{
  "样例性质": "真实记录·已脱敏",
  "patient": {
    "patient_id": "PT-0000512",
    "gender": "男",
    "age": "62岁"
  },
  "encounter": {
    "encounter_id": "OPV-20210828-0001",
    "encounter_type": "门诊",
    "encounter_time": "2021-08-28 08:30",
    "department": "神经内科",
    "physician_title": "主治医师"
  },
  "document": {
    "chief_complaint": "间断头晕1周",
    "present_illness": "近1周劳累后间断头晕，呈头昏沉感，无肢体麻木无力及言语不清，血压波动在150/90mmHg左右。",
    "past_history": "高血压7余年，血压最高160/100mmHg，规律口服缬沙坦分散片80mg qd、酒石酸美托洛尔25mg qd。2型糖尿病3余年，口服阿卡波糖、瑞格列奈及二甲双胍控制血糖，平素空腹血糖多在6-7mmol/L。心肌梗死PCI术后3余年，长期口服阿司匹林、单硝酸异山梨酯及他汀类药物。有高脂血症、反流性食管炎及颈椎病史。否认肝炎、结核、精神疾病史。过敏史：无。",
    "personal_history": "出生并久居本地，否认疫水、疫区接触史，否认放射性物质及毒物接触史。既往吸烟6年，每日约15支，已戒烟10余年；否认饮酒史。",
    "family_history": "父健在，母已逝，母亲曾患偏瘫，兄弟姐妹1人，否认家族中有遗传病史、传染病史及肿瘤病史。",
    "marital_history": "适龄结婚，育有1儿1女，配偶及子女体健。",
    "physical_examination": "体温36.4℃，脉搏74次/分，呼吸18次/分，血压:左150/92mmHg 右148/90mmHg。神志清楚，言语流利，双瞳等大等圆，对光反射灵敏，四肢肌力V级，双侧病理征阴性。心肺腹查体未见明显异常。",
    "auxiliary_examination": "头颅CT：双侧基底节区腔隙灶或缺血性白质改变可能，未见急性出血；颈动脉超声：双侧颈动脉粥样硬化斑块；心电图：窦性心律，部分ST-T改变；LDL-C 2.62mmol/L，HbA1c 6.8%。"
  },
  "diagnosis": [
    {
      "diagnosis_raw": "1.头晕 2.高血压病 3.冠心病PCI术后",
      "mapping_status": "not_standardized"
    }
  ],
  "medication_order": [
    {
      "order_name": "阿司匹林肠溶片(100mg*30片)",
      "generic_name": "阿司匹林肠溶片",
      "brand_name": "拜阿司匹灵",
      "specification": "100mg×30片/盒",
      "single_dose": "100",
      "dose_unit": "mg",
      "frequency": "q.d.",
      "route": "口服",
      "order_nature": "长期医嘱",
      "start_time": "2021-08-28 08:50:00",
      "end_time": "2021-09-25 08:50:00"
    },
    {
      "order_name": "阿托伐他汀钙片(20mg*7片)",
      "generic_name": "阿托伐他汀钙片",
      "brand_name": "立普妥",
      "specification": "20mg×7片/盒",
      "single_dose": "20",
      "dose_unit": "mg",
      "frequency": "q.n.",
      "route": "口服",
      "order_nature": "长期医嘱",
      "start_time": "2021-08-28 08:50:00",
      "end_time": "2021-09-25 08:50:00"
    },
    {
      "order_name": "缬沙坦分散片(80mg*7片)",
      "generic_name": "缬沙坦分散片",
      "brand_name": "代文",
      "specification": "80mg×7片/盒",
      "single_dose": "80",
      "dose_unit": "mg",
      "frequency": "q.d.",
      "route": "口服",
      "order_nature": "长期医嘱",
      "start_time": "2021-08-28 08:50:00",
      "end_time": "2021-09-25 08:50:00"
    }
  ],
  "non_medication_order": [
    {
      "order_name": "普通门诊诊察费",
      "order_type": "挂号费",
      "frequency": "一次",
      "order_nature": "临时医嘱",
      "start_time": "2021-08-28 08:35:00"
    },
    {
      "order_name": "头颅CT平扫",
      "order_type": "检查",
      "frequency": "一次",
      "order_nature": "临时医嘱",
      "start_time": "2021-08-28 08:38:00"
    },
    {
      "order_name": "颈动脉彩色多普勒超声",
      "order_type": "检查",
      "frequency": "一次",
      "order_nature": "临时医嘱",
      "start_time": "2021-08-28 08:39:00"
    },
    {
      "order_name": "十二导联心电图",
      "order_type": "检查",
      "frequency": "一次",
      "order_nature": "临时医嘱",
      "start_time": "2021-08-28 08:40:00"
    },
    {
      "order_name": "血细胞分析（五分类）",
      "order_type": "检验",
      "frequency": "一次",
      "order_nature": "临时医嘱",
      "start_time": "2021-08-28 08:41:00"
    },
    {
      "order_name": "生化P2+P3(新)",
      "order_type": "检验",
      "frequency": "一次",
      "order_nature": "临时医嘱",
