{ "样例性质": "真实记录·已脱敏", "observation_episode": { "available_time": null, "event_time_raw": null, "missing_reason": "not_covered_or_not_applicable", "observation_episode_id": "OBSERVATION_EPISODE-0000001", "parent_object_id": "PARENT_OBJECT-0000001", "record_status": "source_record", "source_object_id": "SOURCE_OBJECT-0000001" }, "cohort_definition": { "available_time": null, "cohort_definition_id": "COHORT_DEFINITION-0000001", "event_time_raw": null, "missing_reason": "not_covered_or_not_applicable", "parent_object_id": "PARENT_OBJECT-0000001", "record_status": "source_record", "source_object_id": "SOURCE_OBJECT-0000001" }, "complication_definition": { "available_time": null, "complication_definition_id": "COMPLICATION_DEFINITION-0000001", "event_time_raw": null, "missing_reason": "not_covered_or_not_applicable", "parent_object_id": "PARENT_OBJECT-0000001", "record_status": "source_record", "source_object_id": "SOURCE_OBJECT-0000001" }, "risk_window_definition": { "available_time": null, "event_time_raw": null, "missing_reason": "not_covered_or_not_applicable", "parent_object_id": "PARENT_OBJECT-0000001", "record_status": "source_record", "risk_window_definition_id": "RISK_WINDOW_DEFINITION-0000001", "source_object_id": "SOURCE_OBJECT-0000001" }, "postoperative_source_document": [ { "available_time": null, "document_content_raw": "2026-07-24 16:54　　　　　首次病程记录\n患者A，女，80岁，无业人员，因“便血1天”于2026-07-24入院。\n一、病史特点：\n1.患者老年女性，起病急、病程短。\n2.以“便血1天”为主要临床表现入院。\n3.既往史：既往既往一般，患高血压20+年，最高达150/？mmHg，目前服用降压药替米沙坦片，，否认心脏病史,否认糖尿病,否认哮喘,20+年前脑梗死，口服阿司匹林肠溶片,否认精神疾病史,否认肝炎，否认结核，否认疟疾，白内障手术，否认外伤史，否认输血史。\n4.查体：体温36.5℃、脉搏64次/分、呼吸20次/分、血压130/78mmHg，生命体征平稳，心肺腹未见明显阳性体征。专科检查：肛门居中，肛门缘可见皮赘，指检直肠下段距离肛门约3-8cm扪及环腔约1/2形态不规则，质地中等偏硬，边界欠清，指套见血染，镜下见直肠新生物糜烂，内痔充血。\n5.辅助检查：-\n二、初步诊断：直肠肿物 高血压\n三、诊断依据：\n1.直肠肿物，诊断依据：患者因“便血1天”入院。专科检查：肛门居中，肛门缘可见皮赘，指检直肠下段距离肛门约3-8cm扪及环腔约1/2形态不规则，质地中等偏硬，边界欠清，指套见血染，镜下见直肠新生物糜烂；\n2.高血压，诊断依据：结合既往史诊断。\n四、鉴别诊断：\n内痔：内痔早期以出血为主要表现，颜色多鲜红，不伴肛门疼痛，可伴有肛门内肿物脱出，肛门镜下可见齿线处粘膜充盈明显，部分齿线消失。内痔痔核为曲张静脉丛，呈桑葚状或结节状突起，颜色紫暗或鲜红。各痔核间常有明显界线或正常的粘膜组织。\n五、入院病情评估：患者生命体征平稳，意识清楚，自主能力正常，告知患者及家属可能疾病诊断、疾病诊疗方法、风险及转归可能，需要24h留陪。入院VTE评分3分，出血风险低危，暂无特殊处理，嘱患者尽早活动。\n六、诊疗计划：1、肛肠科护理常规、二级护理、低盐饮食；2、完善血常规、凝血功能、生化检查、感染性标志物、大小便常规、心电图、心脏彩超、颈部血管彩超等；3、完善肠镜检查。