CN117253573B - A system for constructing structured cases - Google Patents
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Abstract
本发明公开了一种结构化病例的构建系统，涉及医疗设备技术领域。本发明的构建系统包括临床辨析模块、临床信息追加拓展模块、重症超声及方案化评估模块、病理生理及表型解读模块、机体反应表型分析模块、病因分析模块、治疗分析模块和治疗效果反馈分析模块。本发明解决现有病例表现形式参差不齐的情况，规范病例诊疗行为的标准化、结构化展示，使得病例资料的收集更加规范和全面，避免了病例表现形式参差不齐的情况，同时也使得不同水平级别的医生在病例呈现的过程中更加接近统一，以方便后续的病例库管理和教学。
The present invention discloses a system for constructing structured cases, and relates to the field of medical equipment technology. The construction system of the present invention includes a clinical analysis module, a clinical information additional expansion module, a critical ultrasound and program evaluation module, a pathophysiology and phenotype interpretation module, a body reaction phenotype analysis module, a cause analysis module, a treatment analysis module, and a treatment effect feedback analysis module. The present invention solves the problem of uneven presentation of existing cases, standardizes the standardized and structured display of case diagnosis and treatment behaviors, makes the collection of case data more standardized and comprehensive, avoids the situation of uneven presentation of cases, and also makes doctors of different levels closer to unity in the process of case presentation, so as to facilitate subsequent case library management and teaching.
Description
Technical Field
The invention relates to the technical field of medical equipment, in particular to a structuring case building system.
Background
The existing diagnosis and treatment process and analysis presentation mode aiming at severe clinical cases are mainly carried out manually. Most of the cases that the clinician wants to present the content are that clinical diagnosis and treatment information and the like are collected in the cases according to presentation rules of the clinician, and then courseware is produced according to diagnosis and treatment ideas of the clinician. The disadvantage of such presentation forms is also particularly remarkable, including that the ideas and ideas of the case makers of each clinician are different and the level is different, so that the capability of collecting clinical information is uneven, and the case making presentation content mode is confusing and eight, and even the case emphasis cannot be grasped. Is not beneficial to case collection and case teaching, and can also cause some obstruction to later case characteristic analysis and scientific research.
The invention discloses a first digital electronic medical record and a second digital electronic medical record, wherein the first digital electronic medical record comprises a code scanning module for scanning a two-dimensional code of a patient, a diagnosis information acquisition module and a disease preliminary classification module, the diagnosis information acquisition comprises a basic information acquisition unit and a disease history acquisition unit, the basic information acquisition unit is used for completing personal information input of names, ages, professions, sexes, native, family information, through and residence of the patient, and the like, and the disease history acquisition unit is used for completing input of related symptoms, diagnosis and treatment passes, curative effects, past disease histories, family genetic disease histories, operation histories and fertility Shi Dengxiang related information of the patient. The second digital electronic medical record comprises a body checking module, a diagnosis and treatment information module, a patient condition information acquisition module and a doctor auditing and analyzing module, wherein the body checking module is used for recording and extracting information after checking the patient, the diagnosis and treatment information module is used for recording and extracting treatment information in the treatment process, the patient condition information acquisition module is used for recording and extracting symptom improvement conditions and bad symptom conditions in the treatment process of the patient, and the doctor auditing and analyzing module is used for recording and extracting auditing and analyzing conditions of the patient condition checking and treatment operation by a doctor so as to generate the second digital electronic medical record. The diagnosis and treatment information module comprises a doctor advice unit, an auxiliary checking unit and a treatment operation information unit, wherein the doctor advice information unit is used for finishing information input and extraction of aspects such as diet guidance, treatment scheme, rehabilitation training and the like of a patient in the treatment process, the auxiliary checking unit is used for inputting and extracting auxiliary checking information of the patient in the treatment process, and the treatment operation information unit is used for inputting and extracting treatment mode of the patient, operation time during operation, operation mode, bleeding condition, anesthesia mode and complication information.
The first digital electronic medical record and the second digital electronic medical record in the prior art are used for recording basic information, medical history information, examination information, diagnosis and treatment information, patient condition information, doctor examination information and the like of a patient, and the generation of the case for teaching is that a clinician carries out the production and presentation of the case according to the own diagnosis and treatment thought of the clinician according to the content which is wanted to be presented, the production of the case is different from person to person, the content mode of the production and presentation of the case is five-in-eight, the case teaching and the case collection are not facilitated, and some barriers are caused for the subsequent analysis and scientific research of the characteristics of the case.
Disclosure of Invention
In order to overcome the defects and shortcomings in the prior art, the invention provides a construction system of a structured case, and aims to solve the problem that the existing case expression forms are uneven, standardize the standardized and structured display of the case diagnosis and treatment behaviors, enable the collection of the case data to be more standard and comprehensive, avoid the situation that the case expression forms are uneven, and enable doctors with different levels to be more nearly unified in the case presentation process, so that the follow-up case library management and teaching are convenient.
