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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,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。,患者3月余前于我院诊断为“直肠癌”,于2015-10-26在全麻上行腹腔镜直肠癌根治术,,术后病理示:,201518502:(直肠)腺癌(中度分化),浸润溃疡型,体积2.7*2*0.8CM,侵达浆膜。 双端切线及另送“近切线”、“远切线”未查见癌。 肠壁一站(6个)、中间组(3个)、中央组(3个)淋巴结未查见癌。低级别腺管状腺瘤。,免疫组化染色示:TS部分(+)、SYN(-)。,术后病理分期:PT3N0M0,II期,DUKES B。依情2015-11-08.2015-12-09给予奥沙利铂200MG D1+亚叶酸钙0.3G D2-6 +替加氟1G D2-6 静滴,同时辅以镇吐、升血、免疫调节等对症支持治疗。化疗过程总体顺利。现为复查化疗来我院,门诊以“直肠癌术后”收入院。目前患者精神好,食欲及饮食好,夜间睡眠良好,小便正常,大便4-5次/天,基本成形。否认近期明显体重变化。 | |
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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,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。,入院前1月余因“进行性吞咽困难1年”就诊我院,,查胃镜示:,食管占位伴狭窄:癌不能排除,,活检病理示:“鳞状下皮呈乳头状增生,部分鳞状下皮呈低级别下皮内瘤变”,完善颈胸腹部,CT:食管下段部分管壁不规则增厚,考虑为食管癌,伴右侧锁骨下窝、食管旁沟及纵膈内多发淋巴结转移;另病变下缘一食管憩室。考虑食管癌伴纵隔淋巴结转移,为提高手术切除率,建议行术前新辅助化疗,告知患者家属,其表示理解,遂于2016.12.26、2017.01.16按氟尿嘧啶3000MG微量泵泵入+洛铂50MGIVGTTD2+多西他赛(泰索帝)120MGIVGTTD2”第1、2周期化疗,辅以保肝、止吐、制酸、营养支持等治疗,疗程较为顺利,未见明显化疗副反应。现为求进一步治疗,遂再次就诊我科,门诊拟“食管癌术前化疗”收住院。末次出院以来,精神、睡眠一般,大小便如常,体重无明显增减。 | |
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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,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。,者约于1个月前因“结肠恶性肿瘤”于2013-04-28日在全麻上行左半结肠切除术。手术过程顺利,术后给予抗感染及营养支持治疗,患者恢复好。,术后病理:4976.2013 结肠腺癌(中低分化),浸润溃疡型,面积5.5*5.5CM,局部粘液腺癌图像,侵达浆膜脂肪组织。双端切线未查见癌,呈肠壁一站(2/8个)淋巴癌转移。肠壁二站(2个)、中间组(4个)淋巴结未查见癌。,免疫组化染色示癌组织:ERCC1(+),TS(-)。术后分期 PT4N1M0 III期,术后给予化疗治疗,,方案为:奥沙利铂200MG D1+右亚叶酸钙50 MGD2-6 +氟尿苷1000MG D2-6 静滴。 院外期间,患者无发热,无腹痛腹胀不适,大便通畅。现患者为行复查化疗来我科就诊,以“结肠癌术后”收入院。 病人自下次出院以来,神志清,精神可,饮食可,大、小便正常,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,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。,患者2015-09-15因“腹痛伴大便性状习惯改变1月”就诊于我院结直肠科,外院肠镜检查提示结肠肝曲环周肿物,肠镜不能通过,活检病理提示腺癌,遂2015-09-18行全麻上“左半结肠切除术”,过程顺利,,术后病理示:镜检为中分化腺癌,癌组织浸润至肠壁浆膜上层;未见明确脉管内癌栓及神经束侵犯;各切缘未见癌;淋巴结2/10见腺癌转移,,免疫组化:ER(-),ERCC1(+),MSH2(+),MSH6(+),MLH1(+),PMS2(+),KI67(40%+),,分期为:PT3N1BM0IIIB期,术后恢复可。