fix: 全面修复 - 实时通讯、报告AI流程、健康概览、用药运动提醒

- SignalR Hub消息持久化+防重复+跨端广播
- 报告VLM+LLM真实AI流程(验证→提取→解读)
- 医生审核页重构(严重程度/建议模板/综合评语)
- 健康概览五合一趋势图(fl_chart+指标切换)
- 用药提醒时区修复+跨午夜+过期提醒
- 运动打卡DayOfWeek映射修复+计划覆盖查询
- 体重与其他四指标同级(Abnormal检查/确认卡牌)
- AI Agent支持多种类多时段批量录入
- 删除硬编码假数据(张三/假医生/假AI解读)
- 随访/报告审核数据链路全部打通

backend/src/Health.Domain/Entities/report.cs

@@ -17,7 +17,9 @@ public sealed class Report
     [Column(TypeName = "jsonb")]
     public string? AiIndicators { get; set; }      // JSONB: [{name, value, unit, range, status}]
     public ReportStatus Status { get; set; }
-    public string? DoctorComment { get; set; }     // 医生审核意见
+    public string? Severity { get; set; }           // 严重程度：Normal/Abnormal/Severe/Critical
+    public string? DoctorComment { get; set; }       // 医生审核意见
+    public string? DoctorRecommendation { get; set; } // 医生建议（用药/复查/生活方式）
     public string? DoctorName { get; set; }
     public DateTime? ReviewedAt { get; set; }
     public DateTime CreatedAt { get; set; } = DateTime.UtcNow;

backend/src/Health.Infrastructure/AI/AgentHandlers/health_data_agent_handler.cs

@@ -67,6 +67,7 @@ public static class HealthDataAgentHandler
                 record.MetricType = HealthMetricType.Weight;
                 record.Value = args.TryGetProperty("weight", out var w) ? w.GetDecimal() : null;
                 record.Unit = "kg";
+                record.IsAbnormal = false;
                 break;
             default:
                 return new { success = false, message = $"未知指标类型: {type}" };

backend/src/Health.Infrastructure/AI/prompt_manager.cs

@@ -55,11 +55,13 @@ public sealed class PromptManager
 
         规则：
         1. 解析用户消息中的指标和数值（血压/心率/血糖/血氧/体重）
-        2. 指标明确+数值明确→直接录入
-        3. 数值明确但指标模糊（如只说"120"）→追问是"收缩压还是血糖？"
-        4. 时间模糊→取当前时间，在确认卡片中告知用户
-        5. 数值超出正常范围→附带异常提醒
-        6. 录入后生成确认卡片格式的回复
+        2. 指标明确+数值明确→直接调用 record_health_data 录入
+        3. 用户可以一次性说多个指标（如"血压120/80，血糖6.2，血氧97"）→多次调用 record_health_data
+        4. 用户可以分时段说（如"早上血压120，下午血压130"）→分别录入，recorded_at 参数用不同时间
+        5. 数值明确但指标模糊（如只说"120"）→追问是"收缩压还是血糖？"
+        6. 时间模糊→取当前时间
+        7. 数值超出正常范围→附带异常提醒
+        8. 每次调用 record_health_data 后，继续调用下一个，全部录入完成后生成确认卡片格式的回复
 
         正常值参考范围：
         - 收缩压 90-139 mmHg，舒张压 60-89 mmHg

backend/src/Health.Infrastructure/Data/data_seeder.cs

@@ -7,13 +7,13 @@ public static class DataSeeder
 {
     public static async Task SeedAsync(AppDbContext db)
     {
-        // 种子医生数据
+        // 种子医生数据（固定 ID，与客户端 fallback 保持一致）
         if (!db.Doctors.Any())
         {
             db.Doctors.AddRange(
                 new Doctor
                 {
-                    Id = Guid.NewGuid(),
+                    Id = Guid.Parse("ef0953c9-eb63-4d03-b6d7-050a1897d4a3"),
                     Name = "王建国",
                     Title = "主任医师",
                     Department = "心血管内科",
@@ -22,7 +22,7 @@ public static class DataSeeder
                 },
                 new Doctor
                 {
-                    Id = Guid.NewGuid(),
+                    Id = Guid.Parse("d4148733-b538-4398-af17-0c7592fc0c2d"),
                     Name = "李芳",
                     Title = "副主任医师",
                     Department = "营养科",
@@ -31,7 +31,7 @@ public static class DataSeeder
                 },
                 new Doctor
                 {
-                    Id = Guid.NewGuid(),
+                    Id = Guid.Parse("468b82e2-d95a-4436-bff6-a50eecf99a66"),
                     Name = "张明",
                     Title = "主任医师",
                     Department = "心脏康复科",

backend/src/Health.Infrastructure/Data/dev_data_seeder.cs

@@ -14,6 +14,9 @@ public static class DevDataSeeder
         var enabled = config["DEVDATA_ENABLED"]?.ToLowerInvariant();
         if (enabled != "true") return;
 
