{
  "样例性质": "真实记录·已脱敏",
  "patient": {
    "patient_id": "PT-0000512",
    "gender": "男",
    "age": "64岁"
  },
  "inpatient_encounter": {
    "encounter_id": "IPV-20240404-0001",
    "patient_id": "PT-0000512",
    "admission_time": "2024-04-04 09:40:00",
    "discharge_time": "2024年04月10日 10:00",
    "department": "神经内科",
    "admission_time_semantic": "source_admission_time",
    "discharge_time_semantic": "source_discharge_time"
  },
  "admission_record": {
    "chief_complaint": "右侧肢体麻木伴言语欠利1天",
    "present_illness": "患者1天前晨起出现右手及右侧口角麻木，伴言语欠利，约30分钟后缓解，无意识障碍、抽搐、头痛及呕吐。此后仍感右上肢麻木不适，门诊查体未见明显肌力下降，考虑急性缺血性脑血管病，建议住院完善头MRI及血管评估。患者自发病以来精神可，饮食睡眠尚可，大小便正常。",
    "past_history": "高血压9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5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5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。",
    "allergy_history": "无",
    "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。",
    "physical_examination": "体温36.4℃，脉搏76次/分，呼吸18次/分，血压:左148/92mmHg 右146/90mmHg。发育正常，营养中等，神志清楚，言语可，心肺腹查体未见明显异常，双下肢无水肿。",
    "specialist_examination": "神清，言语流利，理解及执行指令可。双瞳等大等圆，对光反射灵敏，双眼动充分。右侧口角针刺觉较左侧稍减退，伸舌居中。右上肢肌力V-级，右手精细动作稍差，余肢体肌力V级，双侧病理征阴性。NIHSS评分1分。",
    "auxiliary_examination": "2024-04-04头颅CT未见出血；2024-04-05头颅MRI+DWI提示左侧基底节区及放射冠点片状新近梗死灶；头颈CTA提示双侧颈内动脉虹吸段及椎基底动脉粥样硬化改变，未见责任大血管闭塞；糖化血红蛋白7.1%，LDL-C 2.35mmol/L。",
    "preliminary_diagnosis": "1.急性缺血性脑卒中 2.高血压2级（很高危） 3.陈旧性心肌梗死PCI术后 4.2型糖尿病 5.高脂血症 6.脑动脉粥样硬化 7.反流性食管炎",
    "confirmed_diagnosis": "1.急性脑梗死（左侧基底节区及放射冠） 2.脑动脉粥样硬化 3.高血压2级（很高危） 4.陈旧性心肌梗死PCI术后 5.2型糖尿病 6.高脂血症 7.反流性食管炎"
  },
  "first_course_document": {
    "record_time": "2024-04-04 11:55:00",
    "case_features": "1.患者，男，64岁，因“右侧肢体麻木伴言语欠利1天”入院。2.既往有高血压、2型糖尿病、陈旧性心肌梗死PCI术后、高脂血症等脑血管病危险因素。3.本次起病急，症状与脑血管缺血事件相关，入院辅助检查：2024-04-04头颅CT未见出血；2024-04-05头颅MRI+DWI提示左侧基底节区及放射冠点片状新近梗死灶；头颈CTA提示双侧颈内动脉虹吸段及椎基底动脉粥样硬化改变，未见责任大血管闭塞；糖化血红蛋白7.1%，LDL-C 2.35mmol/L。",
    "admission_diagnosis": "1.急性缺血性脑卒中 2.高血压2级（很高危） 3.陈旧性心肌梗死PCI术后 4.2型糖尿病 5.高脂血症 6.脑动脉粥样硬化 7.反流性食管炎",
    "diagnosis_basis": "右手及右侧口角麻木伴一过性言语欠利，症状符合左侧半球缺血事件；头颅CT未见出血，MRI+DWI示左侧基底节区及放射冠新近脑梗死，头颈CTA示动脉粥样硬化改变，急性脑梗死诊断明确。",
    "differential_diagnosis": "短暂性脑缺血发作：症状可缓解，但MRI已有新近梗死灶，故不作为主要诊断。脑出血：头颅CT未见出血。低血糖、癫痫发作后状态与病史及检查不符。",
    "treatment_plan": "完善头颈CTA、动态心电图、超声心动图及卒中危险因素筛查；予双联抗血小板、强化他汀、丁苯酞改善侧支循环、依达拉奉清除自由基；控制血压血糖，评估吞咽及肢体功能，必要时康复训练。"
  },
  "course_document": [
    {
      "record_time": "2024-04-04 11:40:00",
      "document_title": "首次病程记录",
      "document_type": "首次病程记录",
      "clinical_content": "患者基本信息：患者，男，64岁，因“右侧肢体麻木伴言语欠利1天”于2024年04月04日 09:40入科。病例特点：患者1天前晨起出现右手及右侧口角麻木，伴言语欠利，约30分钟后缓解，无意识障碍、抽搐、头痛及呕吐。此后仍感右上肢麻木不适，门诊查体未见明显肌力下降，考虑急性缺血性脑血管病，建议住院完善头MRI及血管评估。患者自发病以来精神可，饮食睡眠尚可，大小便正常。 既往高血压9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5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5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。 入院诊断：1.急性缺血性脑卒中 2.高血压2级（很高危） 3.陈旧性心肌梗死PCI术后 4.2型糖尿病 5.高脂血症 6.脑动脉粥样硬化 7.反流性食管炎。诊疗计划：完善卒中相关检查，给予抗血小板、强化降脂、改善循环及控制危险因素治疗。"
