{ "样例性质": "真实记录·已脱敏", "annotation_document": [ { "document_id": "DOCUMENT-0000001", "recorded_time_missing_reason": "source_recorded_time_missing", "recorded_time_raw": null, "source_document_key": "SOURCE_DOCUMENT-0000001", "source_record_locator": "门诊病历", "text_version": "P33-CANDIDATE-TEXT-v1", "scan_field": "fallback_source_fields", "document_text": "{\"就诊时间\": \"2026-07-14T13:00:00\", \"就诊医院\": \"医院A\", \"就诊科室\": \"肛肠科门诊\", \"医生职称\": \"职称B\", \"性别\": \"女\", \"年龄\": \"80岁\", \"主诉\": \"便血1天\", \"现病史\": \"便血1天，大便次数增多，肛门坠胀，昨日大便7次，无腹痛。\", \"既往史\": \"既往有高血压。\", \"过敏史\": \"否认食物、药物过敏史。 \", \"月经史\": \"已绝经\", \"婚育史\": \"已婚，配偶健在。育有2子2女 ，子女体健。\", \"家族史\": \"既往无特殊病史。\", \"个人史\": \"出生于D省E市F县、居住在D省E市F县80年，无疫区居留史。无业人员及无毒物接触史，无吸烟史，无嗜酒史，无冶游史。\", \"体格检查\": \"已检查。\", \"检查检验/辅助检查\": \"无\", \"诊断\": \"直肠肿物,大便习惯改变,内痔,外痔,高血压\", \"医嘱/处理建议/诊疗计划\": \"拟收治入院，完善相关检查。\"}" }, { "document_id": "DOCUMENT-0000002", "recorded_time_missing_reason": "source_recorded_time_missing", "recorded_time_raw": null, "source_document_key": "SOURCE_DOCUMENT-0000002", "source_record_locator": "入院记录", "text_version": "P33-CANDIDATE-TEXT-v1", "scan_field": "fallback_source_fields", "document_text": "{\"入院时间\": \"2026-07-14T13:46:27\", \"性别\": \"女\", \"年龄\": \"80岁\", \"就诊医院\": \"医院A\", \"就诊科室\": \"胃肠外科一病区\", \"就诊医生\": \"医生C\", \"主诉\": \"便血1天\", \"现病史\": \"患者于入院前1天出现便血，量多，呈暗红色，昨日解便7次，不伴腹痛，今为求进一步治疗，遂至我科门诊就诊，门诊以“大便习惯改变”收治入院。一般情况：神清、精神可，胃纳可，夜寐安，小便通畅，大便情况如上所述。\", \"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，否认外伤史，否认输血史，过敏原：否认， 过敏症状：无，预防接种史不详。\", \"个人史\": \"出生于D省E市F县、居住在D省E市F县80年，无疫区居留史。无业人员及无毒物接触史，无吸烟史，无嗜酒史，无冶游史。\", \"过敏史\": \"无食物药物过敏史。\", \"月经史\": \"已绝经。\", \"婚育史\": \"已婚，配偶健在。育有2子2女 ，子女体健。\", \"家族史\": \"家族中无同类病人；无遗传倾向的疾患。直系亲属中无与患者类似疾病，无遗传史，无传染病，无慢性病史。\", \"体格检查\": \"体温：36.5℃，脉搏：64次/分，呼吸：20次/分，血压：130/78mmHg,身高：155cm，体重：65kg\", \"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。\", \"检查检验/辅助检查\": \"—\", \"入院诊断\": \"初步诊断：\\n西医诊断\\n1.直肠肿物\\n2.高血压\\n修正诊断：\\n西医诊断：\\n1.直肠癌\\n2.低蛋白血症\\n3.高血压\\n4.动脉粥样硬化\\n5.胆囊结石伴慢性胆囊炎\\n6.胆总管结石\\n7.肾结石\\n8.单纯性肾囊肿\"}" }, { "document_id": "DOCUMENT-0000003", "recorded_time_missing_reason": null, "recorded_time_raw": "2026-07-14T16:54:51", "source_document_key": "SOURCE_DOCUMENT-0000003", "source_record_locator": "首次病程记录", "text_version": "P33-CANDIDATE-TEXT-v1", "scan_field": "fallback_source_fields", "document_text": "{\"文档记录时间\": \"2026-07-14T16:54:51\", \"病例特点\": \"1.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：-\", \"入院诊断\": \"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。\", \"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。