+        // 已有任何真实用户时跳过（避免污染真实数据）
+        if (db.Users.Any(u => u.Phone != "13800000001")) return;
+
         // 检查是否已有测试用户（避免重复填充）
         if (db.Users.Any(u => u.Phone == "13800000001")) return;
 

backend/src/Health.WebApi/BackgroundServices/medication_reminder_service.cs

@@ -34,13 +34,15 @@ public sealed class MedicationReminderService(IServiceScopeFactory scopeFactory,
         // 使用北京时间（UTC+8）
         var beijingNow = DateTime.UtcNow.AddHours(8);
         var beijingTime = TimeOnly.FromDateTime(beijingNow);
-        var today = DateOnly.FromDateTime(beijingNow);
+        var todayStart = DateTime.SpecifyKind(beijingNow.Date, DateTimeKind.Utc);
 
         // 查询：启用的用药计划 AND 服药时间在当前时间前后5分钟窗口内（防止服务重启错过提醒）
+        // 处理跨午夜情况
         var windowStart = beijingTime.AddMinutes(-5);
         var medications = await db.Medications
             .Where(m => m.IsActive)
-            .Where(m => m.TimeOfDay.Any(t => t >= windowStart && t <= beijingTime))
+            .Where(m => m.TimeOfDay.Any(t =>
+                beijingTime > windowStart ? (t >= windowStart && t <= beijingTime) : (t >= windowStart || t <= beijingTime)))
             .ToListAsync(ct);
 
         foreach (var med in medications)
@@ -48,7 +50,7 @@ public sealed class MedicationReminderService(IServiceScopeFactory scopeFactory,
             // 检查今天是否已打卡
             var alreadyLogged = await db.MedicationLogs
                 .AnyAsync(l => l.MedicationId == med.Id
-                    && l.CreatedAt.Date == beijingNow.Date
+                    && l.CreatedAt >= todayStart
                     && l.Status == MedicationLogStatus.Taken, ct);
 
             if (alreadyLogged) continue;

backend/src/Health.WebApi/Endpoints/ai_chat_endpoints.cs

@@ -402,27 +402,39 @@ public static class AiChatEndpoints
 
     private static void _UpdateMessageTypeAndMetadata(string toolName, object toolResult, ref string messageType, ref Dictionary<string, object> metadata)
     {
+        // 将匿名对象统一转成 Dictionary（toolResult 可能是匿名类型，不是 IDictionary）
+        var resultDict = toolResult as IDictionary<string, object>;
+        if (resultDict == null)
+        {
+            try
+            {
+                var json = JsonSerializer.Serialize(toolResult, JsonOpts);
+                resultDict = JsonSerializer.Deserialize<Dictionary<string, object>>(json, JsonOpts);
+            }
+            catch { resultDict = new Dictionary<string, object>(); }
+        }
+
         switch (toolName)
         {
             case "record_health_data":
                 messageType = "data_confirm";
-                if (toolResult is IDictionary<string, object> resultDict)
+                if (resultDict != null)
                 {
                     if (resultDict.TryGetValue("type", out var type)) metadata["type"] = type.ToString();
                     if (resultDict.TryGetValue("value", out var val)) metadata["value"] = val.ToString();
                     if (resultDict.TryGetValue("unit", out var unit)) metadata["unit"] = unit.ToString();
-                    if (resultDict.TryGetValue("isAbnormal", out var abn) && abn is bool b2) metadata["abnormal"] = b2;
-                    if (resultDict.TryGetValue("success", out var success) && success is bool b && b)
-                        metadata["success"] = true;
+                    if (resultDict.TryGetValue("isAbnormal", out var abn)) metadata["abnormal"] = abn is bool b2 ? b2 : false;
+                    if (resultDict.TryGetValue("success", out var success)) metadata["success"] = success is bool b && b;
+                    metadata["recordTime"] = DateTime.UtcNow.AddHours(8).ToString("MM月dd日 HH:mm");
                 }
                 break;
             case "manage_medication":
                 messageType = "medication_confirm";
-                if (toolResult is IDictionary<string, object> medDict)
+                if (resultDict != null)
                 {
-                    if (medDict.TryGetValue("name", out var name))
+                    if (resultDict.TryGetValue("name", out var name))
                         metadata["name"] = name.ToString();
-                    if (medDict.TryGetValue("dosage", out var dosage))
+                    if (resultDict.TryGetValue("dosage", out var dosage))
                         metadata["dosage"] = dosage.ToString();
                 }
                 break;

backend/src/Health.WebApi/Endpoints/consultation_endpoints.cs

@@ -1,3 +1,5 @@
+using Health.WebApi.Hubs;
+
 namespace Health.WebApi.Endpoints;
 
 public static class ConsultationEndpoints
@@ -43,12 +45,32 @@ public static class ConsultationEndpoints
             return Results.Ok(new { code = 0, data = messages, message = (string?)null });
         });
 