2015-10-15于我科行第1程XELOX方案术后辅助化疗,过程顺利,现患者为行进一步治疗入我科。患者3周来,无发热,胃纳可,睡眠一般,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,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。,患者2010年8月无明显诱因上出现下腹部疼痛,呈阵发性,隐痛,不剧烈,不伴恶心、呕吐、腹泻、便血、黑便、呕血等,外院查肠镜检查,未见明显异常,于2011年3月8日外院胃镜示胃体肿瘤?胃窦多发息肉(I型),,我院会诊病理示:(胃底)粘膜固有层内见异型细胞,部分呈印戒细胞样,肿瘤性病变不能除外,免疫组化考虑非霍奇金淋巴瘤,,弥漫大B细胞型:CK广(-)、CK8(-)、LCA(+++)、CD79A(+++100%)、CD20(+++100%)、CD3(少数小淋巴细胞+)、CD10(部分+)、BCL-2(+)、MUC-1(部分+)、KI-67(++90%)、CD30(++)、CD15(-)、CD56(-)、GRANB(-)。,外院腹部B超:脾稍大、肝胆囊胰体肾未见明显异常、腹腔未见明显积液。2011年3月21,外院行腹部CT示:下腹部CT增强未见明显异常。遂于2011/3/25收入我科。,入院后血常规:,红细胞计数: 4.65X10^12/L;,血红蛋白: 132G/L;,血小板计数: 168X10^9/L;,白细胞计数: 4.53X10^9/L;,中性粒细胞百分比: 66.7%;,淋巴细胞百分比: 22.7%;PET/,CT:淋巴瘤病例;胃体、胃窦局部胃壁增厚伴糖代谢异常增高,符合淋巴瘤图像表现。,骨髓穿刺涂片:骨髓增生欠活跃,髓象中红系增生尚可,粒、巨二系增生欠活跃,形态、比例均无明显异常。,骨髓活检:(骨髓)镜上为骨髓滴,免疫组化结果示,造血组织三系细胞均可见到,各系细胞形态未见明显异常,未见到淋巴瘤累及骨髓证据,请结合临床。免疫组化(11-N1436),:MPO(粒系+) CD61(巨核+) CD68(组织细胞+) CD34(-) CD20(少数淋巴+) CD79A(少数淋巴+) CD3(少数淋巴+) CD56(-) KI-67(50%+) CYCLIND1(-) VS38C(少数+) BCL-2(少数淋巴+) CD10(-) TDT(-) 网染示网状纤维不增生。患者于2011-3-29/2011-4-29行R-CHOP方案化疗(美罗华 0.6 D0+CTX1.2 D1+盖诺40MG D1+EADM120MG D1+DEX15MG D1-D5),化疗过程中无明显不适。,患者出院后随访血常规:5/11,红细胞计数: 4.02X10^12/L;,血红蛋白:112G/L;,血小板计数:140X10^9/L;,白细胞计数:1.2X10^9/L;,中性粒细胞百分比:24.0%;,淋巴细胞百分比: 0.7%;5-18,随访血常规: 红细胞计数 4.57X10^12/L;,血红蛋白:125G/L;,血小板计数:292X10^9/L;,白细胞计数:6.3X10^9/L;,中性粒细胞百分比:83.9%;,淋巴细胞百分比: 14.6%。患者出院后无明显不适,现为行第3次化疗收入病房。患者发病以来,神清,精神可,胃纳可,二便可,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,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。,缘于入院前1年余患者因“体检发现“血PSA”升高1个月”为主诉入院,,入院后查免疫:T--PSA5.05NG/ML、F--PSA0.463NG/ML、F/T9.2。行“B超引导上经直肠前列腺穿刺活检”,恢复好,病理报告(201231203),:1.(右外侧中部),:前列腺癌GLEANSON分级III级(评分2+3=5分)。,免疫组化染色:灶性CK(H)、P63示腺体基底细胞消失,P504S腺体阳性。2.(右、左外侧基底部)、(左外侧中部)、(右、左外侧尖部),:前列腺增生症,伴PINI级。,免疫组化染色:CK(H)(基底细胞+),P63(基底细胞+),P504S(-)。,全身骨ECT示:未见明显异常。当时予拟手术治疗,因患者暂不想手术并要求出院,故未经手术治疗,予口服‘氟他安’治疗,并嘱其出院后定期复查。1年患者定期复查PSA均无异常。今为进一步诊疗求诊我院。门诊拟“前列腺癌”收入院。患者自发病来体重无明显变化,体力情况良好,小便如前所述,大便正常,睡眠良好,食欲一般,精神状态一般。 | |