In order to solve the problems in the prior art, the invention is realized by the following technical scheme.
The invention discloses a construction system of a structured case, which comprises a clinical resolution module, a clinical information additional expansion module, a severe ultrasound and scheme evaluation module, a pathophysiology and phenotype reading module, an organism reaction phenotype analysis module, a etiology analysis module, a treatment analysis module and a treatment effect feedback analysis module, wherein,
The clinical analysis module is used for inputting basic information, main complaint information and medical history information of a patient, and combing and presenting the characteristics of the illness state and the diagnosis and treatment progress at different time points respectively according to a mode taking time as an axis for the current medical history of the patient and the diagnosis and treatment progress before the change of the illness state of a core of the patient to generate an illness state time line;
An organ system evaluation sub-module is arranged in the clinical analysis module, an organ system evaluation rule base is associated in the organ system evaluation sub-module, and an organ system evaluation rule is preset in the organ system evaluation rule base; the organ system evaluation submodule is used for classifying according to organ systems and evaluating the organ systems according to any one or more data of symptoms, check data, auxiliary check data and/or organ system support force of each organ system in combination with preset organ system evaluation rules, wherein the organ system support force refers to support treatment means applied to a patient for the corresponding organ system;
carrying out clinical analysis based on the disease time line and the system evaluation result of the viscera system evaluation sub-module, and obtaining main clinical problems and/or collaborative clinical problems of the current patient by the analysis;
The clinical information additional expansion module is used for combing and presenting the basic condition of the organ system related to the main clinical problem and/or the collaborative clinical problem according to the main clinical problem and/or the collaborative clinical problem which are distinguished by the clinical distinguishing module, and adding and recording clinical details;
the severe ultrasound and planning evaluation module is used for inputting ultrasound evaluation data of a patient;
The system comprises a pathophysiological and phenotype interpretation module, a critical ultrasound and scheme evaluation module, a processing module and a processing module, wherein a plurality of pathophysiological informationized framework structures and pathophysiological phenotype thinking graphs are preset in the pathophysiological and phenotype interpretation module, and judging rules for the pathophysiological phenotype are preset in the pathophysiological phenotype thinking graphs;
The system comprises an organism reaction phenotype analysis module, an organism reaction phenotype analysis module and an organism reaction phenotype analysis module, wherein the organism reaction phenotype analysis module is used for analyzing the organism reaction phenotype of the organism;
The etiology analysis module is used for carrying out etiology analysis and recording according to the clinical analysis result of the clinical analysis module, the basic condition and clinical detail of the organ system of the clinical information additional expansion module, the ultrasonic interpretation result of the severe ultrasonic and scheme evaluation module, the interpretation result of the pathophysiology and phenotype interpretation module and the matrix reaction phenotype determined by the organism reaction phenotype analysis module;
the treatment analysis module is used for selectively adding judgment contents in the pathophysiology and phenotype reading module, the organism reaction phenotype analysis module and the etiology analysis module into the treatment analysis module and adding corresponding treatment analysis contents according to the added contents;
The treatment effect feedback analysis module is used for presenting and recording treatment effects.
Further preferably, a plurality of severe ultrasound data entry schemes are built in the severe ultrasound and scheme evaluation module, corresponding severe ultrasound data entry schemes are selected according to the entered ultrasound data, and ultrasound data are correspondingly entered according to the corresponding severe ultrasound data entry schemes.
Still further preferably, the severe ultrasound and planning evaluation module further includes an image quality control sub-module, and the image quality control sub-module is configured to perform image quality control processing on the input ultrasound data, where the ultrasound data meeting the image quality control requirement can be input into the severe ultrasound and planning evaluation module.
Still further preferably, the intensive ultrasound and planned evaluation module is provided with any one or more of an intensive ultrasound circulation evaluation module, an intensive ultrasound respiration evaluation module and an expanded organ function evaluation module, wherein the intensive ultrasound circulation evaluation module is used for inputting ultrasound data reflecting a circulation system, the intensive ultrasound respiration evaluation module is used for inputting ultrasound data reflecting a respiration system, and the expanded organ function evaluation module is used for inputting ultrasound data of other organs.
Still more preferably, the ultrasound data of the other organ includes any one or more of brain ultrasound data, gastrointestinal tract ultrasound data, and kidney ultrasound data.
Still further preferably, the plurality of intensive ultrasound data entry protocols in the intensive ultrasound and planning evaluation module include any combination of one or more of E-FATE (Extended Focus Assessed Transthoracic Echo, extended target-oriented echocardiography protocol), BLUE-PLUS (BedsideLungUltrasound IN EMERGENCY-PLUS, bedside pulmonary ultrasound evaluation protocol), twelve-partition protocol for pulmonary ultrasound, M-BLUE protocol, and PLUE protocol.
