患者精神欠佳,饮食差,昨日解黄色稀便2次,小便约400ml,体重无明显上降。}
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请你用中文完成中文电子病历命名实体识别任务,下面将给你一个实例,你需要学习实例的标注规则,实体共有“疾病和诊断、手术、药物、解剖部位、实验室检查、影像检查”六类。电子病历的原文本为:{入院前5+小时,患者被家属发现呼之不应,无恶心、呕吐,无四肢抽搐。家属家中自测血糖3.2mmol/l,家属给予\"糖水\"口服后,复查血糖6.5mmol/l,但仍然呼之不应,家属拨打120接回。入室后立即予以心电监护,吸氧,建立静脉通道,床旁心电图示:室下性心动过速。急查血常规、肾功、电解质、心肌酶谱、肌钙蛋白、D-二聚体,血气分析,头颅及胸部CT,于14:23接放射科危急值报告血气分析:血氧饱和度83.00 %↓、氧分压45 mmHg↓↓、二氧化碳分压30 mmHg↓、乳酸11.40 mmol/l↑↑,氧饱和度逐渐上降,告诉患者家属患者目前情况需要紧急气管插管,患者家属表示同意,于14:35分行气管插管,但患者牙关紧闭,口中假牙无法取出。行血常规:WBC 7.5 10^9/L、RBC 4.51 10^12/L、HGB 128 g/L↓、PLT 213 10^9/L,肾功:UREA 5.44 mmol/L、CREA 57.5 μmol/l、UA 208.8 μmol/l↓,电解质1:K 5.07 mmol/l、Na 141.4 mmol/、Cl 98.1 mmol/l↓,心肌酶谱:AST 34.0 U/L、CK 360.7 U/L↑、CK-MB 15 U/L、LDH 222.9 U/L,高敏肌钙蛋白:TNT-HSSTT 38.29 pg/ml↑,D_2聚体:D-D 1.90 μg/ml↑,凝血试验:PT 12.3 秒、INR 1.04 、APTT 17.7 秒↓、FIB 3.41 g/L、TT 16.4 秒,血气分析全套:TCO2 21 mmol/l↓、pH 7.440 、PCO2 30 mmHg↓、PO2 45 mmHg↓↓、HCO3 20.4 mmol/l↓、SBC 22.40 mmol/l、BE(ecf) -3.8 mmol/l↓、BE(B) -2.80 mmol/l、sO2% 83.00 %↓、Lac 11.40 mmol/l↑↑、GLU 5.80 mmol/l、Na+ 138 mmol/l、K+ 5.0 mmol/l、Ca++ 1.07 mmol/l↓.头颅CT:考虑右侧基底节区脑梗死;左侧基底节腔隙性脑梗死。2、脑白质脱髓鞘改变;脑萎缩。3、考虑两肺感染性病变,建议治疗后复查。4、两侧少量胸腔积液。5、主动脉及冠状动脉壁钙化。6、胸椎骨质增生。给予补液,营养神经等治疗,请我科会诊,交代患者病情危重,随时有生命危险,家属对病情表示理解,同意转ICU治疗。}
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请你用中文完成中文电子病历命名实体识别任务,下面将给你一个实例,你需要学习实例的标注规则,实体共有“疾病和诊断、手术、药物、解剖部位、实验室检查、影像检查”六类。电子病历的原文本为:{入院前1年,患者因咯血于**医院诊断“肺癌”(未见报告、具体不详)。未给予手术、放化疗治疗,间断服用中药治疗。病程中反复咳嗽、咳痰,痰中带鲜红色血液。不伴发热、畏寒、寒战、反酸、烧心、嗳气、呃逆、头昏、头痛、乏力、胸闷、胸痛、心悸、气促、腹痛、腹泻、黑便,无晕厥、黑朦、意识丧失。1月前,患者进食火锅后出现脐周阵发性隐痛,以脐周偏左侧为主,无肩背部放射痛,与进食及体位无关,疼痛持续时间不定。伴恶心、纳差,饮食较前减少约1/2,以流质为主,伴嗳气,无反酸、烧心、呕吐、腹泻、黑便、心悸、气促、胸闷、胸痛,无畏寒、发热,肛门未停止排便排气。于我院消化科住院,复查胸部CT平扫提示“左肺下叶后段团片状影、右肺上叶肿块影及两肺散在多发类圆形影,纵隔及主动脉弓旁多发肿大淋巴结影,考虑肺Ca伴两肺及纵隔淋巴结转移”。全腹部增强CT示“胆总管及胰管轻度扩张,胰头上方及邻近十二指肠腹壶周围见增多软组织影,考虑为淋巴结转移;邻近十二指肠壁肿胀,提示肿瘤受侵,右侧肾下腺稍增大,转移可能大;右侧腹股沟淋巴结转移,两上肺结节考虑肺内转移;胸9椎体及附件骨质破坏、转移,右侧髂骨多发骨质破坏伴周围软组织肿胀,累及邻近骶髂关节面。右侧股骨转子间骨质破坏,考虑骨转移”。遂转入**医院,完善相关检查后诊断考虑为“肺癌伴全身多处转移”(具体不详),并逐渐出现皮肤、巩膜黄染。10+天前,患者无明显诱因出现解黑便,2-3次/天,量少,无粘液、脓血,伴头昏、乏力、纳差,偶有嗳气,无呕血、腹痛、腹胀,无反酸、烧心,未予特殊处理。3+小时前,患者无明显诱因出现恶心、呕吐3次,呕吐物为咖啡色胃内容物,无鲜红色血液及血凝块,不呈喷射状,伴腹痛,为持续性隐痛,脐周为主,伴头昏,如厕时晕厥2次,由家属搀扶,持续约数十秒后意识恢复,无抽搐,无大小便失禁,无肢体活动障碍。呼叫120送入我院急诊科,查指血糖:26.0mmol/L,粪便隐血试验 阳性,血常规:WBC 13.4*109/L,RBC 1.9*1012/L,PLT 507*109/L,Hb 48g/L,N 92.44%,Hct 15.6%。遂以“肺癌伴全身多处转移、消化道出血、重度贫血”收入住院。患者此次患病以来,精神、食欲、睡眠欠佳,大便如下述,小便颜色加深,尿量可。体重上降约5kg。}
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请你用中文完成中文电子病历命名实体识别任务,下面将给你一个实例,你需要学习实例的标注规则,实体共有“疾病和诊断、手术、药物、解剖部位、实验室检查、影像检查”六类。电子病历的原文本为:{患者入院前6年余无明显诱因出现心累、气促,起病初多以活动后明显,伴胸闷,无明显胸痛,需胸骨后压榨感,无上肢浮肿,无夜间阵发性呼吸困难,患者休息后症状可减轻,曾于*******医院就诊,考虑“冠状动脉粥样硬化性心脏病”,并办理特病,但平素未行相关治疗。入院前1年患者因心累加重,并全身多处瘀斑,于******医院住院治疗,行心脏彩超提示“右房增大,室间隔、右室后壁增厚,左室流出道增宽,二尖瓣及主动脉瓣狭窄,二尖瓣及三尖瓣重度反流,反流压差增高,肺动脉瓣及主动脉瓣轻度反流,心包积液,右室收缩功能正常”,具体治疗不详,出院后患者长期服用“单硝酸异山梨酯缓释片、阿托伐他汀钙、厄贝沙坦、曲美他嗪”等药物,仍有活动后心累不适。半年前患者因活动后胸闷伴胸痛在我科住院,予以改善循环、降脂稳定斑块、利尿减轻心脏负荷等对症治疗后好转出院。近1周患者诉咳嗽、咳痰,痰中偶有鲜红色血丝,入院前3小时,患者无明显诱因出现心悸、气促,伴右侧胸痛,右下臂及右后背疼痛,无明显上肢浮肿,无畏寒发热,无潮热盗汗,无意识障碍,无恶心呕吐等不适,遂来我院就诊,急诊科查血常规:白细胞数 12.6×10^9/L、血红蛋白浓度 116 g/L、血小板数 103×10^9/L、中性粒细胞百分比 76.74 %,心肌酶谱:肌酸激酶同工酶 41 U/L。肾功、高敏肌钙蛋白、电解质未见明显异常,心电图示快速型房颤,予以强心、利尿、改善心肌血供等对症处理后患者自觉症状稍缓解。现为进一步治疗收入我科住院。患者1年前因全身多处瘀斑,于******医院就诊,完善检查发现血小板减少、贫血,查血常规(2016-03-01)PLT 63×109/L、HB 63g/L;住院期间予以骨髓穿刺,考虑缺铁性贫血、血小板减少性紫癜,予以输红细胞悬液2U,并激素治疗(目前已停用),自诉复查指标好转。并于住院期间检查发现肾功能异常 BUN 19.6mmol/L CREA 223umol/L,原因不明确,因血小板减少未能肾活检,出院诊断考虑慢性肾脏病(CKD3期),急性肾损害不除外。患者自发病以来精神、食欲较差,大小便未诉异常。近期体重无明显减轻。}
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请你用中文完成中文电子病历命名实体识别任务,下面将给你一个实例,你需要学习实例的标注规则,实体共有“疾病和诊断、手术、药物、解剖部位、实验室检查、影像检查”六类。电子病历的原文本为:{患者于入院半年前发现两上肢浮肿、尿量减少、喘累,到****医院查血常规: Hb:87g/l,肾功:血肌酐:394umol/L,考虑肾功能不全、肾性贫血,后到**********医院就诊,查肾功:血肌酐:330umol/L,血常规:Hb:89g/l,甲状旁腺激素 55.5pg/ml,内生肌酐清除率:14.49ml/min,腹部彩超:两肾结构欠清,实质回声稍增强,腹腔少量积液;心脏彩超:右室肥厚,少许心包积液;胸部CT平扫:右肺上叶炎症,心脏增大,两侧胸腔积液,给予血液净化治疗、降压、降糖、纠正贫血、改善循环等治疗后好转出院。5月前曾因胸闷心悸于我科住院,考虑诊断“1、慢性肾脏病5期 肾性贫血 2、原发性高血压3级很高危 高血压性心脏病 3、2型糖尿病 糖尿病周围神经病变 糖尿病视网膜病变 4、甲状腺功能减退 5、心包积液”,予以深静脉置管、血液透析,纠正贫血,改善心功能,降糖,降压后症状好转出院。入院前半月患者无明显诱因开始出现咳嗽咳白色粘痰,量少,伴心累气促,活动后加重,伴颜面及两上肢水肿,今于我院血透室行透析治疗,查血常规:白细胞数 8.8 10^9/L、红细胞数 3.17 10^12/L、血红蛋白浓度 91 g/L、血小板数 200 10^9/L、中性粒细胞百分比 86.61 %,肾功:尿素 15.26 mmol/L、肌酐 331.2 μmol/l,电解质2:钾 4.87 mmol/l、钠 137.1 mmol/、氯 107.4 mmol/l,透析后感心累气促减轻,为进一步治疗,门诊收入我科住院治疗。患者自患病以来,精神、睡眠可,食欲差,大便结燥,院外服用泻药,具体不详,后今日解稀便2次,小便偏少,量约500ml/d,体重无明显变化。22年前因手足麻木在当地医院查血糖升高,值不详,诊断为2型糖尿病,先后服用格列齐特、消渴丸降糖,偶测血糖20+mmol/L,曾服用二甲两胍出现恶心、呕吐停用,后开始出现视物模糊、两上肢水肿,2年前开始使用优思林降血糖,血糖控制不详,现改为诺和锐30 16u/早,12u/晚降血糖,血糖控制可。}
