Detailed Treatment Process
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Male, 42 years old The following is the discharge summary from the first hospitalization. Department: Inpatient Gastroenterology Admission date: March 31, 18:20:29 Discharge date: April 4, 08:46:10 Admission status and treatment summary: The patient, a 42-year-old male, was admitted on March 31 at 18:20:29 with a one-month history of poor appetite and weight loss. Physical examination: Temperature 36.5°C, pulse 114 beats/min, respirations 20 breaths/min, blood pressure 132/87 mmHg. No obvious jaundice of the skin or mucous membranes, no rash, no bleeding spots, no liver palms, no spider nevi. No enlargement of superficial lymph nodes. Breath sounds clear in both lungs, with no significant dry or wet rales and no pleural friction rub. No abnormal precordial bulge or pulsation; the cardiac apex beat was located 0.5 cm medial to the left midclavicular line in the fifth intercostal space, with no thrill. Cardiac borders were normal; heart rate 95 beats/min, regular rhythm; no murmurs heard in any valve area and no pericardial friction rub. Abdomen flat, no visible gastrointestinal pattern or peristaltic waves, no abdominal wall varices. Abdomen soft, no tenderness, no rebound tenderness or muscle tension, no palpable masses. Liver and spleen not palpable below the costal margin. Murphy's sign negative, McBurney's point non-tender. Abdomen tympanitic on percussion, no shifting dullness. No tenderness in the liver area or bilateral renal areas. Bowel sounds 4 times/min. No edema in the lower limbs. Pathological reflexes not elicited. Auxiliary examinations: Gastroscopy suggested: "Esophagitis (fungal?), gastric retention (cause?), chronic non-atrophic gastritis." Chest CT suggested: "Increased and thickened markings in both lungs, with a small amount of inflammation in both lungs, some chronic. Mild bronchiectasis in the right middle lobe, left lingular segment, and parts of both lower lobes. Local calcification of the aorta and coronary arteries." Electrocardiogram suggested: "Sinus tachycardia, tall peaked P waves, T-wave changes." Routine blood work: white blood cell count (WBC) 11.29 × 10⁹/L, neutrophil percentage (NEUT%) 81.2%, lymphocyte percentage (LYMPH%) 13.4%. The remainder were normal. Amylase and lipase normal. Liver function, kidney function, and electrolytes normal. Tumor markers: carbohydrate antigen CA125 (CA125) 75.38 U/ml. CA199 and carcinoembryonic antigen negative. HIV antibody and routine urinalysis normal. Contrast-enhanced CT of the entire abdomen suggested: "Mass-like thickening of the proximal jejunal wall with enhancement, narrowed lumen, and dilatation of the proximal bowel and stomach. Nature uncertain; neoplastic lesion cannot be excluded. Please correlate with clinical findings and further examinations. Small left renal cyst." Gastroscopy suggested: "Non-atrophic pangastritis with bile reflux, mild gastric retention." After admission, the patient was given fasting, gastrointestinal decompression, fluid supplementation, and symptomatic treatment. The jejunal wall thickening could not exclude a tumor; transfer to surgery was recommended. The patient requested transfer back to a local hospital for further treatment and was discharged after signing the relevant forms. Discharge diagnoses: 1) Proximal jejunal wall thickening: tumor? other? 2) Esophagitis; 3) Gastric retention; 4) Chronic non-atrophic pangastritis with bile reflux Discharge instructions and follow-up guidance: Further treatment at a local hospital.