    },
    {
      "record_time": "2024-04-04 14:40:00",
      "document_title": "主治医师查房记录",
      "document_type": "主治医师查房记录",
      "clinical_content": "今日主治医师查房，患者仍有右手麻木，言语欠利未再发作。查体：神清，言语流利，右上肢肌力V-级。查房意见：头颅MRI提示新近梗死，继续抗血小板、强化降脂及改善侧支循环治疗，监测神经功能有无进展。"
    },
    {
      "record_time": "2024-04-05 18:40:00",
      "document_title": "日常病程记录",
      "document_type": "日常病程记录",
      "clinical_content": "患者住院第2天，右手麻木较前略减轻，言语欠利未再发。查体：神清语利，右上肢肌力V-级，双侧病理征阴性。头颅MRI已提示左侧基底节区及放射冠新近脑梗死，继续抗血小板及强化降脂治疗。"
    },
    {
      "record_time": "2024-04-06 09:05:00",
      "document_title": "术前小结",
      "document_type": "术前小结",
      "clinical_content": "患者因右侧肢体麻木伴言语欠利入院，头颅MRI提示左侧基底节区及放射冠新近脑梗死，头颈CTA提示头颈动脉粥样硬化改变。为进一步明确颅内外血管狭窄程度及责任血管情况，拟今日局麻下行经桡动脉全脑血管造影术。术前凝血功能及血小板计数未见明显异常，已向患者及家属交代穿刺点出血、血肿、造影剂过敏、肾功能损害及脑血管事件等风险。"
    },
    {
      "record_time": "2024-04-06 11:20:00",
      "document_title": "术后记录",
      "document_type": "术后记录",
      "clinical_content": "患者今日局麻下行经桡动脉全脑血管造影术，术中示双侧颈内动脉虹吸段轻度狭窄，左侧大脑中动脉M1段管壁稍毛糙，未见责任大血管闭塞，未行支架及取栓处理。术后安返病房，神清语利，右侧肢体麻木同前，右桡动脉穿刺点加压包扎在位，未见活动性渗血，右手末梢循环可。继续抗血小板、强化降脂及控制危险因素治疗。"
    },
    {
      "record_time": "2024-04-06 18:40:00",
      "document_title": "上级医师查房记录",
      "document_type": "上级医师查房记录",
      "clinical_content": "今日上级医师查房。患者症状较入院缓解，影像及血管检查结果已回报。上级医师意见：目前诊断考虑1.急性脑梗死（左侧基底节区及放射冠） 2.脑动脉粥样硬化 3.高血压2级（很高危） 4.陈旧性心肌梗死PCI术后 5.2型糖尿病 6.高脂血症 7.反流性食管炎，治疗方向正确，继续二级预防，注意抗血小板相关出血风险及血压、血糖达标情况。"
    },
    {
      "record_time": "2024-04-08 18:40:00",
      "document_title": "日常病程记录",
      "document_type": "日常病程记录",
      "clinical_content": "患者右侧肢体麻木继续缓解，可自行下床活动。复查生化未见明显肝肾功能异常。继续控制血压、血糖，指导床旁肢体功能训练。"
    },
    {
      "record_time": "2024-04-09 09:00:00",
      "document_title": "日常病程记录",
      "document_type": "日常病程记录",
      "clinical_content": "患者住院第6天，诉头晕较前减轻，无新发言语不清、饮水呛咳、肢体无力及意识障碍。查体：神清语利，双瞳等大等圆，对光反射灵敏，四肢肌力基本正常，双侧病理征阴性。继续目前抗血小板、降脂稳定斑块、改善循环及控制血压血糖治疗，等待/复核相关检查结果。"
    },
    {
      "record_time": "2024-04-10 09:00:00",
      "document_title": "出院前病程记录",
      "document_type": "出院前病程记录",
      "clinical_content": "患者今日拟出院。患者右侧肢体麻木较入院明显减轻，言语流利，饮水无呛咳。查体：神清语利，右上肢肌力V-级，余肢体肌力V级，双侧病理征阴性。生命体征平稳。 已向患者及家属交代出院后规律服药、复查及卒中预警症状。患者及家属表示理解，办理出院。"
    }
  ],
  "procedure": [
    {
      "start_time": "2024年04月06日 10:10",
      "end_time": "2024年04月06日 10:52",
      "procedure_name": "经桡动脉全脑血管造影术",
      "procedure_code": "88.41001",
      "body_site": "脑血管",
      "anesthesia_method": "局部麻醉",
      "preop_diagnosis": "1.急性脑梗死（左侧基底节区及放射冠） 2.脑动脉粥样硬化 3.高血压2级（很高危） 4.陈旧性心肌梗死PCI术后 5.2型糖尿病 6.高脂血症",
      "postop_diagnosis": "1.急性脑梗死（左侧基底节区及放射冠） 2.脑动脉粥样硬化 3.双侧颈内动脉虹吸段轻度狭窄 4.高血压2级（很高危） 5.陈旧性心肌梗死PCI术后 6.2型糖尿病 7.高脂血症",
      "procedure_narrative": "患者取平卧位，常规消毒铺巾，局麻满意后穿刺右侧桡动脉，置入动脉鞘。肝素化后在导丝引导下分别行主动脉弓、双侧颈总动脉、双侧颈内动脉、双侧椎动脉造影。造影示双侧颈内动脉虹吸段管壁欠光整，轻度狭窄；左侧大脑中动脉M1段管壁稍毛糙，未见闭塞；椎基底动脉显影可，未见动静脉畸形及动脉瘤征象。未行取栓及支架处理。退出导管及鞘管，右桡动脉加压包扎，术毕患者安返病房。"
    }
  ],
  "diagnosis": [
    {
      "diagnosis_raw": "1.急性脑梗死（左侧基底节区及放射冠） 2.脑动脉粥样硬化 3.高血压2级（很高危） 4.陈旧性心肌梗死PCI术后 5.2型糖尿病 6.高脂血症 7.反流性食管炎",