\"}" }, { "document_id": "DOCUMENT-0000004", "recorded_time_missing_reason": null, "recorded_time_raw": "2026-07-14T16:54:51", "source_document_key": "SOURCE_DOCUMENT-0000004", "source_record_locator": "病程和查房记录", "text_version": "P33-CANDIDATE-TEXT-v1", "scan_field": "文档内容", "document_text": "2026-07-14 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2026-07-14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_id": "DOCUMENT-0000005", "recorded_time_missing_reason": null, "recorded_time_raw": "2026-07-15T08:08:43", "source_document_key": "SOURCE_DOCUMENT-0000005", "source_record_locator": "病程和查房记录", "text_version": "P33-CANDIDATE-TEXT-v1", "scan_field": "文档内容", "document_text": "2026-07-15 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 :2026-07-14 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、2026-07-14 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_id": "DOCUMENT-0000006", "recorded_time_missing_reason": null, "recorded_time_raw": "2026-07-16T12:06:48", "source_document_key": "SOURCE_DOCUMENT-0000006", "source_record_locator": "病程和查房记录", "text_version": "P33-CANDIDATE-TEXT-v1", "scan_field": "文档内容", "document_text": "2026-07-16 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:2026-07-16 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。2026-07-16 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_id": "DOCUMENT-0000007", "recorded_time_missing_reason": null, "recorded_time_raw": "2026-07-17T09:12:53", "source_document_key": "SOURCE_DOCUMENT-0000007", "source_record_locator": "病程和查房记录", "text_version": "P33-CANDIDATE-TEXT-v1", "scan_field": "文档内容", "document_text": "2026-07-17 09:12　　　　　转出记录\n患者A，女，80岁，因便血1天于2026-07-14入院。\n入院科室：肛肠科，转出日期：2026-07-17 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2026-07-14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，2026-07-14 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、2026-07-14 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。2026-07-16 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。2026-07-16 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_id": "DOCUMENT-0000008", "recorded_time_missing_reason": null, "recorded_time_raw": "2026-07-17T10:40:05", "source_document_key": "SOURCE_DOCUMENT-0000008", "source_record_locator": "病程和查房记录", "text_version": "P33-CANDIDATE-TEXT-v1", "scan_field": "文档内容", "document_text": "2026-07-17 10:40　　　　　转入记录\n患者A，女，80岁，因“便血1天”于2026-07-14入院。\n入院科室：肛肠科，转入日期：2026-07-17 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2026-07-14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，2026-07-14 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、2026-07-14 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。2026-07-16 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。