      "start_time": "2021-08-28 08:42:00"
    },
    {
      "order_name": "血脂四项",
      "order_type": "检验",
      "frequency": "一次",
      "order_nature": "临时医嘱",
      "start_time": "2021-08-28 08:43:00"
    },
    {
      "order_name": "糖化血红蛋白(HbA1c)测定",
      "order_type": "检验",
      "frequency": "一次",
      "order_nature": "临时医嘱",
      "start_time": "2021-08-28 08:44:00"
    }
  ],
  "laboratory_result": [
    {
      "panel_name": "血细胞分析（五分类）",
      "specimen": "全血",
      "result_time": "2021-08-28 09:50:00",
      "item_name": "白细胞计数",
      "item_code": "WBC",
      "value": "6.2",
      "unit": "10^9/L",
      "reference_range": "3.5-9.5"
    },
    {
      "panel_name": "血细胞分析（五分类）",
      "specimen": "全血",
      "result_time": "2021-08-28 09:50:00",
      "item_name": "红细胞计数",
      "item_code": "RBC",
      "value": "4.72",
      "unit": "10^12/L",
      "reference_range": "4.3-5.8"
    },
    {
      "panel_name": "血细胞分析（五分类）",
      "specimen": "全血",
      "result_time": "2021-08-28 09:50:00",
      "item_name": "血红蛋白",
      "item_code": "HGB",
      "value": "145",
      "unit": "g/L",
      "reference_range": "130-175"
    },
    {
      "panel_name": "血细胞分析（五分类）",
      "specimen": "全血",
      "result_time": "2021-08-28 09:50:00",
      "item_name": "红细胞压积",
      "item_code": "HCT",
      "value": "43.5",
      "unit": "%",
      "reference_range": "40-50"
    },
    {
      "panel_name": "血细胞分析（五分类）",
      "specimen": "全血",
      "result_time": "2021-08-28 09:50:00",
      "item_name": "血小板计数",
      "item_code": "PLT",
      "value": "218",
      "unit": "10^9/L",
      "reference_range": "125-350"
    },
    {
      "panel_name": "血细胞分析（五分类）",
      "specimen": "全血",
      "result_time": "2021-08-28 09:50:00",
      "item_name": "中性粒细胞百分比",
      "item_code": "NEUT%",
      "value": "62.1",
      "unit": "%",
      "reference_range": "40-75"
    },
    {
      "panel_name": "血细胞分析（五分类）",
      "specimen": "全血",
      "result_time": "2021-08-28 09:50:00",
      "item_name": "淋巴细胞百分比",
      "item_code": "LYMPH%",
      "value": "28.4",
      "unit": "%",
      "reference_range": "20-50"
    },
    {
      "panel_name": "生化P2+P3(新)",
      "specimen": "静脉血",
      "result_time": "2021-08-28 09:50:00",
      "item_name": "丙氨酸氨基转移酶",
      "item_code": "ALT",
      "value": "24.6",
      "unit": "U/L",
      "reference_range": "9-50"
    },
    {
      "panel_name": "生化P2+P3(新)",
      "specimen": "静脉血",
      "result_time": "2021-08-28 09:50:00",
      "item_name": "天门冬氨酸氨基转移酶",
      "item_code": "AST",
      "value": "22.3",
      "unit": "U/L",
      "reference_range": "15-40"
    },
    {
      "panel_name": "生化P2+P3(新)",
      "specimen": "静脉血",
      "result_time": "2021-08-28 09:50:00",
      "item_name": "总胆红素",
      "item_code": "T-BIL",
      "value": "16.8",
      "unit": "umol/L",
      "reference_range": "5.1-22.2"
    },
    {
      "panel_name": "生化P2+P3(新)",
      "specimen": "静脉血",
      "result_time": "2021-08-28 09:50:00",
      "item_name": "肌酐",
      "item_code": "CREA",
      "value": "75",
      "unit": "umol/L",
      "reference_range": "57-111"
    },
    {
      "panel_name": "生化P2+P3(新)",
      "specimen": "静脉血",
      "result_time": "2021-08-28 09:50:00",
      "item_name": "尿素",
      "item_code": "UREA",
      "value": "5.6",
      "unit": "mmol/L",