\n医师签名：医生I\n", "document_time_raw": "2026-07-24T16:54:51", "event_time_raw": null, "missing_reason": "not_covered_or_not_applicable", "parent_object_id": "PARENT_OBJECT-0000001", "postoperative_document_id": "POSTOPERATIVE_DOCUMENT-0000001", "record_status": "source_record", "source_object_id": "SOURCE_OBJECT-0000001" }, { "available_time": null, "document_content_raw": "2026-07-25 08:08　　　　　医生I职称B首次查房记录\n 今医生I职称B查看病人及总结病史特点如下：患者老年女性，起病急、病程短。“便血1天”入院。既往史：既往一般，患高血压20+年，最高达150/？mmHg，目前服用降压药替米沙坦片，否认心脏病史,否认糖尿病,否认哮喘,20+年前脑梗死，口服阿司匹林肠溶片,否认精神疾病史,否认肝炎，否认结核，否认疟疾，白内障手术。查体:肛门居中，肛门缘可见皮赘，指检直肠下段距离肛门约3-8cm扪及环腔约1/2形态不规则，质地中等偏硬，边界欠清，指套见血染，镜下见直肠新生物糜烂，内痔充血。辅助检查 :2026-07-24 心脏彩超+心功能,彩超计算机图文报告,左房增、室间隔基底段增厚、主动脉瓣轻度反流、2026-07-24 颈部血管(含双侧颈总动脉、双侧颈内动脉、双侧椎动脉),彩超计算机图文报告,头臂干分叉处斑块形成。目前诊断:直肠肿物，高血压。诊断依据：1.直肠肿物，诊断依据：患者因“便血1天”入院。专科检查：肛门居中，肛门缘可见皮赘，指检直肠下段距离肛门约3-8cm扪及环腔约1/2形态不规则，质地中等偏硬，边界欠清，指套见血染，镜下见直肠新生物糜烂；2.高血压，诊断依据：结合既往史诊断。鉴别诊断:内痔：内痔早期以出血为主要表现，颜色多鲜红，不伴肛门疼痛，可伴有肛门内肿物脱出，肛门镜下可见齿线处粘膜充盈明显，部分齿线消失。内痔痔核为曲张静脉丛，呈桑葚状或结节状突起，颜色紫暗或鲜红。各痔核间常有明显界线或正常的粘膜组织。查房指示： 1、完善结肠镜检查等。2、明确手术禁忌，积极术前准备，择期行手术治疗。3、术后养成良好饮食排便习惯。4、注意讲明白手术方案及风险。\n医师签名:医生I\n", "document_time_raw": "2026-07-25T08:08:43", "event_time_raw": null, "missing_reason": "not_covered_or_not_applicable", "parent_object_id": "PARENT_OBJECT-0000001", "postoperative_document_id": "POSTOPERATIVE_DOCUMENT-0000002", "record_status": "source_record", "source_object_id": "SOURCE_OBJECT-0000001" }, { "available_time": null, "document_content_raw": "2026-07-26 12:06　　　　　医生P职称C首次查房记录\n 医生P职称C查房，患者老年女性，起病急、病程短。“便血1天”入院。既往史：既往一般，患高血压20+年，最高达150/？mmHg，目前服用降压药替米沙坦片，否认心脏病史,否认糖尿病,否认哮喘,20+年前脑梗死，口服阿司匹林肠溶片,白内障手术。查体:肛门居中，肛门缘可见皮赘，指检直肠下段距离肛门约3-8cm扪及环腔约1/2形态不规则，质地中等偏硬，边界欠清，指套见血染，镜下见直肠新生物糜烂，内痔充血。辅助检查:2026-07-26 上腹+下腹+盆腔CT薄层平扫+薄层增强+能量成像（空腹+适度胀尿）,能量成像（CT平扫）（加收）,能量成像（CT增强）（加收）,CT薄层平扫（加收）,CT薄层增强（加收）,1、直肠中下段壁增厚，病灶与正常肠壁分界不清，浆膜面光滑，周围脂肪间隙清晰，建议结合肠镜。2、胆囊多发结石并慢性胆囊炎。3、肝内外胆管稍扩张。4、右肾小结石，左肾点状钙化灶或结石；双肾少量囊肿。5、膀胱充盈欠佳。6、回盲部及部分升结肠壁可疑不均匀增厚或充盈不佳，增强未见明显异常强化，建议结合镜检。7、胰腺、脾脏、双肾上腺、子宫及双侧附件CT平扫及增强未见明显异常。8、腹腔系膜局部密度稍增高并散在小淋巴结影。2026-07-26 快速石蜡切片检查与诊断,“直肠近肛门隆起中央”小活检组织，查见腺癌。目前诊断: 直肠肿物 高血压。诊断依据：1.直肠恶性肿瘤，诊断依据：患者因“便血1天”入院。专科检查：肛门居中，肛门缘可见皮赘，指检直肠下段距离肛门约3-8cm扪及环腔约1/2形态不规则，质地中等偏硬，边界欠清，指套见血染，镜下见直肠新生物糜烂；2.高血压，诊断依据：结合既往史诊断。鉴别诊断:内痔：内痔早期以出血为主要表现，颜色多鲜红，不伴肛门疼痛，可伴有肛门内肿物脱出，肛门镜下可见齿线处粘膜充盈明显，部分齿线消失。内痔痔核为曲张静脉丛，呈桑葚状或结节状突起，颜色紫暗或鲜红。各痔核间常有明显界线或正常的粘膜组织。诊疗计划:1、告知患者家属病情；2.患者家属要求转科治疗。\n医师签名：医生P/医生I\n", "document_time_raw": "2026-07-26T12:06:48", "event_time_raw": null, "missing_reason": "not_covered_or_not_applicable", "parent_object_id": "PARENT_OBJECT-0000001", "postoperative_document_id": "POSTOPERATIVE_DOCUMENT-0000003", "record_status": "source_record", "source_object_id": "SOURCE_OBJECT-0000001" }, { "available_time": null, "document_content_raw": "2026-07-27 09:12　　　　　转出记录\n患者A，女，80岁，因便血1天于2026-07-24入院。