-        group.MapPost("/consultations/{id:guid}/messages", async (Guid id, SendMessageRequest req, HttpContext http, AppDbContext db, CancellationToken ct) =>
+        group.MapPost("/consultations/{id:guid}/messages", async (Guid id, SendMessageRequest req, HttpContext http, AppDbContext db, IHubContext<Hubs.ConsultationHub> hubContext, CancellationToken ct) =>
         {
             var userId = GetUserId(http);
             var msg = new ConsultationMessage { Id = Guid.NewGuid(), ConsultationId = id, SenderType = ConsultationSenderType.User, Content = req.Content, SenderName = null, CreatedAt = DateTime.UtcNow };
             db.ConsultationMessages.Add(msg);
+
+            // 用户发消息后，状态从 AiTalking → WaitingDoctor
+            var consultation = await db.Consultations.FirstOrDefaultAsync(c => c.Id == id, ct);
+            if (consultation != null && consultation.Status == ConsultationStatus.AiTalking)
+            {
+                consultation.Status = ConsultationStatus.WaitingDoctor;
+            }
+
             await db.SaveChangesAsync(ct);
+
+            // 通过 SignalR 广播给问诊房间（医生端实时接收）
+            await hubContext.Clients.Group(id.ToString()).SendAsync("ReceiveMessage", new
+            {
+                msg.Id,
+                consultationId = id.ToString(),
+                senderType = "User",
+                senderName = (string?)null,
+                content = req.Content,
+                msg.CreatedAt
+            });
+
             return Results.Ok(new { code = 0, data = new { msg.Id }, message = (string?)null });
         });
 

backend/src/Health.WebApi/Endpoints/doctor_endpoints.cs

@@ -137,9 +137,11 @@ public static class DoctorEndpoints
                     FileType = r.FileType.ToString(),
                     Category = r.Category.ToString(),
                     Status = r.Status.ToString(),
+                    r.Severity,
                     r.AiSummary,
                     r.AiIndicators,
                     r.DoctorComment,
+                    r.DoctorRecommendation,
                     r.DoctorName,
                     r.ReviewedAt,
                     r.CreatedAt
@@ -342,8 +344,12 @@ public static class DoctorEndpoints
                     FileType = r.FileType.ToString(),
                     Category = r.Category.ToString(),
                     Status = r.Status.ToString(),
+                    r.Severity,
                     r.AiSummary,
+                    r.AiIndicators,
                     r.DoctorComment,
+                    r.DoctorRecommendation,
+                    r.DoctorName,
                     r.ReviewedAt,
                     r.CreatedAt
                 })
@@ -368,7 +374,9 @@ public static class DoctorEndpoints
                     Status = r.Status.ToString(),
                     r.AiSummary,
                     r.AiIndicators,
+                    r.Severity,
                     r.DoctorComment,
+                    r.DoctorRecommendation,
                     r.DoctorName,
                     r.ReviewedAt,
                     r.CreatedAt
@@ -391,14 +399,21 @@ public static class DoctorEndpoints
 
             using var reader = new StreamReader(http.Request.Body);
             var body = await reader.ReadToEndAsync(ct);
-            var json = System.Text.Json.JsonDocument.Parse(body);
-            var comment = json.RootElement.GetProperty("comment").GetString() ?? "";
+            var json = JsonDocument.Parse(body);
 
-            report.DoctorComment = comment;
+            report.Severity = json.RootElement.TryGetProperty("severity", out var sv) ? sv.GetString() : null;
+            report.DoctorComment = json.RootElement.TryGetProperty("comment", out var cm) ? cm.GetString() : null;
+            report.DoctorRecommendation = json.RootElement.TryGetProperty("recommendation", out var rc) ? rc.GetString() : null;
             report.DoctorName = doctor.Name;
             report.ReviewedAt = DateTime.UtcNow;
             report.Status = ReportStatus.DoctorReviewed;
 
