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emr_example.json
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[
{
"auxiliary_examination": "2023.8.21 血常规：中性粒细胞80.5%↑，淋巴细胞：15.2% 平均血红蛋白浓度：307g/L 嗜酸性粒细胞：0.3% 中性粒细胞绝对值：7.18*10^9/L C反应蛋白：24.3mg/L。\n胸部CT示左肺上叶少许炎性改变，两肺少许纤维灶。左侧斜裂胸膜增厚，心脏稍大。附见：脂肪肝。胆囊结石。请结合临床，随诊复查，必要时进一步检查。",
"outpatient_number": 7213629,
"chief_complaint": "发热1天.",
"physician_signature": "杨晶*",
"preliminary_diagnosis": "发热 ； 肺部感染 ；",
"drug_allergy_history": "无",
"treatment_opinion": "检查 胸部CT平扫+冠状位重建 ；检验 血细胞分析(五分类) ；C-反应蛋白测定(CRP) ；甲流,乙流,副流感抗体（IgM）检测（全血） ；\n处方\n[乙10%]先诺特韦片/利托那韦片组合包装(0.375g*4#/0.1g*2#)/板*5板/盒 1盒 0.75 g q12h 口服\n\n\n\n\n门诊随访。",
"present_illness_history": "患者发热1天,体温37.4℃,伴全身酸痛,头痛，咽喉痛，有咳嗽，黄痰，伴咽痒，无腹痛，无恶心呕吐,无尿频尿急,无咯血或痰中带血，无胸闷胸痛，无呼吸困难，无双下肢浮肿，无关节肿痛等。自测新冠抗原阳性。",
"physical_examination": "神情，气平，咽红，双侧扁桃体无肿大。两肺呼吸音粗，未及罗音。HR90次/分，律齐。腹部软，无压痛。双下肢不肿。无皮疹及关节肿痛。",
"notes": "饮食忌辛辣海鲜，忌烟忌酒，多饮水，监测体温。明日呼吸内科门诊复诊，3天内复查血常规，若病情无好转或加重，需及时就诊。",
"past_history": "否认糖尿病史。否认吸烟史。",
"department": "发热门诊",
"age": "60岁",
"name": "陆***",
"gender": "女",
"patient_id": "A7525BA35AB4F3E11D7753E13CEC1760",
"visit_date": "2023-08-21 09:37:49"
},
{
"auxiliary_examination": "尿常规：RBC+ CT：左输尿管下段结石8mm，双肾小结石",
"outpatient_number": 6924797,
"chief_complaint": "排尿不畅10天",
"physician_signature": "王*",
"preliminary_diagnosis": "输尿管结石 ； 肾结石 ；",
"drug_allergy_history": "无",
"treatment_opinion": "检查 输尿管，膀胱CT平扫+冠状位 ；\n检验 尿液分析+尿沉渣定量 ；\n处方\n[甲]国[甲]〓盐酸坦索罗辛缓释胶曩0.2mg*10#*2板/盒 1盒 0.2 mg qn 口服\n[甲]市[甲]复方金钱草颗粒（无糖型）3g*18袋/盒 2盒 3 g 每天三次 口服\n[甲]市[甲]萆薢分清丸6g/瓶(水丸） 40瓶 6 g 每天两次 口服\n\n\n\n\n门诊随访。",
"present_illness_history": "伴有里急后重。肾结石、输尿管结石史",
"physical_examination": "耻骨上未触及充盈膀胱",
"notes": "复查CT",
"past_history": "否认高血压病史。否认糖尿病病史。否认心脏病病史。否认手术外伤史。",
"department": "泌尿外科",
"age": "54岁",
"name": "周***",
"gender": "男",
"patient_id": "F8494A09B5B34A5F9739BDFA69A6F55B",
"visit_date": "2023-04-12 13:48:19"
},
{
"auxiliary_examination": "无",
"outpatient_number": 7253856,
"chief_complaint": "腹胀数周",
"physician_signature": "俞赛*",
"preliminary_diagnosis": "腹胀 ；",
"drug_allergy_history": "无",
"treatment_opinion": "处方\n[甲]市[甲]〓(济诺)雷贝拉唑钠肠溶胶囊 20mg*7#/盒 2盒 20 mg 每天一次 口服\n[甲][甲]复方阿嗪米特肠溶片 75mg*10#*2板/盒 5盒 150 mg 每天三次 口服\n[甲]国[甲]匹维溴铵片 50mg*15#/盒 30粒 50 mg 每天三次 口服\n[乙10%]复方嗜酸乳杆菌片 0.5g*6#*4板/盒 4盒 1 g 每天三次 口服\n\n\n\n\n门诊随访。",
"present_illness_history": "腹胀伴大便不尽感，无明显腹痛。一年前胃镜检查提示食管片状粗糙，十二指肠球部隆起。结肠息肉 已摘除。",
"physical_examination": "一般可，心肺无殊，腹软，无压痛。",
"notes": "注意休息，定期随访",
"past_history": "无",
"department": "消化内科",
"age": "58岁",
"name": "龚***",
"gender": "男",
"patient_id": "54D06AE9A0D39BAA89A2282A1CB474A8",
"visit_date": "2023-09-07 15:41:42"
},
{
"auxiliary_examination": "尿常规：WBC35 B超：膀胱壁毛糙，前列腺增大钙化，RU10ml",
"outpatient_number": 6835588,
"chief_complaint": "夜尿增多1年",
"physician_signature": "王*",
"preliminary_diagnosis": "前列腺增生 ； 前列腺炎 ；",