\n入院科室：肛肠科，转出日期：2026-07-27 08:13。转入科室：胃肠外科一病区，已住院3天。\n入院情况：患者A，女，80岁，无业人员，因“便血1天”于2026-07-24入院。专科检查：肛门居中，肛门缘可见皮赘，指检直肠下段距离肛门约3-8cm扪及环腔约1/2形态不规则，质地中等偏硬，边界欠清，指套见血染，镜下见直肠新生物糜烂，内痔充血。\n入院诊断：直肠肿物，高血压。\n诊疗经过：入院后完善相关检查，2026-07-24 心脏彩超+心功能,彩超计算机图文报告,左房增、室间隔基底段增厚、主动脉瓣轻度反流、2026-07-24 颈部血管(含双侧颈总动脉、双侧颈内动脉、双侧椎动脉),彩超计算机图文报告,头臂干分叉处斑块形成。2026-07-26 上腹+下腹+盆腔CT薄层平扫+薄层增强+能量成像（空腹+适度胀尿）,能量成像（CT平扫）（加收）,能量成像（CT增强）（加收）,CT薄层平扫（加收）,CT薄层增强（加收）。1、直肠中下段壁增厚，病灶与正常肠壁分界不清，浆膜面光滑，周围脂肪间隙清晰，建议结合肠镜。2、胆囊多发结石并慢性胆囊炎。3、肝内外胆管稍扩张。4、右肾小结石，左肾点状钙化灶或结石；双肾少量囊肿。5、膀胱充盈欠佳。6、回盲部及部分升结肠壁可疑不均匀增厚或充盈不佳，增强未见明显异常强化，建议结合镜检。7、胰腺、脾脏、双肾上腺、子宫及双侧附件CT平扫及增强未见明显异常。8、腹腔系膜局部密度稍增高并散在小淋巴结影。2026-07-26 快速石蜡切片检查与诊断,“直肠近肛门隆起中央”小活检组织，查见腺癌；患者家属商量后，要求转入胃肠外科一病区进一步治疗。\n目前情况：患者一般情况可。\n转出诊断：直肠恶性肿瘤，高血压，头臂干分叉处斑块。\n转科目的：进一步治疗。\n注意事项：遵贵科。\n医师签名：医生I\n\n", "document_time_raw": "2026-07-27T09:12:53", "event_time_raw": null, "missing_reason": "not_covered_or_not_applicable", "parent_object_id": "PARENT_OBJECT-0000001", "postoperative_document_id": "POSTOPERATIVE_DOCUMENT-0000004", "record_status": "source_record", "source_object_id": "SOURCE_OBJECT-0000001" }, { "available_time": null, "document_content_raw": "2026-07-27 10:40　　　　　转入记录\n患者A，女，80岁，因“便血1天”于2026-07-24入院。\n入院科室：肛肠科，转入日期：2026-07-27 09:41。转入科室：胃肠外科一病区 已住院3天\n入院情况：患者A，女，80岁，因“便血1天”于2026-07-24入院。专科检查：肛门居中，肛门缘可见皮赘，指检直肠下段距离肛门约3-8cm扪及环腔约1/2形态不规则，质地中等偏硬，边界欠清，指套见血染，镜下见直肠新生物糜烂，内痔充血。\n入院诊断：直肠肿物，高血压。\n诊疗经过：入院后完善相关检查，2026-07-24 心脏彩超+心功能,彩超计算机图文报告,左房增、室间隔基底段增厚、主动脉瓣轻度反流、2026-07-24 颈部血管(含双侧颈总动脉、双侧颈内动脉、双侧椎动脉),彩超计算机图文报告,头臂干分叉处斑块形成。2026-07-26 上腹+下腹+盆腔CT薄层平扫+薄层增强+能量成像（空腹+适度胀尿）,能量成像（CT平扫）（加收）,能量成像（CT增强）（加收）,CT薄层平扫（加收）,CT薄层增强（加收）,1、直肠中下段壁增厚，病灶与正常肠壁分界不清，浆膜面光滑，周围脂肪间隙清晰，建议结合肠镜。2、胆囊多发结石并慢性胆囊炎。3、肝内外胆管稍扩张。4、右肾小结石，左肾点状钙化灶或结石；双肾少量囊肿。5、膀胱充盈欠佳。6、回盲部及部分升结肠壁可疑不均匀增厚或充盈不佳，增强未见明显异常强化，建议结合镜检。7、胰腺、脾脏、双肾上腺、子宫及双侧附件CT平扫及增强未见明显异常。8、腹腔系膜局部密度稍增高并散在小淋巴结影。2026-07-26 快速石蜡切片检查与诊断,“直肠近肛门隆起中央”小活检组织，查见腺癌；患者家属商量后，要求转入胃肠外科一病区进一步治疗。\n目前情况：患者一般情况可。\n转入诊断：直肠恶性肿瘤，高血压，头臂干分叉处斑块。\n诊疗计划：完善术前检查，给与对症治疗，限期手术治疗。\n医师签名：医生C\n", "document_time_raw": "2026-07-27T10:40:05", "event_time_raw": null, "missing_reason": "not_covered_or_not_applicable", "parent_object_id": "PARENT_OBJECT-0000001", "postoperative_document_id": "POSTOPERATIVE_DOCUMENT-0000005", "record_status": "source_record", "source_object_id": "SOURCE_OBJECT-0000001" }, { "available_time": null, "document_content_raw": "2026-07-28 15:08　　　　　医生C职称B查房记录(首次)\n 今医生C职称B查看病人及总结病史特点如下：患者A，女，80岁，因“便血1天”于2026-07-24入院。