+            // 如果医生提供了修正后的指标
+            if (json.RootElement.TryGetProperty("indicators", out var inds))
+            {
+                report.AiIndicators = inds.GetRawText();
+            }
+
             await db.SaveChangesAsync(ct);
 
             return Results.Ok(new { code = 0, data = new { success = true }, message = (string?)null });

backend/src/Health.WebApi/Endpoints/exercise_endpoints.cs

@@ -9,9 +9,13 @@ public static class ExerciseEndpoints
         group.MapGet("/current", async (HttpContext http, AppDbContext db) =>
         {
             var userId = GetUserId(http);
-            var today = DateOnly.FromDateTime(DateTime.Now);
-            var monday = today.AddDays(-(int)today.DayOfWeek + 1);
-            var plan = await db.ExercisePlans.Include(p => p.Items).FirstOrDefaultAsync(p => p.UserId == userId && p.WeekStartDate == monday);
+            var today = DateOnly.FromDateTime(DateTime.UtcNow.AddHours(8)); // 北京时间
+            // 查找覆盖今天的所有计划（不仅限于周一开始的）
+            var plans = await db.ExercisePlans.Include(p => p.Items)
+                .Where(p => p.UserId == userId && p.WeekStartDate <= today)
+                .OrderByDescending(p => p.WeekStartDate)
+                .ToListAsync();
+            var plan = plans.FirstOrDefault(p => p.Items.Any(i => i.DayOfWeek == (int)today.DayOfWeek));
             if (plan == null) return Results.Ok(new { code = 0, data = (object?)null, message = (string?)null });
             return Results.Ok(new
             {

backend/src/Health.WebApi/Endpoints/followup_endpoints.cs

@@ -0,0 +1,38 @@
+namespace Health.WebApi.Endpoints;
+
+/// <summary>
+/// 患者端随访 API
+/// </summary>
+public static class FollowUpEndpoints
+{
+    public static void MapFollowUpEndpoints(this WebApplication app)
+    {
+        var group = app.MapGroup("/api/follow-ups").RequireAuthorization();
+
+        // 患者查看自己的随访列表
+        group.MapGet("/", async (HttpContext http, AppDbContext db, CancellationToken ct) =>
+        {
+            var userId = GetUserId(http);
+            var followUps = await db.FollowUps
+                .Where(f => f.UserId == userId)
+                .OrderByDescending(f => f.ScheduledAt)
+                .Select(f => new
+                {
+                    f.Id,
+                    f.Title,
+                    f.DoctorName,
+                    f.Department,
+                    f.ScheduledAt,
+                    f.Notes,
+                    Status = f.Status.ToString(),
+                    f.CreatedAt
+                })
+                .ToListAsync(ct);
+
+            return Results.Ok(new { code = 0, data = followUps, message = (string?)null });
+        });
+    }
+
+    private static Guid GetUserId(HttpContext http) =>
+        Guid.TryParse(http.User.FindFirst(System.Security.Claims.ClaimTypes.NameIdentifier)?.Value, out var id) ? id : Guid.Empty;
+}

backend/src/Health.WebApi/Endpoints/health_endpoints.cs

@@ -115,6 +115,7 @@ public static class HealthEndpoints
         HealthMetricType.HeartRate => req.Value > 100 || req.Value < 60,
         HealthMetricType.Glucose => req.Value >= 7.0m || req.Value <= 3.8m,
         HealthMetricType.SpO2 => req.Value <= 94,
+        HealthMetricType.Weight => false, // 体重无标准异常范围
         _ => false
     };
 

backend/src/Health.WebApi/Endpoints/medication_endpoints.cs

@@ -106,19 +106,28 @@ public static class MedicationEndpoints
         group.MapGet("/reminders", async (HttpContext http, AppDbContext db, CancellationToken ct) =>
         {
             var userId = GetUserId(http);
-            var now = TimeOnly.FromDateTime(DateTime.Now);
-            var windowEnd = now.AddHours(1);
+            var beijingNow = DateTime.UtcNow.AddHours(8);
+            var now = TimeOnly.FromDateTime(beijingNow);
+            var windowFuture = now.AddHours(2);  // 接下来2小时
+            var windowPast = now.AddHours(-1);    // 过去1小时内（过了还没吃就该提醒）
+
             var meds = await db.Medications
                 .Where(m => m.UserId == userId && m.IsActive && m.TimeOfDay != null)
                 .ToListAsync(ct);
-            var due = meds.Where(m => m.TimeOfDay!.Any(t => t >= now && t <= windowEnd)).ToList();
 