An image classification model is preset in an image quality control sub-module in the severe ultrasound and scheme evaluation module, the image classification model performs image classification processing on input ultrasound data, the input ultrasound data is divided into a qualified image and a unqualified image, the image qualification rate of the input ultrasound data is calculated, and after the image qualification rate of the input ultrasound data reaches a set image qualification rate threshold value, the ultrasound data is input into the severe ultrasound and scheme evaluation module.
Still preferably, the treatment effect feedback analysis module includes a system evaluation feedback sub-module, configured to collect symptoms, check-up data and auxiliary check-up data of the treated organ system, and perform presentation and recording of treatment effects of the organ system before and after treatment according to the evaluation result of the organ system by the clinical analysis module and the evaluation result of the treated organ system.
Still more preferably, the treatment effect feedback analysis module further includes a pathophysiological treatment feedback sub-module, and the pathophysiological treatment feedback sub-module is used for collecting ultrasonic images after treatment, comparing the ultrasonic images before and after treatment, and analyzing, recording and presenting the physiological change condition of the case before and after treatment.
Still more preferably, the treatment effect feedback analysis module further includes an organism reaction feedback sub-module, and the organism reaction feedback sub-module is used for feeding back the contrast change condition before and after the treatment of the organism reaction layer.
Still more preferably, the treatment effect feedback analysis module further includes a leading etiology treatment feedback sub-module for feeding back a change condition before and after treatment of the leading etiology layer.
Still further preferably, the treatment effect feedback analysis module further includes a basic etiology treatment feedback sub-module, and the basic etiology treatment feedback sub-module is used for feeding back the change condition of the basic etiology treatment of the patient before and after the basic etiology treatment.
Further preferably, the organ system evaluation rule base in the organ system evaluation sub-module includes any one or a combination of a circulatory system evaluation rule, a respiratory system evaluation rule, a nervous system evaluation rule, a liver function system evaluation rule, a renal function system evaluation rule, an abdominal system evaluation rule, a blood coagulation function system evaluation rule, an inflammatory system evaluation rule, and an infection system evaluation rule.
Further preferably, the pathophysiological and phenotypic interpretation module is preset with a severe ultrasound lung pathophysiological informationized framework structure, and the severe ultrasound lung pathophysiological informationized framework structure comprises any one or a combination of a plurality of acute and chronic information, gravity dependent condition information, distribution area information, lesion type information and lung change etiology information.
Further preferably, the pathophysiological and phenotype interpretation module is preset with a severe ultrasound circulation pathophysiological informationized framework structure, wherein the severe ultrasound circulation pathophysiological informationized framework structure comprises any one or a combination of a plurality of basic body general structure problem information, capacity and capacity reactivity information, right heart information, left heart diastole information, left heart contraction information, cardiac output information and peripheral resistance information.
Still more preferably, the pathophysiological and phenotypic interpretation module is provided with a hemodynamic phenotype mind map in advance, and the judging rules in the hemodynamic phenotype mind map include any one or more of venous volume judgment, venous pressure judgment, right heart volume judgment, right heart pressure judgment, right heart contraction function judgment, right heart contraction mode judgment, left diastolic function judgment, left atrial pressure judgment, left ventricular contraction judgment, stroke volume judgment, heart stroke volume judgment and peripheral vascular tension judgment.
Further preferred, the organism-response phenotyping module comprises a combination of one or more of an immune-inflammatory-coagulation disorder phenotype, a neuro-neuroendocrine disorder response phenotype, and a metabolic bioenergy disorder phenotype.
Still more preferably, the immune-inflammatory-coagulation disorder phenotype is judged according to a combination comprising any one or more of sepsis inflammatory response disorder, non-sepsis inflammatory response disorder, and coagulation response disorder, wherein the non-sepsis inflammatory response disorder is judged according to a combination comprising any one or more of non-infectivity, tumor immunotherapy cytokine release syndrome, general allergy, and immune response.
Still more preferably, the phenotype of the neuro-neuroendocrine disorder response is judged based on a criterion comprising a central nervous response, an autonomic nervous response or a neuroendocrine response, and the neuro-neuroendocrine disorder response is classified into a central origin and an extrinsic Zhou Yuan.
Still more preferably, the metabolic dysbiosis phenotype is judged based on conditions of high oxygen consumption, oxygen utilization disorders and abnormal oxygen distribution.
Compared with the prior art, the beneficial technical effects brought by the invention are as follows:
1. The invention performs standardized, structured and layered presentation of case information through the arrangement of eight modules, namely a clinical analysis module, a clinical information additional expansion module, a severe ultrasound and scheme evaluation module, a pathophysiology and phenotype interpretation module, an organism reaction phenotype analysis module, a etiology analysis module, a treatment analysis module and a treatment effect feedback analysis module, so that the data collection of the case is more standard, comprehensive and practical, the situation of uneven case expression forms is avoided, meanwhile, doctors with different levels are more nearly unified in the process of case presentation, thereby facilitating the subsequent case library management, case teaching, case research and the like, and playing a role of teaching, standard case diagnosis and treatment standard thinking guide and learning for the doctors with lower level in the process of case collection and manufacture.