2026-07-16 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_id": "DOCUMENT-0000009", "recorded_time_missing_reason": null, "recorded_time_raw": "2026-07-18T15:08:30", "source_document_key": "SOURCE_DOCUMENT-0000009", "source_record_locator": "病程和查房记录", "text_version": "P33-CANDIDATE-TEXT-v1", "scan_field": "文档内容", "document_text": "2026-07-18 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2026-07-14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 :2026-07-14 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、2026-07-14 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。2026-07-16 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。2026-07-16 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_id": "DOCUMENT-0000010", "recorded_time_missing_reason": null, "recorded_time_raw": "2026-07-18T17:09:18", "source_document_key": "SOURCE_DOCUMENT-0000010", "source_record_locator": "病程和查房记录", "text_version": "P33-CANDIDATE-TEXT-v1", "scan_field": "文档内容", "document_text": "2026-07-18 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：2026-07-14，血常规:大型血小板比率 50.3(%)↑，平均血小板体积 13.6(fL)↑；2026-07-14，凝血功能:活化部分凝血活酶时间 23.3(sec)↓；2026-07-4，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_id": "DOCUMENT-0000011", "recorded_time_missing_reason": null, "recorded_time_raw": "2026-07-19T09:10:54", "source_document_key": "SOURCE_DOCUMENT-0000011", "source_record_locator": "病程和查房记录", "text_version": "P33-CANDIDATE-TEXT-v1", "scan_field": "文档内容", "document_text": "2026-07-19 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2026-07-14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:2026-07-14 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、2026-07-14 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。2026-07-16 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。2026-07-16 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_id": "DOCUMENT-0000012", "recorded_time_missing_reason": null, "recorded_time_raw": "2026-07-19T15:13:08", "source_document_key": "SOURCE_DOCUMENT-0000012", "source_record_locator": "病程和查房记录", "text_version": "P33-CANDIDATE-TEXT-v1", "scan_field": "文档内容", "document_text": "2026-07-19 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：2026-07-14 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。2026-07-14 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。2026-07-15 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。2026-07-16 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。2026-07-16 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。2026-07-17 常规心电图+十二通道加收,1.窦性心律；2.T波改变。2026-07-18 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（-）。2026-07-18 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_id": "DOCUMENT-0000013", "recorded_time_missing_reason": null, "recorded_time_raw": "2026-07-19T16:35:05", "source_document_key": "SOURCE_DOCUMENT-0000013", "source_record_locator": "病程和查房记录", "text_version": "P33-CANDIDATE-TEXT-v1", "scan_field": "文档内容", "document_text": "2026-07-19 16:35　　　　　术前讨论记录\n讨论日期：2026-07-19 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2026-07-14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 :2026-07-14 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。