"drug_allergy_history": "无",
"treatment_opinion": "检查 [超声]肾、输尿管、膀胱、前列腺 ；[超声]残余尿 ；\n检验 急诊肝功能检测TBIL,AST,ALT,ALP,γ-GT,TP, ；急诊电解质检测K,NA,CL,MG,CA ；急诊肾功能CREA,UREA ；尿液分析+尿沉渣定量 ；前列腺肿瘤筛查TPSA,FPSA ；尿核基质蛋白(NMP22)测定 ；\n处方\n[甲]国[甲]〓盐酸特拉唑嗪片2mg*14粒/盒 2盒 2 mg qn 口服\n[甲]市[甲]萆薢分清丸6g/瓶(水丸） 60瓶 6 g bid 口服\n[甲][甲]阿莫西林/克拉维酸钾分散片&228.5mg*12#/盒 6盒 685.5 mg bid 口服\n\n\n\n\n门诊随访。",
"present_illness_history": "无尿急尿痛",
"physical_examination": "耻骨上未触及充盈膀胱",
"notes": "复查B超、尿常规",
"past_history": "否认高血压病史。否认糖尿病病史。否认心脏病病史。否认手术外伤史。",
"department": "泌尿外科",
"age": "65岁",
"name": "朱***",
"gender": "男",
"patient_id": "22E3171DA966FAF6E4E066DE1D4EBF58",
"visit_date": "2023-03-06 07:44:19"
},
{
"auxiliary_examination": "见报告",
"outpatient_number": 7090488,
"chief_complaint": "咽部疼痛2天",
"physician_signature": "陈佳*",
"preliminary_diagnosis": "急性咽炎 ；",
"drug_allergy_history": "无",
"treatment_opinion": "处方\n[甲]市[甲]〓(帅先)头孢克洛缓释片0.375g*7#*2板/盒 2盒 0.375 g 每天两次 口服\n[乙10%]金喉健喷雾剂30ml/瓶 1瓶 0.1 ml 每天三次 喷雾\n\n\n\n\n门诊随访。2周后复查",
"present_illness_history": "无发热",
"physical_examination": "咽部急性充血。",
"notes": "忌食辛辣，注意保暖",
"past_history": "无眩晕",
"department": "耳鼻咽喉头颈外科",
"age": "89岁",
"name": "郝***",
"gender": "女",
"patient_id": "EC18FF710F2CC0AAFD044C94A52C08CD",
"visit_date": "2023-06-25 16:01:04"
},
{
"auxiliary_examination": "CT：右输尿管结石，右肾积水。",
"outpatient_number": 7168973,
"chief_complaint": "反复右侧腰腹部疼痛2天，加重3小时。",
"physician_signature": "曾*",
"preliminary_diagnosis": "肾绞痛 ； 输尿管结石伴有积水和感染 ；",
"drug_allergy_history": "无",
"treatment_opinion": "检查 输尿管，膀胱CT平扫+冠状位 ；CT平扫第二部位 ；\n检验 血细胞分析(五分类) ；C-反应蛋白测定(CRP) ；血清淀粉样蛋白测定(SAA) ；白介素6 ；急诊肝功能检测TBIL,AST,ALT,ALP,γ-GT,TP, ；葡萄糖测定(随机或空腹，干化学法) ；急诊肾功能CREA,UREA ；尿液分析+尿沉渣定量 ；\n处方\n▲[乙10%]〓酮咯酸氨丁三醇注射液1ml:30mg*10支/盒 2支 60 mg 临时 肌肉\n[甲]国[甲]氢溴酸山莨菪碱注射液1ml:10mg*2支/盒 1支 10 mg 临时 肌肉\n[甲]市[甲]复方金钱草颗粒（无糖型）3g*18袋/盒 6盒 6 g 每天三次 口服\n[乙10%]热淋清胶曩0.3g*60#/瓶 6瓶 1.8 g 每天三次 口服\n\n\n治疗[甲]肌肉注射1次 ；\n\n2周门诊复查随访。",
"present_illness_history": "恶心不适，无发热。左侧肾结石病史。",
"physical_examination": "一般可",
"notes": "清洁外阴，多饮水，忌酒，忌久坐，忌辛辣食物。",
"past_history": "否认高血压病史。否认糖尿病病史。否认心脏病病史。否认手术外伤史。",
"department": "泌尿外科",
"age": "45岁",
"name": "朱***",
"gender": "男",
"patient_id": "9018C2BFCCD5610374DC254A830ABA5A",
"visit_date": "2023-07-31 11:29:45"
},
{
"auxiliary_examination": "阴道分泌物：霉菌（+）",
"outpatient_number": 7193924,
"chief_complaint": "体检发现霉菌性阴道炎要求治疗",
"physician_signature": "张*",
"preliminary_diagnosis": "霉菌性阴道炎 ；",
"drug_allergy_history": "无",
"treatment_opinion": "处方\n[甲]国[甲](浙江)克霉唑阴道片0.5g*3#/盒 2盒 0.5 g 每天一次 阴道用\n\n\n\n\n门诊随访。",
"present_illness_history": "末次月经7-10.TCT：NILM",
"physical_examination": "/",
"notes": "保持外阴清洁。\n同房使用避孕套避免传染。\n注意个人卫生。",
"past_history": "否认高血压病史。否认糖尿病病史。否认心脏病病史。否认手术外伤史。",
"department": "妇科",
"age": "34岁",
"name": "陶***",
"gender": "女",
"patient_id": "BBB48F32BC2F67C0C0CC374D682F3F4D",
"visit_date": "2023-08-11 10:22:44"
}
]