      "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": "2024-04-04 10:05:00",
      "end_time": "2024-04-10 09:30:00"
    },
    {
      "order_name": "氯吡格雷片(75mg*7片)",
      "generic_name": "硫酸氢氯吡格雷片",
      "brand_name": "波立维",
      "specification": "75mg×7片/盒",
      "single_dose": "75",
      "dose_unit": "mg",
      "frequency": "q.d.",
      "route": "口服",
      "order_nature": "长期医嘱",
      "start_time": "2024-04-04 10:05:00",
      "end_time": "2024-04-10 09:30:00"
    },
    {
      "order_name": "阿托伐他汀钙片(40mg*7片)",
      "generic_name": "阿托伐他汀钙片",
      "brand_name": "立普妥",
      "specification": "40mg×7片/盒",
      "single_dose": "40",
      "dose_unit": "mg",
      "frequency": "q.n.",
      "route": "口服",
      "order_nature": "长期医嘱",
      "start_time": "2024-04-04 10:05:00",
      "end_time": "2024-04-10 09:30:00"
    },
    {
      "order_name": "丁苯酞氯化钠注射液(100ml:25mg)",
      "generic_name": "丁苯酞氯化钠注射液",
      "brand_name": "恩必普",
      "specification": "100ml:25mg/瓶",
      "single_dose": "25",
      "dose_unit": "mg",
      "frequency": "b.i.d.",
      "route": "静脉滴注",
      "order_nature": "长期医嘱",
      "start_time": "2024-04-04 10:05:00",
      "end_time": "2024-04-10 09:30:00"
    },
    {
      "order_name": "依达拉奉注射液(20ml:30mg)",
      "generic_name": "依达拉奉注射液",
      "brand_name": "必存",
      "specification": "20ml:30mg/支",
      "single_dose": "30",
      "dose_unit": "mg",
      "frequency": "b.i.d.",
      "route": "静脉滴注",
      "order_nature": "长期医嘱",
      "start_time": "2024-04-04 10:05:00",
      "end_time": "2024-04-10 09:30:00"
    },
    {
      "order_name": "泮托拉唑钠肠溶片(40mg*14片)",
      "generic_name": "泮托拉唑钠肠溶片",
      "brand_name": "泮立苏",
      "specification": "40mg×14片/盒",
      "single_dose": "40",
      "dose_unit": "mg",
      "frequency": "q.d.",
      "route": "口服",
      "order_nature": "长期医嘱",
      "start_time": "2024-04-04 10:05:00",
      "end_time": "2024-04-10 09:30:00"
    },
    {
      "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": "2024-04-04 10:05:00",
      "end_time": "2024-04-10 09:30:00"
    },
    {
      "order_name": "酒石酸美托洛尔片(25mg*20片)",
      "generic_name": "酒石酸美托洛尔片",
      "brand_name": "倍他乐克",
      "specification": "25mg×20片/盒",
      "single_dose": "25",
      "dose_unit": "mg",
      "frequency": "q.d.",
      "route": "口服",
      "order_nature": "长期医嘱",
      "start_time": "2024-04-04 10:05:00",
      "end_time": "2024-04-10 09:30:00"
    },
    {
      "order_name": "二甲双胍缓释片(0.5g*30片)",
      "generic_name": "盐酸二甲双胍缓释片",
      "brand_name": "格华止",
      "specification": "0.5g×30片/盒",
      "single_dose": "1",
      "dose_unit": "g",
      "frequency": "b.i.d.",
      "route": "口服",
      "order_nature": "长期医嘱",
      "start_time": "2024-04-04 10:05:00",
      "end_time": "2024-04-10 09:30:00"
    },
    {
      "order_name": "阿卡波糖片(50mg*30片)",
      "generic_name": "阿卡波糖片",