      "reference_range": "3.1-8.0"
    },
    {
      "panel_name": "生化P2+P3(新)",
      "specimen": "静脉血",
      "result_time": "2021-08-28 09:50:00",
      "item_name": "尿酸",
      "item_code": "UA",
      "value": "356",
      "unit": "umol/L",
      "reference_range": "208-428"
    },
    {
      "panel_name": "生化P2+P3(新)",
      "specimen": "静脉血",
      "result_time": "2021-08-28 09:50:00",
      "item_name": "葡萄糖",
      "item_code": "GLU",
      "value": "6.7",
      "unit": "mmol/L",
      "reference_range": "3.9-6.1"
    },
    {
      "panel_name": "生化P2+P3(新)",
      "specimen": "静脉血",
      "result_time": "2021-08-28 09:50:00",
      "item_name": "钾",
      "item_code": "K",
      "value": "4.15",
      "unit": "mmol/L",
      "reference_range": "3.5-5.3"
    },
    {
      "panel_name": "生化P2+P3(新)",
      "specimen": "静脉血",
      "result_time": "2021-08-28 09:50:00",
      "item_name": "钠",
      "item_code": "Na",
      "value": "140.2",
      "unit": "mmol/L",
      "reference_range": "137-147"
    },
    {
      "panel_name": "生化P2+P3(新)",
      "specimen": "静脉血",
      "result_time": "2021-08-28 09:50:00",
      "item_name": "氯",
      "item_code": "Cl",
      "value": "103.5",
      "unit": "mmol/L",
      "reference_range": "99-110"
    },
    {
      "panel_name": "血脂四项",
      "specimen": "静脉血",
      "result_time": "2021-08-28 09:50:00",
      "item_name": "总胆固醇",
      "item_code": "CHOL",
      "value": "4.82",
      "unit": "mmol/L",
      "reference_range": "2.8-5.2"
    },
    {
      "panel_name": "血脂四项",
      "specimen": "静脉血",
      "result_time": "2021-08-28 09:50:00",
      "item_name": "甘油三酯",
      "item_code": "TG",
      "value": "1.82",
      "unit": "mmol/L",
      "reference_range": "0.56-1.70"
    },
    {
      "panel_name": "血脂四项",
      "specimen": "静脉血",
      "result_time": "2021-08-28 09:50:00",
      "item_name": "高密度脂蛋白胆固醇",
      "item_code": "HDL-C",
      "value": "1.1",
      "unit": "mmol/L",
      "reference_range": "1.04-1.55"
    },
    {
      "panel_name": "血脂四项",
      "specimen": "静脉血",
      "result_time": "2021-08-28 09:50:00",
      "item_name": "低密度脂蛋白胆固醇",
      "item_code": "LDL-C",
      "value": "2.62",
      "unit": "mmol/L",
      "reference_range": "0-3.37"
    },
    {
      "panel_name": "糖化血红蛋白(HbA1c)测定",
      "specimen": "静脉血",
      "result_time": "2021-08-28 09:50:00",
      "item_name": "糖化血红蛋白",
      "item_code": "HbA1c",
      "value": "6.8",
      "unit": "%",
      "reference_range": "4.27-6.07"
    }
  ],
  "examination_report": [
    {
      "exam_time": "2021-08-28 10:16:00",
      "exam_name": "头颅CT平扫",
      "exam_type": "CT",
      "body_part": "头颅",
      "findings": "双侧基底节区见点片状低密度影，脑室系统未见受压，中线结构居中，颅内未见出血征象。",
      "conclusion": "双侧基底节区腔隙灶或缺血性白质改变可能；颅内未见急性出血。"
    },
    {
      "exam_time": "2021-08-28 10:42:00",
      "exam_name": "颈动脉彩色多普勒超声",
      "exam_type": "超声",
      "body_part": "颈部血管",
      "findings": "双侧颈总动脉内中膜增厚，双侧颈动脉分叉处可见斑块回声，管腔未见明显狭窄。",
      "conclusion": "双侧颈动脉粥样硬化斑块形成。"
    },
    {
      "exam_time": "2021-08-28 09:48:00",
      "exam_name": "十二导联心电图",
      "exam_type": "心电图",
      "body_part": "心脏",
      "findings": "窦性心律，心率约72次/分，ST-T轻度改变。",
      "conclusion": "窦性心律，部分ST-T改变。"
    }
  ],
  "treatment_plan": {
    "plan_raw": "调整降压药物，完善头颅CT、颈动脉超声、血脂血糖检查，继续阿司匹林及他汀治疗。"
  }
}