Detailed Treatment Process
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Male, 18 years old. Outpatient record: Date: February 14, 07:53 Department: Orthopedics Chief complaint: Right shoulder pain and swelling for one day after trauma. History of present illness: Immediately after the injury, the patient experienced pain and swelling in the right shoulder with limited movement. There was no transient loss of consciousness, fever, palpitations, dizziness, or vomiting. He presented to the emergency department. Physical examination: Tenderness over the right shoulder (+), swelling present, no obvious bruising or ecchymosis, normal local skin temperature, limited joint mobility, longitudinal percussion tenderness of the left upper limb (+), no wrist drop; sensation normal. Distal blood supply normal, radial artery pulse normal. Auxiliary examinations: See reports. Preliminary outpatient diagnosis: Injury. Treatment plan: 1. Examination: Shoulder anteroposterior DR. Management: Outpatient follow-up in one week, orthopedic clinic review. 2. Certain medication orally 50mg * 14. 3. NSAR. (The above items 2 and 3 are handwritten, illegible, and contrast sharply with the printed text. It is impossible to confirm whether these entries were written at the same time as the printed content, implying they may have been added later.) Laboratory report: Specimen type: Whole blood Department: General Surgery Sampling date: February 14 Clinical diagnosis: Upper limb venous thrombosis with pain? No. Item Result Reference Unit 1 Prothrombin time 11.10 (9-13s) 2 Prothrombin time INR 1.01 (0.84-1.19) 3 Activated partial thromboplastin time 28.3 (26-39s) 4 Fibrinogen 2.57 (2.0-4.0g/L) 5 Thrombin time 12.90 (12-17s) 6 D-dimer 2.40 ↑ (0-0.5mg/L FEU) 7 Antithrombin activity 102 (75.6-122.4%) 8 Fibrin (ogen) degradation products 8.50 ↑ (0-5mg/L) Test date: February 14 Report date: February 14, 11:38 Radiology report Department: Orthopedics Clinical diagnosis: Injury, right shoulder pain and swelling for one day after trauma. Requesting physician: Assist in diagnosis Examination: CR shoulder joint, anteroposterior view Radiological findings: No obvious displaced fractures in the bones of the right shoulder joint; mild thickening of surrounding soft tissues. Joints in position, normal joint space. Radiological diagnosis: No obvious displaced fractures in the bones of the right shoulder joint. Please correlate with clinical findings; further CT may be needed if necessary. Examination time: February 14, 08:02 Dictation time: February 14, 08:45 Verification time: February 14, 09:22 Radiology report Department: General Surgery Clinical diagnosis: Pain, right upper limb swelling and pain for 12 hours. Requesting physician: Assist in diagnosis Examination: CT chest, non-contrast Method: Chest (non-contrast), spiral CT, X-ray computed tomography Radiological findings: Symmetric thorax, midline mediastinum, patent trachea and carina, normal hilar shadows bilaterally, normal cardiac size and shape, normal bronchovascular markings bilaterally, tiny ground-glass density nodule in the right lower lobe (im40); soft tissue density nodule at the right anterior margin of the T5 vertebral body, measuring approximately 1.5 cm × 2.5 cm with smooth margins; no obvious pleural thickening, no chest wall abnormalities. Radiological diagnosis: Nodule at the right anterior margin of the T5 vertebral body—enhanced CT recommended for further evaluation; tiny nodule in the right lower lobe—follow-up suggested. Examination time: February 14, 10:17 Dictation time: February 14, 11:13 Verification time: February 14, 11:17 Discharge summary Department: Cardiothoracic Surgery Admission date: February 15, 07:57 Discharge date: February 27, 08:30 Outpatient diagnosis: Right upper limb deep vein thrombosis Admission diagnosis: Right upper limb deep vein thrombosis Discharge diagnosis: 1. Cardiac foreign body; 2. Tricuspid regurgitation; 3. Right upper limb deep vein thrombosis Major symptoms and signs on admission: 1. Male, 18 years old. 2. Chief complaint: Right upper limb swelling for 3 days 3. Physical examination: Alert, comfortable breathing, normal heart and lungs. Soft abdomen, no tenderness or rebound, no muscle guarding, no masses. Liver and spleen not palpable below costal margin, Murphy sign negative. No shifting dullness. Bowel sounds present, 3 times per minute. Right upper limb swollen with mild tenderness, skin mildly erythematous, no ulceration, upper limb arterial pulses palpable. 