查体:肛门居中，肛门缘可见皮赘，指检直肠下段距离肛门约3-8cm扪及环腔约1/2形态不规则，质地中等偏硬，边界欠清，指套见血染，镜下见直肠新生物糜烂，内痔充血。辅助检查 :2026-07-24 心脏彩超+心功能,彩超计算机图文报告,左房增、室间隔基底段增厚、主动脉瓣轻度反流、2026-07-24 颈部血管(含双侧颈总动脉、双侧颈内动脉、双侧椎动脉),彩超计算机图文报告,头臂干分叉处斑块形成。2026-07-26 上腹+下腹+盆腔CT薄层平扫+薄层增强+能量成像（空腹+适度胀尿）,能量成像（CT平扫）（加收）,能量成像（CT增强）（加收）,CT薄层平扫（加收）,CT薄层增强（加收）,1、直肠中下段壁增厚，病灶与正常肠壁分界不清，浆膜面光滑，周围脂肪间隙清晰，建议结合肠镜。2、胆囊多发结石并慢性胆囊炎。3、肝内外胆管稍扩张。4、右肾小结石，左肾点状钙化灶或结石；双肾少量囊肿。5、膀胱充盈欠佳。6、回盲部及部分升结肠壁可疑不均匀增厚或充盈不佳，增强未见明显异常强化，建议结合镜检。7、胰腺、脾脏、双肾上腺、子宫及双侧附件CT平扫及增强未见明显异常。8、腹腔系膜局部密度稍增高并散在小淋巴结影。2026-07-26 快速石蜡切片检查与诊断,“直肠近肛门隆起中央”小活检组织，查见腺癌。目前诊断: 直肠恶性肿瘤，高血压，头臂干分叉处斑块。诊断依据：结合患者主诉、查体及辅助检查可诊断。鉴别诊断:1.内痔：内痔早期以出血为主要表现，颜色多鲜红，不伴肛门疼痛，可伴有肛门内肿物脱出，肛门镜下可见齿线处粘膜充盈明显，部分齿线消失。内痔痔核为曲张静脉丛，呈桑葚状或结节状突起，颜色紫暗或鲜红。各痔核间常有明显界线或正常的粘膜组织。2.直肠息肉：此病可有大便不适，也可以是便血，有些患者还伴有脓血便，目前结肠镜及活检结果不支持。3.溃疡性结直肠炎：本病以腹泻、黏液便、脓血便、大便次数增多、腹胀、腹痛等为主要症状，目前肠镜结果不支持。查房指示：完善术前检查，给与对症治疗，限期手术治疗。\n医师签名:医生C\n", "document_time_raw": "2026-07-28T15:08:30", "event_time_raw": null, "missing_reason": "not_covered_or_not_applicable", "parent_object_id": "PARENT_OBJECT-0000001", "postoperative_document_id": "POSTOPERATIVE_DOCUMENT-0000006", "record_status": "source_record", "source_object_id": "SOURCE_OBJECT-0000001" }, { "available_time": null, "document_content_raw": "2026-07-28 17:09　　　　　日常病程记录\n 今日查房，患者诉轻微排便不适，无明显咳嗽咳痰，无畏寒发热，无胸闷气喘心悸等不适，小便可。查体情况：心律齐，未闻及杂音，肺部呼吸音粗，未闻及明显干湿啰音，腹软，未见肠型及蠕动波，腹式呼吸存在，未触及包块。全腹部无明显压痛、反跳痛及肌紧张，肝脾未及肿大，双肾区无叩痛，移动性浊音阴性，肠鸣4-5次/分。辅助检查情况：2026-07-24，血常规:大型血小板比率 50.3(%)↑，平均血小板体积 13.6(fL)↑；2026-07-24，凝血功能:活化部分凝血活酶时间 23.3(sec)↓；2026-07-14，生化全套:总蛋白 60.4(g/L)↓，白蛋白 39.5(g/L)↓，总胆红素 22.4(umol/L)↑，直接胆红素 4.9(umol/L)↑，间接胆红素 17.5(umol/L)↑；诊疗计划：继续完善术前相关检查，给予对症治疗。\n医师签名：医生C\n", "document_time_raw": "2026-07-28T17:09:18", "event_time_raw": null, "missing_reason": "not_covered_or_not_applicable", "parent_object_id": "PARENT_OBJECT-0000001", "postoperative_document_id": "POSTOPERATIVE_DOCUMENT-0000007", "record_status": "source_record", "source_object_id": "SOURCE_OBJECT-0000001" }, { "available_time": null, "document_content_raw": "2026-07-29 09:10　　　　　医生H职称C查房记录(首次)\n 医生H职称C查房：老年女性，因“便血1天”于2026-07-24入院。查体:肛门居中，肛门缘可见皮赘，指检直肠下段距离肛门约3-8cm扪及环腔约1/2形态不规则，质地中等偏硬，边界欠清，指套见血染，镜下见直肠新生物糜烂，内痔充血。辅助检查:2026-07-24 心脏彩超+心功能,彩超计算机图文报告,左房增、室间隔基底段增厚、主动脉瓣轻度反流、2026-07-24 颈部血管(含双侧颈总动脉、双侧颈内动脉、双侧椎动脉),彩超计算机图文报告,头臂干分叉处斑块形成。2026-07-26 上腹+下腹+盆腔CT薄层平扫+薄层增强+能量成像（空腹+适度胀尿）,能量成像（CT平扫）（加收）,能量成像（CT增强）（加收）,CT薄层平扫（加收）,CT薄层增强（加收）。