2. According to the invention, the illness state characteristics and the diagnosis and treatment passes at different time points are combed in a time-based manner according to the current medical history of the patient and the diagnosis and treatment passes before the change of the core illness state of the patient, and the conditions of symptoms, physical examination, auxiliary examination and the like of the respective viscera systems are integrated and combed according to the viscera systems. The complex clinical information can be combed clearly by combining the time line of the illness state and the system combing, so that a clinician can conveniently conduct clinical differentiation by combining the illness state, and the main clinical problems and the collaborative clinical problems of the patient can be found, so that the central subject presented in the diagnosis and treatment process of the illness state is clear.
3. The clinical information additional expansion module comprises two parts of contents, wherein the first part aims at the clinical problem distinguished by the clinical distinguishing module to carry out the basic condition combing of the organ system related to the main clinical problem/the collaborative clinical problem, and if the clinical problem considers the respiratory circulatory dysfunction, the first part needs to remind a doctor to inquire the basic cardiopulmonary function of a patient, the basic cardiopulmonary disease diagnosis and treatment and control condition and the like. The second part is clinical details append related to clinical problems. The main clinical problems are found through the clinical analysis module, and then doctors are required to be reminded of carrying out detail circulation aiming at the clinical problems through the part, and the problems of primary inquiry omission and the like are supplemented, so that the disease cases are more true, detailed and detailed.
4. The severe ultrasonic and scheme evaluation module is preset with a plurality of severe ultrasonic modularized information frames, and a case producer can be well reminded to collect case information according to a standardized scheme through the preset severe ultrasonic modularized information frames without omission. And standardization and comprehensiveness of case information acquisition are achieved. The image quality control module is arranged to control the quality of the recorded ultrasonic image data, and when the quality of the recorded ultrasonic image data is poor, a case producer is reminded to replace the recorded ultrasonic image data, and the ultrasonic image data with better quality is used, so that subsequent case analysis and interpretation of the ultrasonic image data are facilitated. The severe ultrasound and scheme evaluation module in the invention also presets an ultrasound image interpretation text information frame, so that a disease case producer can interpret an ultrasound image according to preset interpretation rules to unify text expression of ultrasound image interpretation, and the case is more standard and better unified.
5. The organism reaction phenotype analysis module is used for combing organism reaction phenotypes in case layering combing, and a preset thinking chart of various organism reaction phenotypes can assist a case producer to determine the organism reaction phenotypes of a patient according to the evaluation results of a disease time line and an organ system so as to achieve standardization and unification of organism reaction phenotype judgment.
6. The treatment effect feedback analysis module comprises a system evaluation feedback sub-module, a pathophysiology treatment feedback sub-module, an organism reaction feedback sub-module, a leading cause treatment feedback sub-module and a basic cause treatment feedback sub-module, wherein the feedback content of the illness state is comprehensive and various, so that the illness state is displayed in a more hierarchical manner. Through the arrangement of the sub-modules, various treatment effect feedback is arranged in a layering manner, and is respectively presented through a plurality of parts, so that the treatment effect feedback of the cases is more clear, and the change condition of the treatment effect can be accurately fed back.
Drawings
FIG. 1 is a schematic diagram of a system architecture of a structured case building system of the present invention;
FIG. 2 is a schematic diagram of a severe ultrasound modularized information framework built in the pathophysiological and phenotypic interpretation module of the invention;
FIG. 3 is a diagram of a pathophysiologic and phenotypic mind preset in the pathophysiologic and phenotypic interpretation module of the present invention;
FIG. 4 is a schematic diagram of a critical ultrasound modularized information framework of a critical ultrasound hemodynamic cycle preset in the pathophysiological and phenotypic interpretation module of the present invention;
FIG. 5 is a diagram of a cyclic pathophysiological phenotype mind preset in the pathophysiological and phenotype interpretation module according to the present invention;
FIG. 6 is a diagram illustrating the mind of a phenotype of an organism reaction preset in the module for analyzing the phenotype of an organism reaction according to the present invention;
Detailed Description
The following are example embodiments of the invention defined by the claims and their equivalents, taken in conjunction with the accompanying drawings, in which the specific details are to be regarded as illustrative only and not limiting the scope of the invention. Accordingly, various changes and modifications to the embodiments may be made by one of ordinary skill in the art without departing from the scope and spirit of the invention.
Example 1
As a preferred embodiment of the present invention, referring to fig. 1 of the specification, the present embodiment discloses a system for constructing a structured case, which includes a clinical analysis module, a clinical information additional expansion module, a severe ultrasound and protocol evaluation module, a pathophysiology and phenotype interpretation module, an organism reaction phenotype analysis module, a etiology analysis module, a treatment analysis module, and a treatment effect feedback analysis module.