The following is the discharge summary from the second hospitalization. Department: General Surgery Admission time: April 6, 10:52 Discharge date: May 27 Outpatient diagnosis: Small bowel obstruction Admission diagnosis: Small bowel obstruction Discharge diagnosis: Small bowel obstruction; acute appendicitis Condition on admission: The patient, a 42-year-old male, was admitted with a one-month history of abdominal pain, distension, and vomiting. Physical examination: Abdomen flat, no visible gastrointestinal pattern or peristaltic waves. Abdominal breathing present. Mild tenderness in the right mid-abdomen near the umbilicus, no rebound tenderness, no muscle tension. Liver and spleen not palpable below the costal margin. No tenderness in the liver or kidney areas. No abnormal masses palpated. No shifting dullness. Active bowel sounds. Digital rectal examination: empty, no abnormal masses. Auxiliary examinations: CT on April 1 (outside hospital) suggested proximal jejunal wall mass-like thickening with enhancement, narrowed lumen, and dilatation of the proximal bowel and stomach. Nature uncertain; neoplastic lesion cannot be excluded. Gastroscopy on April 3 (outside hospital) suggested non-atrophic pangastritis with bile reflux and gastric retention. Main laboratory results: May 20, 10:18:21: Emergency glucose: 4.55 May 20, 11:13:46: White blood cells: 8.81 × 10⁹/L, red blood cells: 5.44 × 10¹²/L, platelets: 151 × 10⁹/L, hemoglobin: 166 g/L, hematocrit: 48.40%, neutrophil ratio: 53.40%, lymphocyte ratio: 36.90%, monocyte ratio: 8.90%, eosinophil ratio: 0.2↓%, basophil ratio: 0.60%, neutrophil count: 4.71 × 10⁹/L, lymphocyte count: 3.25↑ × 10⁹/L, monocyte count: 0.78↑ × 10⁹/L, eosinophils: 0.02↓ × 10⁹/L, basophils: 0.05 × 10⁹/L, mean corpuscular volume: 89.0 fL, mean corpuscular hemoglobin: 30.5 pg, mean corpuscular hemoglobin concentration: 343 g/L, red blood cell distribution width: 49.2%, RDW-CV: 15.10↑%, platelet distribution width: 13.0 fL, mean platelet volume: 10.5 fL, plateletcrit: 0.160, large platelet ratio: 28.40%, C-reactive protein: 4.16 mg/L, serum amyloid A: 43.09↑ mg/L May 20, 12:03:54: Alanine aminotransferase: 9 U/L, aspartate aminotransferase: 21 U/L, AST isoenzyme: 2.9 U/L, lactate dehydrogenase: 223 U/L, alkaline phosphatase: 78 U/L, gamma-glutamyl transferase: 23 U/L, total bilirubin: 22.2↑ μmol/L, direct bilirubin: 2.5 μmol/L, total protein: 73 g/L, albumin: 40 g/L, globulin: 33↑ g/L, albumin/globulin ratio: 1.2↓, prealbumin: 151↓ mg/L, haptoglobin: 2.02 g/L, α1-acid glycoprotein: 1.55↑ g/L, total bile acids: 1.6 μmol/L, cholinesterase: 5967 U/L, glycocholic acid: 0.82 mg/L, urea: 2.98↓ mmol/L, creatinine: 51↓ μmol/L, uric acid: 329 μmol/L, cystatin C: 0.96 mg/L, retinol-binding protein: 18.3↓ mg/L, blood β2-microglobulin: 2.53 mg/L, potassium: 4.33 mmol/L, sodium: 139.85 mmol/L, chloride: 96.15 mmol/L, bicarbonate: 28.9 mmol/L, serum albumin: 57.40↓%, serum protein α1: 6.30↑%, serum protein α2: 11.80↑%, serum protein β1: 3.80↓%, serum protein β2: 4.50%, Gamma: 16.20 May 6, 14:22:44. Stool routine: Color brown, consistency pasty, red blood cells 2-3, white blood cells 0-1, macrophages 0/HP, hookworm eggs not found, roundworm eggs not found, whipworm eggs not found, undigested food a small amount, occult blood positive (1+), fungi not found, fecal transferrin positive (1+). April 10, 14:46:18: ANA (homogeneous type 1:100): negative, ANA (speckled type 1:100): negative, and all other listed ANA patterns negative. Anti-double-stranded DNA antibody: negative (-), and all other listed autoantibodies negative. Adenovirus antibody: negative, and all other listed respiratory virus and atypical pathogen antibodies negative. April 9, 15:46:15: Fungal β-D-glucan: <10 pg/mL, lipopolysaccharide: <5 pg/mL April 7, 10:55:26: ABO blood type: B, Rh blood type: positive, irregular antibody screen: negative April 7, 10:03:42: Urine: Color light yellow, clarity clear, glucose