data_example_en.json

{
  "id": 1,
  "clinical_case_uid": "2e4ff11eaa244c2d8124e537d2b061e3",
  "language": "en",
  "clinical_department": "Gastroenterology",
  "principal_diagnosis": "Rupture and bleeding of esophagogastric varices",
  "preliminary_diagnosis": "1. Upper gastrointestinal bleeding; 2. Uptured esophagogastric varices bleeding; 3. Liver cirrhosis; 4. Anemia; 5. Electrolyte imbalance.",
  "diagnostic_basis": "1. History of chronic Hepatitis B, and vomiting blood for 2 days after eating hard food.\n2. Physical examination supports the diagnosis: (1) Flat abdomen, no gastrointestinal peristaltic waves, abdominal breathing present, no visible abdominal wall vein varicosity. (2) Soft abdomen, no fluid wave or shifting dullness, no palpable masses, no significant tenderness or rebound pain, liver and spleen not palpable below the ribs, Murphy's sign negative, no evident renal tenderness or percussion pain, no abnormal vascular pulsation in the abdomen. (3) No significant tenderness at bilateral ureteral pressure points. Liver dullness present, upper boundary at the right mid-clavicular line at the fifth intercostal space, no shifting dullness. (4) Normal bowel sounds.\n3. Imaging examinations support the diagnosis: (1) CT Scan (Plain + Contrast) showing liver cirrhosis, splenomegaly, varices at the lower end of the esophagus and the gastric fundus, and varices in front of the spleen. (2) MRI (Plain + Contrast) indicating liver cirrhosis, fibrosis, enlarged spleen, portal hypertension. (3) Endoscopy (Esophagus, Stomach, Duodenum) revealing ruptured esophageal varices and portal hypertensive gastropathy.\n4. Laboratory examinations support the diagnosis: (1) Routine Blood Test shows: decreased red blood cells (RBC), decreased hemoglobin (HGB), and decreased hematocrit (HCT). (2) Blood biochemistry Test shows: increased aspartate aminotransferase (AST), decreased total protein (TP), decreased albumin (ALB), decreased albumin/globulin ratio (A/G), increased total bilirubin (TBIL), increased direct bilirubin (DBIL), increased indirect bilirubin (IBIL), decreased prealbumin (PA), decreased calcium (Ca), decreased natrium (Na), and decreased osmolarity (OSM). (3) Coagulation Function Test shows: increased prothrombin time (PT), increased thrombin time\# (TT\#), decreased fibrinogen\# (Fg\#), decreased percent activity (PT\%), and increased International Normalized Ratio (PT.INR). ",
  "differential_diagnosis": "1. Gastric and Duodenal Ulcer with Bleeding: Bleeding is a common complication of ulcer disease. Minor bleeding often presents with no clinical symptoms and is only detected during fecal occult blood tests. A bleed greater than 500ml is considered severe, primarily manifested as vomiting blood, bloody stools, and varying degrees of anemia. In patients with a history of ulcer disease presenting with significant gastrointestinal bleeding, gastric and duodenal ulcers should be the first consideration.\n2. Mallory-Weiss Tear: This condition involves a longitudinal mucosal tear at the gastroesophageal junction or cardia leading to upper gastrointestinal bleeding, with 85\% of patients presenting with symptoms of vomiting blood. The typical presentation occurs after an episode of nausea or vomiting. Gastroscopy can diagnose this condition by identifying active bleeding, adherent blood clots, or a fibrin crust on or near the mucosal tear at the gastroesophageal junction.\n3. Gastrointestinal Tumor with Bleeding: About 5\% of cases may experience significant bleeding, presenting as vomiting blood and/or melena (black stools). It is commonly seen in individuals over 40 years old, especially males, who have recently experienced poor general condition, abdominal pain, or other gastrointestinal symptoms. Patients with a personal or family history of gastrointestinal tumors should be particularly considered.",