2026-07-14 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。2026-07-15 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。2026-07-16 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。2026-07-16 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。2026-07-17 常规心电图+十二通道加收,1.窦性心律；2.T波改变。2026-07-18 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（-）。2026-07-18 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。2026-07-14 血常规:大型血小板比率 50.3(%)↑，平均血小板体积 13.6(fL)↑；2026-07-14 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)↑。\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_id": "DOCUMENT-0000014", "recorded_time_missing_reason": null, "recorded_time_raw": "2026-07-19T17:17:15", "source_document_key": "SOURCE_DOCUMENT-0000014", "source_record_locator": "病程和查房记录", "text_version": "P33-CANDIDATE-TEXT-v1", "scan_field": "文档内容", "document_text": "2026-07-19 17:17　　　　　术前小结\n 患者患者A，女性，80岁，因“便血1天”于2026-07-14入院。\n目前诊断为：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诊断依据：结合患者主诉、病史、查体及辅助检查可诊断。\n拟行手术：腹腔镜直肠癌根治术。\n拟行手术部位：直肠。\n手术时间：2026-07-20。\n手术人员：医生L、医生C、规培医师。\n拟行麻醉方式：全麻。\n手术禁忌症： 目前已经完善术前相关检查，未见明显手术禁忌症。 \n1.放射影像类异常检查结果: 2026-07-16 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。2026-07-18 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（-）。2026-07-18 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。 \n2.超声类异常检查结果: 2026-07-14 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。2026-07-14 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。 \n3.病理检查结果： 2026-07-15 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。2026-07-16 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。 \n4.心脏电生理类检查结果： 2026-07-17 常规心电图+十二通道加收,1.窦性心律；2.T波改变。 \n5.凝血功能结果: 2026-07-14 凝血功能:活化部分凝血活酶时间 23.3(sec)↓； \n6.其他异常辅检结果: 2026-07-14 血常规:大型血小板比率 50.3(%)↑，平均血小板体积 13.6(fL)↑；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)↑。 \n7.术前是否使用抗凝药物：否 桥接方案: - \n8.65岁以上患者术前智力评估结果：2至3分无失智 术前是否已确诊认知障碍:否\n以上8条禁忌症相关内容，请认真填写，上级认真审核，应填未填，单否乙级。\n手术指征：患者的病史、临床表现、检验、影像及病理检查等支持诊断。\n注意事项：1、出血--术中注意止血；2、感染--注意无菌操作；3、损伤邻近组织--仔细操作与保护；4、切除临近器官--与家属沟通；5、病变无法切除--与家属沟通。\n手术要点：术中完整切除直肠癌，清扫周围淋巴结，术中注意保护输尿管、神经等，止血彻底。\n术前准备：术前完善更衣、备皮、禁食项目，术前拟使用头孢呋辛预防感染。目前检查患者能耐受手术，拟明日手术。\n术前手术者查看患者情况记录：\n今日查看患者，精神、饮食、睡眠可，无咳嗽咳痰，无畏寒发热，无胸闷气喘心悸等特殊不适，大小便可。查体：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。目前术前检查完善，无明显手术禁忌症，有手术指针，按计划明日手术，积极术前准备。\n医师签名：医生L/医生C\n" }, { "document_id": "DOCUMENT-0000015", "recorded_time_missing_reason": null, "recorded_time_raw": "2026-07-20T15:55:23", "source_document_key": "SOURCE_DOCUMENT-0000015", "source_record_locator": "病程和查房记录", "text_version": "P33-CANDIDATE-TEXT-v1", "scan_field": "文档内容", "document_text": "2026-07-20 15:55　　　　　术后首次病程记录\n 患者于今日在全身麻醉下行腹腔镜下直肠前切除术+回肠预防性单腔造口术。