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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,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。入院前2+月,因诊断结肠肿瘤于我科住院治疗,于2015年09月24日在全麻上行腹腔镜上腹腔探查术、中转开腹,右半结肠癌根治术、小肠系膜结节活检、开腹肿瘤特殊治疗、肠粘连松解术。术后病检示(病理号1508031):右半结肠粘液性腺癌(中分化),侵及浆膜层外脂肪组织、肠系膜及网膜癌转移、肠系膜淋巴结未见癌转移(0/14),两侧切缘未见癌累及。术后予以止血、镇痛、补液、抑酸、雾化祛痰、抗感染等对症治疗。目前患者无恶心、呕吐、腹痛、腹胀、便血等表现,今日前来我院,拟行第2次化疗,故以\"右半结肠癌术后 第2次化疗\"收入我科住院治疗。 近期患者精神、食欲、睡眠可,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,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。,2016.2.17行“胃癌切除术”,具体术式不详,术后病理示(远端胃及大网膜),切除:溃疡型低分化腺癌,伴印戒细胞癌,LAUREN,分型:弥漫型;癌侵及浆膜;可见脉管癌栓及神经侵犯(免疫组化CD34、D2-40证实);十二指肠残端及胃残端未见癌;网膜组织未见癌;淋巴结可见癌转移(第1组6/12,第3组1/1,第4SB组0/0,第4D组0/1,第5组1/1,第6组6/8,第7组1/1,第8组1/3,第9组0/3,第11P组0/0,第12A组0/0,第14V组1/1);(第1组淋巴结)其中一枚淋巴结内见异位胰腺组织;- ,肿瘤病理分期:PT4AN3B。,免疫组化结果显示肿瘤:AFP(-),CMET(1+),EBER(-),EGFR(2+),HER2(0),KI-67(+25~50%),MLH1(+>75%),MSH2(+>75%),MSH6(+>75%),PDL-1(-),PMS2(+>75%),SALL4(-),CK(+)。,淋巴结转移癌:CK(+)。入组RESOLVE A组 已行XELOX方案化疗3周期,末次化疗2016.04.11,化疗后出现恶心2度,影响进食,目前患者大小便基本正常,化疗后体重上降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,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。,患者5年余前因\"升结肠癌\"在外院手术治疗,术后规律完成辅助化疗(XELOX方案化疗8程),但未规律复查。近1年偶有大便带血,量少,大便不成形,1-3次/天,无腹痛、腹胀,无黑便、恶心等,未予重视。于2015-01月至外院复查肠镜发现距肛40CM结肠肿物,肠镜不能通过,活检病理提示腺癌。 于2015-01-22至我院全麻上行\"右半结肠切除术\",,术后病理示:(乙状结肠大体)镜检为肠低分化腺癌(印戒细胞癌),浸润至肠壁浆膜上层,未见脉管内癌栓及神经束侵犯;网膜组织未见癌。区域淋巴结15/22(+),,免疫组化:ER(-),ERCC1(+),MLH1(+),MSH2(-),MSH6(-),PMS2(+),KI67(40%+),CK(+)。,术后分期:PT3N2BM0 IIIC期。于2015-03-25、2015-04-11、2015-04-28、2015-05-12及2015-05-26;2015-6-9、2015-06-23给予 FOLFOX 方案化疗7程顺利,化疗耐受性可,今为进一步治疗入院。近期患者精神胃纳睡眠尚可,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,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。,患者5月余前因“发作性胸闷、憋气半年余,加重1月余”入院,,行肠镜检查提示:结肠癌、结肠多发息肉。查无手术禁忌后于2016-11-03日在全身麻醉上行左半结肠切除术。,术后病理示:结肠腺癌(中-低度分化),浸润溃疡型,体积7.5*4*1.7CM,侵穿浆膜,未累及底部切除面及双端切线。 “一站”(7个)、“二站”(5个)、“三站”(12个)淋巴结未查见癌。慢性阑尾炎,外膜有较多中性粒细胞浸润。,癌组织免疫组化染色示:SYN(-)、BRAF(-)、MLH1(+)、MSH2(+)、MSH6(+)、PMS2(±)。