The clinical analysis module is used for inputting basic information, complaint information and medical history information of a patient, and combing and presenting the characteristics of the illness state and the diagnosis and treatment progress at different time points respectively according to a mode taking time as a shaft for the current medical history of the patient and the diagnosis and treatment progress before the change of the core illness state of the patient to generate an illness state time line;
The clinical analysis module is provided with an organ system evaluation submodule, the organ system evaluation submodule is internally associated with an organ system evaluation rule base, the organ system evaluation rule base is preset with an organ system evaluation rule, the organ system evaluation submodule is used for classifying according to organ systems and evaluating the organ systems according to any one or a combination of a plurality of data of symptoms, check data, auxiliary examination data and/or organ system support force of each organ system and combining with the preset organ system evaluation rule, and the organ system support force refers to support treatment means applied to a patient, such as a patient with respiratory failure, and the respiratory system support force is oxygen inhalation, invasive ventilator support or noninvasive ventilator support.
And carrying out clinical analysis based on the disease time line and the system evaluation result of the viscera system evaluation submodule, and obtaining the main clinical problem and/or the collaborative clinical problem of the current patient by the analysis.
The clinical information additional expansion module is used for combing and presenting the basic condition of the organ system related to the main clinical problem and/or the collaborative clinical problem according to the main clinical problem and/or the collaborative clinical problem which are distinguished by the clinical distinguishing module, and adding and recording clinical details.
The severe ultrasound and planning evaluation module is used for inputting ultrasound data of a patient, and comprises a heart ultrasound evaluation architecture, a lung ultrasound evaluation architecture, an expanded organ function evaluation, other section acquisition image interfaces and ultrasound measurement data page display and input as shown in fig. 2.
As shown in fig. 2-5, the pathophysiological and phenotype interpretation module is preset with a plurality of pathophysiological informationized framework structures and a pathophysiological phenotype thinking diagram, and the pathophysiological phenotype thinking diagram is preset with a judgment rule for the pathophysiological phenotype; selecting a corresponding pathophysiological informatization framework structure and a pathophysiological phenotype thinking chart according to the ultrasonic data recorded in the severe ultrasonic and schematized evaluation module, combing and presenting the interpretation information of the ultrasonic data according to the selected pathophysiological informatization framework structure rule, and determining the pathophysiological phenotype according to the corresponding pathophysiological phenotype thinking chart according to the combing and presenting pathophysiological information;
As shown in FIG. 6, the organism reaction phenotype analysis module is provided with a plurality of organism reaction phenotypes, the organism reaction phenotypes are provided with judgment bases for the organism reaction phenotypes, and the organism reaction phenotypes are determined according to the illness state time line of the clinical analysis module and the viscera system evaluation result and by combining with the preset thinking charts.
The etiology analysis module is used for carrying out etiology analysis and recording according to the clinical analysis result of the clinical analysis module, the basic condition and clinical detail of the organ system of the clinical information additional expansion module, the ultrasonic interpretation result of the severe ultrasonic and scheme evaluation module, the interpretation result of the pathophysiology and phenotype interpretation module and the matrix reaction phenotype determined by the organism reaction phenotype analysis module.
The feedback treatment analysis module is used for selectively adding judgment contents in the pathophysiology and phenotype interpretation module, the organism reaction phenotype analysis module and the etiology analysis module into the treatment analysis module, and adding corresponding treatment analysis contents according to the added contents.
The treatment effect feedback analysis module is used for presenting and recording treatment effects.
In this embodiment, the information of the eight-seven modules including the clinical analysis module, the clinical information additional expansion module, the severe ultrasound and planning evaluation module, the pathophysiology and phenotype interpretation module, the organism reaction phenotype analysis module, the etiology analysis module and the feedback treatment analysis module is combed and presented, so that the case information is standardized, structured and displayed in a layered manner, the data collection of the case is more standard and comprehensive, the situation that the case expression forms are irregular is avoided, and meanwhile, doctors with different levels are more nearly unified in the case presentation process, so that the follow-up case library management, case teaching, case research and the like are facilitated.
Example 2
As a further preferred embodiment of the present invention, this embodiment is further elaborated and supplemented with the technical solution of the present invention based on embodiment 1 described above. In this embodiment, a plurality of severe ultrasound data entry schemes are built in the severe ultrasound and scheme evaluation module, corresponding severe ultrasound data entry schemes are selected according to the entered ultrasound data, and ultrasound data are correspondingly entered according to the corresponding severe ultrasound data entry schemes.
Further, a plurality of severe ultrasonic data recording schemes are built in the severe ultrasonic and scheme evaluation module, corresponding severe ultrasonic data recording schemes are selected according to recorded ultrasonic data, and ultrasonic data are correspondingly recorded according to the corresponding severe ultrasonic data recording schemes.
As an example, the severe ultrasound and planning evaluation module is provided with any one or more of a severe ultrasound circulation evaluation module, a severe ultrasound respiration evaluation module and an expanded organ function evaluation module, wherein the severe ultrasound circulation evaluation module is used for inputting ultrasound data reflecting a circulation system, the severe ultrasound respiration evaluation module is used for inputting ultrasound data reflecting a respiration system, and the expanded organ function evaluation module is used for inputting ultrasound data of other organs.