      "brand_name": "拜唐苹",
      "specification": "50mg×30片/盒",
      "single_dose": "50",
      "dose_unit": "mg",
      "frequency": "t.i.d.",
      "route": "口服",
      "order_nature": "长期医嘱",
      "start_time": "2024-04-04 10:05:00",
      "end_time": "2024-04-10 09:30:00"
    }
  ],
  "non_medication_order": [
    {
      "order_name": "入院护理评估",
      "order_type": "护理",
      "frequency": "一次",
      "order_nature": "临时医嘱",
      "start_time": "2024-04-04 09:45:00"
    },
    {
      "order_name": "二级护理",
      "order_type": "护理",
      "frequency": "持续",
      "order_nature": "长期医嘱",
      "start_time": "2024-04-04 09:50:00"
    },
    {
      "order_name": "低盐低脂糖尿病饮食",
      "order_type": "饮食",
      "frequency": "每日",
      "order_nature": "长期医嘱",
      "start_time": "2024-04-04 09:52:00"
    },
    {
      "order_name": "测血压",
      "order_type": "监测",
      "frequency": "b.i.d.",
      "order_nature": "长期医嘱",
      "start_time": "2024-04-04 09:55:00"
    },
    {
      "order_name": "指尖血糖监测",
      "order_type": "监测",
      "frequency": "q.i.d.",
      "order_nature": "长期医嘱",
      "start_time": "2024-04-04 09:56:00"
    },
    {
      "order_name": "神经系统查体观察",
      "order_type": "护理",
      "frequency": "q4h",
      "order_nature": "长期医嘱",
      "start_time": "2024-04-04 09:58:00"
    },
    {
      "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": "2024-04-04 10:00:00"
    },
    {
      "order_name": "生化P2+P3(新)",
      "order_type": "检验",
      "frequency": "一次",
      "order_nature": "临时医嘱",
      "start_time": "2024-04-04 10:01:00"
    },
    {
      "order_name": "凝血四项",
      "order_type": "检验",
      "frequency": "一次",
      "order_nature": "临时医嘱",
      "start_time": "2024-04-04 10:02:00"
    },
    {
      "order_name": "血脂四项",
      "order_type": "检验",
      "frequency": "一次",
      "order_nature": "临时医嘱",
      "start_time": "2024-04-04 10:03:00"
    },
    {
      "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": "2024-04-04 10:04:00"
    },
    {
      "order_name": "同型半胱氨酸(Hcy)测定",
      "order_type": "检验",
      "frequency": "一次",
      "order_nature": "临时医嘱",
      "start_time": "2024-04-04 10:05:00"
    },
    {
      "order_name": "尿液分析",
      "order_type": "检验",
      "frequency": "一次",
      "order_nature": "临时医嘱",
      "start_time": "2024-04-04 10:06:00"
    },
    {
      "order_name": "头颅CT平扫",
      "order_type": "检查",
      "frequency": "一次",
      "order_nature": "临时医嘱",
      "start_time": "2024-04-04 10:10:00"
    },
    {
      "order_name": "头颅MRI平扫+DWI",
      "order_type": "检查",
      "frequency": "一次",
      "order_nature": "临时医嘱",
      "start_time": "2024-04-04 10:40:00"
    },
    {
      "order_name": "头颈CTA",
      "order_type": "检查",
      "frequency": "一次",
      "order_nature": "临时医嘱",
      "start_time": "2024-04-04 10:45:00"
    },
    {
      "order_name": "超声心动图",
      "order_type": "检查",
      "frequency": "一次",
      "order_nature": "临时医嘱",