  "treatment_plan": "1. Based on the patient's condition, establish intravenous access, withhold food and water, and monitor vital signs;。\n2. For treatment, administer intravenous infusion of omeprazole and somatostatin to stop bleeding and protect the stomach from acid; ceftriaxone to prevent infection, and magnesium isoglycyrrhizinate to improve liver function abnormalities; regularly monitor complete blood count, and perform blood transfusion treatment when necessary; provide fluid replacement to maintain stability of electrolytes and acid-base balance, as well as nutritional support and other symptomatic treatments.\n3. Complete routine admission tests such as electrocardiograms and cardiac echocardiography, determine surgical indications, rule out contraindications for surgery, and then schedule endoscopic surgery when appropriate.",
  "clinical_case_summary": "Case Summary\nPatient Basic Information: Middle-aged male, XX years old. (We anonymize the age information in the sample data presented.)\nChief Complaint: Vomiting blood for 2 days after eating.\nMedical History: The patient experienced vomiting of coffee-colored gastric contents (approximately 100ml) accompanied by dizziness, palpitations, and weakness after consuming hard food 2 days ago. There was no abdominal distension, pain, melena, or bloody stool, nor any confusion. The patient was treated conservatively with acid-suppressing and hemostatic medications, after which symptoms of vomiting blood improved. The patient has a history of chronic Hepatitis B for three years, which has not been treated. \nPhysical Examination: Pale skin and mucous membranes, flat abdomen with no visible peristaltic waves and presence of abdominal breathing. No abdominal wall vein varicosity was observed. The abdomen was soft without fluid wave or shifting dullness, and no palpable masses. There was no significant tenderness or rebound tenderness, and the liver and spleen were not palpable below the ribs. Murphy's sign was negative. No evident kidney area tenderness or percussion pain, and no abnormal vascular pulsation in the abdomen. No significant tenderness at bilateral ureteral pressure points. Liver dullness was present, with the upper boundary at the right mid-clavicular line at the fifth intercostal space, with no shifting dullness. Bowel sounds were normal. \nAuxiliary Examination：\n（1）Imaging Examination：\nCT Scan (Plain + Contrast): 1. Ground glass nodule in the lower lobe of the right lung, suggest a follow-up CT in 3-6 months. 2. Linear opacities in the lower lobes of both lungs. 3. Liver cirrhosis, splenomegaly, varices at the lower end of the esophagus and the gastric fundus, and varices in front of the spleen. 4. Possible subcapsular hemangioma in liver segment S7, further examination with MRI suggested. 5. Multiple small cysts in the right lobe of the liver. 6. Fluid accumulation in the gallbladder fossa. 7. No apparent abnormalities in the lower abdominal CT scan.\nMRI (Plain + Contrast)：1. Liver cirrhosis, fibrosis; enlarged spleen; portal hypertension. 2. Small cyst in liver segment S5. 3. Minor fluid accumulation in the gallbladder fossa.\nEsophagogastroduodenoscopy: 1. Esophageal varices rupture treated with banding and tissue glue sclerotherapy. 2. Esophageal drug injection via gastroscopy. 3. Endoscopic hemostasis. 4. Portal hypertensive gastropathy.\n（2）Laboratory Examination：\nRoutine Blood Test: 1. Red Blood Cells (RBC) 3.0*10^12/L ↓; 2. Hemoglobin (HGB) 97g/L ↓; 3. Hematocrit (HCT) 27.9% ↓; 4. Platelet Count (Impedance Method) (PLT-I) 47*10^9/L ↓; 5. Mean Platelet Volume (MPV) 13.2fL ↑; 6. Plateletcrit (PCT) 0.06% ↓.\nBlood Biochemistry Test: 1. Aspartate Aminotransferase (AST) 60U/L ↑; 2. Total Protein (TP) 61.6g/L ↓; 3. Albumin (ALB) 31.7g/L ↓; 4. Albumin/Globulin Ratio (A/G) 1.11.2-2.4 ↓; 5. Total Bilirubin (TBIL) 41.5μmol/L ↑; 6. Direct Bilirubin (DBIL) 10.0μmol/L ↑; 7. Indirect Bilirubin (IBIL) 31.5μmol/L ↑; 8. Prealbumin (PA) 93.5mg/L ↓; 9. Calcium (Ca) 2.10mmol/L ↓; 10. Sodium (Na) 136mmol/L ↓; 11. Osmotic Pressure (OSM) 272mOsm/kg ↓.\nCoagulation Function Test: 1. Prothrombin Time# (PT#) 20.8S ↑; 2. Thrombin Time# (TT#) 19.5S ↑; 3. Fibrinogen# (Fg#) 1.1g/L ↓; 4. Percentage Activity (PT%) 43% ↓; 5. International Normalized Ratio (PT.INR) 1.810.85-1.25 ↑.\nTumor Marker Test: 1. Alpha-Fetoprotein (AFP) 307.2ng/mL ↑; 2. Carbohydrate Antigen 19-9 (CA19-9) 69.9U/mL ↑.\n(3) Pathological Examination: None at the moment.",