4. Auxiliary examination results: February 14 hospital report: [Findings] Nodule at right anterior margin of T5 vertebral body—enhanced CT recommended; tiny nodule in right lower lobe—follow-up suggested. February 14 hospital report: [Findings] No obvious displaced fractures in right shoulder joint bones; correlate with clinical signs and consider further CT if needed. Temperature: 36.3℃ Pulse: 93 beats/min Respiration: 20 breaths/min Blood pressure: 130/70 mmHg Major laboratory results: (February 24, 09:26) Blood routine + CRP: CRP 4 mg/L, white blood cell count 6.75 × 10⁹/L, neutrophils 65.7%, lymphocytes 21.80%, monocytes 9.60%, eosinophils 2.80%, basophils 0.10%, neutrophil absolute 4.43 × 10⁹/L, monocyte absolute 0.65 × 10⁹/L, lymphocyte absolute 1.47 × 10⁹/L, eosinophil absolute 0.19 × 10⁹/L, basophil absolute 0.01 × 10⁹/L, red blood cell count 3.93 × 10¹²/L, hemoglobin 131 g/L, hematocrit 38.30%, mean corpuscular volume 97.5 fl↑, mean corpuscular hemoglobin 33.4 pg↑, mean corpuscular hemoglobin concentration 343 g/L, red cell distribution width (CV) 11.7%, platelet count 195.00 × 10⁹/L, plateletcrit 0.19%, platelet distribution width 16.3 fl, mean platelet volume 9.50 fl; (February 24, 08:41) Electrolytes: Sodium 138.5 mmol/L, potassium 4.43 mmol/L, chloride 104.0 mmol/L; (February 22, 10:02) Sputum culture + Haemophilus: General bacterial culture—no growth; Haemophilus culture—Haemophilus influenzae not detected; WBC >25, squamous epithelial cells <25 (per 100× field), specimen adequate; (February 21, 09:47) Renal function + troponin: Urea nitrogen 6.0 mmol/L, creatinine 59.9 μmol/L, uric acid 200.90 μmol/L↓, troponin I 0.779 ng/ml↑; (February 20, 10:18) Troponin I 1.827 ng/ml↑, repeat consistent; (February 18, 14:46) Pre-transfusion testing (no ALT): Hepatitis C core antigen negative; (February 18, 08:45) Pre-transfusion testing: HIV negative, HCV-Ab negative, TP-Ab negative, HBsAg negative, HBsAb negative, etc. (all markers negative); (February 17, 10:55) Blood typing: ABO AB, Rh positive, antibody screen negative; (February 17, 10:26) Coagulation: Prothrombin time 12.70 s, INR 1.10, APTT 29.1 s, fibrinogen 3.19 g/L, thrombin time 16.30 s; (February 17, 08:51) Glucose 5.99 mmol/L; Special examinations and consultations: February 25 contrast-enhanced CT (≥64-slice): CTPA normal pulmonary arteries; post-cardiac surgery changes with subcutaneous emphysema in right chest wall; nodules at right anterior margins of T5 and T8 vertebrae, possible foregut duplication cyst—correlate clinically; possible alveolar hemorrhage in left lower lobe; tiny nodule in right lower lobe—follow-up suggested; small right pleural effusion. February 23 echocardiography (cardiothoracic): Post-cardiac foreign body removal—no abnormal echoes in right heart; post-tricuspid annuloplasty—good function; small right pleural effusion. February 20 digital radiography: Right chest drain in place, slightly increased lung markings—correlate clinically. February 20 echocardiography: Post-tricuspid annuloplasty—good function; normal left ventricular systolic function; no significant bilateral pleural effusion. February 19 digital radiography: Right internal jugular catheter in place, small right pneumothorax, mediastinal emphysema—correlate clinically. February 17 echocardiography: Foreign body in right ventricle (correlate clinically); severe tricuspid regurgitation (estimated pulmonary artery systolic pressure 32 mmHg); normal left ventricular systolic and diastolic function. February 16 ECG: Sinus rhythm, incomplete right bundle branch block pattern, T wave flattening in II, inversion in III and aVF. February 16 ECG: Sinus rhythm, multifocal ventricular premature beats, occasional couplets. February 15 ECG: Normal. Course and treatment outcome: After admission, preoperative preparations were completed. On February 15, upper limb venography, inferior vena cava filter placement, and catheter-directed thrombolysis were performed, followed by thrombolytic and flow-promoting therapy. On February 16, repeat venography showed recanalization of right femoral and subclavian vein thrombi with residual distal mural thrombus; venous sheath and thrombolysis catheter removed. The superior vena cava filter had migrated to the junction of the right atrium and right ventricle. Multiple attempts via right femoral vein puncture to retrieve the filter under interventional guidance were unsuccessful. The patient was transferred to cardiothoracic surgery on February 16. After further preparation, on February 19 he underwent minimally invasive cardiac foreign body removal and tricuspid annuloplasty under general anesthesia. Postoperative supportive care was provided. The patient is now stable and ready for discharge. Complications: None Discharge status: Alert, comfortable breathing, normal heart and lungs. Soft abdomen, no tenderness or rebound, no muscle guarding, no masses. Liver and spleen not palpable, Murphy sign negative. No shifting dullness. Bowel sounds normal. No obvious swelling in either upper limb, no ulceration, arterial pulses palpable. Chest wound healing well, no significant oozing. Discharge medications and advice: Health education: Balanced nutrition, adequate rest, quit smoking and alcohol, low-salt low-fat diet, weight control; avoid strenuous exercise for now. Monitor blood pressure, glucose, and lipids. Follow up in clinic as scheduled and continue medications as prescribed. Cardiothoracic surgery clinic (general mornings, specialist afternoons Monday–Friday). Return in one week for blood tests, chest X-ray, electrolytes, and chest ultrasound; remove sutures (Thursday afternoon deputy chief clinic). Follow up in 3–6 months with deputy chief (Thursday or Tuesday afternoons). Discharge medications: Furosemide tablets 20 mg × 100, 0.5 tablet (10 mg) orally as directed (diuretic; monitor electrolytes and taper according to urine output; one month, adjust at follow-up) Spironolactone tablets 20 mg × 100, 0.5 tablet (10 mg) twice daily orally (diuretic; monitor potassium and taper; one month, adjust at follow-up) Potassium magnesium aspartate tablets, 0.5 tablet twice daily orally (potassium supplement with diuretics; one month, adjust at follow-up) Rivaroxaban tablets 10 mg × 5, 1 tablet (10 mg) once daily orally (recommended for 3 months; anticoagulant—seek immediate care for bleeding signs; long-term use may be needed with clinic adjustment) Treatment outcome: Cured Inpatient summary/certificate: Department: Cardiothoracic Surgery Summary: 1. (Name omitted), male, 18 years old. 2. Chief complaint: Right upper limb swelling for 3 days 3. Physical examination: As above. 4. Auxiliary findings: As noted. After admission, the patient underwent upper limb venography, vena cava filter placement, and catheter-directed thrombolysis on February 15, followed by appropriate therapy. On February 16 repeat imaging showed filter migration to the right heart. Retrieval attempts failed. Transferred to cardiothoracic surgery; on February 19 underwent minimally invasive removal of cardiac foreign body and tricuspid annuloplasty. Now stable for discharge. Preliminary diagnosis: 1. Cardiac foreign body; 2. Tricuspid regurgitation; 3. Right upper limb deep vein thrombosis; Date: February 27, 09:00