As yet another example, a subxiphoid inferior vena cava long axis section ultrasound image, a subxiphoid inferior vena cava short axis section ultrasound image, a subxiphoid four-chamber heart section ultrasound image, a parasternal long axis ultrasound image, a parasternal short axis section ultrasound image, a carpal apex four-chamber heart section ultrasound image, a hepatic inferior vena cava long axis section ultrasound image, a hepatic inferior vena cava short axis section ultrasound image need to be entered in the severe ultrasound loop assessment module.
As yet another example, the ultrasound images entered by the severe ultrasound respiratory assessment module may be entered according to an ultrasound protocol, a twelve-partition protocol, a BLUE plus protocol, an M-BLUE protocol, a PLUE prone protocol, and so on, respectively.
The ultrasound data of the other viscera comprises any one or a combination of more of craniocerebral ultrasound data, gastrointestinal tract ultrasound data and renal ultrasound data.
Still further preferably, the plurality of intensive ultrasound data entry protocols in the intensive ultrasound and planning evaluation module include any combination of one or more of E-FATE (Extended Focus Assessed Transthoracic Echo, extended target-oriented echocardiography protocol), BLUE-PLUS (BedsideLungUltrasound IN EMERGENCY-PLUS, bedside pulmonary ultrasound evaluation protocol), twelve-partition protocol for pulmonary ultrasound, M-BLUE protocol, and PLUE protocol.
An image classification model is preset in an image quality control sub-module in the severe ultrasound and scheme evaluation module, the image classification model performs image classification processing on input ultrasound data, the input ultrasound data is divided into a qualified image and a unqualified image, the image qualification rate of the input ultrasound data is calculated, and after the image qualification rate of the input ultrasound data reaches a set image qualification rate threshold value, the ultrasound data is input into the severe ultrasound and scheme evaluation module.
Example 3
As a further preferred embodiment of the present invention, this embodiment is further elaborated and supplemented with the technical solution of the present invention on the basis of embodiment 1 or embodiment 2 described above. In this embodiment, the treatment effect feedback analysis module includes a system evaluation feedback sub-module, configured to collect symptoms, check-up data, and auxiliary check-up data of the treated organ system, and perform presentation and recording of treatment effects of the organ system before and after treatment according to the evaluation result of the organ system by the clinical analysis module and the evaluation result of the treated organ system.
As another implementation manner of this embodiment, the treatment effect feedback analysis module further includes a pathophysiological treatment feedback sub-module, where the pathophysiological treatment feedback sub-module is configured to collect an ultrasonic image after treatment, compare the ultrasonic images before and after treatment, and analyze, record and present physiological change conditions of cases before and after treatment.
As another implementation manner of this embodiment, the treatment effect feedback analysis module further includes an organism reaction feedback sub-module, where the organism reaction feedback sub-module is used to feedback the pre-treatment and post-treatment contrast change condition of the organism reaction layer.
As a further implementation manner of this embodiment, the treatment effect feedback analysis module further includes a leading etiology treatment feedback sub-module, and the leading etiology treatment feedback sub-module is configured to feedback a change condition before and after treatment on a leading etiology layer.
As a further implementation manner of this embodiment, the treatment effect feedback analysis module further includes a basic etiology treatment feedback sub-module, and the basic etiology treatment feedback sub-module is configured to feedback a change condition of the patient before and after the basic etiology treatment.
Example 4
As a further preferred embodiment of the present invention, this embodiment is further detailed supplement and explanation of the technical solution of the present invention on the basis of embodiment 1, embodiment 2 or embodiment 3 described above. In this embodiment, the organ system evaluation rule base in the organ system evaluation sub-module includes a circulatory system evaluation rule, a respiratory system evaluation rule, a nervous system evaluation rule, a liver function system evaluation rule, a renal function system evaluation rule, an abdominal system evaluation rule, a coagulation function system evaluation rule, an inflammatory system evaluation rule, an infection system evaluation rule, and the like.
Further preferably, the pathophysiological and phenotypic interpretation module is preset with a severe ultrasound lung pathophysiological informationized framework structure, as shown in fig. 3, where the severe ultrasound lung pathophysiological informationized framework structure includes any one or more of acute and chronic information, gravity-dependent condition information, distribution area information, lesion type information and lung change etiology information.
As an example, as shown in fig. 4, the pathophysiological and phenotype interpretation module is preset with a critical ultrasound cyclic pathophysiological informationized framework structure, where the critical ultrasound cyclic pathophysiological informationized framework structure includes any one or more of basic body general structure problem information, capacity and capacity reactivity information, right heart information, left heart diastole information, left heart systole information, cardiac output information and peripheral resistance information.