  "imageological_examination": {
    "plain_computed_tomography_scan+contrast_computed_tomography_scan": {
      "findings": "(1) Lungs: There is a ground-glass nodule in the dorsal segment of the right lower lobe, approximately 5mm x 4mm in size. There are strip-like high-density shadows in both lower lobes. (2) Mediastinum: The structures of both hilum are normal; trachea and bronchi are patent. No significantly enlarged lymph nodes seen in the mediastinum. The heart is normal in size, shape, and position. No pleural thickening on both sides. Dilated and tortuous vessels are visible at the lower end of the esophagus and the fundus of the stomach. (3) Liver: Increased volume of the left hepatic lobe with uneven parenchymal density and irregular liver margins. A small patchy slightly hyperdense shadow is seen subcapsularly in liver segment S7, about 1.1cm in diameter, showing progressive enhancement post-contrast. Multiple small round hypo-dense shadows are seen in the right lobe, the largest being about 0.7cm in diameter, with no enhancement post-contrast. No dilatation of the intrahepatic and extrahepatic bile ducts.  (4) Gallbladder: Normal size, no wall thickening, no abnormal density within the lumen, fluid seen in the gallbladder fossa. (5) Spleen: Enlarged spleen with no obvious abnormal enhancement, multiple dilated and tortuous vascular shadows anterior to the hilum. (6) Pancreas: Clear outline, normal shape and size, no abnormal density or pancreatic duct dilation. (6) Adrenal Area:  No significant abnormalities. (7) Kidneys: Symmetrical kidneys, normal in shape and size, no abnormal density. (8) Abdomen and Pelvis: No enlarged lymph nodes in the abdominal cavity and retroperitoneal space. Normal prostate morphology and size, no abnormalities within. Normal seminal vesicle glands in size, shape, and density. The bladder is well-filled, with no wall thickening, and no abnormal density within. No enlarged lymph nodes in both pelvic walls and inguinal areas.",
      "impression": "(1) Ground-glass nodule in the dorsal segment of the right lower lobe, recommend follow-up CT in 3-6 months. (2) Strip-like densities in both lower lobes. (3) Cirrhosis, splenomegaly, esophageal and gastric fundal varices, varices anterior to the spleen hilum. (4) Possible small hemangioma subcapsularly in liver segment S7, recommend further examination with MRI. (5) Multiple small cysts in the right lobe of the liver. (6) Fluid in the gallbladder fossa. (7) No significant abnormalities in the lower abdominal CT scan. "
    },
    "plain_magnetic_resonance_imaging_scan+contrast_magnetic_resonance_imaging_scan": {
      "findings": "(1) Liver: Not large in volume, with diffuse distribution of thin, reticular high signal T2 fat-suppressed strands; small round high signal T2 lesion in liver segment S5, about 6mm in diameter. Gallbladder is small, with no significant abnormal signal within; a small amount of liquid signal in the gallbladder fossa. (2) Spleen: Significantly enlarged, with uniform signal. (3) Pancreas and Kidneys: Regular shape, uniform signal. (4) Adjacent to the gastroesophageal junction and gastric fundus: Twisted small vascular shadows. Portal vein and splenic vein are thickened.",
      "impression": "(1) Cirrhosis, fibrosis. (2) Splenomegaly. (3) Portal hypertension.(4) Small cyst in liver segment S5. (5) Small amount of fluid in the gallbladder fossa."