1、直肠中下段壁增厚，病灶与正常肠壁分界不清，浆膜面光滑，周围脂肪间隙清晰，建议结合肠镜。2、胆囊多发结石并慢性胆囊炎。3、肝内外胆管稍扩张。4、右肾小结石，左肾点状钙化灶或结石；双肾少量囊肿。5、膀胱充盈欠佳。6、回盲部及部分升结肠壁可疑不均匀增厚或充盈不佳，增强未见明显异常强化，建议结合镜检。7、胰腺、脾脏、双肾上腺、子宫及双侧附件CT平扫及增强未见明显异常。8、腹腔系膜局部密度稍增高并散在小淋巴结影。2026-07-26 快速石蜡切片检查与诊断,“直肠近肛门隆起中央”小活检组织，查见腺癌。目前诊断: 直肠恶性肿瘤，高血压，头臂干分叉处斑块。诊断依据：结合患者主诉、查体及辅助检查可诊断。鉴别诊断:1.内痔：内痔早期以出血为主要表现，颜色多鲜红，不伴肛门疼痛，可伴有肛门内肿物脱出，肛门镜下可见齿线处粘膜充盈明显，部分齿线消失。内痔痔核为曲张静脉丛，呈桑葚状或结节状突起，颜色紫暗或鲜红。各痔核间常有明显界线或正常的粘膜组织。2.直肠息肉：此病可有大便不适，也可以是便血，有些患者还伴有脓血便，目前结肠镜及活检结果不支持。3.溃疡性结直肠炎：本病以腹泻、黏液便、脓血便、大便次数增多、腹胀、腹痛等为主要症状，目前肠镜结果不支持。诊疗计划:目前治疗方案：1、保守治疗：可选择行放化疗等保守治疗，但可能患者对保守治疗效果差，肿瘤继续出血、梗阻，耽误手术时机等。2、手术治疗：解决肿瘤引起的出血、梗阻等症状，切除肿瘤后延迟生命，但需要承担手术风险，术后根据病检结果决定是否进一步行放化疗。与患者及其家属充分沟通，交代治疗方式及风险。继续完善入院术前相关检查，等待检查结果。患者诉轻微排便不适，给予对症治疗，指导患者加强肺功能锻炼。\n医师签名：医生H/医生C\n", "document_time_raw": "2026-07-29T09:10:54", "event_time_raw": null, "missing_reason": "not_covered_or_not_applicable", "parent_object_id": "PARENT_OBJECT-0000001", "postoperative_document_id": "POSTOPERATIVE_DOCUMENT-0000008", "record_status": "source_record", "source_object_id": "SOURCE_OBJECT-0000001" }, { "available_time": null, "document_content_raw": "2026-07-29 15:13　　　　　日常病程记录\n 今日查看患者，精神、饮食、睡眠可，轻微排便不适，无咳嗽咳痰，无畏寒发热，无胸闷气喘心悸等特殊不适，小便可。查体情况：心脏未见明显异常，双肺呼吸音粗，未闻及明显干湿啰音，腹软，未见肠型及蠕动波，全腹无明显压痛、反跳痛及肌紧张，肝脾未及肿大，未触及包块，双肾区无叩痛，移动性浊音阴性，肠鸣4-5次/分。辅助检查情况：2026-07-24 颈部血管(含双侧颈总动脉、双侧颈内动脉、双侧椎动脉),彩超计算机图文报告,头臂干分叉处斑块形成。2026-07-24 心脏彩超+心功能,彩超计算机图文报告,左房增大；室间隔基底段增厚；主动脉瓣轻度反流。2026-07-25 无感觉电子结肠直肠镜检查,直肠LST（中央隆起区域性质？）；直肠息肉；内镜色素NBI、靛胭脂染色检查术。2026-07-26 快速石蜡切片检查与诊断,“直肠近肛门隆起中央”小活检组织，查见腺癌。2026-07-26 上腹+下腹+盆腔CT薄层平扫+薄层增强+能量成像（空腹+适度胀尿）,能量成像（CT平扫）（加收）,能量成像（CT增强）（加收）,CT薄层平扫（加收）,CT薄层增强（加收）。1、直肠中下段壁增厚，病灶与正常肠壁分界不清，浆膜面光滑，周围脂肪间隙清晰，建议结合肠镜。2、胆囊多发结石并慢性胆囊炎。3、肝内外胆管稍扩张。4、右肾小结石，左肾点状钙化灶或结石；双肾少量囊肿。5、膀胱充盈欠佳。6、回盲部及部分升结肠壁可疑不均匀增厚或充盈不佳，增强未见明显异常强化，建议结合镜检。7、胰腺、脾脏、双肾上腺、子宫及双侧附件CT平扫及增强未见明显异常。8、腹腔系膜局部密度稍增高并散在小淋巴结影。2026-07-27 常规心电图+十二通道加收,1.窦性心律；2.T波改变。2026-07-28 上腹部MR平扫+DWI+胰胆管薄层扫描成像（MRCP),直肠MR平扫+DWI+增强高分辨薄层扫描,MR平扫特殊方式成像,MR增强特殊方式成像。1、胆囊多发结石伴胆囊炎。2、胆总管内多发小结石，肝内外胆管稍扩张。3、肝实质、胰腺、脾脏平扫未见确切异常，必要时增强检查。4、扫及：双肾囊肿、右肾盂旁囊肿可能。5、直肠下段Ca（mrT2N0M0），直肠系膜筋膜MRF（-），直肠壁外血管侵犯EMVI（-）。2026-07-28 胸部CT薄层平扫+薄层增强+能量成像,能量成像（CT平扫）（加收）,能量成像（CT增强）（加收）,CT薄层平扫（加收）,CT薄层增强（加收）,1、双肺散在纤维灶，胸膜下坠积效应，较前相似。2、右肺下叶背段小结节，LU-RADS 2类，较前部分结节此次未见显示。3、冠状动脉及主动脉钙化。4、双侧胸膜稍增厚。5、扫及胆囊结石可能；甲状腺右侧叶低密度结节，请结合超声检查。诊疗计划：给予对症治疗，指导肺部功能锻炼。