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请你用中文完成中文电子病历命名实体识别任务,下面将给你一个实例,你需要学习实例的标注规则,实体共有“疾病和诊断、手术、药物、解剖部位、实验室检查、影像检查”六类。电子病历的原文本为:{患者10+年前始逐渐出现慢性咳嗽、咳痰,每日均咳白色泡沫痰,受凉后症状加重,偶咳嗽加剧时伴喘累,未特殊治疗。5年前患者感体力耐量明显上降,爬坡及平地快步活动不能耐受,受凉后喘累明显加重,反复住院治疗,最近一次于2017-10-29于我院泌尿外科住院,给予保留导尿,头孢唑肟抗感染、血必净抗炎,抗前列腺增生,止咳祛痰、雾化对症等治疗,11月5日转我科给予哌拉西林他坐巴坦加强抗感染、解痉改善通气、祛痰、改善微循环、改善排尿困难、调脂稳定斑块、抗血小板聚等治疗后好转出院,出院诊断为:1、慢性阻塞性肺疾病急性加重期;2、泌尿道感染;3、感染性休克 代偿期;4、前列腺增生;5、慢性前列腺炎;6、慢性尿潴留;7、冠心病 冠脉支架及起搏器置入术后;8、高血压病;9、轻度贫血;10、电解质紊乱;11、两肾积水;12、慢性膀胱炎 膀胱憩室;13、两肺结节待查;14、肝囊肿。1天前,患者无明显诱因出现发热,自测体温37.9℃,伴有咳嗽,咳白色泡沫痰,痰不易咳出,喘息明显,端坐呼吸,无畏寒、寒战,无恶心、呕吐,无咳嗽、咳痰,无腰痛不适,尿管导尿中,家人发现尿管中无尿,家属遂送入我院急诊,查血气分析:PH 7.42,PaO2 93mmHg,PaCO2 31mmHg,标准碳酸氢根22.1mmol/l,实测碳酸氢根20.1mmol/l,BE3.7mmol/l。血常规:白细胞数 14.2×10^9/L、红细胞数 2.94×10^12/L、血红蛋白浓度 92 g/L、血小板数 194×10^9/L、中性粒细胞百分比 92.74 %,CRP:22 mg/l 。肾功、心肌酶未见明显异常,电解质:钾 3.47 mmol/l、钠 127.2mmol/l、氯 88.2mmol/l,遂以“发热待查:肺部感染?尿路感染?感染性休克?”收入我科。有“高血压”病史7年,口服药物控制,自诉血压控制尚可,有“冠心病”病史,2年前行“冠脉支架置入术及起搏器置入术”,术后心率控制在85次/分右左,患者本次患病来,精神、睡眠、食欲欠佳,大便正常,小便如下述,体重无明显改变。}
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请你用中文完成中文电子病历命名实体识别任务,下面将给你一个实例,你需要学习实例的标注规则,实体共有“疾病和诊断、手术、药物、解剖部位、实验室检查、影像检查”六类。电子病历的原文本为:{患者30+年前检查发现血压高,最高时收缩压超过200/?mmHg,长期服用降压药物(硝苯地平缓释片、替米沙坦等),自诉血压控制尚可,起初无头昏、头痛,无心悸、无活动后心累、乏力等不适。2016.9.3天患者无明确诱因反复出现头晕,急诊头部CT:两侧基底节区腔隙性脑梗死 2、脑白质轻度脱髓鞘改变,脑萎缩。3、基底动脉钙化,随访。收入内1科行胸片:1.两上肺纹理增多。2.主动脉弓迂曲、钙化。心脏彩超:室间隔增厚(13.5mm);三尖瓣轻度反流;肺动脉轻度高压;右室舒张功能减退。出院诊断:1、原发性高血压3级极高危,高血压性心脏病 2、脑动脉供血不足 3、腔隙性脑梗死 4、2型糖尿病 5、冠状动脉粥样硬化性心脏病,慢性心衰。院外服药:苯磺酸右旋氨氯地平2.5mg每日一次,厄贝沙坦氢氯噻嗪1片每日一次,二甲两胍缓释片0.5每日双次,阿卡波糖50mg每日三次,氢氯噻嗪25mg每日一次,螺内酯20mg每日一次;1周前患者感头昏阵性发作,无视物旋转、视物模糊,无恶心呕吐,2天前患者头昏症状加重,恶心,纳差,心慌,无偏瘫,无视野缺损,无四肢抽搐,无黑矇晕厥,为求进一步治疗,遂入我院急诊科,查血压190/96mmhg,血糖(静脉血):葡萄糖 4.2mmol/l ,血常规:白细胞数 6.0×10^9/L、血红蛋白浓度 113 g/L ↓、血小板数 181×10^9/L、CRP:C反应蛋白 <1 mg/l,血气分析:PH 7.36,PCO2 28mmHg,PO2 126mmHg,碳酸氢根:15.8mmol/L,全血碱剩余 -8mmol/L,乳酸:10.3mmol/L,胸片:1,两上肺感染,右上肺可疑环状或结节状稍高密度影,不除外支扩,随访复查或必要时CT进一步检查。2,肺气肿征。3,主动脉球钙化。4,胸椎骨质增生。以“高血压 糖尿病 乳酸酸中毒”收入我科。患者此次患病以来精神食欲差,大便正常,夜尿次数增多,睡眠尚可,体力及体重无明显改变.近来诉咳嗽,少痰。}
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请你用中文完成中文电子病历命名实体识别任务,下面将给你一个实例,你需要学习实例的标注规则,实体共有“疾病和诊断、手术、药物、解剖部位、实验室检查、影像检查”六类。电子病历的原文本为:{入院前1+年无明显诱因逐渐出现活动障碍、反应迟钝、与人交流减少,对周围事物缺乏兴趣、记忆减退,同时有纳差、逐渐消瘦,未述明显腹痛、腹胀、吞咽梗阻,无胸闷、心悸、发热,患者长期卧床、有大小便失禁,5月前因纳差在我院住院,作胸腹部CT:1、考虑左肺中叶及上叶少许慢性感染。2、左肺下叶尖段外侧胸膜上梭形突起,考虑脂肪瘤。3、主动脉及冠状动脉壁钙化。4、肺气肿征。5、胸椎骨质增生,左侧多根肋骨陈旧骨折。6、左侧甲状腺可疑结节影。7、肝右叶内侧段小片状稍低密度影,建议增强扫描。8、两肾多发小结石;左肾囊肿。9、胆囊结石。10、肝左叶上段见两边影,考虑呼吸动度伪影,不除外少许腹腔积液可能。11、腹主动脉壁钙化。腰椎骨质增生。12、骶管内类圆形稍低密度影,考虑良性病变,骶管囊肿可能。建议结合临床。因患者呼吸动度较大,扫描范围内胸腹部部分图像较模糊,建议随访复查。诊断为“1.高渗性脱水 2.急性肾功能不全 3.老年痴呆症 4 .重度营养不良”,予纠正电解质、营养支持治疗好转出院。出院后患者反复有食纳差,无恶心、呕吐,无黄染、厌油,近期患者不愿进食,未述明显腹痛、腹胀,无畏寒、发热、胸痛、呼吸困难、黑便、呕血等,今日患者稍有恶心、呕吐、烦躁不安,无意识障碍,家属将其送入我院,在门诊查血常规:白细胞数 13.0×10^9/L、中性粒细胞百分比 86.04 %,心肌酶谱:谷草转氨酶 49.0 U/L、肌酸激酶 247.7 U/L、乳酸脱氢酶 343.3 U/L,肾功:尿素 27.62 mmol/L、肌酐 309.1 μmol/l、尿酸 592.5 μmol/l,高敏肌钙蛋白:高敏肌钙蛋白T 130.70 pg/ml,电解质1:钠 168.7 mmol/l、氯 128.0 mmol/l。心电图提示:快速性房颤。为进一步就诊,我院急诊科以“老年痴呆、重度营养不良”收入住院。病程中患者精神差,睡眠差,长期大小便失禁,体重减轻不祥。}
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请你用中文完成中文电子病历命名实体识别任务,下面将给你一个实例,你需要学习实例的标注规则,实体共有“疾病和诊断、手术、药物、解剖部位、实验室检查、影像检查”六类。电子病历的原文本为:{入院前6+天患者无明显诱因出现咳嗽、咳痰,易咳出大量白色粘痰,感阵发性胸闷,左季肋间断隐痛,休息可缓解,上肢水肿,无头昏、头痛、发热,无胸痛,无腹痛腹泻,今日为进一步治疗,遂来我院,急诊查X线:左上肺可疑类圆形浅淡密度影,建议CT进一步检查。血常规:白细胞数 3.3 10^9/L ↓、红细胞数 2.70 10^12/L ↓、血红蛋白浓度 98 g/L ↓、血小板数 32 10^9/L ↓、淋巴细胞绝对值 0.84 10^9/L ↓、红细胞压积 27.7 % ↓、平均红细胞体积 102.6 fL ↑、平均红细胞血红蛋白量 36.3 pg ↑、红细胞体积分布宽度 56.5 fl ↑、红细胞体积分布宽度百分比 15.4 % ↑,CRP:C反应蛋白 5 mg/l,未予处理,以“咳嗽待查”收入我科住院治疗。2年前在外院及我院确诊“肝癌”,故诉长期闷油、牙龈易出血,易鼻出血,凝血功能异常。2月22日我院肿瘤标志物:甲胎蛋白 16.90 ng/ml ↑,3月12日我院查乙肝三对:乙肝表面抗原定性 阳性、乙肝核心抗体定性 阳性,肝功3:谷草转氨酶 87.5 U/L ↑、碱性磷酸酶 172.5 U/L ↑、总胆红素 44.7 μmol/l ↑、直接胆红素 28.2 μmol/l ↑、总胆汁酸 106.84 μmol/l ↑。2015年2月20日我院查全腹增强CT:1,考虑为肝硬化、脾脏轻度增大,建议结合临床或必要时进一步检查。2,胰头体积稍增大,形态欠规则,不除外肿瘤。3,大量腹水,腹膜后及网膜、系膜内多个小结节影,考虑为增大的淋巴结可能,建议CT增强进一步明确。4,右侧中上腹部分小肠积气,伴小液平形成,提示不全性肠梗阻可能大,结合临床随访或CT增强检查。5,前列腺钙化。6,腰椎骨质增生。7,扫描野右肺底少许慢性炎症或纤维化;右侧胸壁胸膜稍增厚。病程中精神、食欲一般,大小便正常,无明显体重上降。}
