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Male, 85 years old Chest CT report Examination site: HRCT-chest (lung and mediastinum) plain scan Report time: June 9, 13:20:50 Findings The bony thorax showed a barrel shape. Both lung markings were increased and disordered, with slightly increased radiolucency. A solid nodule measuring approximately 3 mm × 2 mm was seen in the apicoposterior segment of the left upper lobe (IM83). Scattered linear and patchy opacities were present in both lungs. The hila were not enlarged, and bronchial openings were patent. The mediastinum was central with no enlarged lymph nodes. The heart shadow was enlarged, mainly the left ventricle. High-density shadows were noted in the walls of the aorta and both coronary arteries. Bilateral pleural thickening was present without pleural effusion. Multiple nodular and patchy slightly low-density shadows, along with some patchy slightly high-density shadows, were seen in the liver. Diagnostic impressions 1. Bilateral pulmonary emphysema; interstitial changes in both lungs; scattered chronic inflammation in both lungs, with some areas showing fibrosis. 2. Small nodule in the apicoposterior segment of the left upper lobe, likely inflammatory; follow-up recommended. 3. Enlarged heart, predominantly the left ventricle; calcified plaques in the walls of the aorta and both coronary arteries. 4. Bilateral pleural thickening. 5. Multiple abnormal densities in the liver as described; further evaluation recommended.
Laboratory report Department: Hepatobiliary Surgery Tests: ★AMS + ★P-AMY + ★LIP Sample time: June 10, 08:56:33 Report time: June 10, 10:42:25 Test item \ Result \ Flag \ Reference range Pancreatic amylase 19 (0-50 U/L) Lipase 19 (10-60 U/L) Amylase 35 (32-135 U/L)
Laboratory report Department: Hepatobiliary Surgery Tests: ★Tnt + ★MYO + ★ProBNP + ★CKMB mass Sample time: June 10, 08:59:24 Report time: June 10, 09:50:34 Test item \ Result \ Flag \ Reference range Myoglobin 81.74 (<72.00 ng/mL) Creatine kinase-MB mass 4.87 (0-4.87 ng/mL) High-sensitivity cardiac troponin-T 0.771 ↑ (0-0.014 ng/mL) N-terminal pro-B-type natriuretic peptide 2471.00 ↑ (0-300 pg/mL)
Laboratory report Tests: Liver tumor markers + CA125 Sample time: June 10, 09:24:35 Report time: June 10, 14:11:01 Test item \ Result \ Flag \ Reference range Carbohydrate antigen CA-125 16.7 (0.0-35.0 U/mL) Abnormal prothrombin 20.17 (0.00-27.80 mAU/ml) Alpha-fetoprotein 10.70 (0.00-20.00 ug/L) Carcinoembryonic antigen 1.63 (0.00-5.00 U/L) Carbohydrate antigen CA19-9 22.9 (0.00-37.00 U/mL) Ferritin 233.40 (22-322 ng/mL)
Laboratory report Department: Hepatobiliary Surgery Test: CA242 Sample time: June 10, 09:29:19 Report time: June 10, 10:36:38 Test item \ Result \ Flag \ Reference range Carbohydrate antigen 242 3.53 (0.00-15.00 IU/mL)
Imaging report (MRI with contrast) Examination site: Upper abdominal MRI plain scan + contrast + MRCP Report time: June 12, 13:30:35 Findings A mass-like abnormal signal was seen at the fundus of the gallbladder, appearing cystic-solid and involving adjacent liver parenchyma, measuring approximately 11.7 cm × 6.9 cm. The internal signal was heterogeneous, mainly mixed high and slightly low on T1WI, and mainly mixed high and isointense on T2 fat-suppressed images, with partial diffusion restriction on DWI. Enhancement was heterogeneous, with prominent cyst wall enhancement. An oval short T2, short T1 signal shadow measuring about 3.7 × 2.9 cm was present inside, showing minimal enhancement; multiple small nodular short T2 signals were also seen within it. Several other nodular long T2 signals were noted in the liver, without enhancement, the largest about 1.0 cm in diameter. Additional nodular abnormal signals were present in the gallbladder, high on both T1WI and T2 fat-suppressed images, the largest measuring about 1.9 × 0.9 cm, with diffusion restriction on DWI and no obvious enhancement. A small nodular low T2 signal, about 1.0 cm in diameter, was seen in the cystic duct. Mild dilatation of intra- and extrahepatic bile ducts was present. Multiple lymph nodes were visible at the hepatic hilum, the largest measuring about 1.6 × 1.3 cm, showing marked enhancement. The pancreas was normal in morphology and size, with no abnormal parenchymal signals and clear peripancreatic fat planes; the main pancreatic duct was not dilated. The spleen was normal. Multiple small nodular long T2 signals were seen in both kidneys, the largest about 1.5 cm, without enhancement. No abdominal effusion. Diagnostic impressions 1. The changes at the gallbladder fundus are highly suspicious for gallbladder carcinoma with invasion of adjacent liver; multiple enlarged hilar lymph nodes. 