      "start_time": "2024-04-04 10:50:00"
    },
    {
      "order_name": "动态心电图",
      "order_type": "检查",
      "frequency": "一次",
      "order_nature": "临时医嘱",
      "start_time": "2024-04-04 10:55:00"
    },
    {
      "order_name": "偏瘫肢体综合训练",
      "order_type": "治疗",
      "frequency": "q.d.",
      "order_nature": "长期医嘱",
      "start_time": "2024-04-06 11:40:00"
    },
    {
      "order_name": "复查血细胞分析（五分类）",
      "order_type": "检验",
      "frequency": "一次",
      "order_nature": "临时医嘱",
      "start_time": "2024-04-06 15:40:00"
    },
    {
      "order_name": "复查生化P2+P3(新)",
      "order_type": "检验",
      "frequency": "一次",
      "order_nature": "临时医嘱",
      "start_time": "2024-04-06 15:41:00"
    },
    {
      "order_name": "出院带药指导",
      "order_type": "处置",
      "frequency": "一次",
      "order_nature": "临时医嘱",
      "start_time": "2024-04-10 08:00:00"
    },
    {
      "order_name": "出院",
      "order_type": "处置",
      "frequency": "一次",
      "order_nature": "临时医嘱",
      "start_time": "2024-04-10 09:50:00"
    },
    {
      "order_name": "经桡动脉全脑血管造影术",
      "order_type": "手术",
      "frequency": "一次",
      "order_nature": "临时医嘱",
      "start_time": "2024-04-06 09:20:00"
    },
    {
      "order_name": "术前禁食水",
      "order_type": "处置",
      "frequency": "持续",
      "order_nature": "临时医嘱",
      "start_time": "2024-04-06 06:00:00"
    },
    {
      "order_name": "右桡动脉穿刺点加压包扎观察",
      "order_type": "护理",
      "frequency": "q2h",
      "order_nature": "临时医嘱",
      "start_time": "2024-04-06 11:00:00"
    }
  ],
  "laboratory_result": [
    {
      "panel_name": "血细胞分析（五分类）",
      "specimen": "全血",
      "result_time": "2024-04-04 11:45:00",
      "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": "2024-04-04 11:45:00",
      "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": "2024-04-04 11:45:00",
      "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": "2024-04-04 11:45:00",
      "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": "2024-04-04 11:45:00",
      "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": "2024-04-04 11:45:00",
      "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": "2024-04-04 11:45:00",
      "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": "2024-04-04 11:45:00",
      "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": "2024-04-04 11:45:00",
      "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": "2024-04-04 11:45:00",
      "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": "2024-04-04 11:45:00",
      "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": "2024-04-04 11:45:00",
      "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": "2024-04-04 11:45:00",
      "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": "2024-04-04 11:45:00",
      "item_name": "葡萄糖",
      "item_code": "GLU",
      "value": "7.8",
      "unit": "mmol/L",
      "reference_range": "3.9-6.1"
    },