    },
    "esophagogastroduodenoscopy": {
      "findings": "The passage through the esophagus was smooth, with moderate varices in the lower segment appearing beaded and exhibiting positive red signs. Five rings of esophageal variceal ligation were performed using a variceal banding device. The gastroesophageal junction was well-functioning and patent, with esophageal varices extending to the fundus of the stomach, where cluster-like varices were visible. Sandwich method applied: two sites injected with 10 ml of polidocanol each and 3 ml of tissue adhesive (6 vials each). The gastric body mucosa was inflamed and eroded. The mucosa of the gastric antrum was congested and edematous, primarily red with interspersed white, showing scattered small patches of erosion. The pylorus was round and well-functioning; no obvious abnormalities were observed in the duodenal bulb.",
      "impression": " (1) Esophageal variceal rupture with banding and tissue adhesive sclerotherapy. (2) Esophagogastroscopic medication injection. (3) Endoscopic hemostasis. (4) Portal hypertensive gastropathy."
    }
  },
  "laboratory_examination": {
    "routine_blood_test": {
      "result": "1 White Blood Cells WBC 5.9 *10^9/L 3.5-9.5 ;2 Lymphocytes Percentage LYMPH% 40.7 % 20.0-50.0 ;3 Monocytes Percentage MONO% 7.5 % 3.0-10.0 ;4 Neutrophils Percentage NEUT% 49.8 % 40.0-75.0 ;5 Absolute Lymphocyte Count LYMPH# 2.4 *10^9/L 1.1-3.2 ;6 Absolute Monocyte Count MONO# 0.44 *10^9/L 0.10-0.60 ;7 Absolute Neutrophil Count NEUT# 2.9 *10^9/L 1.8-6.3 ;8 Red Blood Cells RBC 3.0 ↓ *10^12/L 4.3-5.8 ;9 Hemoglobin HGB 97 ↓ g/L 130-175 ;10 Hematocrit HCT 27.9 ↓ % 40.0-50.0 ;11 Mean Corpuscular Volume MCV 92 fL 82-100 ;12 Mean Corpuscular Hemoglobin MCH 32 pg 27-34 ;13 Mean Corpuscular Hemoglobin Concentration MCHC 345 g/L 316-354 ;14 Red Cell Distribution Width (CV) RDW-CV 12.9 % <15.0 ;15 Platelet Count (Impedance Method) PLT-I 47 ↓ *10^9/L 125-350 ;16 Mean Platelet Volume MPV 13.2 ↑ fL 8.0-10.0 ;17 Platelet Distribution Width PDW 16.7 fL 9.0-17.0 ;18 Eosinophils Percentage EO% 1.7 % 0.4-8.0 ;19 Basophils Percentage BASO% 0.3 % 0.0-1.0 ;20 Absolute Eosinophil Count EO# 0.10 *10^9/L 0.02-0.52 ;21 Absolute Basophil Count BASO# 0.02 *10^9/L 0-0.06 ;22 Plateletcrit PCT 0.06 ↓ % 0.17-0.35 ;23 C-reactive Protein CRP 2.86 mg/L 0-4.00 ;",
      "abnormal": "1. Red Blood Cells (RBC) 3.0*10^12/L ↓; 2. Hemoglobin (HGB) 97g/L ↓; 3. Hematocrit (HCT) 27.9% ↓; 4. Platelet count (Impedance method) (PLT-I) 47*10^9/L ↓; 5. Mean Platelet Volume (MPV) 13.2fL ↑; 6. Plateletcrit (PCT) 0.06% ↓."