术中见:腹腔清亮腹水约50ml，腹膜、肝脏表面光滑无结节，肝胆脾胃结肠未见明显异常。小肠部分粘连，直肠中下段质硬包块，侵及肌层，边界不清，较固定，直径3cm*2cm*2cm。肠系膜下动脉根部，乙状结肠系膜见多个肿大淋巴结。手术简要经过：1.全麻成功后，取截石位，常规消毒铺巾，取脐上1.2cm小切口置入1.2cmTroca建立气腹和观察孔，取左下腹及耻骨上各置入0.5cmTroca建立辅助操作孔、取右下腹及耻骨上小切口分别置入1.2cm及0.5cmTroca建立主操作孔，术中所见如上述。2.消融电极解剖器松解粘连小肠，超声刀打开乙状结肠及直肠系膜，松解左侧粘连输尿管并注意保护，游离肠系膜下动脉及静脉，游离并保留左结肠动脉，清扫其周围淋巴结送病检，于肠系膜下动脉及静脉远端用塑料夹夹闭后切断，遇到较大血管使用塑料夹夹闭。超声刀游离乙状结肠及直肠至包块远端3cm，于包块远端2cm处用切割闭合器及2个闭合钉闭合并切断。静脉注射吲哚菁绿帮助术中显示边缘血管血供，判断近端肠管切除位置，切割闭合器及2个闭合钉闭闭合并切断，撤除气腹。3.经下腹切口，逐层进腹，安置切口保护套，移出标本。近端肠管断端置入26#吻合器头，丝线固定。放回腹腔，重新建立气腹，于肛门放吻合器，近远端行结肠-直肠端端吻合。安置盆腔及肛门引流管。4.经右下腹环形切口直径约2.5cm逐层进腹，距回盲部约20cm拖出回肠，使用切割闭合器及1个闭合钉切断回肠，近端回肠分层固定于前鞘及皮下，术中开放，丝线固定肠壁于皮下。5.查无活动性出血，清点纱布器械无误，缝合各穿刺孔，手术顺利，术中满意，术后患者送PACU复苏观察。术后诊断：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。术后处理：予以禁食禁水、心电监测、吸氧、血氧饱和度监测、监测血糖、伤口换药等对症处理，予以头孢呋辛钠预防性抗感染、吸入用布地奈德混悬液雾化、氨茶碱解痉、盐酸氨溴索化痰、琥珀酰明胶注射液扩容、血凝酶止血、法莫替丁抑酸、营养支持等对症治疗。予以红蓝激光促进伤口愈合、双下肢气压治疗预防深静脉血栓、低频脉冲电治疗治疗老年患者术后排尿困难、排痰机辅助排痰，密切关注引流情况及病情变化。\n医师签名：医生C\n" }, { "document_id": "DOCUMENT-0000016", "recorded_time_missing_reason": null, "recorded_time_raw": "2026-07-21T07:43:17", "source_document_key": "SOURCE_DOCUMENT-0000016", "source_record_locator": "病程和查房记录", "text_version": "P33-CANDIDATE-TEXT-v1", "scan_field": "文档内容", "document_text": "2026-07-21 07:43　　　　　中医治疗协作会诊申请\n 协作会诊申请时间：2026-07-21 07:43\n一般病史及诊疗经过： \n会诊治疗项目：中药热熨敷技术，穴位敷贴技术。 \n协作会诊申请目的：请中医及中西医结合科协作、指导治疗。\n医师签名：医生C\n\n\n" }, { "document_id": "DOCUMENT-0000017", "recorded_time_missing_reason": null, "recorded_time_raw": "2026-07-21T09:09:50", "source_document_key": "SOURCE_DOCUMENT-0000017", "source_record_locator": "病程和查房记录", "text_version": "P33-CANDIDATE-TEXT-v1", "scan_field": "文档内容", "document_text": "2026-07-21 09:09　　　　　医生C职称B查房记录\n今日医生C职称B查房：患者神清，精神稍差，自诉手术切口疼痛不适，轻微咳嗽咳痰，轻微恶心反酸烧心不适，偶有干呕，偶有轻微胸闷气促不适，无畏寒发热，小便可，造口少许未排气排便。查体：生命体征平稳，心脏未见明显异常，双肺呼吸音粗，未闻及明显干湿啰音，腹部轻微压痛、无明显反跳痛及肌紧张，切口敷料少许渗出。引流管通畅，引出少量鲜红色血性液体；尿管通畅，尿量可，颜色正常。双下肢无水肿。造瘘口处肠粘膜红润、水肿，造瘘袋中少许气体及粪水溢出。查房指示：目前患者病重，生命体征较平稳，继续吸氧，一级护理及心电监护。目前予以头孢呋辛钠预防抗感染、氨茶碱扩张支气管、氨溴索祛痰、布地奈德雾化、氟比洛芬酯止痛、恩丹西酮止吐、脂肪乳氨基酸(17)葡萄糖(11%)注射液(1440ml/袋)加强营养支持、艾普拉唑钠抑酸预防应激性溃疡出血、补充微量元素及维生素、矛头蝮蛇血凝酶止血、输白蛋白纠正低蛋白症状等对症治疗，维持水电解质平衡。患者术后VTE评估为高危，出血高风险，目前无静脉血栓相关表现，药物抗凝可能加重术后出血，目前暂时给予双下肢、双足气压物理治疗防止下肢血栓形成，必要时可行血管彩超检查、药物抗凝治疗。给予切口激光治疗，每日换药观察切口情况，机械辅助排痰，嘱患者主动咳嗽及适当活动，翻身排背。观察四肢血循环。低频脉冲电治疗促进膀胱功能恢复，功能性电刺激促进胃肠功能恢复。加强造口护理、会阴护理、口腔护理、引流管护理，避免引流管滑脱，保持敷料清洁干燥。指导小茴香热敷，促进胃肠功能恢复，复查血常规及生化等检测，控制血压、血糖水平，密切观察病情变化。\n医师签名：医生C\n" }, { "document_id": "DOCUMENT-0000018", "recorded_time_missing_reason": null, "recorded_time_raw": "2026-07-21T11:57:27", "source_document_key": "SOURCE_DOCUMENT-0000018", "source_record_locator": "病程和查房记录", "text_version": "P33-CANDIDATE-TEXT-v1", "scan_field": "文档内容", "document_text": "2026-07-21 11:57　　　　　中医治疗协作会诊记录\n会诊意见：病史敬悉，结合患者病史及查体，有中医技术治疗指征，建议使用以下治疗技术:中药热熨敷技术，穴位敷贴技术. \n穴位敷贴：可用吴茱萸、党参、佛手贴：天枢、中脘、脾俞、胃俞、大肠俞、气海、关元、足三里等。