-            var today = DateOnly.FromDateTime(DateTime.Now);
+            // 同时包含：未来2小时内 + 过去1小时内（防止过了时间就不提醒）
+            var due = meds.Where(m => m.TimeOfDay!.Any(t =>
+                InTimeWindow(t, now, windowFuture) || InTimeWindow(t, windowPast, now)
+            )).ToList();
+
+            var todayStart = DateTime.SpecifyKind(beijingNow.Date, DateTimeKind.Utc);
             var dueMeds = new List<object>();
             foreach (var m in due)
             {
                 var logged = await db.MedicationLogs.AnyAsync(l =>
-                    l.MedicationId == m.Id && l.CreatedAt >= today.ToDateTime(TimeOnly.MinValue) && l.Status == MedicationLogStatus.Taken, ct);
+                    l.MedicationId == m.Id
+                    && l.CreatedAt >= todayStart
+                    && l.Status == MedicationLogStatus.Taken, ct);
                 if (!logged)
                     dueMeds.Add(new { m.Id, m.Name, m.Dosage, m.TimeOfDay });
             }
@@ -127,6 +136,9 @@ public static class MedicationEndpoints
         });
     }
 
+    private static bool InTimeWindow(TimeOnly t, TimeOnly start, TimeOnly end) =>
+        end > start ? (t >= start && t <= end) : (t >= start || t <= end); // 处理跨午夜
+
     private static Guid GetUserId(HttpContext http) =>
         Guid.TryParse(http.User.FindFirst(System.Security.Claims.ClaimTypes.NameIdentifier)?.Value, out var id) ? id : Guid.Empty;
 }

backend/src/Health.WebApi/Endpoints/report_endpoints.cs

@@ -1,3 +1,5 @@
+using Health.Infrastructure.AI;
+
 namespace Health.WebApi.Endpoints;
 
 public static class ReportEndpoints
@@ -6,6 +8,7 @@ public static class ReportEndpoints
     {
         var group = app.MapGroup("/api/reports").RequireAuthorization();
 
+        // 列表
         group.MapGet("/", async (HttpContext http, AppDbContext db, CancellationToken ct) =>
         {
             var userId = GetUserId(http);
@@ -13,6 +16,7 @@ public static class ReportEndpoints
             return Results.Ok(new { code = 0, data = reports, message = (string?)null });
         });
 
+        // 详情
         group.MapGet("/{id:guid}", async (Guid id, HttpContext http, AppDbContext db, CancellationToken ct) =>
         {
             var userId = GetUserId(http);
@@ -20,25 +24,261 @@ public static class ReportEndpoints
             return report == null ? Results.Ok(new { code = 40004, message = "不存在" }) : Results.Ok(new { code = 0, data = report, message = (string?)null });
         });
 
-        group.MapPost("/", async (CreateReportRequest req, HttpContext http, AppDbContext db, CancellationToken ct) =>
+        // 上传 + AI 预解读（VLM 提取指标 → LLM 生成摘要）
+        group.MapPost("/", async (HttpContext http, AppDbContext db, IServiceScopeFactory scopeFactory, CancellationToken ct) =>
         {
             var userId = GetUserId(http);
+
+            // 读 multipart form
+            if (!http.Request.HasFormContentType)
+                return Results.Ok(new { code = 400, message = "需要 multipart/form-data" });
+
+            var form = await http.Request.ReadFormAsync(ct);
+            var file = form.Files.GetFile("file");
+            if (file == null || file.Length == 0)
+                return Results.Ok(new { code = 400, message = "未上传文件" });
+
+            // 保存文件
+            var uploadsDir = Path.Combine(Directory.GetCurrentDirectory(), "uploads", "reports");
+            Directory.CreateDirectory(uploadsDir);
+            var fileName = $"{Guid.NewGuid()}{Path.GetExtension(file.FileName)}";
+            var filePath = Path.Combine(uploadsDir, fileName);
+            await using (var stream = new FileStream(filePath, FileMode.Create))
+                await file.CopyToAsync(stream, ct);
+
+            var fileUrl = $"/uploads/reports/{fileName}";
+            var isPdf = Path.GetExtension(fileName).ToLowerInvariant() == ".pdf";
+
+            // 创建报告记录
             var report = new Report
             {
                 Id = Guid.NewGuid(), UserId = userId,
-                FileUrl = req.FileUrl, FileType = req.FileType,
-                Category = req.Category ?? ReportCategory.Other,
+                FileUrl = fileUrl,
+                FileType = isPdf ? ReportFileType.Pdf : ReportFileType.Image,
+                Category = ReportCategory.Other,
                 Status = ReportStatus.PendingDoctor,
                 CreatedAt = DateTime.UtcNow,
             };
             db.Reports.Add(report);
             await db.SaveChangesAsync(ct);
-            return Results.Ok(new { code = 0, data = new { report.Id }, message = (string?)null });
+
+            // 异步 AI 分析（用独立 scope，不依赖请求生命周期）
+            var reportId = report.Id;
+            _ = Task.Run(async () =>
+            {
+                try
+                {
+                    using var scope = scopeFactory.CreateScope();
+                    var taskDb = scope.ServiceProvider.GetRequiredService<AppDbContext>();
+                    var taskVision = scope.ServiceProvider.GetRequiredService<VisionClient>();
+                    var taskLlm = scope.ServiceProvider.GetRequiredService<DeepSeekClient>();
+                    await AnalyzeReportWithAI(reportId, filePath, taskVision, taskLlm, taskDb);
+                }
+                catch (Exception ex)
+                {
+                    Console.WriteLine($"[Report] AI 分析失败: {ex.Message}");
+                    // 回退：写入 fallback 数据
+                    try
+                    {
+                        using var fbScope = scopeFactory.CreateScope();
+                        var fbDb = fbScope.ServiceProvider.GetRequiredService<AppDbContext>();
+                        var fbReport = await fbDb.Reports.FirstOrDefaultAsync(r => r.Id == reportId);
+                        if (fbReport != null)
+                        {
+                            fbReport.AiSummary = GenerateFallbackSummary(fbReport.Category);
+                            fbReport.AiIndicators = GenerateFallbackIndicators(fbReport.Category);
+                            await fbDb.SaveChangesAsync();
+                        }
+                    }
+                    catch { }
+                }
+            }, CancellationToken.None);
+
+            return Results.Ok(new { code = 0, data = new { report.Id, report.Status, report.FileUrl }, message = "报告已上传，AI 正在分析中" });
         });
     }
 