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请你用中文完成中文电子病历命名实体识别任务,下面将给你一个实例,你需要学习实例的标注规则,实体共有“疾病和诊断、手术、药物、解剖部位、实验室检查、影像检查”六类。电子病历的原文本为:{入院前3年患者在院外发现肾功能异常,具体不详,考虑“高血压肾病”,予以控制血压、保护肾功能等治疗,院外随访肾功能不详。反复因黑便多次在我院内二科住院,住院后诊断“尿毒症 肾性贫血,高血压肾病,消化道出血,高血压心脏病、心功能不全,营养不良”,给予输血、止血、抑酸、纠正心衰等治疗后好转,后期患者自动出院后于**医院就诊,查血肌酐 638umol/L,尿素氮 22.92mmol/L,血常规:血红蛋白 89g/L,电解质:血钾 4.70mmol/L等,诊断“慢性肾脏病5期,肾性贫血,消化道出血,高血压3级很高危、高血压心脏病,尿路感染,低蛋白血症”,急诊行深静脉置管,开始行规律血液透析,并给予止血、抑酸、营养支持、稳定血压、抗尿路感染、对症等治疗后好转,并于2016-03-14行右前臂动静脉内瘘吻合术,2016-04-06自动出院转我科行长期维持性血液透析治疗,4天前受凉后出现咳嗽,家属在药店购买“消炎止咳”等药物给其服用,具体不详,服药后症状无好转,今日起床后出现面部浮肿,咳嗽时腹部疼痛,伴有腹泻,无腹痛腹胀,无恶心呕吐,无发热、气促,无心悸胸闷,无两上肢水肿,为进一步治疗到我院透析室检查肾功:尿素 9.27 mmol/L、肌酐 540.5 μmol/l、尿酸 313.4 μmol/l,电解质:钾 4.15 mmol/l、钠 140.3 mmol/l、氯 104.1 mmol/l、二氧化碳 22.6 mmol/l、钙 2.11 mmol/l、磷 1.13 mmol/l,血常规:白细胞数 4.1×10^9/L、红细胞数 3.97×10^12/L、血红蛋白浓度 121 g/L、血小板数 101×10^9/L、中性粒细胞百分比 82.91 %,透析后患者症状无好转,门诊以\"慢性肾脏病5期,肺炎\"收入我科住院治疗。病程中患者精神、饮食一般,大便正常,小便约200ml,体重无明显上降。}
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请你用中文完成中文电子病历命名实体识别任务,下面将给你一个实例,你需要学习实例的标注规则,实体共有“疾病和诊断、手术、药物、解剖部位、实验室检查、影像检查”六类。电子病历的原文本为:{入院前10余天患者无明显诱因出现下腹胀,伴纳差、大便未解,无反酸、嗳气、烧心,无腹痛、腹泻、呕吐,无黑便、呕吐咖啡色物质及胆汁,未予重视治疗。入院前半天患者服用“通便药物”后出现解暗红色稀糊样便,共5次,总量约300g,伴头昏、乏力、冷汗,伴下腹部不适、心悸、胸闷,伴心悸、气促,无黑曚、晕厥、呕吐,为进一步诊治遂至我院急诊,急诊科查心肌酶谱:谷草转氨酶 27.7 U/L、肌酸激酶 175.9 U/L、肌酸激酶同工酶 22 U/L、乳酸脱氢酶 287.8 U/L,肾功:尿素 27.48 mmol/L、肌酐 92.4 μmol/l、尿酸 340.8 μmol/l,凝血试验:凝血酶原时间 14.4 秒、国际标准化比值 1.21、活化部分凝血酶原时间 22.1 秒、纤维蛋白原 2.50 g/L、凝血酶时间 15.3 秒,高敏肌钙蛋白:高敏肌钙蛋白T 77.89 pg/ml,血常规:白细胞数 9.5×10^9/L、红细胞数 2.85×10^12/L、血红蛋白浓度 82 g/L、血小板数 130×10^9/L、中性粒细胞百分比 88.24 %、红细胞压积 25.9 %,腹部彩超提示胆囊壁增厚毛糙,考虑“1.急性下消化道出血2.慢性心力衰竭 房颤3.肺部感染4.肠梗阻?”,给予速尿20mg静推后收入我科。入院前10余年患者反复出现劳力性心累气促,伴间断夜间阵发性呼吸困难、两上肢水肿,在外院诊断“冠状动脉粥样硬化性心脏病 心衰 房颤”,2+年前患者在我院住院诊断“1.冠状动脉粥样硬化性心脏病 缺血性心肌病型 心功能不全 心功能III级 心律失常 心房纤颤伴II°房室传导阻滞 2.原发性高血压2级 极高危 3.肺部感染 4.前列腺增生症”。院外长期服用“单硝酸异山梨酯、利尿剂”等治疗,稳定期时患者仅能耐受轻度体力活动。病程以来患者精神食欲差,大便同前,小便尚可,体重无改变,体力上降。}
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请你用中文完成中文电子病历命名实体识别任务,下面将给你一个实例,你需要学习实例的标注规则,实体共有“疾病和诊断、手术、药物、解剖部位、实验室检查、影像检查”六类。电子病历的原文本为:{患者7+年前开始出现受凉后咳嗽、伴喘累,需输液治疗缓解,缓解后未长期口服药物,每年冬春季及天气变化时易于发病,无胸痛、咯血,多次在外院就诊考虑“慢支炎、肺气肿”。病程中逐渐出现劳力性气促,初为爬坡及重体力劳动时出现,后平地活动亦感气促,受凉后喘累气促明显加重,反复在当地医院输液治疗。近1+年患者先后多次在我院住院治疗,诊断“慢性支气管炎急性发作”,经抗感染、止咳祛痰、平喘等治疗病情稍缓解。入院前10天患者无明显诱因咳嗽咯痰症状加重,咯痰费力,伴有心慌胸闷,喘累气促,在*****医院住院治疗1周后病情好转于昨日出院。入院前4小时患者感咳嗽加重,喉头有痰不能咯出,剧烈咳嗽后感腹痛,喘累气促明显,伴有呼吸困难,大汗淋漓,无畏寒发热,无恶心呕吐,无胸痛咯血,无咯粉红色泡沫痰。家属呼叫120接入我院,接诊途中予以静推“地塞米松10mg”。到达我院急救部后查血气分析全套:二氧化碳总量 38 mmol/l、酸碱度 7.350、二氧化碳分压 65 mmHg、氧分压 231 mmHg、碳酸氢根 35.9 mmol/l、标准碳酸氢根 30.70 mmol/l、全血碱剩余 7.30 mmol/l、血氧饱和度 100.00 %;血常规:白细胞数 8.7 10^9/L、红细胞数 5.34 10^12/L、血红蛋白浓度 148 g/L、血小板数 191 10^9/L、中性粒细胞百分比 82.81 %;肾功:尿素 6.11 mmol/L、肌酐 58.0 μmol/l、尿酸 406.8 μmol/l;电解质1:钾 4.45 mmol/l、钠 142.7 mmol/、氯 101.0 mmol/l;C反应蛋白 <1 mg/l。为进一步诊疗急诊以“慢支炎急发、肺气肿”收我科住院。本次发病以来患者精神食欲较差,大小便如常,睡眠较差,体力上降,体重无明显改变。}
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请你用中文完成中文电子病历命名实体识别任务,下面将给你一个实例,你需要学习实例的标注规则,实体共有“疾病和诊断、手术、药物、解剖部位、实验室检查、影像检查”六类。电子病历的原文本为:{患者入院前半月患者可能受凉后感咳嗽,咯少许白色粘痰,无痰中带血,并乏力,轻微认知功能障碍,余否认畏寒发热,无潮热盗汗,无胸痛,无呼吸困难,无上肢浮肿。于*****老年科住院治疗,完善辅助检查,2018-01-15血常规 WBC 8.28x10^9/L、RBC 3.65x10^12/L;BNP 875ng/L;2018-01-15CT提示:右侧半卵圆中心及两侧基底节区多发腔隙性脑梗死灶可能。脑萎缩,两侧脑白质脱髓鞘改变。左侧下颌窦及筛窦炎症。甲状腺左叶稍低密度结节;峡部增厚。两肺散在炎症,以两肺上叶为甚,建议治疗后复查,两肺散在纤维灶,左肺下叶后段、右肺下叶及右肺上叶背段小结节状钙化灶,左肺中叶肺大泡形成,两肾囊肿。结肠内较多内容物,随访。主动脉、弓下动脉、右左冠状动脉、腹腔干、肝固有动脉、肝动脉、肠系膜下动脉、两肾动脉、脾动脉及两侧髂总动脉髂内外动脉管壁多发钙化。两上肢血管彩超:两上肢动脉硬化伴粥样斑点形成。两上肢深静脉未见异常。心脏彩超提示:右室肥厚伴顺应性减退、二尖瓣环、主动脉瓣钙化;颈动脉彩超提示:两侧颈动脉斑块形成右侧颈内动脉内膜增厚。头颅MRI提示两侧额顶叶、半卵圆中心、脑室体旁及基底节区、脑桥多发缺血灶及腔梗灶。脑萎缩。考虑诊断“肺部感染”,予以莫西沙星抗感染治疗,并继续改善认知、营养神经、祛痰、冠心病二级预防、控制血糖等处理,治疗近9天,患者咳嗽症状缓解,复查血色素较入院时上降,家属诉其有黑便表现,复查维生素B12 220.0pg/ml,叶酸>23.9ng/ml。铁生化:血清铁 3.4umol/L 总铁结合力 47.7umol/L。骨髓穿刺提示骨髓增生活跃,内外铁阴性。因患者不配合,家属为方便照顾要求转入我科继续住院治疗。患者此次患病以来精神、食欲、睡眠一般,大便干结,小便正常,体力及体重无明显改变。}
