Detailed Treatment Process
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Male, 64 years old The following is the chest CT report Department: Surgery Ward: General Surgery, Thoracic Surgery Examination site: Enhanced chest CT Findings The mid-to-upper esophagus is dilated with wall thickening, measuring approximately 48 × 37 × 55 mm. The CT value is about 18 HU, increasing to about 44 HU in the arterial phase and 55 HU in the venous phase after contrast enhancement. The thoracic cage is symmetric bilaterally, and the trachea and mediastinum are midline. There is a faint patchy density increase in the right upper lobe with ill-defined margins. A small round lucency is seen in the right lower lobe. The lingular segment bronchus of the left upper lobe is slightly dilated. A tiny nodule, about 3 mm in diameter, is present in the left upper lobe (im49). Lymph nodes are visible in the mediastinum, the largest measuring about 16 × 12 mm with enhancement after contrast. The heart is normal in size and shape. Bilateral pleural thickening is noted without obvious pleural effusion. The diaphragmatic surfaces are smooth, and the costophrenic angles are sharp. Impression 1. Occupying lesion in the mid-to-upper esophagus: esophageal cancer is highly suspected; enlarged mediastinal lymph nodes; please correlate with clinical findings. 2. Possible mild inflammation in the right upper lobe; please correlate with clinical findings. 3. Tiny nodule in the left upper lobe; follow-up recommended. 4. Pulmonary bulla in the right lower lobe. 5. Mild dilatation of the lingular segment bronchus in the left upper lobe.
The following is the discharge summary Department: Surgery Ward: Surgery, General Surgery Admission date: June 28, 15:49 Discharge date: July 6, 08:00 Outpatient diagnosis: Malignant tumor of the upper thoracic esophagus Admission diagnosis: Malignant tumor of the upper thoracic esophagus Discharge diagnosis: Malignant tumor of the upper thoracic esophagus Main symptoms and signs on admission: Dysphagia with retrosternal pain for 2 weeks after eating. Physical findings: Normal chest wall contour; breath sounds present bilaterally without rales. Abdomen soft and flat without tenderness; liver and spleen not palpable below the costal margin; no tenderness over the liver or kidney areas. Main examination results during hospitalization: June 30 laboratory report: White blood cells 6.9 × 10⁹/L (3.5-9.5 × 10⁹/L), lymphocytes 26.9% (20-50%), monocytes 10.3% (3-10%), neutrophils 62.1% (40-75%), eosinophils 0.4% (0.4-8%), basophils 0.3% (0-1%), lymphocyte count 1.85 × 10⁹/L (1.1-3.2 × 10⁹/L), monocyte count 0.71 × 10⁹/L (0.1-0.6 × 10⁹/L), neutrophil count 4.28 × 10⁹/L (1.8-6.3 × 10⁹/L), eosinophil count 0.03 × 10⁹/L (0.02-0.52 × 10⁹/L), basophil count 0.02 × 10⁹/L (0-0.06 × 10⁹/L), red blood cells 5.08 × 10¹²/L (4.3-5.8 × 10¹²/L), hemoglobin 149 g/L (130-175 g/L), hematocrit 0.447 L/L (0.4-0.5 L/L), MCV 88.0 fL (82-100 fL), MCH 29.3 pg (27-34 pg), MCHC 333 g/L (316-354 g/L), platelets 307 × 10⁹/L (125-350 × 10⁹/L), PCT 0.33% (0.11-0.28%), MPV 10.6 fL (9.4-12.5 fL), PDW 13.0% CV (9-17% CV), red cell distribution width CV 12.2% (11-16%); Biochemistry: HBsAg 0.00 IU/ml (<0.05 IU/ml), HBsAb 4.90 mIU/ml (<10 mIU/ml), HBeAg 0.00 COI (<1 COI), HBeAb 32.50 Inh% (>30 Inh%), HBcAb 27.90 COI (<1 COI), anti-HCV [0.00] negative, anti-HIV1/2 [0.00] negative, anti-syphilis antibody [0.00] negative, TRUST negative; Protein electrophoresis: Albumin 55.0% (55.8-66.1%), α1-globulin 4.4% (2.9-4.9%), α2-globulin 10.2% (7.1-11.8%), β1-globulin 6.6% (4.7-7.2%), β2-globulin 7.3% (3.2-6.5%), γ-globulin 16.5% (11.1-18.8%); Pro-BNP <70 (0-300); High-sensitivity troponin I 