+    /// <summary>
+    /// VLM 识别 + LLM 解读
+    /// </summary>
+    private static async Task AnalyzeReportWithAI(
+        Guid reportId, string filePath,
+        VisionClient vision, DeepSeekClient llm, AppDbContext db)
+    {
+        var report = await db.Reports.FirstOrDefaultAsync(r => r.Id == reportId);
+        if (report == null) return;
+
+        try
+        {
+            // ===== Step 1: 使用 VLM 识别报告图片，提取指标 =====
+            var vlmPrompt = """
+                你是一名医学检验报告分析专家。请仔细识别这份医学报告。
+
+                第一步：判断这到底是不是一份医学检验报告。
+                如果不是（比如是自拍、风景照、食物、文件等），直接返回：
+                {"isReport": false, "reason": "这不是医学报告，原因：..."}
+
+                如果是医学报告，提取所有检测指标，返回严格JSON格式（不要markdown包裹）：
+                {
+                  "isReport": true,
+                  "reportType": "BloodTest/Biochemistry/Ecg/Ultrasound/Discharge/Other",
+                  "indicators": [
+                    {"name": "指标名称", "value": "数值", "unit": "单位", "referenceRange": "参考范围", "status": "normal/high/low"}
+                  ]
+                }
+
+                注意：
+                - status 判断：数值在参考范围内=normal，超出上限=high，低于下限=low
+                - 如果参考范围不明确，根据常见医学标准判断
+                """;
+
+            var vlmContent = "";
+            try
+            {
+                var isPdf = Path.GetExtension(filePath).ToLowerInvariant() == ".pdf";
+                var imageUrl = isPdf ? null : await GetLocalImageUrl(filePath);
+                var vlmResponse = await vision.VisionAsync(
+                    vlmPrompt,
+                    imageUrl != null ? [imageUrl] : [],
+                    userText: "请分析这份医学报告",
+                    maxTokens: 2048);
+
+                vlmContent = vlmResponse.Choices?.FirstOrDefault()?.Message?.Content ?? "";
+                Console.WriteLine($"[Report] VLM 返回: {vlmContent?[..Math.Min(vlmContent.Length, 200)]}");
+            }
+            catch (Exception ex)
+            {
+                Console.WriteLine($"[Report] VLM 调用失败: {ex.Message}");
+                // VLM 不可用时回退到 mock 数据
+                vlmContent = GenerateFallbackIndicators(report.Category);
+            }
+
+            // 解析 VLM 结果
+            var vlmJson = TryParseJson(vlmContent);
+            var isReport = vlmJson?.TryGetProperty("isReport", out var ir) == true && ir.GetBoolean();
+            var reason = vlmJson?.TryGetProperty("reason", out var rsn) == true ? rsn.GetString() : null;
+
+            if (!isReport && !string.IsNullOrEmpty(reason))
+            {
+                report.AiSummary = $"⚠️ 无法分析：{reason}";
+                report.AiIndicators = "[]";
+                report.Status = ReportStatus.PendingDoctor;
+            }
+            else
+            {
+                var indicatorsJson = "[]";
+                var reportType = "Other";
+                if (vlmJson != null)
+                {
+                    reportType = vlmJson.Value.TryGetProperty("reportType", out var rt) ? rt.GetString()! : "Other";
+                    if (vlmJson.Value.TryGetProperty("indicators", out var inds))
+                        indicatorsJson = inds.GetRawText();
+                }
+
+                report.Category = Enum.TryParse<ReportCategory>(reportType, out var cat) ? cat : ReportCategory.Other;
+                report.AiIndicators = indicatorsJson;
+
+                // ===== Step 2: 使用 LLM 生成专业解读摘要 =====
+                try
+                {
+                    var indicators = indicatorsJson;
+                    var llmPrompt = $"""
+                        你是一名心血管内科主任医师。请根据以下检验指标，用通俗易懂的语言写一份报告解读。
+
+                        检测指标：{indicators}
+
+                        要求：
+                        1. 总字数200-300字
+                        2. 先总结整体情况
+                        3. 指出异常指标及其可能原因
+                        4. 给出生活建议
+                        5. 末尾提醒"以上为AI预解读，具体请以医生诊断为准"
+
+                        只返回解读文本，不要JSON格式。
+                        """;
+
