example-ref.jsonl

{"icd": "I63.900", "sex": "male", "age": "43", "emr": {"chief_complaint": "Left upper limb weakness for 3 days.", "history_of_present_illness": "Three days prior to admission, the patient developed left upper extremity weakness and facial asymmetry at the mouth corner without an obvious trigger. No significant dizziness, headache, or sensory disturbance was reported. He presented to a local hospital, where head CT showed a low-density lesion adjacent to the left lateral ventricle. Acute cerebral infarction was considered. He was then admitted to our department for further evaluation and treatment of cerebral infarction. During the course of illness, he remained alert and coherent, with normal bowel and bladder function, acceptable sleep and appetite, and no significant recent weight change.", "hospital_course": "After admission, relevant examinations were completed. The patient received antiplatelet therapy, plaque-stabilizing treatment, free-radical scavenging therapy, circulation-supportive therapy, and blood glucose and blood pressure monitoring with control. Clinical status remained stable, and he was discharged today.", "discharge_instructions": "1. Follow a low-salt, low-fat diabetic diet and continue blood glucose and blood pressure monitoring. 2. Attend rehabilitation clinic follow-up and continue rehabilitation therapy. 3. Discharge medications: Aspirin 0.1 g once daily (patient-supplied); Clopidogrel 75 mg once daily; Atorvastatin calcium 20 mg once daily in the evening; Butylphthalide soft capsules 0.2 g three times daily before meals; Valsartan/Amlodipine 1 tablet once daily; Gliclazide 80 mg twice daily; Metformin 0.25 g three times daily before meals (patient-supplied). 4. Follow up with our department, Neurology, and Cardiology."}, "entity": {"chief_complaint": {"symptom": ["weakness"]}, "history_of_present_illness": {"symptom": ["weakness", "facial asymmetry"], "examination": ["head CT"]}, "hospital_course": {}, "discharge_instructions": {"medication": ["Aspirin", "Clopidogrel", "Atorvastatin calcium", "Butylphthalide soft capsules", "Valsartan/Amlodipine", "Gliclazide", "Metformin"]}}}
{"icd": "I25.103", "sex": "female", "age": "85", "emr": {"chief_complaint": "Recurrent chest tightness for 2 months.", "history_of_present_illness": "Approximately 2 months before admission, the patient developed chest tightness and shortness of breath without a clear precipitating factor, accompanied by palpitations, dizziness, and diaphoresis. She denied chest pain, nausea, vomiting, transient visual blackout, or syncope, and had no orthopnea at night. Symptoms occurred mainly with activity and at night, usually lasting about 20 minutes before partial relief. Episodes recurred and have gradually worsened recently. She presented to our hospital for further evaluation and was admitted with a working diagnosis of chest tightness of unclear etiology. Recently, she remained alert, in fair general condition, with preserved appetite, normal bowel and bladder habits, and no significant recent weight loss.", "hospital_course": "After admission, the patient received antiplatelet, lipid-lowering, gastric mucosal protection, and anxiolytic therapy, with completion of relevant ancillary examinations.", "discharge_instructions": "1. Rest adequately. Follow a low-salt, low-fat diet, and avoid overexertion and cold exposure. Attend regular follow-up in our clinic, Endocrinology, and Neurology. 2. Discharge medications: Clopidogrel 75 mg qd; Felodipine 5 mg qd; Rosuvastatin 10 mg qd; Diltiazem hydrochloride tablets 30 mg bid; Flupentixol/Melitracen tablets 1 tablet qd (morning and before lunch as instructed); Yupingfeng granules 1 sachet tid. 3. Monitor heart rate and blood pressure. Recheck liver and renal function and electrolytes periodically. Seek medical attention promptly for chest pain, worsening chest tightness/palpitations, skin bruising, bleeding, or melena."}, "entity": {"chief_complaint": {"symptom": ["chest tightness"]}, "history_of_present_illness": {"symptom": ["shortness of breath", "palpitations", "chest tightness"]}, "hospital_course": {}, "discharge_instructions": {"medication": ["Diltiazem hydrochloride tablets", "Rosuvastatin", "Yupingfeng granules", "Felodipine", "Flupentixol/Melitracen tablets", "Clopidogrel"], "auxiliary_examination": ["heart rate"], "laboratory_examination": ["electrolytes", "liver and renal function"], "symptom": ["melena", "chest tightness", "palpitations", "ecchymosis", "chest pain"]}}}