    },
    "blood_biochemistry_test": {
      "result": "1 Alanine Aminotransferase ALT 42 U/L 9-50; 2 Aspartate Aminotransferase AST 60 ↑ U/L 15-40; 3 Glutamic Oxaloacetic Transaminase/Alanine Aminotransferase AST/ALT 1.43; 4 Total Protein TP 61.6 ↓ g/L 65.0-85.0; 5 Albumin ALB 31.7 ↓ g/L 40.0-55.0; 6 Globulin GLB 29.9 g/L 20.0-40.0; 7 Albumin/Globulin Ratio A/G 1.1 ↓ 1.2-2.4; 8 Total Bilirubin TBIL 41.5 ↑ μmol/L <23.0; 9 Direct Bilirubin DBIL 10.0 ↑ μmol/L <4.0; 10 Indirect Bilirubin IBIL 31.5 ↑ μmol/L <19.0; 11 Alkaline Phosphatase ALP 99 U/L 40-150; 12 γ-Glutamyltransferase GGT 31 U/L 10-60; 13 Prealbumin PA 93.5 ↓ mg/L 200.0-430.0; 14 Glucose GLU 4.66 mmol/L 3.90-6.10; 15 Urea Urea 5.05 mmol/L 3.10-8.00; 16 Creatinine Cr 89 μmol/L 57-97; 17 Uric Acid UA 287 μmol/L 208-428; 18 Calcium Ca 2.10 ↓ mmol/L 2.11-2.52; 19 Potassium K 4.71 mmol/L 3.50-5.30; 20 Sodium Na 136 ↓ mmol/L 137-147; 21 Chloride Cl 100.2 mmol/L 99.0-110.0; 22 Osmotic Pressure OSM 272 ↓ mOsm/kg 275-300; 23 Hemolysis HEM -; 24 Jaundice ICT +; 25 Lipemia LIP -;",
      "abnormal": "1. Aspartate Aminotransferase (AST) 60U/L ↑; 2. Total Protein (TP) 61.6g/L ↓; 3. Albumin (ALB) 31.7g/L ↓; 4. Albumin/Globulin Ratio (A/G) 1.11.2-2.4 ↓; 5. Total Bilirubin (TBIL) 41.5μmol/L ↑; 6. Direct Bilirubin (DBIL) 10.0μmol/L ↑; 7. Indirect Bilirubin (IBIL) 31.5μmol/L ↑; 8. Prealbumin (PA) 93.5mg/L ↓; 9. Calcium (Ca) 2.10mmol/L ↓; 10. Sodium (Na) 136mmol/L ↓; 11. Osmotic Pressure (OSM) 272mOsm/kg ↓."
    },
    "coagulation_function_test": {
      "result": "1 Prothrombin Time# PT# 20.8 ↑ S 9.4-12.5 ;2 Activated Partial Thromboplastin Time# APTT# 36.5 S 25.1-36.5 ;3 Thrombin Time# TT# 19.5 ↑ S 10.3-16.6 ;4 Fibrinogen# Fg# 1.1 ↓ g/L 2.0-4.0 ;5 Percent Activity PT% 43 ↓ % 70-130 ;6 International Normalized Ratio PT.INR 1.81 ↑ 0.85-1.25 ;",
      "abnormal": "1. Prothrombin Time# (PT#) 20.8S ↑; 2. Thrombin Time# (TT#) 19.5S ↑; 3. Fibrinogen# (Fg#) 1.1g/L ↓; 4. Percentage activity (PT%) 43% ↓; 5. International Normalized Ratio (PT.INR) 1.81 (reference range: 0.85-1.25) ↑."
    },
    "tumor_marker_test": {
      "result": "1 Carcinoembryonic Antigen (CEA) 1.8 ng/mL ≤5.0; 2 Alpha-Fetoprotein (AFP) 307.2 ↑ ng/mL ≤7.0; 3 Cancer Antigen 125 (CA125) 9.4 U/mL ≤35.0; 4 Cancer Antigen 19-9 (CA19-9) 69.9 ↑ U/mL ≤25.0; 5 Cancer Antigen 72-4 (CA72-4) <2 U/mL <10.0;",
      "abnormal": "1. Alpha-Fetoprotein (AFP) 307.2ng/mL ↑; 2. Carbohydrate Antigen 19-9 (CA19-9) 69.9U/mL ↑."
    }
  },
  "pathological_examination": "Not available.",
  "therapeutic_principle": "1. Based on the patient's condition, establish intravenous access, withhold food and water, and monitor vital signs. 2. For treatment, administer intravenous infusion of omeprazole and somatostatin to stop bleeding and protect the stomach from acid; ceftriaxone to prevent infection, and magnesium isoglycyrrhizinate to improve liver function abnormalities; regularly monitor complete blood count, and perform blood transfusion treatment when necessary; provide fluid replacement to maintain stability of electrolytes and acid-base balance, as well as nutritional support and other symptomatic treatments. 3. Complete routine admission tests such as electrocardiograms and cardiac echocardiography, determine surgical indications, rule out contraindications for surgery, and then schedule endoscopic surgery when appropriate."
}