    {
      "panel_name": "生化P2+P3(新)",
      "specimen": "静脉血",
      "result_time": "2024-04-04 11:45:00",
      "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": "2024-04-04 11:45:00",
      "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": "2024-04-04 11:45:00",
      "item_name": "氯",
      "item_code": "Cl",
      "value": "103.5",
      "unit": "mmol/L",
      "reference_range": "99-110"
    },
    {
      "panel_name": "凝血四项",
      "specimen": "静脉血",
      "result_time": "2024-04-04 11:45:00",
      "item_name": "凝血酶原时间",
      "item_code": "PT",
      "value": "10.8",
      "unit": "s",
      "reference_range": "9.4-12.5"
    },
    {
      "panel_name": "凝血四项",
      "specimen": "静脉血",
      "result_time": "2024-04-04 11:45:00",
      "item_name": "国际标准化比值",
      "item_code": "INR",
      "value": "0.98",
      "unit": null,
      "reference_range": "0.8-1.2"
    },
    {
      "panel_name": "凝血四项",
      "specimen": "静脉血",
      "result_time": "2024-04-04 11:45:00",
      "item_name": "活化部分凝血活酶时间",
      "item_code": "APTT",
      "value": "31.6",
      "unit": "s",
      "reference_range": "25.1-36.5"
    },
    {
      "panel_name": "凝血四项",
      "specimen": "静脉血",
      "result_time": "2024-04-04 11:45:00",
      "item_name": "纤维蛋白原",
      "item_code": "FIB",
      "value": "3.1",
      "unit": "g/L",
      "reference_range": "2.0-4.0"
    },
    {
      "panel_name": "凝血四项",
      "specimen": "静脉血",
      "result_time": "2024-04-04 11:45:00",
      "item_name": "D-二聚体",
      "item_code": "D-D",
      "value": "0.32",
      "unit": "mg/L FEU",
      "reference_range": "0-0.55"
    },
    {
      "panel_name": "血脂四项",
      "specimen": "静脉血",
      "result_time": "2024-04-04 11:45:00",
      "item_name": "总胆固醇",
      "item_code": "CHOL",
      "value": "4.55",
      "unit": "mmol/L",
      "reference_range": "2.8-5.2"
    },
    {
      "panel_name": "血脂四项",
      "specimen": "静脉血",
      "result_time": "2024-04-04 11:45:00",
      "item_name": "甘油三酯",
      "item_code": "TG",
      "value": "1.96",
      "unit": "mmol/L",
      "reference_range": "0.56-1.70"
    },
    {
      "panel_name": "血脂四项",
      "specimen": "静脉血",
      "result_time": "2024-04-04 11:45:00",
      "item_name": "高密度脂蛋白胆固醇",
      "item_code": "HDL-C",
      "value": "1.02",
      "unit": "mmol/L",
      "reference_range": "1.04-1.55"
    },
    {
      "panel_name": "血脂四项",
      "specimen": "静脉血",
      "result_time": "2024-04-04 11:45:00",
      "item_name": "低密度脂蛋白胆固醇",
      "item_code": "LDL-C",
      "value": "2.35",
      "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": "2024-04-04 11:45:00",
      "item_name": "糖化血红蛋白",
      "item_code": "HbA1c",
      "value": "7.1",
      "unit": "%",
      "reference_range": "4.27-6.07"
    },
    {
      "panel_name": "同型半胱氨酸(Hcy)测定",
      "specimen": "静脉血",
      "result_time": "2024-04-04 11:45:00",
      "item_name": "同型半胱氨酸",
      "item_code": "HCY",