院外期间患者一般情况好,无恶心,无腹痛腹胀胀不适,现患者为行复查及化疗来院就诊,门诊以“结肠癌术后”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,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。,患者2016年2月因“反复下腹痛4月余。”入院,入院完善辅助检查,,明确诊断:胃癌。后于2016-02-17在OR于全麻上行“腹腔镜辅助胃癌根治术(远端胃切除+B-II重建+空肠空肠Braun吻合)”,术后予以预防感染,对症支持治疗,恢复顺利,,术后病理回报:(胃大体)镜检为中-低分化腺癌,部分为印戒细胞癌,LAUREN,分型:混合型,癌组织浸润至胃壁浆膜上层,可见脉管内癌栓及神经束侵犯。切缘未见癌。淋巴结)2/46见腺癌转移。,免疫组化:CK(+),VEGF(+),HER-2(-)。,原位杂交:EBERS(-)。 术后于2016-03-21、2016-04-11、2016-05-03、2016-05-23、2016-06-13、2016-07-05在我院行(奥沙利铂 150MG Q3W IVDRIP D1 + 替吉奥 60MG BID PO D1-14)化疗6疗程,过程顺利。现为行术后第7疗程化疗返院治疗。自下次出院以来,患者体重无明显变化。 | |
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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,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。患者因“下腹部疼痛不适,以进食后尤甚,伴返酸、嗳气”,在我院确诊胃癌,遂于2015.3.13在我院手术室全麻上行\"胃癌根治术(远端胃大部切除+ROUX-EN-Y重建)\",术程顺利,术后恢复可。术后病理提示:T3N3M0,IIIB。 已于2015.4.3、2015.4.22、2015-05-14、2015-6-4,2015-6-26行5程化疗,方案为奥沙利铂+替吉奥,化疗期间无明显副反应,现复查血常规、肝肾功能结果基本正常。现为行上一程化疗收入我科。起病以来,患者精神尚可,食欲一般,大小便正常,身体无明显消瘦。 | |
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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,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。,患者2015年9月9日于全麻上经腹腔镜直肠癌DIXON术,,术后病理:直肠癌(浆膜上层),扁平隆起型,高分化腺癌,I级,断端无癌,淋巴结可见癌转移(5/13枚),,浸润深度:浆膜上层,周围神经节侵犯(+),脉管癌栓(-),结外肿瘤种植(-),PTNM,分期:T3N2AM0,IIIB期,,免疫组化:KI67(50-70%+),P53(>90%+),CDX2(>90%+),CA199(+),CEA(+++),GSTP1(+++),EGFR(+++),VEGF(++),MLH1(>90%+),MSH2(>90%+),MSH6(>90%+),PMS2(>90%+)。血管内皮细胞CD34(+)其内未见癌栓,淋巴管内皮细胞D2-40(+)其内未见癌栓,周围神经S100(+)可见癌侵犯,,病理号:1806。术后患者恢复良好,术后行腹腔穿刺化疗一次,今为求进一步治疗收入我科。近日无发热,饮食睡眠可,大小便正常,无腹痛,无便血,近来体重未见明显变化。ECOG,评分:1分。 | |
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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,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。,患者约于5月前因“乙状结肠癌”于2017-02-07在全麻上行乙状结肠癌根治术,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:(乙状结肠)腺癌,中、低度分化,浸润溃疡型,体积5*3*1.3CM,侵穿浆膜, 双端切线及另送“近切线”、“远切线”未查见癌。 呈肠壁一站(4/10个)淋巴结癌转移。 中间组淋巴结(1个)未查见癌。,免疫组化染色示:SYN(-)、BRAF(-)、MLH1(+)、MSH2(+)、 MSH6(+)、PMS2(+)。