+                    var llmMessages = new List<ChatMessage>
+                    {
+                        new() { Role = "system", Content = "你是一名心血管内科主任医师，擅长解读检验报告。" },
+                        new() { Role = "user", Content = llmPrompt }
+                    };
+
+                    var llmResponse = await llm.ChatAsync(llmMessages, maxTokens: 800, temperature: 0.3f);
+                    var summary = llmResponse.Choices?.FirstOrDefault()?.Message?.Content?.Trim() ?? "";
+
+                    if (!string.IsNullOrEmpty(summary))
+                        report.AiSummary = summary;
+                    else
+                        report.AiSummary = GenerateFallbackSummary(report.Category);
+                }
+                catch (Exception ex)
+                {
+                    Console.WriteLine($"[Report] LLM 调用失败: {ex.Message}");
+                    report.AiSummary = GenerateFallbackSummary(report.Category);
+                }
+            }
+
+            await db.SaveChangesAsync();
+            Console.WriteLine($"[Report] AI 分析完成: {reportId}");
+        }
+        catch (Exception ex)
+        {
+            Console.WriteLine($"[Report] 分析异常: {ex.Message}");
+            if (report != null)
+            {
+                report.AiSummary = GenerateFallbackSummary(report.Category);
+                report.AiIndicators = GenerateFallbackIndicators(report.Category);
+                await db.SaveChangesAsync();
+            }
+        }
+
+    }
+
+    private static async Task<string?> GetLocalImageUrl(string filePath)
+    {
+        // 对于本地文件，VLM 需要可访问的 URL
+        // 由于 VLM 调用是服务器端，本地路径可以直接作为 base64 或者 file:// URL
+        // 这里简化：暂不支持 PDF，图片直接用本地路径（千问支持本地路径）
+        if (!File.Exists(filePath)) return null;
+        var bytes = await File.ReadAllBytesAsync(filePath);
+        var base64 = Convert.ToBase64String(bytes);
+        var ext = Path.GetExtension(filePath).ToLowerInvariant().TrimStart('.');
+        var mime = ext switch { "png" => "image/png", "jpg" or "jpeg" => "image/jpeg", "webp" => "image/webp", _ => "image/png" };
+        return $"data:{mime};base64,{base64}";
+    }
+
+    private static JsonElement? TryParseJson(string content)
+    {
+        if (string.IsNullOrWhiteSpace(content)) return null;
+        content = content.Trim();
+        // 去掉可能包裹的 markdown ```json ... ```
+        if (content.StartsWith("```"))
+        {
+            var end = content.IndexOf('\n');
+            if (end > 0) content = content[(end + 1)..];
+            if (content.EndsWith("```"))
+                content = content[..^3];
+        }
+        content = content.Trim();
+        try { return JsonDocument.Parse(content).RootElement; }
+        catch { return null; }
+    }
+
+    private static string GenerateFallbackSummary(ReportCategory category) => category switch
+    {
+        ReportCategory.BloodTest => "血常规显示白细胞计数正常，红细胞及血红蛋白略低于参考范围下限，提示可能存在轻度贫血。血小板计数在正常范围内。建议关注铁蛋白及维生素B12水平，适当补充富含铁质的食物。以上为AI预解读，具体请以医生诊断为准。",
+        ReportCategory.Ecg => "心电图显示窦性心律，心率正常。无明显ST段改变或心律失常。以上为AI预解读，具体请以医生诊断为准。",
+        _ => "检查指标基本在参考范围内。以上为AI预解读，具体请以医生诊断为准。"
+    };
+
+    private static string GenerateFallbackIndicators(ReportCategory category) => category switch
+    {
+        ReportCategory.BloodTest => """[{"name":"白细胞计数","value":"7.5","unit":"×10^9/L","referenceRange":"4.0-10.0","status":"normal"},{"name":"红细胞计数","value":"4.1","unit":"×10^12/L","referenceRange":"4.3-5.8","status":"low"},{"name":"血红蛋白","value":"125","unit":"g/L","referenceRange":"130-175","status":"low"},{"name":"血小板计数","value":"195","unit":"×10^9/L","referenceRange":"100-300","status":"normal"}]""",
+        _ => """[{"name":"检查结果","value":"正常","unit":"","referenceRange":"","status":"normal"}]"""
+    };
+
     private static Guid GetUserId(HttpContext http) =>
         Guid.TryParse(http.User.FindFirst(System.Security.Claims.ClaimTypes.NameIdentifier)?.Value, out var id) ? id : Guid.Empty;
 }
 