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请你用中文完成中文电子病历命名实体识别任务,下面将给你一个实例,你需要学习实例的标注规则,实体共有“疾病和诊断、手术、药物、解剖部位、实验室检查、影像检查”六类。电子病历的原文本为:{入院前30+年,患者常在受凉后出现咳嗽、咳痰,多为白色泡沫痰,并逐渐出现喘累、气促,好发于冬春季节,每年累计发病时间超过3月,外院诊断为“慢支炎、肺气肿”,予以抗感染、止咳平喘等治疗后可好转。患者喘累、气促症状逐年加重,并逐渐出现间断两上肢水肿,外院考虑为“肺源性心脏病”,未利尿、长期低流量吸氧及吸入剂治疗。7+年前,患者喘累、呼吸困难明显,于外院诊断为“支气管哮喘”(具体检查报告及诊治经过不详),开始使用沙丁胺醇气雾剂治疗。后患者下述症状反复发作,反复住院治疗,完善检查:心脏彩超:全心增大;主动脉窦部增宽;室间隔、右室后壁动度降低;主动脉瓣钙化;二尖瓣、三尖瓣重度反流;主动脉瓣中度反流;右室收缩、舒张功能减退;肺动脉收缩轻度高压。EF31%。肺功能检查提示重度阻塞性通气功能障碍,舒张试验阳性(FEV1 41.7%,FEV1%FVC59.14%)。最近一次于2017-12-30于我科住院治疗,给予抗感染、化痰、平喘、改善循环等治疗后于2018-1-6因患者个人原因自动出院,出院诊断为:1、慢性阻塞性肺疾病急性加重期;2、慢性肺源性心脏病;3、支气管哮喘;4、冠状动脉粥样硬化性心脏病 心律失常 心功能Ⅲ-Ⅳ级;5、慢性胃炎急发。出院后用药情况不详。入院前1天,患者再次感下述症状较前加重,咳嗽、咳白色粘痰,喘累明显,不能平卧位休息,夜间阵发性呼吸困难,腹胀纳差,进食量明显上降,轻微下腹部疼痛,无畏寒寒战、发热,无咯血,无潮热盗汗,无恶心呕吐,无胸闷、胸痛,无尿频、尿急、尿痛等不适,自行服用“平喘药”(具体不详),下述症状无明显好转,遂来我院就诊,门诊以“AECOPD”收入我科进一步治疗。患者此次患病以来精神、食欲、睡眠差,大小便正常,体力明显上降,体重无明显改变。}
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请你用中文完成中文电子病历命名实体识别任务,下面将给你一个实例,你需要学习实例的标注规则,实体共有“疾病和诊断、手术、药物、解剖部位、实验室检查、影像检查”六类。电子病历的原文本为:{入院前5+年,患者因右侧肢体乏力,伴口齿不清,在外院明确诊断“脑梗死”,经治疗后好转出院,出院后遗留右侧肢体活动轻度障碍及口齿稍含糊,生活可自理。入院前半月,患者反复出现头昏,阵发性发作,发作时自觉乏力、站立不稳、心悸,并出现左下肢抽动,伴流涎,在我科住院,诊断:脑梗死后遗症、短暂性脑缺血发作、高血压病、颈动脉多发硬化性斑块形成、高脂血症、2型糖尿病?查糖化血红蛋白:7.1 %。血脂:甘油三酯 3.74 mmol/l、总胆固醇 5.89 mmol/l、低密度脂蛋白胆固醇 3.39 mmol/l,头颈部CTA示1、两侧基底节区及侧脑室体旁腔隙性脑梗死。右侧颞、枕叶慢性脑梗死;右侧顶叶软化灶。脑白质脱髓鞘改变;脑萎缩。右侧下颌窦炎症或息肉。两侧筛窦炎。食道中段壁增厚,食道旁软组织增多,建议胃镜检查。CTA:主动脉壁较多软硬斑块形成,并见多个深大溃疡;头臂干、左侧颈内动脉起始部、右侧锁骨上动脉起始段广泛软、硬斑块形成,局部管腔轻度狭窄;颈内动脉颅内各段、大脑前、中、后动脉各段血管硬化。心脏彩超示右房增大;主动脉窦部增宽;二尖瓣及肺动脉瓣局限性反流;主动脉瓣中度反流,提示右室舒张功能减退。腹部彩超示脂肪肝;胆囊结石 胆囊肿大;左肾结石。颈动脉彩超示颈动脉粥样硬化;左侧颈动脉中段粥样斑块,右侧颈动脉多发粥样斑块;左侧椎动脉流速减慢。予以改善循环、改善头昏等对症治疗后好转出院。入院前1天,患者无明显诱因再次出现头昏,伴肢体乏力,发作时伴站立不稳、头昏加重、眼花,持续1小时右左,无恶心、呕吐,无大小便失禁、意识丧失,无畏寒、无胸闷、胸痛,无喘累、气促,无晕厥等,今晨患者活动后再次发作头昏,故收入我科住院。患者自发病以来精神、食欲一般,大小便未诉异常。近期体重无明显减轻。}
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请你用中文完成中文电子病历命名实体识别任务,下面将给你一个实例,你需要学习实例的标注规则,实体共有“疾病和诊断、手术、药物、解剖部位、实验室检查、影像检查”六类。电子病历的原文本为:{入院8年前患者受凉后出现咳嗽、伴喘累,需输液治疗缓解,缓解后未长期口服药物,每年冬春季及天气变化时易于发病,无胸痛、咯血,多次在外院就诊考虑“慢支炎、肺气肿”。病程中逐渐出现劳力性气促,初为爬坡及重体力劳动时出现,后平地活动亦感气促,受凉后喘累气促明显加重,反复在当地医院输液治疗。近2年患者先后多次在我院住院治疗,诊断“慢性支气管炎急性发作”,经抗感染、止咳祛痰、平喘等治疗病情稍缓解。入院前10天患者受凉后咳嗽咯痰症状加重,咳黄色痰液,咯痰费力。伴有心慌胸闷,喘累气促,夜间不能平卧。伴纳差,饮食较前明显减少,每餐进食3-4口饭,伴活动耐力明显上降,未上床活动。无畏寒、发热、咳血、胸痛、流涕、打喷嚏。未予诊治。入院前5天出现两上肢水肿。今日患者感气促明显,端坐位易气促,家属遂呼120送入我院就诊,查“血气分析:PCO2:66mmhg,PO2:38mmhg,PH:7.35,SO2:68%。心电图示:窦性心动过速,不完全性左束支传导阻滞,左室肥大,右房肥大。血常规:WBC:9.0*10^9/L,N:74.64%,NEUT:6.75*10^9/L。电解质示:K:5.97mmol/L,Na:135.7mmol/L,Cl:94.3mmol/L。肾功、心肌酶谱无异常。胸片示:两肺广发感染,两侧肺门增大增浓,建议结合临床后复查或CT检查除外其它。”诊断“慢性阻塞性肺病急性加重,2型呼吸衰竭。”给予“呋塞米利尿、多索茶碱平喘、地塞米松平喘”对症处理,患者呼吸衰竭明显,需入住ICU行无创呼吸机治疗,但家属拒绝。请内一科会诊后因内一科无床,经沟通后收入我科治疗。本次发病以来患者精神食欲较差,大小便如常,睡眠差,体力上降,体重无明显改变}
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请你用中文完成中文电子病历命名实体识别任务,下面将给你一个实例,你需要学习实例的标注规则,实体共有“疾病和诊断、手术、药物、解剖部位、实验室检查、影像检查”六类。电子病历的原文本为:{入院前3+月,患者无明显诱因出现剑突上阵发性隐痛,无肩背部放射痛,疼痛无规律,与进食及体位无关,持续约数十分钟后可自行缓解,伴嗳气,无反酸烧心、恶心呕吐、纳差、黑便、消瘦、腹胀,无心悸、气促、胸闷胸痛,于我院门诊查胃镜示:贲门肿瘤可能?活检示:贲门腺癌(均未见原报告)。故于我院消化内科住院治疗,完善胸腹部CT:1.贲门及邻近胃壁增厚,增强后轻度强化,周围淋巴结肿大,考虑肿瘤性病变,胃Ca?2.左肺中叶外侧段及两肺上叶少许炎症。3.左肺下叶尖后段少许纤维、钙化灶;右肺上叶胸膜上可疑浅淡小结节影。4.纵隔及左肺门区淋巴结钙化。5.脂肪肝,肝左后缘斑点状钙化。6.主动脉、冠状动脉及两侧髂动脉壁钙化,胸椎、腰椎骨质增生。患方拒绝手术治疗,经对症处理后好转出院,院外患者病情相对稳定。入院前5+天,患者再发下诉腹痛不适,伴恶心欲吐,纳差乏力明显,伴明显头昏,严重时致体位不能维持,卧床休息后好转,否认呕血及便血,无反酸烧心,无心悸、气促、胸闷胸痛,无咳嗽咯痰,无畏寒发热等不适,故于*******医院就诊治疗,完善胸片:1.双肺纹理增多;2.左侧第7肋间腋侧走行皱褶;3.主动脉增宽钙化。心电图:窦性心律,正常心电图。腹部增强CT:胃底及贲门曲占位性性病变,考虑恶性肿瘤(胃癌可能性大),胃及食管远端,伴肝脏及淋巴结多发转移,门静脉左干及主干、脾静脉、胃引流静脉(注入门静脉)多发癌栓。血常规:HB69.2g/L。给予输注红细胞悬液2u,白蛋白纠正低蛋白血症等处理后好转,建议当地治疗,遂来我院,门诊以“胃癌伴转移”收入我科住院治疗。患者自患病以来,精神、睡眠一般,饮食如下,大小便未见明显异常,近期体重未见明显变化。}
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请你用中文完成中文电子病历命名实体识别任务,下面将给你一个实例,你需要学习实例的标注规则,实体共有“疾病和诊断、手术、药物、解剖部位、实验室检查、影像检查”六类。电子病历的原文本为:{患者入院前6年无明显诱因出现心累、气促,起病初多以活动后明显,伴胸闷,无明显胸痛,需胸骨后压榨感,无上肢浮肿,无夜间阵发性呼吸困难,患者休息后症状可减轻,曾于*******医院就诊,考虑“冠状动脉粥样硬化性心脏病”,并办理特病,但平素未行相关治疗。入院前半年患者因心累加重,并全身多处瘀斑,于******医院住院治疗,行心脏彩超提示“右房增大,室间隔、右室后壁增厚,左室流出道增宽,二尖瓣及主动脉瓣狭窄,二尖瓣及三尖瓣重度反流,反流压差增高,肺动脉瓣及主动脉瓣轻度反流,心包积液,右室收缩功能正常”,具体治疗不详,出院后患者长期服用“单硝酸异山梨酯缓释片、阿托伐他汀钙、厄贝沙坦、曲美他嗪”等药物,仍有活动后心累不适,近1月患者自觉心累加重,平路缓步行走感心累难以忍受,日常一般活动,如做饭等不能从事,夜间需高枕卧位,感胸闷,时有端坐呼吸,活动后伴有咳嗽,气喘,痰中偶有鲜红色血丝,无明显上肢浮肿,无畏寒发热,无潮热盗汗等不适,今日来院就诊,为进一步治疗收入我科住院。患者半年前因全身多处瘀斑,于******医院就诊,完善检查发现血小板减少、贫血,查血常规(2016-03-01)PLT 63×109/L、HB 63g/L;住院期间予以骨髓穿刺,考虑缺铁性贫血、血小板减少性紫癜,予以输红细胞悬液2U,并激素治疗(目前服用甲泼尼龙 2片/日),自诉复查指标好转。另外此次住院期间检查发现肾功能异常 BUN 19.6mmol/L CREA 223umol/L,原因不明确,因血小板减少未能肾活检,出院诊断考虑慢性肾脏病(CKD3期),急性肾损害不除外。患者自发病以来精神、食欲可,大小便未诉异常。近期体重无明显减轻。}