As yet another example, as shown in fig. 5, the pathophysiological and phenotyping module is pre-configured with a hemodynamic phenotype mind map, and the judgment rules in the hemodynamic phenotype mind map include any one or more of venous volume judgment, venous pressure judgment, right heart volume judgment, right heart pressure judgment, right heart contraction function judgment, right heart contraction mode judgment, left diastolic function judgment, left atrial pressure judgment, left ventricular contraction judgment, stroke volume judgment, and peripheral vascular tension judgment.
As yet another example, the organism-reflected phenotypes in the organism-responsive phenotyping module include a combination of one or more of an immune-inflammatory-coagulation disorder phenotype, a neuro-neuroendocrine disorder response phenotype, and a metabolic bioenergy disorder phenotype.
Further, the immune-inflammatory-coagulation disorder phenotype is judged according to any one or more of sepsis inflammatory response disorder, non-sepsis inflammatory response disorder and coagulation response disorder, wherein the non-sepsis inflammatory response disorder is judged according to any one or more of non-infectivity, tumor immunotherapy cytokine release syndrome, general allergy and immune response.
The judgment basis of the neuro-neuroendocrine dyscrasia response phenotype comprises central nervous response, autonomic nervous response or neuroendocrine response, and the neuro-neuroendocrine dyscrasia response is divided into central origin and extrinsic Zhou Yuan. The judging basis of the metabolic biological energy disorder phenotype comprises a high oxygen consumption state, oxygen utilization disorder and abnormal oxygen distribution.
Example 5
As a further preferred embodiment of the present invention, this embodiment provides a construction example of a structured case to assist in understanding the technical solution of the present invention.
The existing generation of the case for teaching is that a clinician carries out the production and presentation of the case according to the content which the clinician wants to present and the diagnosis and treatment thought of the clinician, the production of the case is different from person to person, the content of the case presentation is confusing and eight, the case teaching and the case collection are not facilitated, and some barriers are caused for the characteristic analysis and the scientific research of the later case.
In order to solve the above problems, the present embodiment provides a system for constructing structured cases, and it is desirable to unify the case making flows and specifications of different doctors through the system, so as to unify the case making, and unify the standardization of presentation contents and thinking modes. In particular, the method comprises the steps of,
When a case producer needs to make a new case, first, medical record information related to the case needs to be collected, including but not limited to basic information (name, gender, age, department, hospital, hospitalization number and the like), complaints, current medical history and the like of a patient, then a structured case construction system is logged in, an operation section of a clinical analysis module is opened, and corresponding information is input into the clinical analysis module according to prompt contents in the clinical analysis module.
In the process, if the patient corresponding to the case to be made is a patient of the hospital, the structured case construction system and the hospital HIS system can be connected through the data interface, and at the moment, the relevant information of the corresponding patient can be directly called from the hospital HIS system through the clinical resolution module and is called into the clinical resolution module.
When a case producer inputs information or calls information in the clinical analysis module, the information is input or called according to the time node mode on a time line for the current medical history of a patient and the diagnosis and treatment process before the change of the core disease condition of the patient, and after the input or call is completed, the clinical analysis module can comb and present the disease characteristics and the diagnosis and treatment process at different time points according to the mode taking time as an axis to generate a disease time line.
Then, according to the diagnosis result of the patient at present or in hospital, a case producer selects a corresponding organ system in a system rule base associated with a clinical analysis module, and relevant prompt information is preset in an operation interface of each organ system to prompt the case producer of the type and content of information to be input, and according to the prompt of the operation interface of the organ system, the symptom, the check-up data, the auxiliary monitoring data and the organ system supporting force of the organ system of the patient are input or called, wherein the organ system supporting force refers to supporting treatment means applied to the patient for the corresponding organ system, for example, if the patient is a respiratory system problem, the organ system supporting force refers to whether oxygen inhalation exists, whether invasive breathing machine intervention or noninvasive breathing machine intervention is adopted, and the like. After each item of data of the organ system of the patient is recorded or called, the clinical analysis module evaluates the organ system of the patient according to a preset organ system evaluation rule and generates an evaluation result, and at the moment, a case producer can also appropriately modify the generated evaluation result according to clinical experience and by combining the generated evaluation result.
Then, the case producer can conduct clinical differentiation based on the disease time line of the patient and the evaluation result of the organ system, the main clinical problem of the current patient is differentiated, whether the cooperative clinical problem exists is differentiated, and if the cooperative clinical problem exists, the cooperative clinical problem of the current patient is correspondingly supplemented. So far, the relevant data of the clinical analysis module is input and stored in the corresponding case database. After the operation of the clinical analysis module is finished, the construction system can automatically jump out of the operation interface of the clinical information additional expansion module, or take the operation interface of the clinical information additional expansion module as a pull-down interface of the clinical analysis module, namely, after the operation of the clinical analysis module is finished, the operation of the clinical information additional expansion module can be carried out.