negative, bilirubin negative, ketones +, specific gravity 1.015, pH 6, protein negative, urobilinogen normal, nitrite negative, vitamin C negative, occult blood negative, leukocyte esterase negative, calcium oxalate crystals 0.00, quantitative red blood cells 0.49 p/μL, quantitative white blood cells 1.10 p/μL, non-squamous epithelial cells 0.49 p/μL, squamous epithelial cells (quantitative) 0.00 p/μL April 9, 09:44:25: Procalcitonin: 2.04 ng/mL Special examinations and important consultations: May 21: X-ray: Low intestinal obstruction, recommend follow-up. May 21: X-ray: Low intestinal obstruction May 7: X-ray: Incomplete small bowel obstruction May 9: CT: Small bowel obstruction, suspicious thickening of the intestinal wall in the left mid-abdomen with surrounding exudation. Bilateral pleural thickening noted. April 28: CT: Post-abdominal surgery with local exudative changes in the abdominal cavity (slightly increased compared with April 17), fecal impaction in the colon, dilatation and fluid accumulation in parts of the small bowel, possible incomplete intestinal obstruction. April 17: CT: Post-abdominal surgery with drainage in place, mild local exudation, dilatation and fluid accumulation in parts of the small bowel, fecal impaction in the colon. April 6: CT: Bronchial disease, focal interstitial hyperplasia in both lungs with scattered interstitial and parenchymal inflammation, nodule in the left upper lobe, local pleural thickening and adhesions, anterior superior mediastinal lesion; enhanced CT recommended. Postoperative pathology: Acute appendicitis. Treatment course: Admission examinations were completed. On April 8, appendectomy plus small bowel ulcer repair was performed under general anesthesia. Postoperative treatment included anti-inflammatory therapy, nutritional support, acid suppression, and maintenance of water and electrolyte balance. The patient experienced recurrent abdominal distension with irregular passage of gas and stool. Treatment with laxatives and agents to promote gastrointestinal motility was given. The patient eventually passed gas and stool and was discharged. Complications: None Condition at discharge: The patient was generally stable with no specific complaints. Post-discharge medications and recommendations: 1. Rest and a light diet. 2. Maintain regular bowel movements; seek medical attention if discomfort occurs. Treatment outcome: Improved
The patient was discharged on May 27 at his own request. The discharge diagnosis remained low intestinal obstruction, with no clear record of complications. One month later he died at another hospital. The cause of death was septic shock. The following is the discharge summary from the first hospitalization Department: Inpatient Gastroenterology Admission date: March 31, 18:20:29 Discharge date: April 4, 08:46:10 Admission status and treatment summary: The patient, a 42-year-old male, was admitted on March 31 at 18:20:29 with “poor appetite and weight loss for more than one month.” Physical examination: Temperature 36.5℃, pulse 114 beats/min, respiration 20 breaths/min, blood pressure 132/87 mmHg. No obvious jaundice of the skin or mucous membranes, no rash, no petechiae, no liver palms, no spider nevi. Superficial lymph nodes not enlarged. Breath sounds clear in both lungs, no significant dry or wet rales, no pleural friction rub. No abnormal precordial bulge or pulsation; apical impulse located 0.5 cm medial to the left midclavicular line in the fifth intercostal space, no thrill, normal cardiac borders, heart rate 95 beats/min, regular rhythm, no murmurs in any valvular area, no pericardial friction rub. Abdomen flat, no visible gastrointestinal pattern or peristalsis, no abdominal wall varices, soft abdomen, no tenderness, no rebound tenderness or muscle tension, no palpable masses, liver and spleen not palpable below the costal margin, Murphy’s sign negative, McBurney’s point