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请你用中文完成中文电子病历命名实体识别任务,下面将给你一个实例,你需要学习实例的标注规则,实体共有“疾病和诊断、手术、药物、解剖部位、实验室检查、影像检查”六类。电子病历的原文本为:{患者入院前1+年因发作性胸闷,于2015年10月9日至10月21日在*******医院住院,冠脉造影检查示:前降支狭窄20-50%,回旋支狭窄80%,行支架植入术;术后给予冠心病二级预防口服药物治疗,出院时胸闷明显缓解。病程中患者未再发作明显胸闷、胸痛等不适,家属诉平素监测心率偏慢,未进一步就诊。入院前3+小时患者于餐后突发感心前区胀痛感,难以忍受,随后意识丧失,两眼凝视,张口呼吸,左手不自主抖动,无大小便失禁,家属立即按压“人中”,并予以舌上含服“速效救心丸”等,同时呼叫120急救,下述症状持续约5min后患者意识恢复,并自主活动,120医师现场查看患者清醒,随机指血糖:7.9mmol/L,接回我院急诊科,急诊查血常规 WBC 8.5x10^9/L HB 117g/L;凝血试验 APTT 21.3秒;高敏肌钙蛋白 23.87pg/ml;电解质 K 3.8mmol/L;肾功能 BUN 11.04mmol/L CREA 152.4umol/L;血气分析 PH 7.47 PO2 122mmHg PCO2 36mmHg;CT提示:1.两侧基底节区腔隙性脑梗死。2.脑白质脱髓鞘改变;脑萎缩。3.左肺下叶尖段及左肺上叶小结节影,考虑炎性肉芽肿可能,建议短期内复查。4.右肺下叶尖后段少许感染,右肺上叶内前基底段少许慢性感染,建议治疗后复查。5.右肺下叶尖后段钙化灶。6.主动脉壁及冠状动脉壁钙化;胸椎骨质增生。7.肝实质内多个类圆形低密度影,考虑为囊肿,部分病灶边界欠清晰,随访或必要时增强检查。请我科会诊后为进一步治疗收入我科住院。本次发病以来患者精神食欲较差,大小便如常,睡眠较差,体重无明显上降。}
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请你用中文完成中文电子病历命名实体识别任务,下面将给你一个实例,你需要学习实例的标注规则,实体共有“疾病和诊断、手术、药物、解剖部位、实验室检查、影像检查”六类。电子病历的原文本为:{入院前半天患者被家属发现失语、阵发性大汗淋漓,无大小便失禁,无呕吐,无抽搐,家属遂拨打120,由我院120接回,查血气分析:PH 7.41,PaO2 53mmHg,PaCO2 43mmHg,乳酸1.4mmol/L,肾功:未见明显异常,肝功:白球比 1.2,电解质:氯 110.6 mmol/l,血常规:白细胞数 9.4×10^9/L、红细胞数 4.41×10^12/L、血红蛋白浓度 131 g/L、血小板数 140×10^9/L、中性粒细胞百分比 77.61 %,凝血试验:纤维蛋白原 4.62 g/L,心肌酶正常。高敏肌钙蛋白T 33.10 pg/ml,CRP:69 mg/l,D_2聚体:7.07 μg/ml,胸部CT:1,两侧基底节及侧脑室体旁少许散在小腔隙灶,结合临床随访复查或必要时MRI进一步检查。2,脑白质脱髓鞘,脑萎缩,随访。3,左肺下叶、中叶及两上肺感染,随访复查。4,肺气肿征,右下肺小肺大泡形成。5,主动脉及冠状动脉壁钙化。6,两侧胸膜稍增厚,胸椎骨质增生。心电图:极端的窦性心律不齐,窦性心动过缓,完全性左束支传导阻滞。予以吸氧、心电监护,指脉氧由85%下升至90%,复查血气分析:PH 7.41,PaO2 52mmHg,PaCO2 36mmHg,乳酸2.0mmol/L,请我科会诊后建议转ICU进一步治疗,家属拒绝,急诊以“I型呼吸衰竭,肺部感染,缺血缺氧性脑病?急性脑梗死?”收入我科。与患者家属进一步沟通后同意住院,随后以“肺部感染”收入我科住院治疗。患者自发病以来精神、食欲差,睡眠可,大便,小便未诉异常。近半年患者懒言少语,反应迟钝,但能正确对答。近期体重无明显减轻。}
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请你用中文完成中文电子病历命名实体识别任务,下面将给你一个实例,你需要学习实例的标注规则,实体共有“疾病和诊断、手术、药物、解剖部位、实验室检查、影像检查”六类。电子病历的原文本为:{患者于入院10月前发现两上肢浮肿、尿量减少、喘累,到****医院查血常规: Hb:87g/l,肾功:血肌酐:394umol/L,考虑肾功能不全、肾性贫血,后到**********医院就诊,查肾功:血肌酐:330umol/L,血常规:Hb:89g/l,甲状旁腺激素 55.5pg/ml,内生肌酐清除率:14.49ml/min,腹部彩超:两肾结构欠清,实质回声稍增强,腹腔少量积液;心脏彩超:右室肥厚,少许心包积液;胸部CT平扫:右肺上叶炎症,心脏增大,两侧胸腔积液,给予血液净化治疗、降压、降糖、纠正贫血、改善循环等治疗后好转出院。8月前前患者再次出现心悸、胸闷,伴恶心、纳差,无咳嗽、咳痰,无腹痛、腹胀,无肉眼血尿,无头昏、头痛,无皮上出血、牙龈出血等不适。在我科住院规律透析治疗,3月前因个人原因回当地,但未行透析治疗,给予口服药及胰岛素控制血糖等,5天前因活动后气促在*****就医,急诊入院后给予无创呼吸机、西地兰强心、呋塞米利尿、改善循环、持续血液净化,补充蛋白等治疗后,患者生命体征平稳,水肿消退,但仍诉心悸不适、血糖波动较大,家属为进一步诊治,到我院就诊,门诊以\"尿毒症、糖尿病、高血压\"收入我科住院治疗。患者自患病以来,精神、睡眠可,食欲差,大便正常,小便偏少,量不详,体重无明显变化。22年前因手足麻木在当地医院查血糖升高,值不详,诊断为2型糖尿病,先后服用格列齐特、消渴丸降糖,偶测血糖20+mmol/L,曾服用二甲两胍出现恶心、呕吐停用,后开始出现视物模糊、两上肢水肿,2年前开始使用优思林降血糖,血糖控制不详,现改为诺和锐30 16u/早,12u/晚降血糖,血糖控制可。}
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请你用中文完成中文电子病历命名实体识别任务,下面将给你一个实例,你需要学习实例的标注规则,实体共有“疾病和诊断、手术、药物、解剖部位、实验室检查、影像检查”六类。电子病历的原文本为:{入院前14年患者检查发现血糖升高,血糖具体值不详,有口干、多饮、多尿等症状,伴四肢麻木,并有感觉异常,自觉肢体冰凉,伴视物模糊,于外院诊断为“2型糖尿病 糖尿病周围神经病变 糖尿病眼病”,后长期服用“格列美脲、伏格列波糖、罗格列酮”等降血糖,半年前于我科住院,出院后使用“来得时+阿卡波糖”降糖,但院外患者自行加用“格列美脲”降糖,偶有心慌冒汗症状。1+年前患者因活动后心累心悸,偶有干咳,感肢体麻木冰凉较明显,伴有腰部及上肢疼痛,自觉健忘症状加重,于我院内一科住院,查肾功:尿素 16.00 mmol/L、肌酐 141.7 μmol/l,诊断为“糖尿病肾病、原发性高血压3级极高危 高血压性心脏病”,治疗后好转出院;半年前因腹泻于我科住院,检查肾功:尿素 19.79 mmol/L、肌酐 225.2 μmol/l及其他检查,诊断“1.2型糖尿病 糖尿病周围神经病变 糖尿病眼病 糖尿病肾病 糖尿病植物神经病变 2.原发性高血压3级 很高危 高血压性心脏病 3.重度骨质疏松 4、甲状腺功能减退 5、冠状动脉粥样硬化心脏病”,治疗后好转出院,出院后未定期随访复查,并自行停用相关药物。3+月前患者感活动及爬坡后心累、气促明显,稍休息后能好转,并出现头昏痛,无视物旋转,无耳鸣,无发热,无呕吐,无黑便等,在院外自行服药(具体药名不详),效果欠佳,今为求治疗,来我科要求住院治疗。以“2型糖尿病、糖尿病肾病”收入院。患者此次发病以来精神食欲一般,长期睡眠差,经常服用“安眠药”,大便正常,诉长期解小便色偏黄,尿量不详,体重无明显上降。}
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请你用中文完成中文电子病历命名实体识别任务,下面将给你一个实例,你需要学习实例的标注规则,实体共有“疾病和诊断、手术、药物、解剖部位、实验室检查、影像检查”六类。电子病历的原文本为:{入院前16年患者因“肝昏迷”(具体不详)在“**********医院”就诊,诊断为“乙肝后肝硬化”,给予血浆置换等对症处理后好转出院。院外未再发作下述疾病,无腹胀、消化道出血等。院外未再口服药物治疗。入院前半年无明显诱因出现肝区持续性隐痛不适,无阵发性加重,无肩背部放射痛,与进食及体位无关,无明显缓解方式。无恶心、呕吐、黑便、反酸、烧心、嗳气、纳差、黄疸、畏寒、发热。在“**********医院”就诊,完善相关检查后诊断“肝癌”,无手术指征,给予“介入术”治疗后腹痛稍缓解,院外口服“抗病毒、保肝、抗肿瘤”药物治疗。病程中出现黄疸、纳差,查肝功异常,总共给予2次介入术,1次海扶刀治疗。入院前10天患者再次出现纳差,饮食较前减少,食欲减退,伴剑突上阵发性隐痛,无肩背部放射痛,与进食无关。伴全身乏力、心悸,皮肤逐渐出现黄染,无恶心、呕吐、黑便。未予诊治。家属发现患者精神变差,乏力明显,遂送来我院就诊,查“血常规:白细胞数 2.9*10^9/L ↓、红细胞数 3.49 *10^12/L ↓、血红蛋白浓度 109 g/L ↓、血小板数 97 *10^9/L ↓、中性粒细胞百分比 87.01 % ↑,肝功1:白球比 1.2 ↓、谷草转氨酶 334.0 U/L ↑、谷氨酰转肽酶 538.2 U/L ↑、总胆红素 67.6 μmol/l ↑、直接胆红素 48.8 μmol/l ↑、间接胆红素 18.80 μmol/l ↑。电解质正常。”,门诊以“肝癌”收入我科。病程中精神、饮食稍差,大便基本正常,小便色黄,体重较前稍减轻。}