0.004 (0-0.034), CK-MB mass 1.1 ng/ml (0-4.94 ng/ml), myoglobin 19.3 ng/ml (0-106 ng/ml); BNP 38 (0-100); High-sensitivity C-reactive protein 7.24 mg/L (0-5 mg/L); D-dimer 0.76 mg/L (0-0.55 mg/L), PT 12.0 s (9.8-12.4 s), PT activity 89.80% (70-130%), PT-INR 1.03 (0.8-1.2), APTT 27.1 s (21.1-36.5 s), TT 16.1 s (14-21 s), fibrinogen 4.08 g/L (2-4 g/L), ATIII 385.40% (80-120%), FDP 3.0 mg/L (0-5 mg/L); Liver function and other biochemistry within normal ranges except fasting glucose 9.04 mmol/L (3.9-6.1 mmol/L); Tumor markers: AFP 2.44 ng/ml (0-7 ng/ml), CEA 2.76 ng/ml (0-5 ng/ml), SCC 0.80 ng/ml (0-1.5 ng/ml), CA242 23.690 U/ml (0-20 U/ml), CA19-9 10.33 U/ml (0-37 U/ml), CA72-4 2.68 U/ml (0-6.9 U/ml), ferritin 190.4 ng/ml (30-400 ng/ml). July 1 serology: anti-HAV-IgM negative, anti-HEV-IgM negative. Special examinations during hospitalization: June 30 CT: Upper abdominal enhanced CT showed multiple renal cysts, plump pancreas, and dilatation of the distal common bile duct. Pelvic enhanced CT showed postoperative changes in the rectum with local rectal wall thickening; please correlate with clinical and specialty findings. July 1 echocardiography: No obvious abnormalities in wall motion or chamber sizes at rest. July 4 chest enhanced CT: 1. Occupying lesion in the mid-to-upper esophagus: esophageal cancer highly suspected, with enlarged mediastinal lymph nodes; please correlate with clinical findings. 2. Possible mild inflammation in the right upper lobe. 3. Tiny nodule in the left upper lobe; follow-up recommended. 4. Pulmonary bulla in the right lower lobe. 5. Mild dilatation of the lingular segment bronchus in the left upper lobe. Hospital course and treatment outcome: After admission, relevant examinations were completed. Chest CT suggested pneumomediastinum, raising the possibility of a small tumor perforation. The patient was advised to transfer to another hospital’s thoracic surgery department for further management and was discharged. Comorbidities: None Main symptoms and signs at discharge: The patient still had a cough and a sensation of obstruction with solid food but no other discomfort. Physical examination: alert, stable vital signs, clear heart and lungs, soft abdomen without tenderness. Post-discharge medications and recommendations: Further evaluation by thoracic surgery at another hospital recommended. Treatment outcome: Stable Length of stay: 8 days (as documented) Date: July 5 (as documented)
The following is the bronchoscopy report Examination: Bronchoscopy (without brush cytology) Department: Respiratory Outpatient Clinic Scope: Fuji-(34)-16 Examination date: July 7 Chief complaint: Dysphagia with choking cough for over two months (as documented) Premedication: 2% lidocaine hydrochloride. Chest X-ray/CT: Suspected tracheoesophageal fistula Findings: Trachea: Mucosal hyperemia and edema in the lower trachea, with bulging of the membranous portion; carina slightly widened; lumen patent; no obvious fistula seen. Left bronchial tree: Marked hyperemia and edema in the proximal left main bronchus with inward bulging of the membranous wall, mucosal erosion, and significant luminal narrowing. After advancing the scope, the distal segments and upper and lower lobe bronchi were patent. No obvious fistula identified. Right bronchial tree: All bronchi patent with smooth mucosa; no new growths. Ultrasound findings: ROSE: Biopsy site: Not performed Brush site: Not performed Diagnosis: Recommendations: Precautions: Do not eat or drink for 2 hours after the procedure. Seek immediate medical attention if there is significant hemoptysis or chest pain. Pathology report available at the outpatient service desk after seven working days.