2. Multiple nodules in the gallbladder without obvious enhancement—gallstones or other? Correlate with clinical findings and other examinations. 3. Cystic duct stone. 4. Hepatic cysts. 5. Bilateral renal cysts. ********* CT request form Chief complaint: Gallbladder stones discovered more than 10 years ago, worsening for 10 days. History: The patient was found to have gallbladder stones more than 10 years ago on routine examination and reported no particular discomfort, no abdominal pain or distension, no chills or fever, and no cough or sputum. Over the past 10 days, he suddenly developed discomfort in the right upper abdomen with back pain, without nausea or vomiting. No treatment was given during this period. He presented to the outpatient clinic for further management. Outpatient ultrasound on June 9 showed: 1. Gallbladder fossa with stones and surrounding solid mass—abscess or carcinoma? Further evaluation recommended. 2. Hepatic cysts; mild fatty liver. 3. Bilateral renal cysts. 4. Moderate prostatic enlargement with calcifications. Following outpatient evaluation, he was admitted to the department with a diagnosis of “cholelithiasis with cholecystitis and gallbladder occupying lesion.” Physical signs: The patient remained in good spirits and physical condition since onset, with stable weight, dry stools, and normal urination. Clinical diagnosis: Dizziness; benign paroxysmal positional vertigo? Hypertension; coronary atherosclerotic heart disease; cholelithiasis with cholecystitis; gallbladder occupying lesion. 1. Upper abdominal (liver, gallbladder, pancreas, spleen) CT plain scan + contrast Executing department: CT room Requesting department: Hepatobiliary Surgery Ward 2 Requesting physician: Request time: June 15
Imaging report Examination site: HRCT-upper abdomen (liver, gallbladder, pancreas, spleen) plain scan + contrast Report time: June 15, 16:15:57 Findings A rounded mass was seen at the gallbladder fundus, measuring approximately 6.1 × 6.5 cm, with ill-defined borders and irregular margins. Multiple small nodular dense shadows were present inside. The lesion had unclear boundaries with adjacent liver parenchyma and showed mild peripheral enhancement on contrast. Posterior to the lesion was another rounded low-density shadow, measuring about 8.0 × 7.1 cm on the largest cross-section, with mild peripheral enhancement, closely abutting the adjacent liver and duodenum with indistinct borders. The two rounded lesions were adjacent with unclear separation. A nodular dense shadow, about 0.5 cm in diameter, was seen in the cystic duct region. An enlarged lymph node measuring about 1.9 × 1.3 cm was present at the hepatic hilum and showed enhancement. Scattered non-enhancing cystic low-density shadows were seen in the liver parenchyma. No dilatation of intra- or extrahepatic bile ducts. The spleen was normal. No abdominal effusion. Multiple small rounded non-enhancing shadows were present in both kidneys. A small amount of fat herniated into the mediastinum, containing minimal fluid-density material. Diagnostic impressions 1. The changes at the gallbladder fundus are highly suspicious for gallbladder carcinoma with invasion of adjacent liver and partial hilar lymphadenopathy. The rounded low-density shadow posterior to the gallbladder has unclear borders with the fundal lesion—nature to be determined; correlate with clinical findings. 2. Gallbladder stones; cystic duct stone. 3. Hepatic cysts. 4. Bilateral renal cysts; hiatal hernia.