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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:{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:{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:{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。} |