我科随诊，谢邀。\n中药热熨敷：予以小茴香加热外敷腹部行气止痛对症。\n医师签名：医生AQ\n" }, { "document_id": "DOCUMENT-0000019", "recorded_time_missing_reason": null, "recorded_time_raw": "2026-07-21T17:12:53", "source_document_key": "SOURCE_DOCUMENT-0000019", "source_record_locator": "病程和查房记录", "text_version": "P33-CANDIDATE-TEXT-v1", "scan_field": "文档内容", "document_text": "2026-07-21 17:12　　　　　日常病程记录\n 术后第一天，今日查房，患者神清，精神可，自诉手术切口疼痛不适有所好转，轻微咳嗽咳痰，反酸烧心恶心不适有所好转，偶有干呕，无明显畏寒发热，偶有轻微胸闷气紧不适，小便可，造口少许排气排便。查体情况：生命体征平稳，心脏未见明显异常，双肺呼吸音粗，未闻及明显干湿啰音，腹部轻微压痛、无明显反跳痛及肌紧张，切口少许渗出。引流管通畅，引出少量鲜红色血性液体；尿管通畅，尿量可，颜色正常。造瘘口处肠粘膜红润、水肿，造瘘袋中少许气体及粪水溢出。辅助检查情况：2026-07-21 生化全套+肌酶Ⅰ:总蛋白 47.3(g/L)↓，白蛋白 27.3(g/L)↓，总胆红素 34.8(umol/L)↑，直接胆红素 7.5(umol/L)↑，间接胆红素 27.3(umol/L)↑，总钙 2.01(mmol/L)↓，镁 0.69(mmol/L)↓，氯 111.2(mmol/L)↑；2026-07-21 血常规+全血超敏C反应蛋白:【白细胞计数】 7.0(10^9/L)，中性粒细胞比率 77.8(%)↑，血红蛋白 97(g/L)↓，超敏C反应蛋白 36.02(mg/L)↑；2026-07-21 脑钠肽:B型钠尿肽 210.2(pg/mL)↑；2026-07-21 降钙素原+心肌损伤三合一:降钙素原 0.14(ng/mL)↑；诊疗计划：遵上级医师指示执行，嘱其适度咳嗽咳痰、适当活动，密切观察病情变化。\n医师签名：医生C\n" }, { "document_id": "DOCUMENT-0000020", "recorded_time_missing_reason": null, "recorded_time_raw": "2026-07-22T09:14:20", "source_document_key": "SOURCE_DOCUMENT-0000020", "source_record_locator": "病程和查房记录", "text_version": "P33-CANDIDATE-TEXT-v1", "scan_field": "文档内容", "document_text": "2026-07-22 09:14　　　　　日常病程记录\n 术后第二天，患者自诉手术切口疼痛不适有所好转，咳嗽咳痰明显好转，轻微反酸烧心恶心，偶有干呕，无畏寒发热，偶有轻微胸闷气紧不适，小便可，造口少许排气排便。查体情况：生命体征平稳，神志清楚，精神可，双肺呼吸音粗，未闻及明显干湿罗音，心脏查体未见异常，腹软，腹部轻微压痛、无明显反跳痛及肌紧张，手术切口敷料少许渗出，双下肢无明显水肿。引流管通畅，引出少量鲜红色血性液体；尿管通畅，尿量可，颜色正常。造瘘口处肠粘膜红润、水肿，造瘘袋中少许气体及粪水溢出。辅助检查情况：暂无新增。诊疗计划：继续目前治疗方案，密切观察病情变化。\n医师签名：医生C\n" }, { "document_id": "DOCUMENT-0000021", "recorded_time_missing_reason": null, "recorded_time_raw": "2026-07-23T10:38:59", "source_document_key": "SOURCE_DOCUMENT-0000021", "source_record_locator": "病程和查房记录", "text_version": "P33-CANDIDATE-TEXT-v1", "scan_field": "文档内容", "document_text": "2026-07-23 10:38　　　　　日常病程记录\n 术后第三天，患者神清，精神、睡眠可，诉手术切口疼痛不适明显缓解，腹部阵发性轻微胀痛不适，轻微咳嗽咳痰，无明显胸闷气促，无畏寒发热，反酸烧心恶心明显好转，无明显呕吐，小便可，造口少量排气排便。查体情况：心脏未见明显异常，双肺呼吸音粗，未闻及干湿啰音，腹部软，无明显压痛、反跳痛及肌紧张。引流管通畅，引出少量淡血性液体；尿管通畅，尿量可，颜色正常。造瘘口粘膜红润，轻微水肿，无坏死及狭窄。辅助检查情况：暂无新增。诊疗计划：目前患者病情平稳，拟术后复查胸腹部CT、血常规、生化及PCT等检查，继续目前扩管、止咳、祛痰、止痛、营养支持、抑酸、止血、补充微量元素、维持电解质平稳、输白蛋白等对症治疗，给予每天伤口换药，密切观察病情变化。\n医师签名：医生C\n" }, { "document_id": "DOCUMENT-0000022", "recorded_time_missing_reason": null, "recorded_time_raw": "2026-07-26T08:53:14", "source_document_key": "SOURCE_DOCUMENT-0000022", "source_record_locator": "病程和查房记录", "text_version": "P33-CANDIDATE-TEXT-v1", "scan_field": "文档内容", "document_text": "2026-07-26 08:53　　　　　医生H职称C查房记录\n 今日医生H职称C查房：患者精神、睡眠可，诉轻微手术切口疼痛不适，偶有轻微阵发性腹胀腹痛不适，偶有轻微反酸烧心，无恶心呕吐，轻微咳嗽咳痰，偶有轻微胸闷气促，无胸痛心悸不适，大便次数稍增多，稀便，小便正常。