\n医师签名：医生C\n", "document_time_raw": "2026-07-29T15:13:08", "event_time_raw": null, "missing_reason": "not_covered_or_not_applicable", "parent_object_id": "PARENT_OBJECT-0000001", "postoperative_document_id": "POSTOPERATIVE_DOCUMENT-0000009", "record_status": "source_record", "source_object_id": "SOURCE_OBJECT-0000001" }, { "available_time": null, "document_content_raw": "2026-07-29 16:35　　　　　术前讨论记录\n讨论日期：2026-07-29 16:00 讨论地点：外科办公室\n主持人：医生L 病区主任\n参加讨论人员：职称A：医生L；职称C：医生AN、医生H；职称B：医生C、医生AO、医生AP；所有规范化培训医师、实习及进修医师。\n病史汇报：职称B查看病人及总结病史特点如下：患者A，女，80岁，因“便血1天”于2026-07-24入院。查体:肛门居中，肛门缘可见皮赘，指检直肠下段距离肛门约3-8cm扪及环腔约1/2形态不规则，质地中等偏硬，边界欠清，指套见血染，镜下见直肠新生物糜烂，内痔充血。辅助检查 :2026-07-24 颈部血管(含双侧颈总动脉、双侧颈内动脉、双侧椎动脉),彩超计算机图文报告,头臂干分叉处斑块形成。2026-07-24 心脏彩超+心功能,彩超计算机图文报告,左房增大；室间隔基底段增厚；主动脉瓣轻度反流。2026-07-25 无感觉电子结肠直肠镜检查,直肠LST（中央隆起区域性质？）；直肠息肉；内镜色素NBI、靛胭脂染色检查术。2026-07-26 快速石蜡切片检查与诊断,“直肠近肛门隆起中央”小活检组织，查见腺癌。2026-07-26 上腹+下腹+盆腔CT薄层平扫+薄层增强+能量成像（空腹+适度胀尿）,能量成像（CT平扫）（加收）,能量成像（CT增强）（加收）,CT薄层平扫（加收）,CT薄层增强（加收）,1、直肠中下段壁增厚，病灶与正常肠壁分界不清，浆膜面光滑，周围脂肪间隙清晰，建议结合肠镜。2、胆囊多发结石并慢性胆囊炎。3、肝内外胆管稍扩张。4、右肾小结石，左肾点状钙化灶或结石；双肾少量囊肿。5、膀胱充盈欠佳。6、回盲部及部分升结肠壁可疑不均匀增厚或充盈不佳，增强未见明显异常强化，建议结合镜检。7、胰腺、脾脏、双肾上腺、子宫及双侧附件CT平扫及增强未见明显异常。8、腹腔系膜局部密度稍增高并散在小淋巴结影。2026-07-27 常规心电图+十二通道加收,1.窦性心律；2.T波改变。2026-07-28 上腹部MR平扫+DWI+胰胆管薄层扫描成像（MRCP),直肠MR平扫+DWI+增强高分辨薄层扫描,MR平扫特殊方式成像,MR增强特殊方式成像,1、胆囊多发结石伴胆囊炎。2、胆总管内多发小结石，肝内外胆管稍扩张。3、肝实质、胰腺、脾脏平扫未见确切异常，必要时增强检查。4、扫及：双肾囊肿、右肾盂旁囊肿可能。5、直肠下段Ca（mrT2N0M0），直肠系膜筋膜MRF（-），直肠壁外血管侵犯EMVI（-）。2026-07-28 胸部CT薄层平扫+薄层增强+能量成像,能量成像（CT平扫）（加收）,能量成像（CT增强）（加收）,CT薄层平扫（加收）,CT薄层增强（加收）,1、双肺散在纤维灶，胸膜下坠积效应，较前相似。2、右肺下叶背段小结节，LU-RADS 2类，较前部分结节此次未见显示。3、冠状动脉及主动脉钙化。4、双侧胸膜稍增厚。5、扫及胆囊结石可能；甲状腺右侧叶低密度结节，请结合超声检查。2026-07-24 血常规:大型血小板比率 50.3(%)↑，平均血小板体积 13.6(fL)↑；2026-07-24 凝血功能:活化部分凝血活酶时间 23.3(sec)↓；2026-07-24 生化全套:总蛋白 60.4(g/L)↓，白蛋白 39.5(g/L)↓，总胆红素 22.4(umol/L)↑，直接胆红素 4.9(umol/L)↑，间接胆红素 17.5(umol/L)↑。\n术前诊断：直肠癌；高血压；动脉粥样硬化；胆囊多发结石并慢性胆囊炎；胆总管内多发小结石；肾结石；肾囊肿。\n讨论意见：管床规培医师汇报病史：患者病史如上。医生C职称B：目前直肠癌诊断明确，目前治疗方案：1、保守治疗：可选择行新辅助放化疗等保守治疗，但可能患者对保守治疗效果差，肿瘤继续出血、梗阻，耽误手术时机等。2、手术治疗：解决肿瘤引起的出血、梗阻等症状，切除肿瘤后延迟生命，但需要承担手术风险，术后根据病检结果决定是否进一步行放化疗。与患者及其家属充分沟通，交代治疗方式及风险。医生H职称C：患者目前诊断明确：直肠癌，有手术指征，无绝对手术禁忌症。手术为全麻下腹腔镜直肠癌根治术，使用全身麻醉，患者取截石位。入腹后先探查腹膜、肝脏、胃、小肠、大网膜及盆腔等处是否有转移病灶，然后游离直肠及乙状结肠系膜，根据有无远处转移、粘连情况、肿瘤大小、位置等因素决定具体手术方式、切除范围。术中注意操作轻柔，止血牢固，防止损伤骶前静脉丛、输尿管、大血管、神经、膀胱等。术后加强支持治疗。\n手术主刀医生L：拟定主要术式：腹腔镜下直肠根治术, 患者目前诊断明确：直肠癌，为有手术指征，同意手术。各项术前检查未发现明显手术禁忌症。手术方式同意行腹腔镜直肠癌根治术。入腹后常规探查，手术方式需根据术中探查结果决定：根治术；姑息性切除；造瘘；无法切除；其他。若肿瘤大，患者身体情况差，直肠癌位置低，可术中行末端回肠预防性造瘘，如若探查发现患者已失去根治性手术机会，则行结肠造瘘术。术前向患者及其家属说明可能行人工肛门及术后的影响等。术中注意操作轻，止血牢。术中采用直肠全系膜切除术（TME）以期达良好预后情况，注意游离骶前间隙时防止损伤骶前静脉丛，游离直肠时注意保护输尿管，并防止输尿管损伤。