查无化疗禁忌后于2017-03-05开始给予规律化疗5周期,,方案为:奥沙利铂200MG D1,亚叶酸钙0.3G+氟尿嘧啶0.75G D2-D6,同时给与升白细胞、护肝、止吐、免疫增强治疗,患者副反应轻。院外期间患者一般情况好,无恶心,无腹痛腹胀不适,1天前患者发现白细胞低,现患者为行复查及化疗再次来院就诊,门诊以“乙状结肠癌术后”收入院。 发病以来,患者精神好,饮食好,睡眠好,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,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。,患者6月余前因“直肠癌”在我院行直肠癌DIXON手术,手术过程顺利,术后给予抗感染、营养支持并补液治疗,患者2017-02-15因“直肠癌术后吻合口瘘”行“横结肠造口术”,手术过程顺利,术后给予抗感染、营养支持、补液及对症治疗,,术后病理检查结果回示:(直肠)腺癌(中、低度分化,局部伴神经内分泌分化;部分为粘液腺癌,约占30%), 隆起型,体积2*2*1.5CM,局部侵达深肌层,并肠壁外脂肪组织内查见癌转移 灶(1处),长径约0.7CM,双端切线及另送“近切线”、“远切线”未查见癌。 多发性增生性(锯齿状)息肉。 一站淋巴结(8个)未查见癌。,癌组织免疫组化染色示:SYN局部(+)、BRAF(-)、MSH2(+)、MSH6(+)、 MLH1(+)、PMS2(+)。病情稳定后出院.患者于2017-6-2、2017-7-2及2017-7-30来我院入住我科,排除化疗禁忌后给予奥沙利铂200MGD1+氟尿嘧啶0.75G D2-D6+亚叶酸钙0.3G D2-D6,辅以保肝、护胃、止吐等对症支持治疗,过程顺利,患者耐受可,化疗结束后出院。 出院后患者病情稳定,无发热畏寒,无恶心呕吐,无咳嗽胸闷,无腹胀腹泻以及腹痛,精神好,饮食好,睡眠好,小便正常,体重无明显改变。现患者为求进一步治疗入院,门诊以“直肠癌术后”收入院。 | |
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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,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。,缘于入院前4月余在我院诊为“胃窦癌”,于2015年07月21日在全麻上行根治性远端胃切除、胃空肠ROUX-Y吻合术(D2)。,术中见:腹腔内无明显腹水,腹腔内未见转移结节,肝脏质地大小正常,未见明显肿物,胆囊无肿大。病灶位于胃角处向下侵犯胃体中段,明显侵出浆膜面,胃右动脉附近可见一肿大淋巴结,大小约3.0×3.0右左。手术顺利。术后病理(201526673),示:1.(远端胃),:胃体前壁及胃窦溃疡型管状腺癌II-III级,伴坏死,侵出浆膜层。手术标本下切端、上切端及另送(下切端)均未见癌浸润。找到小弯侧淋巴结1/10个,大弯侧淋巴结0/4个,幽门下淋巴结0/1个,幽门上淋巴结1/6个,及另送(胃右动脉根部)淋巴结0/2个,见癌转移。,免疫组化染色结果:CGA(-),CD56(-),SY(-),KI67(60%阳性),CK(PAN)(+++),HER-2(-);术后预防性抗感染、补液、营养等对症治疗,恢复良好后出院。术后分别于2015.09.21、2015.10.26予“奥沙利铂(乐沙定)200MGIVGGTD1+希罗达1500MGPOBIDD1-14”方案化疗2个周期。化疗过程顺利,无特殊不适。今为行第3次化疗,再次就诊于我院,门诊拟“胃管状腺癌术后(PT4AN1M0IIIA期)化疗”收入住院。自下次出院以来,精神可,睡眠可,饮食稍差,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,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。入院前3月,患者因直肠癌于本院行腹腔镜辅助上直肠癌根治术(MILES),手术顺利。术后组织病理检查报告示直肠溃疡型中分化管状腺癌,浸及肠壁全层,可见神经侵犯及癌栓。切端未见癌累及。肠壁淋巴结可见癌转移(1/2)。术后患者恢复好,无畏寒发热,无恶心呕吐,无腹胀腹痛,造瘘口排便排气通畅,已行FOLFOX方案化疗2次,为求术后第3次化疗于今日入院。\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,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。,2012-11-30行右乳癌根治术,术后病理示(右)乳腺浸润性导管癌,II级,大小1.8×XXX1.7×XXX1.5CM,未见脉管癌栓;乳头及皮肤未见特殊。,肿瘤病理分期:PT1C。(右腋窝前哨)淋巴结未见癌转移(0/1);(右腋窝前哨及导丝定位)淋巴结未见癌转移(0/2)。,免疫组化染色结果:CK(-)。,免疫组化:ER(+>75%),PR(+约20%),HER-2(1+)。术后CEF方案化疗6周期,现口服来曲唑(芙瑞)内分泌治疗。 5-20本院胃镜检查提示慢性胃炎,HP(-)。现恶心未吐,进食少,大便可,睡眠差。 | |