查体：心脏未见明显异常，双肺呼吸音粗，未闻及干湿啰音。腹部软，无明显压痛、反跳痛及肌紧张，腹部切口敷料整洁干燥，伤口皮肤轻微发红，少许渗出，无波动感。引流管通畅，少量淡血性液体引出。造瘘口通畅，黏膜红润，水肿减轻，无坏死及狭窄。2026-07-25 胸部CT薄层平扫,上腹部CT薄层平扫（空腹）,盆腔CT薄层平扫（适度胀尿）,CT薄层平扫（加收）,较2026-07-17胸部片1、双肺散在纤维灶，新增双肺下叶少许炎性病变、胸膜下部分肺膨胀不全。2、右肺下叶背段小结节，LU-RADS 2类，较前相似。3、冠状动脉及主动脉钙化。4、双侧胸膜稍增厚，新增双侧胸腔少量积液。5、扫及甲状腺右侧叶低密度结节，请结合超声检查。较2026-07-16腹部片6、新增直肠术后改变，术区高密度影，盆腔筋膜增厚肿胀，盆腔少量积液，右下腹造瘘后改变，盆腔引流后改变，随诊。7、老年性子宫改变，膀胱未见异常。8、胆囊多发结石并慢性胆囊炎，较前相似。9、肝内外胆管稍扩张。10、胰腺、脾脏平扫未见明显异常。11、附及：右肾小结石，左肾点状钙化灶或结石；双肾少量囊肿可能。2026-07-25 生化全套+肌酶Ⅰ:总蛋白 56.1(g/L)↓，白蛋白 34.5(g/L)↓，血清铁 4.0(umol/L)↓，肌酸激酶 31(U/L)↓，乳酸脱氢酶 105(U/L)↓；2026-07-25 血常规+全血超敏C反应蛋白:血红蛋白 100(g/L)↓，超敏C反应蛋白 42.14(mg/L)↑；2026-07-22 一般细菌涂片:鳞状上皮细胞>25个/LP,WBC <10个/LP ，未找到细菌；2026-07-24 细菌培养:正常菌群生长。诊疗计划：继续给予扩管、止咳、祛痰、雾化、营养支持等对症治疗，患者目前病情较稳定，已排气排便，嘱其开始流质饮食，逐步加强营养摄入。给予洛索洛芬钠止痛，铝镁加护胃，四逆散、复方谷氨酰胺促胃肠功能恢复等对症治疗。必要时复查腹腔彩超，若无明显积液，可拔出引流管。患者VTE评估高危，嘱其适度下床活动防止血栓。给予每天伤口换药，注意查看伤口有无感染、液化情况，必要时伤口间断拆线引流。密切观察病情变化，遵指示执行。\n医师签名：医生H/医生C\n" }, { "document_id": "DOCUMENT-0000023", "recorded_time_missing_reason": null, "recorded_time_raw": "2026-07-26T16:55:26", "source_document_key": "SOURCE_DOCUMENT-0000023", "source_record_locator": "病程和查房记录", "text_version": "P33-CANDIDATE-TEXT-v1", "scan_field": "文档内容", "document_text": "2026-07-26 16:55　　　　　日常病程记录\n 术后第六天，患者一般情况可，病情较稳定，咳嗽咳痰明显好转，偶有轻微阵发性腹痛腹胀不适，无明显反酸烧心恶心呕吐，切口轻微疼痛不适，无明显胸痛胸闷心悸等不适，稀便，小便可。查体情况：心脏未见明显异常，双肺呼吸音粗，未闻及干湿啰音。腹部软，无明显压痛、反跳痛及肌紧张，腹部切口少许渗出。引流管均通畅，少量淡血性液体引出。造瘘口通畅，黏膜红润无坏死。辅助检查情况：暂无新增。诊疗计划：遵上级医师指示执行，继续给予对症治疗，嘱其下床活动，密切观察病情变化。\n医师签名：医生C\n" }, { "document_id": "DOCUMENT-0000024", "recorded_time_missing_reason": null, "recorded_time_raw": "2026-07-29T08:47:55", "source_document_key": "SOURCE_DOCUMENT-0000024", "source_record_locator": "病程和查房记录", "text_version": "P33-CANDIDATE-TEXT-v1", "scan_field": "文档内容", "document_text": "2026-07-29 08:47　　　　　日常病程记录\n 现患者精神、睡眠、饮食可，无畏寒发热，无恶心呕吐，无胸痛胸闷，无腹胀腹痛等不适，造瘘口正常排气排便，小便可。查体情况：心肺未见明显异常，腹部软，无明显压痛、反跳痛及肌紧张，腹部切口愈合可，未拆线。造瘘口粘膜红润、通畅。辅助检查情况：术后病检示:1.“直肠及肿瘤”溃疡型中分化腺癌，侵及黏膜下层，癌肿大小3.5cmx2.6cmx1cm；肠旁淋巴结1/13查见癌。2.“253淋巴结”淋巴结2枚未见癌。3.“吻合圈”未见癌。“直肠及肿瘤”腺癌，可见脉管侵犯，未见确切神经侵犯，肿瘤出芽Bd1级。[REDACTED_IDENTIFIER]-1:CD31(示血管),CK-Pan(示出芽),D2-40(示淋巴管),HER2(0),Ki-67(+，约70%),MLH1(+),MSH2(+),MSH6(+),PMS2(+),S100(示神经),p53(+，突变型)。诊疗计划：患者一般情况可，今日出院。出院医嘱：1.出院用药指导：出院休息1月后继续放化疗治疗；2.复诊指导：胃肠外科门诊定期随访（前3年，每3个月随访1次，如无异常，后2年每6个月随访1次，直至术后5年；以后每年1次）；3.其他注意事项：加强营养，注意休息，门诊继续换药拆线，肛门功能锻炼，出院后在家自行扩肛（每周2次）；出院3个月后条件允许下可行造瘘还纳术；避免进食生冷辣烫、粗纤维、糯米等刺激性强及不易消化类食物；避免烟酒熬夜等不良习惯；专科门诊随访，病情变化，及时就诊。随访地点及时间：地址A本部二楼胃肠外科门诊，门诊时间：医生C 每周一上午；地址B二楼胃肠外科门诊，门诊时间：医生H 每周一、四上午，医生L 每周三全天。