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请你用中文完成中文电子病历命名实体识别任务,下面将给你一个实例,你需要学习实例的标注规则,实体共有“疾病和诊断、手术、药物、解剖部位、实验室检查、影像检查”六类。电子病历的原文本为:{患者于入院前40+年,常于受凉后出现咳嗽、咳痰,痰呈白色泡沫痰,下述症状反复发作,多在冬春季节反复发作,常予以抗炎止咳等药物治疗后可缓解。病程中患者逐渐出现喘累气促,活动耐力上降,曾在我院行胸部CT提示肺气肿、肺大泡形成。心脏彩超提示射血分数上降,考虑“慢性阻塞性肺疾病、肺源性心脏病”。院外未使用平喘药物及吸氧。入院前4+月患者因咳嗽、咳痰、喘累复发在我院心内科住院治疗,给予“头孢呋辛抗感染、痰热清及溴己新祛痰、多索茶碱平喘、甲泼尼龙平喘”等对症处理后好转,因心率快未行冠脉CTA检查,给予出院。院外长期口服“阿司匹林肠溶片(100mg/片)每天1次 每次1片、富马酸比索洛尔片(5mg/片)每天1次 每次半片、辛伐他汀 每晚1次 每次1片、螺内酯(20mg/片) 每日1次 每次1片、呋塞米(20mg/片) 每日1次 每次1片”治疗。入院前10+天患者无明显诱因出现中下腹阵发性隐痛,以上午饥饿后明显,无肩背部放射痛,进食后腹痛可稍缓解。伴偶有嗳气、反酸,伴大便改变,每日3次,起始2次解成形黄色大便,后解黄色糊状大便。无粘液脓血便,无黑便、里急后重、腹胀。在外未予处理。入院前5天患者受凉后出现明显喘累、气促,伴咳嗽,咳白色粘液痰,无胸痛咯血,无心慌胸闷,无恶心呕吐,无呼吸困难。在家口服下述药物后无缓解。今日来院就诊,为进一步治疗门诊以“慢性阻塞性肺疾病、腹痛待查”收入我科。患者自发病以来精神稍差,食欲尚可,睡眠一般,大便3次/日,时干时稀,无粘液脓血便,小便正常。近期体力上降,体重无明显减轻。}
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请你用中文完成中文电子病历命名实体识别任务,下面将给你一个实例,你需要学习实例的标注规则,实体共有“疾病和诊断、手术、药物、解剖部位、实验室检查、影像检查”六类。电子病历的原文本为:{入院前14年患者检查发现血糖升高,血糖具体值不详,有口干、多饮、多尿等症状,伴四肢麻木,并有感觉异常,自觉肢体冰凉,伴视物模糊,于外院诊断为“2型糖尿病 糖尿病周围神经病变 糖尿病眼病”,后长期服用“格列美脲、伏格列波糖、罗格列酮”等降血糖,半年前于我科住院,出院后使用“来得时+阿卡波糖”降糖,但院外患者自行加用“格列美脲”降糖,偶有心慌冒汗症状。1+年前患者因活动后心累心悸,偶有干咳,感肢体麻木冰凉较明显,伴有腰部及上肢疼痛,自觉健忘症状加重,于我院内一科住院,查肾功:尿素 16.00 mmol/L、肌酐 141.7 μmol/l,诊断为“糖尿病肾病、原发性高血压3级极高危 高血压性心脏病”,治疗后好转出院;半年前因腹泻于我科住院,检查肾功:尿素 19.79 mmol/L、肌酐 225.2 μmol/l及其他检查,诊断“1.2型糖尿病 糖尿病周围神经病变 糖尿病眼病 糖尿病肾病 糖尿病植物神经病变 2.原发性高血压3级 很高危 高血压性心脏病 3.重度骨质疏松 4、甲状腺功能减退 5、冠状动脉粥样硬化心脏病”,治疗后好转出院,出院后未定期随访复查,并自行停用相关药物。半月前患者无明显诱因开始出现咳嗽,几乎无痰,伴有咽痒,咳嗽时有溢尿,无畏寒发热,无胸闷胸痛,无腹胀腹痛,无腹泻黑便,无上肢水肿,于我院就诊,遂门诊以\"糖尿病,咳嗽待查\"收入我科住院治疗。患者此次发病以来精神食欲可,长期睡眠差,经常服用“安眠药”,大便正常,诉长期解小便色偏黄,伴有尿灼热尿痛,体重无明显上降}
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请你用中文完成中文电子病历命名实体识别任务,下面将给你一个实例,你需要学习实例的标注规则,实体共有“疾病和诊断、手术、药物、解剖部位、实验室检查、影像检查”六类。电子病历的原文本为:{入院前4年患者院外测血压高,最高达230/?mmHg,院外服用坎地沙坦、氨氯地平、卡维地洛药物控制血压(具体剂量不详),院外自测血压约150-160mmHg,平素未感视物模糊,未感头昏。2天前患者骑车时不慎跌倒,至两膝、两手掌、上巴处擦伤,感头昏痛,遂于我院门诊就诊,查血压170/100mmHg,血脂:甘油三酯 3.72 mmol/l ↑、总胆固醇 6.26 mmol/l ↑、载脂蛋白B 1.48 g/l ↑,血糖(静脉血):葡萄糖 9.27 mmol/l ↑,肝功1:谷丙转氨酶 34.3 U/L、谷草转氨酶 20.9 U/L、谷氨酰转肽酶 112.6 U/L ↑,血常规:白细胞数 4.6×10^9/L、红细胞数 5.24×10^12/L、血红蛋白浓度 160 g/L、血小板数 256×10^9/L、中性粒细胞百分比 57.80 %、淋巴细胞百分比 35.90 %,肾功能未见异常,予以硝苯地平缓释片降压处理后好转。1天前患者感头昏减轻,再次于我院就诊,查糖化血红蛋白:糖化血红蛋白 8.7 %,血糖(静脉血):葡萄糖 13.90 mmol/l,尿微量白蛋白定量:尿微量白蛋白 451 mg/L,尿常规:酮体 -、尿胆原 +、蛋白 +、葡萄糖 +++。无意识障碍大小便失禁,无肢体活动受限,否认多饮多食,否认多尿消瘦,无胸闷胸痛,无腹胀腹痛,无上肢水肿,为进一步治疗,门诊以“高血压、糖尿病”收入我科住院治疗。病程中患者精神、饮食一般,大小便正常,体重无明显上降。}
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请你用中文完成中文电子病历命名实体识别任务,下面将给你一个实例,你需要学习实例的标注规则,实体共有“疾病和诊断、手术、药物、解剖部位、实验室检查、影像检查”六类。电子病历的原文本为:{患者7年前始出现反复咳、喘,平时咳少许白色泡沫痰,平地活动可耐受,爬坡等活动感气促明显。近2年活动后气促明显加重,检查发现左侧颈部豌豆大小包块,无疼痛感,因同期被诊断为“肺结核”故考虑肿块性质为结核,给予HRZ方案抗结核治疗2年后停药。病程中颈部包块无增大及缩小,持续无疼痛,未进一步检查。半年多前患者因活动后气促加重在***二院住院,完善多项影像学检查后诊断为“左侧肺癌”,家属放弃积极治疗,院外对症治疗。出院后左侧颈部包块进行性增大,间断有隐痛不适。近半年多来,反复因咳喘症状加重多次在我科住院治疗,给予抗肿瘤、抗感染、止咳平喘、对症治疗后症状好转出院。入院前3月患者感颜面部浮肿,程度不重,于我科治疗,考虑为下腔静脉栓塞。给予治疗后可消退,但反复出现。入院前1+月,患者再次感颜面部浮肿及咳嗽、咳痰、气促、纳差较前加重于我科住院,给予抗肿瘤、抗感染、对症治疗,症状部分缓解。出院后仍感纳差、活动后气促,可耐受10余米距离行走。入院前12天,患者促、水肿症状加重,就诊我科,诊断“1、左肺周围型肺癌 2、转移性淋巴癌 3、慢性阻塞性肺疾病急性加重 4、矽肺 5、陈旧性肺结核 6、压疮”,给予抗感染、止咳祛痰、止痛治疗后好转出院。入院前2天,患者再次出现喘累、气促加重,伴有两下肢及左上肢明显水肿,腹胀,腹泻,稀水样大便。无明显咳嗽咳痰,今为求诊治,就诊我院我科。本次发病以来患者精神食欲睡眠差,小便量少色黄,腹泻,稀水样大便,约5-6次/天。体重变化不明显。}
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请你用中文完成中文电子病历命名实体识别任务,下面将给你一个实例,你需要学习实例的标注规则,实体共有“疾病和诊断、手术、药物、解剖部位、实验室检查、影像检查”六类。电子病历的原文本为:{患者入院前3+天患者受凉后感咽痛,并咳嗽,痰液较少,偶咳出少许白色粘痰,无痰中带血,并畏寒发热,体温未测,无胸痛,无胸骨后压榨感,无明显心累,无上肢浮肿,入院前1天患者在乘坐公交车时,突发晕倒一次,起病前感头晕,无黑朦,症状持续1分钟右左,无大小便失禁,无抽搐,醒后无遗留言语、肢体功能障碍,今日为求进一步治疗收入我科住院。入院前3+年,患者无明确诱因反复出现胸闷、心累,活动后加重,发作时伴头晕、肢体麻木、视物模糊,2014年4月在我院查心电图提示“心房纤颤”,住院治疗症状好转。后就诊于“**医院”,冠脉造影检查提示“四支血管病变”,最严重者狭窄85%(具体不详),于**医院行“冠脉搭桥手术及射频消融术”,术后常感伤口疼痛,胸闷、心累好转。院外长期遵瞩服用“阿司匹林肠溶片、氯吡格雷、瑞舒伐他汀、美托洛尔缓释片”,日常平地活动耐受较好,爬楼约4层感胸闷、气短明显,需休息缓解,否认肢体水肿、黑朦、晕厥史。近1月来患者无明显诱因活动后心累气促较前加重,在我院就诊,动态心电图示:偶发房性早搏,室性早搏(两源),加速的室性逸搏,ST-T未见明显改变。胸片:1.两上肺纹理增多,建议结合临床。2.右侧胸膜增厚或右侧胸腔少量积液。3.胸骨区域多个环状金属密度影,考虑术后改变。心脏彩超:右房增大;主动脉窦部增宽;室间隔动度降低;二尖瓣、三尖瓣轻度反流;肺动脉瓣局限性反流;提示右室舒张功能减退。本次发病以来患者精神食欲尚可,大小便如常,睡眠较差,体重无明显上降。}