In the clinical information additional expansion module, the basic condition combing and presenting of the organ system related to the main clinical problems and/or the collaborative clinical problems can be carried out according to the main clinical problems and/or the collaborative clinical problems which are distinguished by the module, and a case producer can carry out the addition of clinical details according to the information presented by the clinical information additional expansion module and the combination of clinical experience and input the additional clinical detail problems into the clinical information additional expansion module.
After the operation of the additional expansion module of the clinical information is completed, the additional expansion module of the clinical information immediately enters a severe ultrasound and planning evaluation module for relevant operation, a plurality of severe ultrasound modularized information frames are built in the severe ultrasound and planning evaluation module, a case producer needs to select a corresponding severe ultrasound modularized information frame according to main clinical problems of a patient, collaborative clinical problems (if any) and additional clinical details (if any) and combines different clinical information acquisition requirements and analysis requirements, and relevant ultrasound data is correspondingly input or called according to preset rules of the severe ultrasound modularized information frame.
When the input or the calling of the ultrasonic image data is carried out, the image quality control sub-module in the severe ultrasonic and scheme evaluation module can carry out quality control management on the uploaded or called ultrasonic image data, and the ultrasonic image data meeting the ultrasonic image quality requirement can be input or called into the severe ultrasonic and scheme evaluation module so as to improve the accuracy of ultrasonic image interpretation. The severe ultrasound and scheme evaluation module is internally provided with an ultrasound image interpretation text information frame, a case producer can input the ultrasound image content interpreted by the case producer into the severe ultrasound and scheme evaluation module according to the rule of the text information frame, and meanwhile, the severe ultrasound and scheme evaluation module can use a deep learning model to intelligently interpret the ultrasound image and generate interpretation information according to the preset ultrasound image interpretation text information frame structure, so that the standardization and unification of ultrasound image interpretation are realized. The case producer only needs to adaptively modify the ultrasonic image interpretation information intelligently read by the severe ultrasonic and planned evaluation module.
After finishing the input and interpretation of relevant information of the severe ultrasound and the scheme evaluation module, a case producer enters a pathophysiological and phenotype interpretation module, in the module, the case producer selects a corresponding pathophysiological informatization framework structure and a pathophysiological phenotype thinking map according to the interpretation information of the ultrasound data, carries out combing and presenting on the interpretation information of the ultrasound data according to the selected pathophysiological informatization framework structure rule, and determines a pathophysiological phenotype according to the corresponding pathophysiological phenotype thinking map according to the combing and presented pathophysiological information;
And the organism reaction phenotype analysis module is used for selecting a thinking chart of the corresponding organism reaction phenotype according to the illness state time line of the clinical analysis module and the evaluation result of the viscera system by a case producer, and determining the organism reaction phenotype of the patient according to the relevant data of the patient and the judgment basis of the thinking chart of the selected organism reaction phenotype.
After determining the organism reaction phenotype of the patient, a case producer enters an operation interface of an etiology analysis module, and performs etiology analysis and recording according to the clinical analysis result of the clinical analysis module, the basic condition and clinical detail of an organ system of the clinical information additional expansion module, the interpretation result of the ultrasonic diagnosis and severe ultrasonic diagnosis and treatment scheme evaluation module, the interpretation result of the pathophysiology and phenotype interpretation module and the matrix reaction phenotype determined by the organism reaction phenotype analysis module.
After the etiology analysis is completed, a case producer enters an operation interface of a treatment analysis module, judgment contents in the pathophysiology and phenotype reading module, the organism reaction phenotype analysis module and the etiology analysis module are selectively added into the treatment analysis module, and the corresponding treatment analysis contents are added according to the added contents.
After the treatment analysis is completed, the case producer enters an operation interface of the feedback treatment effect analysis module, and correspondingly records the body change condition of the patient after the relevant treatment according to rules and requirements in the treatment effect analysis module. Specifically, the system evaluation feedback sub-module is used for collecting symptoms, check-up data and auxiliary check-up data of the treated organ system, and presenting and recording treatment effects of the organ system before and after treatment according to the evaluation results of the organ system of the clinical analysis module and the evaluation results of the treated organ system;
The pathophysiological treatment feedback submodule is used for collecting ultrasonic images after treatment, comparing the ultrasonic images before and after treatment and analyzing, recording and presenting the physiological change condition of the case before and after treatment;
the organism reaction feedback submodule is used for feeding back the treatment front-back contrast change condition of the organism reaction layer;
the leading etiology treatment feedback submodule is used for feeding back the change condition of the leading etiology layer before and after treatment;
And the basic etiology treatment feedback sub-module is used for feeding back the change condition of the basic etiology treatment of the patient before and after the basic etiology treatment.
After all the operations are completed, the preparation of the case is completed, the case is stored in a case database, and the prepared case can be used in later case teaching and also can be used for case research.
While the present inventive concept has been particularly shown and described with reference to exemplary embodiments thereof, it will be understood by those of ordinary skill in the art that various changes in form and details may be made therein without departing from the spirit and scope of the present invention as defined by the following claims.
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