non-tender. Abdomen tympanitic on percussion, no shifting dullness, no hepatic or renal percussion tenderness, bowel sounds 4 times/min. No edema in the lower limbs. Pathological reflexes not elicited. Auxiliary examinations: Gastroscopy suggested: “Esophagitis (fungal?), gastric retention (cause?), chronic non-atrophic gastritis.” Chest CT suggested: “Increased and thickened lung markings bilaterally, mild inflammation in both lungs, partly chronic. Mild bronchiectasis in the right middle lobe, left lingular segment, and parts of both lower lobes. Local calcification of the aorta and coronary arteries.” Electrocardiogram suggested: “Sinus tachycardia, tall peaked P waves, T-wave changes.” Routine blood work: White blood cell count (WBC) 11.29 × 10⁹/L, neutrophil percentage (NEUT%) 81.2%, lymphocyte percentage (LYMPH%) 13.4%, remainder normal. Amylase and lipase normal. Liver function, kidney function, and electrolytes normal. Tumor markers: CA125 75.38 U/ml. CA199 and CEA negative. HIV antibody and urinalysis normal. Contrast-enhanced CT of the entire abdomen suggested: “Mass-like thickening of the proximal jejunal wall with enhancement, narrowed lumen, dilation of proximal bowel and stomach. Nature uncertain; tumor not excluded. Please correlate with clinical findings and further tests. Small left renal cyst.” Gastroscopy suggested: “Non-atrophic pangastritis with bile reflux, mild gastric retention.” After admission, the patient received fasting, gastrointestinal decompression, fluid supplementation, and symptomatic treatment. The jejunal wall thickening could not exclude tumor; transfer to surgery was recommended. The patient requested discharge to return to his local hospital for further treatment and signed out. Discharge diagnoses: 1) Proximal jejunal wall thickening: tumor? other? 2) Esophagitis; 3) Gastric retention; 4) Chronic non-atrophic pangastritis with bile reflux Discharge orders and follow-up instructions: Further treatment at local hospital
The following is the discharge summary from the second hospitalization Department: General Surgery Admission time: April 6, 10:52 Discharge date: May 27 Outpatient diagnosis: Small bowel obstruction Admission diagnosis: Small bowel obstruction Discharge diagnosis: Small bowel obstruction; acute appendicitis Condition on admission: 42-year-old male admitted with “abdominal pain, distension, and vomiting for more than one month.” Physical examination: Abdomen flat, no visible gastrointestinal pattern or peristalsis, abdominal breathing present. Mild tenderness in the right mid-abdomen near the umbilicus, no rebound tenderness, no muscle tension. Liver and spleen not palpable below costal margin, no hepatic or renal percussion tenderness, no abnormal masses, no shifting dullness. Bowel sounds active. Digital rectal examination empty, no abnormal masses. Auxiliary examinations: CT from outside hospital on April 1: Proximal jejunal wall thickening with enhancement, narrowed lumen, proximal bowel and gastric dilation; nature uncertain, tumor not excluded. Gastroscopy from outside hospital on April 3: Non-atrophic pangastritis with bile reflux, gastric retention. Main laboratory results: May 20, 10:18:21: Emergency glucose 4.55 May 20, 11:13:46: White blood cells 8.81 × 10⁹/L, red blood cells 5.44 × 10¹²/L, platelets 151 × 10⁹/L, hemoglobin 166 g/L, hematocrit 48.40%, neutrophil ratio 53.40%, lymphocyte ratio 36.90%, monocyte ratio 8.90%, eosinophil ratio 0.2↓%, basophil ratio 0.60%, neutrophil count 4.71 × 10⁹/L, lymphocyte count 3.25↑ × 10⁹/L, monocyte count 0.78↑ × 10⁹/L, eosinophil count 0.02↓ × 10⁹/L, basophil count 0.05 × 10⁹/L, mean corpuscular volume 89.0 fL, mean corpuscular hemoglobin 30.5 pg, mean corpuscular hemoglobin concentration 343 g/L, red cell distribution width 49.2%, RDW-CV 15.10↑%, platelet distribution width 13.0 fL, mean platelet volume 10.5 fL, plateletcrit 0.160, large platelet ratio 28.40%, C-reactive