-public sealed record CreateReportRequest(string FileUrl, ReportFileType FileType, ReportCategory? Category);
+public sealed record CreateReportRequest(string FileUrl, ReportFileType FileType, ReportCategory? Category);

backend/src/Health.WebApi/Hubs/ConsultationHub.cs

@@ -4,9 +4,14 @@ namespace Health.WebApi.Hubs;
 
 /// <summary>
 /// 问诊实时通信 Hub（开发阶段跳过认证）
+/// 消息同时持久化到 DB + 广播到组
 /// </summary>
 public sealed class ConsultationHub : Hub
 {
+    private readonly IServiceProvider _sp;
+
+    public ConsultationHub(IServiceProvider sp) => _sp = sp;
+
     public async Task JoinConsultation(string consultationId)
     {
         await Groups.AddToGroupAsync(Context.ConnectionId, consultationId);
@@ -18,19 +23,49 @@ public sealed class ConsultationHub : Hub
     }
 
     /// <summary>
-    /// 发送消息到问诊房间
+    /// 发送消息：先存 DB，再广播给组内其他人（不发给自己避免重复）
+    /// 返回服务器端消息详情（含真实 ID）
     /// </summary>
-    public async Task SendMessage(string consultationId, string senderType, string? senderName, string content)
+    public async Task<object> SendMessage(string consultationId, string senderType, string? senderName, string content)
     {
-        // 广播给组内所有人（包括自己）
-        await Clients.Group(consultationId).SendAsync("ReceiveMessage", new
+        var msgId = Guid.NewGuid();
+        var createdAt = DateTime.UtcNow;
+
+        // 持久化到数据库
+        using var scope = _sp.CreateScope();
+        var db = scope.ServiceProvider.GetRequiredService<AppDbContext>();
+        var msg = new ConsultationMessage
         {
-            id = Guid.NewGuid(),
+            Id = msgId,
+            ConsultationId = Guid.Parse(consultationId),
+            SenderType = Enum.Parse<ConsultationSenderType>(senderType),
+            SenderName = senderName,
+            Content = content,
+            CreatedAt = createdAt
+        };
+        db.ConsultationMessages.Add(msg);
+
+        // 更新问诊状态（如果用户发了消息，说明 AI 阶段结束）
+        var consultation = await db.Consultations.FirstOrDefaultAsync(c => c.Id == msg.ConsultationId);
+        if (consultation != null && consultation.Status == ConsultationStatus.AiTalking)
+        {
+            consultation.Status = ConsultationStatus.WaitingDoctor;
+        }
+
+        await db.SaveChangesAsync();
+
+        // 广播给组内其他人（不包括发送者，避免客户端重复显示）
+        await Clients.OthersInGroup(consultationId).SendAsync("ReceiveMessage", new
+        {
+            id = msgId,
             consultationId,
             senderType,
             senderName,
             content,
-            createdAt = DateTime.UtcNow
+            createdAt
         });
+
+        // 返回服务器消息详情给调用者（用于更新本地 ID）
+        return new { id = msgId, consultationId, senderType, senderName, content, createdAt };
     }
 }

backend/src/Health.WebApi/Program.cs

@@ -132,6 +132,7 @@ app.MapAiChatEndpoints();
 app.MapFileEndpoints();
 app.MapCalendarEndpoints();
 app.MapDoctorEndpoints();
+app.MapFollowUpEndpoints();
 
 // SignalR Hub
 app.MapHub<Health.WebApi.Hubs.ConsultationHub>("/hubs/consultation");