      "value": "21.6",
      "unit": "umol/L",
      "reference_range": "0-15"
    },
    {
      "panel_name": "心肌损伤标志物",
      "specimen": "静脉血",
      "result_time": "2024-04-04 11:45:00",
      "item_name": "肌钙蛋白T",
      "item_code": "TNT",
      "value": "8.4",
      "unit": "ng/L",
      "reference_range": "0-14"
    },
    {
      "panel_name": "心肌损伤标志物",
      "specimen": "静脉血",
      "result_time": "2024-04-04 11:45:00",
      "item_name": "N末端B型钠尿肽前体",
      "item_code": "NT-proBNP",
      "value": "92",
      "unit": "pg/mL",
      "reference_range": "0-125"
    },
    {
      "panel_name": "尿液分析",
      "specimen": "尿液",
      "result_time": "2024-04-04 11:45:00",
      "item_name": "尿蛋白",
      "item_code": "PRO",
      "value": null,
      "unit": null,
      "reference_range": "阴性"
    },
    {
      "panel_name": "尿液分析",
      "specimen": "尿液",
      "result_time": "2024-04-04 11:45:00",
      "item_name": "尿糖",
      "item_code": "GLU",
      "value": null,
      "unit": null,
      "reference_range": "阴性"
    },
    {
      "panel_name": "尿液分析",
      "specimen": "尿液",
      "result_time": "2024-04-04 11:45:00",
      "item_name": "酮体",
      "item_code": "KET",
      "value": null,
      "unit": null,
      "reference_range": "阴性"
    },
    {
      "panel_name": "尿液分析",
      "specimen": "尿液",
      "result_time": "2024-04-04 11:45:00",
      "item_name": "尿红细胞",
      "item_code": "RBC",
      "value": "1",
      "unit": "/HP",
      "reference_range": "0-3"
    },
    {
      "panel_name": "尿液分析",
      "specimen": "尿液",
      "result_time": "2024-04-04 11:45:00",
      "item_name": "尿白细胞",
      "item_code": "WBC",
      "value": "2",
      "unit": "/HP",
      "reference_range": "0-5"
    },
    {
      "panel_name": "血细胞分析（五分类）",
      "specimen": "全血",
      "result_time": "2024-04-06 17:40:00",
      "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": "2024-04-06 17:40:00",
      "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": "2024-04-06 17:40:00",
      "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": "2024-04-06 17:40:00",
      "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": "2024-04-06 17:40:00",
      "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": "2024-04-06 17:40:00",
      "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": "2024-04-06 17:40:00",
      "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": "2024-04-06 17:40:00",
      "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": "2024-04-06 17:40:00",
      "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": "2024-04-06 17:40:00",
      "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": "2024-04-06 17:40:00",
      "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": "2024-04-06 17:40:00",
      "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": "2024-04-06 17:40:00",
      "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": "2024-04-06 17:40:00",