protein 4.16 mg/L, serum amyloid A 43.09↑ mg/L May 20, 12:03:54: Alanine aminotransferase 9 U/L, aspartate aminotransferase 21 U/L, AST isoenzyme 2.9 U/L, lactate dehydrogenase 223 U/L, alkaline phosphatase 78 U/L, gamma-glutamyl transferase 23 U/L, total bilirubin 22.2↑ μmol/L, direct bilirubin 2.5 μmol/L, total protein 73 g/L, albumin 40 g/L, globulin 33↑ g/L, albumin/globulin ratio 1.2↓, prealbumin 151↓ mg/L, haptoglobin 2.02 g/L, α1-acid glycoprotein 1.55↑ g/L, total bile acids 1.6 μmol/L, cholinesterase 5967 U/L, glycocholic acid 0.82 mg/L, urea 2.98↓ mmol/L, creatinine 51↓ μmol/L, uric acid 329 μmol/L, cystatin C 0.96 mg/L, retinol-binding protein 18.3↓ mg/L, β2-microglobulin 2.53 mg/L, potassium 4.33 mmol/L, sodium 139.85 mmol/L, chloride 96.15 mmol/L, bicarbonate 28.9 mmol/L, serum albumin 57.40↓%, serum protein α1 6.30↑%, serum protein α2 11.80↑%, serum protein β1 3.80↓%, serum protein β2 4.50%, Gamma 16.20 May 6, 14:22:44: Stool routine: Color brown, consistency pasty, red blood cells 2-3, white blood cells 0-1, macrophages 0/HP, hookworm eggs not seen, roundworm eggs not seen, whipworm eggs not seen, undigested food a little, occult blood positive (1+), fungi not seen, fecal transferrin positive (1+) April 10, 14:46:18: ANA (homogeneous 1:100) negative, ANA (speckled 1:100) negative, and all other ANA patterns negative. Anti-dsDNA, anti-SS-A, anti-SS-B, anti-Sm, and other listed autoantibodies all negative. Various viral and bacterial antibodies negative. April 9, 15:46:15: Fungal β-D-glucan <10 pg/mL, lipopolysaccharide <5 pg/mL April 7, 10:55:26: ABO blood type B, Rh positive, irregular antibody screen negative April 7, 10:03:42: Urine: Light yellow, clear, glucose negative, bilirubin negative, ketones +, specific gravity 1.015, pH 6, protein negative, urobilinogen normal, nitrite negative, vitamin C negative, occult blood negative, leukocyte esterase negative, etc. April 9, 09:44:25: Procalcitonin 2.04 ng/mL Special examinations and important consultations: May 21 X-ray: Low intestinal obstruction, suggest follow-up. May 21 X-ray: Low intestinal obstruction. May 7 X-ray: Partial small bowel obstruction. May 9 CT: Small bowel obstruction, suspicious thickening of left mid-abdominal bowel wall with perienteric exudation, bilateral pleural thickening. April 28 CT: Post-laparotomy with local peritoneal exudation (slightly increased compared with April 17), fecal impaction in colon, partial small bowel dilation with fluid, possible partial obstruction. April 17 CT: Post-laparotomy with drainage, mild local exudation, partial small bowel dilation with fluid, fecal impaction in colon. April 6 CT: Bronchial disease, focal interstitial hyperplasia in both lungs with scattered interstitial and parenchymal inflammation, nodule in left upper lobe, local pleural thickening and adhesions, anterior superior mediastinal lesion; enhanced CT recommended. Postoperative pathology: Acute appendicitis. Treatment course: Admission examinations completed. On April 8, appendectomy + small intestinal ulcer repair performed under general anesthesia. Postoperative anti-inflammatory treatment, nutritional support, acid suppression, and maintenance of water-electrolyte balance. The patient experienced recurrent abdominal distension with irregular passage of gas and stool. Measures to promote bowel movement and gastrointestinal motility were given. He eventually passed gas and stool and was discharged. Complications: None Condition at discharge: General condition stable, no specific complaints. Post-discharge medication and advice: 1. Rest adequately, light diet. 2. Maintain regular bowel movements; seek medical attention if discomfort arises. Treatment outcome: Improved
On May 27 the patient requested discharge. The discharge diagnosis remained low intestinal obstruction with no clear record of complications. One month later he died at another hospital. The cause of death was septic shock.