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请你用中文完成中文电子病历命名实体识别任务,下面将给你一个实例,你需要学习实例的标注规则,实体共有“疾病和诊断、手术、药物、解剖部位、实验室检查、影像检查”六类。电子病历的原文本为:{1年前,患者不明原因出现记忆力减退,主要表现为近事记忆减退明显,远期记忆正常,当时未引起重视,未予以治疗。并进行性加重,半月前出现性格改变,暴躁、易怒,无幻觉、被害妄想;日常基本生活不能自理,且对自己熟悉的家人不认识,不知道何处下厕所;曾到*********神经内科门诊就诊,行头颅CT检查后诊断“老年痴呆”,具体服药情况不详。在回家服药治疗观察过程中出现2次跌倒,无发作先兆,无明显的头昏、视物旋转、恶心、呕吐,无肢体活动障碍及抽搐,无大小便失禁及意识障碍。家属自觉患者病情重,再次到*********就诊,并住入神经内科,住院过程中出现左侧肢体活动障碍,不能行走,进食出现吞咽困难,饮水呛咳,行头颅CT及MRI检查,诊断“急性脑梗死”,予以“阿司匹林”抗血小板聚集、“阿托伐他汀”调脂,“依达拉奉”抗自由基氧化等对症治疗。由于患者不能进食,予以胃管鼻饲,但胃管内抽出暗红色胃液,考虑“消化道出血”,予以“奥美拉唑、凝血酶粉”等对治疗。3天前,患者出现咳嗽、咯痰,咯黄色粘稠痰,且发热,体温38.1℃,并出现意识加深,呼之不应,行血气分析提示呼吸衰竭,转入重症监护室进一步治疗,予以气管插管,呼吸机辅助呼吸,并予以“莫西沙星”抗感染、营养支持治疗。患者病情重,家属要求转入我院进一步治疗,遂由我院120转入,门诊以“急性脑梗死、急性呼吸衰竭、肺部感染、消化道出血”收住我科。患者患病以来,精神差,一直胃管进食流质,小便正常,大便未解。}
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请你用中文完成中文电子病历命名实体识别任务,下面将给你一个实例,你需要学习实例的标注规则,实体共有“疾病和诊断、手术、药物、解剖部位、实验室检查、影像检查”六类。电子病历的原文本为:{入院前9月患者无明显诱因出现腹胀,无腹痛、腹泻、黑便,无纳差、厌油,无恶心、呕吐,无反酸、嗳气、烧心。在**医院就诊,完善相关检查后诊断“乙肝后肝硬化失代偿期”,给予“保肝、放腹水、抗病毒”等对症处理后好转。入院前2月因中下腹隐痛及腹胀在我院内四科住院,行“胃镜示:慢性非萎缩性胃炎,轻度食管静脉曲张可能。乙肝三对:乙肝表面抗原定性 阳性,乙肝核心抗体定性 阳性。乙肝DNA<5E+02,腹部彩超:肝实质回声异常,符合肝硬化超声表现,胆囊壁增厚毛糙,脾大;”,诊断“肝硬化失代偿期”,给予“泮托拉唑抑酸、还原型谷胱甘肽及甘利欣、门冬氨酸鸟氨酸保肝、保护胃黏膜、改善腹胀等对症处理”后好转出院。院外口服“恩替卡韦片”抗病毒治疗。病程中未出现黑便、呕血、黄疸等。于2014-12-02在**医院复诊肝硬化,查“肾功、血脂、电解质、AFP无明显异常。血常规:WBC:3.59*10^9/L,HB:138g/L。肝功:ALT:44IU/L,GGT:134IU/L。ALB:42.9g/L。”。入院前4小时患者劳动时突然出现肝区持续性胀痛,伴阵发性加重,感左侧背部放射痛,无肩膀放射痛,与饮食及体位无关。无畏寒、发热,无嗳气、反酸、烧心,无纳差、乏力。遂来我院就诊,门诊查腹部彩超示“肝硬化,胆囊壁毛糙增厚,脾大,胰腺未见异常。”,为进一步诊治,门诊以“肝硬化失代偿期”收入我科。病程中精神、饮食尚可,大小便正常。体重无明显上降。}
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请你用中文完成中文电子病历命名实体识别任务,下面将给你一个实例,你需要学习实例的标注规则,实体共有“疾病和诊断、手术、药物、解剖部位、实验室检查、影像检查”六类。电子病历的原文本为:{患者入院前4年活动后感心累、气促,不伴明显胸痛,无胸骨后压榨感,无慢性咳嗽咳痰,经******转诊至*****就诊,具体检查及治疗情况不详,自诉诊断“冠心病、房颤、高血压”,经治疗后症状缓解出院。出院当时服药情况不详,否认服用“华法林”,有服用“阿司匹林肠溶片”病史,近期服用“地高辛、依那普利”,但患者依从性差,常有自行停药情况。入院前4天患者受凉后感心累加重,平路缓步走即感心累,夜间不能平卧,需高枕卧位,并心前区闷胀感,食欲不振,无饥饿感,伴咳嗽,咯白色粘痰,无痰中带血,无畏寒发热,无潮热盗汗,无胸痛,无胸骨后压榨感,无明显上肢浮肿,今日来院就诊,门诊查心电图提示快速型房颤。胸片提示1.两上肺肺纹增多、2.主动脉硬化,心脏重度增大,结合临床、3.两侧肋膈角欠锐利。血常规:白细胞数 6.8 10^9/L、中性粒细胞百分比 78.34 %,心肌酶谱:谷草转氨酶 44.8 U/L、肌酸激酶 198.7 U/L、肌酸激酶同工酶 14 U/L、乳酸脱氢酶 241.6 U/L,肾功:尿素 4.48 mmol/L、肌酐 43.0 μmol/l,高敏肌钙蛋白T 11.93 pg/ml,电解质1:钾 3.77 mmol/l,D_2聚体 0.54 μg/ml。门诊予以静推“胺碘酮 150mg”,静滴“丹参川芎嗪5ml”,为进一步治疗收入我科住院。病程中患者精神、饮食一般,大小便正常,体重无明显上降。}
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请你用中文完成中文电子病历命名实体识别任务,下面将给你一个实例,你需要学习实例的标注规则,实体共有“疾病和诊断、手术、药物、解剖部位、实验室检查、影像检查”六类。电子病历的原文本为:{入院前1+月,患者无明显诱因出现吞咽梗阻,进食固体食物时明显,偶有恶心,呕吐少许白色粘液,不呈喷射状,不含隔夜宿食,无咖啡色物质及血凝块,偶有下腹部隐痛,伴腹胀,伴反酸,伴纳差,饮食较前减少1/2,以流质为主,无烧心、嗳气,无呕血、黑便,无黄疸,无腹泻,无乏力、心悸、头晕、头痛,无胸闷、胸痛、呼吸困难,无畏寒、发热等不适,于1月前就诊于我院,完善腹部彩超提示“两肾结石”,予以口服PPT及曲美布汀治疗,患者症状无明显好转。半月前再次就诊于我院,完善碳14呼气试验阳性,予以“维三联+PPI”抗HP治疗2周,今日于我院完善胃镜检查提示“胃底、胃体巨大溃疡伴出血可能,考虑胃癌可能”(未见报告),为求进一步诊治,遂以“吞咽哽噎原因待查”收入住院。患者此次患病以来精神食欲差,大小便正常,睡眠尚可,体力明显上降,体重无明显改变。入院前10年,患者常在受凉后出现咳嗽、咳痰,并逐渐出现喘累气促,好发于冬春季节,每年累计发病时间超过3月,常就诊于******医院及我院,诊断为“慢支炎、支气管哮喘”,予以抗感染、止咳平喘等治疗后可好转。院外长期服用氨茶碱等药物治疗。半月前,患者于我院行肺功能提示“重度混合性通气功能障碍以阻塞为主(FEV1/FVC 38.28%),舒张试验阳性”。近期患者受凉后感活动后喘累、气促较前加重,有咳嗽,咳白色黏痰,痰不易咯出,无畏寒、寒战、发热,无咯血、胸痛、呼吸困难等不适。}
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请你用中文完成中文电子病历命名实体识别任务,下面将给你一个实例,你需要学习实例的标注规则,实体共有“疾病和诊断、手术、药物、解剖部位、实验室检查、影像检查”六类。电子病历的原文本为:{入院前2天,患者无明显诱因出现纳差、失语,伴发热、流涕,但未测体温,偶有咳痰,无畏寒、寒战,无头昏、头痛,无胸闷、胸痛,无恶心、呕吐,无腹胀、腹痛,无喘累、气促,无端坐呼吸、阵发性呼吸困难,无咯血、黑朦、晕厥,无肢体瘫痪、意识障碍、大小便失禁等。今日未进食,精神较差,故家属送入******,查“血常规示WBC 11.58×10e9/L,RBC 5.30×10e12/L,HGB 144g/L,N 71.1%,L 26.5%。心电图示室下性心动过速”,故转入我院急救部治疗,送入急诊科行床旁心电图示室下性心动过速,心率213次/分,T 37.9℃,立即予以吸氧、心电监护、NS 16ml+维拉帕米10mg缓慢静推,静推约8mg后心律恢复为窦性,心率降至94次/分,同时完善心肌酶谱:谷草转氨酶 17.2 U/L、肌酸激酶 41.5 U/L、肌酸激酶同工酶 8 U/L、乳酸脱氢酶 245.7 U/L ↑,肾功:尿素 8.28 mmol/L ↑、肌酐 66.2 μmol/l、尿酸 251.6 μmol/l,高敏肌钙蛋白:40.75 pg/ml ↑,电解质:钾 3.39 mmol/l ↓、钠 145.2 mmol/l、氯 107.6 mmol/l,凝血功能大致正常。为进一步治疗以“心律失常”收入我科住院。患者自发病以来精神、食欲差,大便干燥,小便未诉异常。近期体重无明显减轻。}
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请你用中文完成中文电子病历命名实体识别任务,下面将给你一个实例,你需要学习实例的标注规则,实体共有“疾病和诊断、手术、药物、解剖部位、实验室检查、影像检查”六类。电子病历的原文本为:{患者于入院前1年余即开始反复出现胸痛症状,心前区压榨感,均在活动及进食后出现,不能耐受平地快走,发作后含服“速效救心丸”或休息后可逐渐缓解。病程中曾多次出现突发呼吸困难、大汗、濒死感,在****医院等住院治疗好转。9月前,患者进餐后再次突然出现呼吸困难,全身大汗、胸痛,诊断为心力衰竭,于我科住院,给予扩管、抗血小板、降压、控制心室率治疗后好转出院。入院前1天,患者感气促加重,有夜间阵发性呼吸困难,如厕即可诱发喘累,伴有咳嗽、咳痰、中下腹疼痛。无心前区压榨感,无恶心、呕吐,无发热、畏寒,肛门有排气排便。家属拨打120由*****医院120送入我院急诊科,查血气分析PH7.43,PO2 104mmHg,PCO2 35mmHg。血常规:白细胞数 6.2×10^9/L、中性粒细胞百分比 78.51 %,心肌酶谱:谷草转氨酶 38.0 U/L、肌酸激酶同工酶 10 U/L、乳酸脱氢酶 279.5 U/L,肾功:肌酐 115.1 μmol/l,高敏肌钙蛋白:264.30 pg/ml。电解质、CRP无异常。胸片提示两肺中上野感染,以左上肺明显。腹部彩超提示胆总管增宽。给予呋塞米20mg静推利尿、单硝酸异山梨酯25mg静滴后患者症状有所缓解。为进一步治疗收治我科。患者此次患病以来精神食欲睡眠差,大便正常,小便量偏少,体力明显上降,体重无明显改变。}