术后注意防止肝肾心肺并发症，注意补液。", "document_time_raw": "2026-07-29T16:35:05", "event_time_raw": null, "missing_reason": "not_covered_or_not_applicable", "parent_object_id": "PARENT_OBJECT-0000001", "postoperative_document_id": "POSTOPERATIVE_DOCUMENT-0000010", "record_status": "source_record", "source_object_id": "SOURCE_OBJECT-0000001" } ], "fall_risk_valid_assessment": [ { "assessment_slot": "1", "assessment_time_raw": "2021-12-25", "available_time": null, "event_time_raw": null, "fall_risk_assessment_id": "FALL_RISK_ASSESSMENT-0000001", "missing_reason": "not_covered_or_not_applicable", "parent_object_id": "PARENT_OBJECT-0000001", "record_status": "source_record", "risk_level_raw": "高度危险", "score_value": "6", "source_object_id": "SOURCE_OBJECT-0000001" }, { "assessment_slot": "2", "assessment_time_raw": "2021-12-29", "available_time": null, "event_time_raw": null, "fall_risk_assessment_id": "FALL_RISK_ASSESSMENT-0000002", "missing_reason": "not_covered_or_not_applicable", "parent_object_id": "PARENT_OBJECT-0000001", "record_status": "source_record", "risk_level_raw": "高度危险", "score_value": "6", "source_object_id": "SOURCE_OBJECT-0000001" }, { "assessment_slot": "3", "assessment_time_raw": "2022-01-05", "available_time": null, "event_time_raw": null, "fall_risk_assessment_id": "FALL_RISK_ASSESSMENT-0000003", "missing_reason": "not_covered_or_not_applicable", "parent_object_id": "PARENT_OBJECT-0000001", "record_status": "source_record", "risk_level_raw": "高度危险", "score_value": "5", "source_object_id": "SOURCE_OBJECT-0000001" }, { "assessment_slot": "1", "assessment_time_raw": "2022-01-09", "available_time": null, "event_time_raw": null, "fall_risk_assessment_id": "FALL_RISK_ASSESSMENT-0000004", "missing_reason": "not_covered_or_not_applicable", "parent_object_id": "PARENT_OBJECT-0000001", "record_status": "source_record", "risk_level_raw": "高度危险", "score_value": "7", "source_object_id": "SOURCE_OBJECT-0000001" }, { "assessment_slot": "2", "assessment_time_raw": "2022-01-12", "available_time": null, "event_time_raw": null, "fall_risk_assessment_id": "FALL_RISK_ASSESSMENT-0000005", "missing_reason": "not_covered_or_not_applicable", "parent_object_id": "PARENT_OBJECT-0000001", "record_status": "source_record", "risk_level_raw": "高度危险", "score_value": "7", "source_object_id": "SOURCE_OBJECT-0000001" }, { "assessment_slot": "3", "assessment_time_raw": "2022-01-15", "available_time": null, "event_time_raw": null, "fall_risk_assessment_id": "FALL_RISK_ASSESSMENT-0000006", "missing_reason": "not_covered_or_not_applicable", "parent_object_id": "PARENT_OBJECT-0000001", "record_status": "source_record", "risk_level_raw": "高度危险", "score_value": "7", "source_object_id": "SOURCE_OBJECT-0000001" }, { 