      "item_name": "葡萄糖",
      "item_code": "GLU",
      "value": "7.8",
      "unit": "mmol/L",
      "reference_range": "3.9-6.1"
    },
    {
      "panel_name": "生化P2+P3(新)",
      "specimen": "静脉血",
      "result_time": "2024-04-06 17:40:00",
      "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": "2024-04-06 17:40:00",
      "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": "2024-04-06 17:40:00",
      "item_name": "氯",
      "item_code": "Cl",
      "value": "103.5",
      "unit": "mmol/L",
      "reference_range": "99-110"
    }
  ],
  "examination_report": [
    {
      "exam_time": "2024-04-04 10:25:00",
      "exam_name": "头颅CT平扫",
      "exam_type": "CT",
      "body_part": "头颅",
      "findings": "双侧基底节区腔隙灶，脑实质内未见急性出血灶，中线结构居中。",
      "conclusion": "颅内未见急性出血；双侧基底节区腔隙灶。"
    },
    {
      "exam_time": "2024-04-05 08:58:00",
      "exam_name": "头颅MRI平扫+DWI",
      "exam_type": "MRI",
      "body_part": "头颅",
      "findings": "左侧基底节区及放射冠见点片状DWI高信号、ADC减低，FLAIR稍高信号；脑室系统未见明显受压。",
      "conclusion": "左侧基底节区及放射冠新近脑梗死。"
    },
    {
      "exam_time": "2024-04-05 14:05:00",
      "exam_name": "头颈CTA",
      "exam_type": "CTA",
      "body_part": "头颈部动脉",
      "findings": "双侧颈内动脉虹吸段、椎基底动脉壁毛糙并散在钙化斑块，未见责任大血管闭塞。",
      "conclusion": "头颈动脉粥样硬化改变；未见责任大血管闭塞。"
    },
    {
      "exam_time": "2024-04-06 09:40:00",
      "exam_name": "超声心动图",
      "exam_type": "超声",
      "body_part": "心脏",
      "findings": "各房室腔大小正常，左室收缩功能正常，节段性室壁运动异常未见明确显示。",
      "conclusion": "左室收缩功能正常。"
    },
    {
      "exam_time": "2024-04-06 15:30:00",
      "exam_name": "动态心电图",
      "exam_type": "心电图",
      "body_part": "心脏",
      "findings": "窦性心律，偶发房性早搏及室性早搏，未见心房颤动。",
      "conclusion": "窦性心律；偶发房早、室早；未见房颤。"
    }
  ],
  "discharge_record": {
    "admission_date": "2024年04月04日 09:40",
    "discharge_date": "2024年04月10日 10:00",
    "admission_diagnosis": "1.急性缺血性脑卒中 2.高血压2级（很高危） 3.陈旧性心肌梗死PCI术后 4.2型糖尿病 5.高脂血症 6.脑动脉粥样硬化 7.反流性食管炎",
    "discharge_diagnosis": "1.急性脑梗死（左侧基底节区及放射冠） 2.脑动脉粥样硬化 3.高血压2级（很高危） 4.陈旧性心肌梗死PCI术后 5.2型糖尿病 6.高脂血症 7.反流性食管炎",
    "admission_condition": "患者因“右侧肢体麻木伴言语欠利1天”入院。患者1天前晨起出现右手及右侧口角麻木，伴言语欠利，约30分钟后缓解，无意识障碍、抽搐、头痛及呕吐。此后仍感右上肢麻木不适，门诊查体未见明显肌力下降，考虑急性缺血性脑血管病，建议住院完善头MRI及血管评估。患者自发病以来精神可，饮食睡眠尚可，大小便正常。 既往高血压9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5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5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。 入院查体及辅助检查支持入院诊断。",
    "discharge_condition": "患者右侧肢体麻木较入院明显减轻，言语流利，饮水无呛咳。查体：神清语利，右上肢肌力V-级，余肢体肌力V级，双侧病理征阴性。生命体征平稳。",
    "treatment_course": "入院后完善卒中相关检查，头颅MRI提示左侧基底节区及放射冠新近梗死灶，结合右侧肢体麻木及短暂言语欠利，诊断急性脑梗死明确。住院期间行经桡动脉全脑血管造影术，提示双侧颈内动脉虹吸段轻度狭窄，未见责任大血管闭塞，未行支架及取栓处理。给予阿司匹林联合氯吡格雷抗血小板、阿托伐他汀强化降脂稳定斑块、丁苯酞改善侧支循环、依达拉奉清除自由基及控制血压血糖治疗。住院期间右侧肢体麻木逐渐减轻，无进展性卒中表现，吞咽及言语功能基本恢复。",
    "discharge_order": "1.出院后继续康复训练，避免跌倒，低盐低脂糖尿病饮食。2.阿司匹林联合氯吡格雷按疗程服用21天，之后按门诊医师意见调整；继续强化他汀，目标LDL-C<1.8mmol/L。3.2-4周复诊，复查血脂、肝功能、肌酶、血糖及血常规。4.右侧肢体麻木加重、言语不清、口角歪斜或出血表现时及时就诊。"
  }
}