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请你用中文完成中文电子病历命名实体识别任务,下面将给你一个实例,你需要学习实例的标注规则,实体共有“疾病和诊断、手术、药物、解剖部位、实验室检查、影像检查”六类。电子病历的原文本为:{入院前9月患者无明显诱因出现腹胀,无腹痛、腹泻、黑便,无纳差、厌油,无恶心、呕吐,无反酸、嗳气、烧心。在**医院就诊,完善相关检查后诊断“乙肝后肝硬化失代偿期”,给予“保肝、放腹水、抗病毒”等对症处理后好转。入院前2月因中下腹隐痛及腹胀在我院内四科住院,行胃镜示:慢性非萎缩性胃炎,轻度食管静脉曲张可能。乙肝三对:乙肝表面抗原定性 阳性,乙肝核心抗体定性 阳性。乙肝DNA<5E+02,腹部彩超:肝实质回声异常,符合肝硬化超声表现,胆囊壁增厚毛糙,脾大。诊断“肝硬化失代偿期”,给予“泮托拉唑抑酸、还原型谷胱甘肽及甘利欣、门冬氨酸鸟氨酸保肝、保护胃黏膜、改善腹胀等对症处理”后好转出院。院外口服“恩替卡韦片”抗病毒治疗。病程中未出现黑便、呕血、黄疸等。于2014-12-02在**医院复诊,查“肾功、血脂、电解质、AFP无明显异常。血常规:WBC:3.59*10^9/L,HB:138g/L。肝功:ALT:44 IU/L,GGT:134 IU/L。ALB:42.9g/L。”。2天前劳动时出现肝区持续性胀痛,在我院治疗好转后出院,半天前患者再次出现肝区胀痛,无阵发性加重,无放射痛,与饮食及体位无关。无嗳气、反酸、烧心,无纳差、乏力,无皮肤黄染。为进一步诊治,门诊以“肝硬化失代偿期”收入我科。病程中精神、饮食尚可,大小便正常。体重无明显上降。}
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请你用中文完成中文电子病历命名实体识别任务,下面将给你一个实例,你需要学习实例的标注规则,实体共有“疾病和诊断、手术、药物、解剖部位、实验室检查、影像检查”六类。电子病历的原文本为:{入院前7年无明显诱因患者感活动后乏力、气促,不伴头昏、头痛、胸闷、心悸、胸痛、晕厥、黑曚、呃逆、反酸、嗳气、烧心、恶心、呕吐、腹痛、腹胀、腹泻、黑便。患者于*****医院诊断“溶血性贫血”,给予输血等处理后病情缓解。病程中如下症状反复发生,多次给予输血治疗后病程好转。2013年4月*****胸片检查:两肺纹理增多,心影轻度增大。心脏彩超:右房、右室稍增大,EF正常。血库:间接Coomb’s试验(+)P,阳性对照(+++),P。骨髓象:增生性骨髓象,红系增生旺盛。2014-4-24(******医院)分钟遗传学检验报告单:未检测到送检样本中G6PD基因G1388A,G1376T,A95G三个常见突变位点,结合临床;新生儿疾病筛查报告单:新生儿G6PD活性试验1.56(正常)。肝功:总胆红素 50umol/L,直接胆红素 10umol/L,ALT 40U/L,AST 18U/L。诊断“G-6-PD酶缺乏症,贫血性心脏病,肝功能不全”明确。经输洗涤红细胞后病情好转。出院后患者反复出现乏力、气促不适,反复经输注洗涤红细胞后缓解。7天前可疑受凉后出现血尿,患者未予处理。今再次出现四肢乏力,活动后气促伴耳鸣。为求进一步治疗今日入我院门诊,门诊以“G-6-PD酶缺乏症”收入我科。患者此次患病以来,精神状态差,大小便正常,体重无明显减轻。}
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请你用中文完成中文电子病历命名实体识别任务,下面将给你一个实例,你需要学习实例的标注规则,实体共有“疾病和诊断、手术、药物、解剖部位、实验室检查、影像检查”六类。电子病历的原文本为:{患者于入院前40+年,常于受凉后出现咳嗽、咳痰,痰呈白色泡沫痰,下述症状反复发作,多在冬春季节反复发作,常予以抗炎止咳等药物治疗后可缓解。病程中患者逐渐出现喘累气促,活动耐力上降,曾在我院行胸部CT提示肺气肿、肺大泡形成,多次在我院住院治疗,经抗感染等治疗后好转。病程中曾出现上肢浮肿、气促,考虑肺源性心脏病。入院前半年,患者因下诉症状再发于我科住院,行心脏彩超示EF 25%,室间隔、右室后壁增厚;室间隔、右室后壁动度降低;二尖瓣、三尖瓣中度反流;右室舒张、收缩功能减退。考虑“慢性阻塞性肺疾病、肺源性心脏病、冠心病?”,予以抗感染、祛痰、利尿等治疗后好转,建议患者进一步完善冠脉造影,但患者未遵医嘱。患者曾于2017年5月2日在我院行胸部CT提示:1.两肺上叶感染,治疗后复查。2.慢支炎、肺气肿,肺大泡形成。3.两下肺纤维斑块病灶;左肺下叶及右肺上叶支气管局段性扩张。4.左侧肺门及心后软组织块影,建议患者定期复查,患者此后未再复查。入院前2天患者受凉感冒,自觉咳嗽,咯黄痰,并觉畏寒发热,喘累症状加重,无胸痛咯血,无心慌胸闷,无恶心呕吐,无腹痛纳差,无呼吸困难。今日来院就诊,为进一步治疗今日到我科住院。患者自发病以来精神、食欲可,进食好,睡眠一般,大便4-5次/日,时干时稀,无粘液脓血便,小便正常。近期体力上降,体重无明显减轻。}
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请你用中文完成中文电子病历命名实体识别任务,下面将给你一个实例,你需要学习实例的标注规则,实体共有“疾病和诊断、手术、药物、解剖部位、实验室检查、影像检查”六类。电子病历的原文本为:{入院前30+年,患者常在受凉后出现咳嗽、咳痰,多为白色泡沫痰,并逐渐出现喘累、气促,好发于冬春季节,每年累计发病时间超过3月,外院诊断为“慢支炎、肺气肿”,予以抗感染、止咳平喘等治疗后可好转。患者喘累、气促症状逐年加重,并逐渐出现间断两上肢水肿,外院考虑为“肺源性心脏病”,未利尿、长期低流量吸氧及吸入剂治疗。7+年前,患者喘累、呼吸困难明显,于外院诊断为“支气管哮喘”(具体检查报告及诊治经过不详),开始使用沙丁胺醇气雾剂治疗。后患者下述症状反复发作,反复住院治疗,最近一次于2017-10-29于我科住院治疗,给予抗感染、化痰、平喘、改善循环等治疗后好转出院,出院诊断为:1.慢性阻塞性肺疾病急性加重期;2、慢性肺源性心脏病;3、支气管哮喘 ;4、冠心病 频发多源性房早,频发室早?院外长期平喘化痰对症治疗。入院前2天前,患者受凉后下述症状较前加重,咳嗽、咳黄白色粘痰,喘累明显,不能平卧位休息,夜间阵发性呼吸困难,伴有头昏,偶有头疼,无畏寒、寒战、发热,无咯血,无潮热、盗汗,无恶心、呕吐,无腹胀、腹痛,无胸闷、胸痛,无尿频、尿急、尿痛等不适,自行服用“平喘药”(具体不详),下述症状无明显好转,遂来我院就诊,门诊以“AECOPD”收入我科进一步治疗。患者此次患病以来精神、食欲、睡眠差,大小便正常,体力明显上降,体重无明显改变。}
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请你用中文完成中文电子病历命名实体识别任务,下面将给你一个实例,你需要学习实例的标注规则,实体共有“疾病和诊断、手术、药物、解剖部位、实验室检查、影像检查”六类。电子病历的原文本为:{入院前10余年,患者无明显诱因出现活动后心累、气促,间断出现两上肢水肿、夜间喜高枕卧位,偶有胸闷,于当地医院就诊,考虑为“冠心病”。5年前因“心累、气促”加重,于“**医院”就诊,查“心率30次/分”右左,给予安置“起搏器”,后喘累症状稍所好转,平素缓慢走平路即感气促,无明显胸闷、胸痛等不适。院外长期口服心脏疾病相关药物(具体不详)治疗。近1年来,患者反复因喘累、气促在我院住院治疗,予以改善循环、利尿、营养心肌等对症治疗后好转出院。入院前10+天,患者受凉后诉心累、气促症状加重,夜间明显,夜间高枕卧位,难以平卧,伴心悸、胸闷,伴中下腹部不适,伴咳嗽、咳痰,咳出白色粘痰,否认胸痛、心前区压榨感,无恶心、呕吐,无咯血、腹泻等,遂就诊于我院急诊科,查血常规:WBC 3.9×109/L,HGB 117g/l、N 66.2%。凝血试验、D2聚体、肾功、电解质、心肌酶谱、肌钙蛋白均未见明显异常。腹部彩超示肝胆胰脾肾未见明显异常。胸片示1.两肺中上野感染,建议治疗后复查。2.心影稍增大,主动脉弓少许钙化;心脏人工起搏器术后改变,结合临床。3.胸椎骨质增生。予以平喘、改善循环后症状稍有改善,为进一步治疗,门诊以“高血压、肺部感染”收入我科住院治疗。患者此次患病以来精神食欲欠佳,大小便未诉异常,睡眠尚可,体力明显上降,体重无明显改变。}
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请你用中文完成中文电子病历命名实体识别任务,下面将给你一个实例,你需要学习实例的标注规则,实体共有“疾病和诊断、手术、药物、解剖部位、实验室检查、影像检查”六类。电子病历的原文本为:{患者4月前发现皮肤、巩膜黄染,伴食欲上降,晚餐后明显,时有阵发性腹痛、恶心,无腹泻、呕吐,时有胸闷、憋气、头晕,无头痛,无视物旋转,无发热、咳嗽,无胸痛、喘憋,大便颜色较前变浅。于我科住院,行腹部增强MRI+MRCP:胆总管末端占位,胆管癌可能性大,右肾下腺结节,考虑腺瘤,右肾囊肿,两侧胸腔积液。请肝胆外科会诊,认为患者无手术指征,于2017-4-24全麻上行ERCP+胆总管金属支架植入,术后患者恢复良好。并给以抗感染、抗肿瘤、免疫调节、平稳降糖、降压等对症治疗,全身及巩膜黄染逐渐减轻,化验指标逐渐改善,办理周转后继续于我科巩固治疗,黄疸逐渐消失,症状改善,请肿瘤科会诊,认为胆总管癌并两肺转移,患者高龄,多种慢性疾病,不宜放化疗,对症支持治疗为主,向患者家属详细说明病情,家属亦不同意放化疗。因患者住院时间较长再次办理**,继续于我科住院巩固治疗。门诊以“胆管癌”收入我科。 患者自发病以来,饮食差,睡眠可,小便正常,大便便秘,口服杜密克及外用开塞露治疗,平均每3天大便一次,大便干结,体重无明显变化。}