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"not_covered_or_not_applicable", "parent_object_id": "PARENT_OBJECT-0000001", "record_status": "source_record", "risk_level_raw": "高度危险", "score_value": "4", "source_object_id": "SOURCE_OBJECT-0000001" }, { "assessment_slot": "1", "assessment_time_raw": "2022-01-05", "available_time": null, "event_time_raw": null, "fall_risk_assessment_id": "FALL_RISK_ASSESSMENT-0000010", "missing_reason": "not_covered_or_not_applicable", "parent_object_id": "PARENT_OBJECT-0000001", "record_status": "source_record", "risk_level_raw": "高度危险", "score_value": "6", "source_object_id": "SOURCE_OBJECT-0000001" }, { "assessment_slot": "2", "assessment_time_raw": "2022-01-06", "available_time": null, "event_time_raw": null, "fall_risk_assessment_id": "FALL_RISK_ASSESSMENT-0000011", "missing_reason": "not_covered_or_not_applicable", "parent_object_id": "PARENT_OBJECT-0000001", "record_status": "source_record", "risk_level_raw": "高度危险", "score_value": "6", "source_object_id": "SOURCE_OBJECT-0000001" }, { 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"not_covered_or_not_applicable", "parent_object_id": "PARENT_OBJECT-0000001", "record_status": "source_record", "risk_level_raw": "否", "score_value": "3", "source_object_id": "SOURCE_OBJECT-0000001" }, { "assessment_slot": "1", "assessment_time_raw": "2022-08-11", "available_time": null, "event_time_raw": null, "fall_risk_assessment_id": "FALL_RISK_ASSESSMENT-0000015", "missing_reason": "not_covered_or_not_applicable", "parent_object_id": "PARENT_OBJECT-0000001", "record_status": "source_record", "risk_level_raw": "高度危险", "score_value": "4", "source_object_id": "SOURCE_OBJECT-0000001" }, { "assessment_slot": "2", "assessment_time_raw": "2022-08-17", "available_time": null, "event_time_raw": null, "fall_risk_assessment_id": "FALL_RISK_ASSESSMENT-0000016", "missing_reason": "not_covered_or_not_applicable", "parent_object_id": "PARENT_OBJECT-0000001", "record_status": "source_record", "risk_level_raw": "高度危险", "score_value": "4", "source_object_id": "SOURCE_OBJECT-0000001" }, { 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