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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,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。缘于入院前4年余因“乙状结肠癌”于我院行“腹腔镜辅助上乙状结肠癌根治术”,术后病理(201131862)回报“(乙状)结肠蕈伞型管状腺癌II级,侵及浆膜层,手术标本下、上切端及另送(下、上切端)未见癌浸润,找到肠周淋巴结11个均未见癌转移,另送(肠系膜上动脉根部淋巴结)为脂肪脉管结缔组织”,术后恢复良好出院,出院后于门诊定期复查期间发现肝、肺、骨多发转移。3年前开始口服希罗达及中药治疗(具体不详),治疗期间未诉不适。入院前2天患者无明显诱因出现纳差,并逐渐出现乏力感,无恶心、呕吐,无腹痛、腹胀、腹泻,无发热、畏寒等不适,今为求进一步诊治,就诊我院,门诊拟“乙状结肠癌术后伴肝、骨、肺多发转移”收治入院,自发病以来,饮食较差,睡眠可,二便正常,体重较前无明显改变。 | |
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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,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。,缘于入院前[主诉单一时间1年于我院诊断“降结肠癌”,查无禁忌后,于2014年04月28日在全麻上行腹腔镜上右半结肠切除术。,术中见:无腹水,肝表面光滑,胃及空肠未见明显病变。降结肠可见一大约2*3CM隆起型肿物,质硬,侵出浆膜层,肠系膜根部未见明显肿大淋巴结,术顺,术后予抗炎、制酸、补液等对症治疗,,术后病理示:(结肠),:肠隆起型管状腺癌II级,侵及粘膜上层,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14个,及另送(肠系膜动脉根部)淋巴结2个,均未见癌转移。,免疫组化结果:KI67(40%阳性),P53(-),P170(+),GSTπ(+),EGFR(-),5-FU(++),MLH1(++),MSH6(++),MGMT(++)。该病例未检测到BRAF基因V600E突变、未检测到KRAS基因12、13号密码子热点突变。术后恢复良好。1周前患者于我院行PET-CT提示肝转移,无寒战、发热,无恶心、呕吐,无反酸、嗳气、腹胀、消瘦、头晕、乏力、皮肤巩膜黄染再次。就诊于我院,遂门诊拟降结肠癌术后收入院。自发病以来,精神、睡眠、食欲尚可,大便如下述,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,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。患者1月余前因“胃恶性肿瘤”于我院就诊,于2016-10-25在全麻上行“胃癌根治术”,手术顺利,术后恢复良好,术后病理胃窦小弯腺癌(中度分化),体积4*3.5*1.4CM,浸润溃疡型,侵达浆膜,累及十二指肠,于部分脉管中查见癌栓,未累及近端切线。距远端切线甚近。呈“五组”(1/1个)、“第六组”(2/2个)淋巴结癌转移。四组(7个)、六组(7个)、“一三七组”(10个)淋巴结未查见癌。免疫组化染色示癌组织:CERBB-2(2+)、SYN(-)、β-TUBULIN-III(-)、RRM1少数(+)、TOPOII多数(+)、CD34血管(+)、D2-40淋巴结(+)。结合患者病情及肿瘤病理与分期继续予行术后化疗,给予“奥沙利铂200MG D1+亚叶酸钙0.3G D2-6 +替加氟1000MG D2-6 静滴”方案化疗,同时辅以镇吐、升血、免疫调节等对症支持治疗,恢复良好出院。今为行第二次化疗于我科就诊,门诊以“胃癌术后”收入院。 患者自发病以来,精神情绪及体力良好,食欲、饮食、睡眠好,小便正常。体重无明显变化。 |
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