\n医师签名：医生C\n" }, { "document_id": "DOCUMENT-0000025", "recorded_time_missing_reason": "source_recorded_time_missing", "recorded_time_raw": null, "source_document_key": "SOURCE_DOCUMENT-0000025", "source_record_locator": "手术记录", "text_version": "P33-CANDIDATE-TEXT-v1", "scan_field": "fallback_source_fields", "document_text": "{\"手术开始时间\": \"2026-07-20T09:00:00\", \"手术结束时间\": \"2026-07-20T11:50:00\", \"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2026-07-20 09:00 2026-07-20 11:50\", \"术后诊断\": \"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\", \"手术名称\": \"腹腔镜下直肠前切除术+回肠预防性单腔造口术\", \"麻醉方法\": \"全身麻醉\", \"手术经过\": \"1.全麻成功后，取截石位，常规消毒铺巾，取脐上1.2cm小切口置入1.2cmTroca建立气腹和观察孔，取左下腹及耻骨上各置入0.5cmTroca建立辅助操作孔、取右下腹及耻骨上小切口分别置入1.2cm及0.5cmTroca建立主操作孔，术中所见如上述。2.消融电极解剖器松解粘连小肠，超声刀打开乙状结肠及直肠系膜，松解左侧粘连输尿管并注意保护，游离肠系膜下动脉及静脉，游离并保留左结肠动脉，清扫其周围淋巴结送病检，于肠系膜下动脉及静脉远端用塑料夹夹闭后切断，遇到较大血管使用塑料夹夹闭。超声刀游离乙状结肠及直肠至包块远端3cm，于包块远端2cm处用切割闭合器及2个闭合钉闭合并切断。静脉注射吲哚菁绿帮助术中显示边缘血管血供，判断近端肠管切除位置，切割闭合器及2个闭合钉闭闭合并切断，撤除气腹。3.经下腹切口，逐层进腹，安置切口保护套，移出标本。近端肠管断端置入26#吻合器头，丝线固定。放回腹腔，重新建立气腹，于肛门放吻合器，近远端行结肠-直肠端端吻合。安置盆腔及肛门引流管。4.经右下腹环形切口直径约2.5cm逐层进腹，距回盲部约20cm拖出回肠，使用切割闭合器及1个闭合钉切断回肠，近端回肠分层固定于前鞘及皮下，术中开放，丝线固定肠壁于皮下。5.查无活动性出血，清点纱布器械无误，缝合各穿刺孔，手术顺利，术中满意，术毕病员送PACU。\"}" }, { "document_id": "DOCUMENT-0000026", "recorded_time_missing_reason": "source_recorded_time_missing", "recorded_time_raw": null, "source_document_key": "SOURCE_DOCUMENT-0000026", "source_record_locator": "出院记录", "text_version": "P33-CANDIDATE-TEXT-v1", "scan_field": "fallback_source_fields", "document_text": "{\"入院日期\": \"2026-07-14T13:15:22\", \"出院日期\": \"2026-07-29T08:08:16\", \"入院诊断\": \"直肠肿物；高血压\", \"出院诊断\": \"主要诊断：直肠癌（T1N1M0 ⅢA期） 次要诊断：低蛋白血症；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。\", \"入院情况\": \"患者A，女，80岁，因“便血1天”于2026-07-14入院。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。\", \"出院情况\": \"现患者精神、睡眠、饮食可，无畏寒发热，无恶心呕吐，无胸痛胸闷，无腹胀腹痛等不适，造瘘口正常排气排便，小便可。查体：心肺未见明显异常，腹部软，无明显压痛、反跳痛及肌紧张，腹部切口愈合可，未拆线。造瘘口粘膜红润、通畅。患者一般情况可，今日出院。\", \"诊疗经过\": \"入院后完善相关辅助检查，完善肠镜及病检示直肠腺癌，于2026-07-17转入我科，积极术前准备，未见明显手术禁忌症，于2026-07-20在全身麻醉下行腹腔镜下直肠前切除术+回肠预防性单腔造口术。术中见:腹腔清亮腹水约50ml，腹膜、肝脏表面光滑无结节，肝胆脾胃结肠未见明显异常。小肠部分粘连，直肠中下段质硬包块，侵及肌层，边界不清，较固定，直径3cm*2cm*2cm。肠系膜下动脉根部，乙状结肠系膜见多个肿大淋巴结。手术顺利，术后予以抗炎、扩管、止咳、祛痰、止痛、营养支持、抑酸、止血、补充微量元素、维持电解质平稳等对症治疗。术后病检示:1.“直肠及肿瘤”溃疡型中分化腺癌，侵及黏膜下层，癌肿大小3.5cmx2.6cmx1cm；肠旁淋巴结1/13查见癌。2.“253淋巴结”淋巴结2枚未见癌。3.“吻合圈”未见癌。“直肠及肿瘤”腺癌，可见脉管侵犯，未见确切神经侵犯，肿瘤出芽Bd1级。[REDACTED_IDENTIFIER]-1:CD31(示血管),CK-Pan(示出芽),D2-40(示淋巴管),HER2(0),Ki-67(+，约70%),MLH1(+),MSH2(+),MSH6(+),PMS2(+),S100(示神经),p53(+，突变型)。\", \"出院医嘱\": \"1.出院用药指导：出院休息1月后继续放化疗治疗；2.复诊指导：胃肠外科门诊定期随访（前3年，每3个月随访1次，如无异常，后2年每6个月随访1次，直至术后5年；以后每年1次）；3.其他注意事项：加强营养，注意休息，门诊继续换药拆线，肛门功能锻炼，出院后在家自行扩肛（每周2次）；出院3个月后条件允许下可行造瘘还纳术；避免进食生冷辣烫、粗纤维、糯米等刺激性强及不易消化类食物；避免烟酒熬夜等不良习惯；专科门诊随访，病情变化，及时就诊。\"}" } ], "anchor_reference": [ { "anchor_id": "ANCHOR-0000001", "anchor_status": "source_value_missing", "anchor_type": "source_recorded_time", "anchor_value": null, "document_id": "DOCUMENT-0000001" }, { "anchor_id": "ANCHOR-0000002", 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