Detailed Treatment Process
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Female, 88 years old Lower abdominal CT scan report Department: Emergency Internal Medicine Requesting physician: Assist in diagnosis Clinical diagnosis: Anemia Examination number 1 Examination name: Lower abdominal CT scan (plain) Radiological findings: Cystic low-density lesion in the appendiceal region, approximately 27 mm in diameter, CT value about 11 HU. The terminal ileum and ileocecal region show marked irregular wall thickening with slightly blurred surrounding fat planes, accompanied by scattered enlarged lymph nodes. Multiple enlarged lymph nodes are also present in the right retroperitoneum. No obvious abnormal masses in the rest of the lower abdomen. No abnormalities in the uterine region or obvious lesions. The bladder is well distended. No significantly enlarged lymph nodes in the pelvis, with a small amount of pelvic fluid. Additional findings: Multiple wedge-shaped deformities of T12-L2 vertebral bodies with increased bone density; mild anterior spondylolisthesis of L4. Examination time: August 2, 11:26:45 Report time: August 2, 11:51:34
Upper abdominal CT scan report Department: Emergency Internal Medicine Ward: Emergency Internal Medicine Bed Requesting physician: Assist in diagnosis Clinical diagnosis: Anemia Examination number 1 Examination name: Upper abdominal CT scan (plain) Radiological findings: The liver surface is smooth, with normal lobe proportions. Multiple scattered slightly low-density lesions within the liver, with ill-defined borders and suboptimal visualization. No intrahepatic bile duct dilatation. No abnormalities in the gallbladder region or obvious lesions. The pancreas appears normal. The spleen is not enlarged with homogeneous density. Both kidneys appear normal. No significantly enlarged retroperitoneal lymph nodes. Small amounts of fluid around the liver and spleen. Radiological impression: Multiple scattered slightly low-density lesions in the liver, metastases to be excluded; small amount of abdominal fluid. Please correlate with clinical findings and consider further contrast-enhanced MRI. Gastrointestinal evaluation suggested with endoscopy. Examination time: August 2, 11:26:45 Report time: August 2, 11:51:34
Laboratory report Department: Gastroenterology Specimen type: Plasma Test item \ Result \ Reference range High-sensitivity troponin I 0.106 ↑ (0-0.037 ng/ml) Hepatitis B surface antigen < 0.10 (negative:<1 index; positive:>50 index; borderline:1-50 index) Collection time: August 2, 08:46 Receipt time: August 2, 09:48 Test time: August 2, 10:33 Review time: August 2, 11:11 Print time: August 2, 12:50 ********* Discharge summary Department: General Surgery Admission time: August 3, 09:02 Discharge time: August 15, 08:55 Outpatient diagnosis: 1. Colon mass Admission diagnosis: 1. Colon mass; 2. Primary hypertension; 3. Lumbar spondylolisthesis Discharge diagnosis: 1. Ileocecal malignant tumor pT₄NxM1 stage IV 2. Secondary liver malignancy pT4NxM1 stage IV 3. Small bowel obstruction; 4. Primary hypertension; 5. Lumbar spondylolisthesis Admission status: 1) Admitted to our hospital on August 3 at 09:02 for "poor appetite for 1 week." 2) History of present illness: The patient developed poor appetite and fatigue more than one week ago without obvious cause, accompanied by belching. No abdominal pain, nausea, vomiting, cessation of flatus or stool, acid reflux, heartburn, fever, or chills. She presented to the outpatient clinic, where CT showed multiple scattered slightly low-density liver lesions suspicious for metastases, small amount of abdominal fluid, and irregular thickening of the terminal ileum and ileocecal wall with blurred surrounding planes, scattered enlarged lymph nodes, and a low-density lesion near the appendix. Pelvic fluid was also noted. Further enhanced imaging and endoscopy were recommended. Additional findings included multiple wedge-shaped vertebral deformities at T12-L2 with increased bone density and mild anterior spondylolisthesis of L4. She was admitted for further treatment under the diagnosis of colon mass. Since onset, she has had fatigue, poor appetite, normal urination, stool as described, good sleep, and no significant weight loss. 3) Physical examination: Alert, normal breathing, fair general condition. No jaundice. Abdomen symmetric, no distended abdominal veins, no visible gastric or intestinal patterns or peristalsis, no protruding masses. Soft abdomen, no tenderness, rebound, or guarding. Negative shifting dullness. Digital rectal examination: No rectal mass, no blood on glove. 4) Auxiliary examinations: As per CT findings above. Treatment course: After admission, relevant examinations were completed. Absolute surgical contraindications were ruled out, and clear surgical indications existed. Preoperative preparation and informed consent were obtained. On August 7, laparoscopic exploration, right hemicolectomy, and liver tumor resection were performed under general anesthesia. The procedure went smoothly. Postoperatively, the patient recovered well, tolerated liquid diet without discomfort, and was discharged. Main laboratory results August 3, 13:35:36: Triglycerides 1.30 mmol/L; total cholesterol 4.50 mmol/L; HDL cholesterol 0.72 mmol/L ↓; LDL cholesterol 3.630 mmol/L ↑; small dense LDL cholesterol 0.58 mmol/L; non-HDL cholesterol 3.8 mmol/L; apolipoprotein AI 0.82 g/L; apolipoprotein AII 418 mg/L; apolipoprotein CII 42 mg/L ↑; apolipoprotein CIII 70 mg/L; apolipoprotein B 1.07 g/L; apolipoprotein E 44.5 mg/L; lipoprotein(a) 334 mg/L ↑; free fatty acids 0.90 mmol/L ↑ August 3, 14:54:48: Hepatitis B surface antigen 0.04 IU/ml; hepatitis B surface antibody 116.44 mIU/ml ↑; HBeAg <0.05 index; HBeAb 4.50 index ↑; HBcAb 8.00 index ↑; HBcAb IgM 0.09 index; HCV antibody 0.22 index; syphilis antibody 0.16 index August 3, 14:55:01: β-hCG <2.0 mIU/ml; AFP <1.3 ng/ml; CEA 26.61 ng/ml; CA19-9 1896.01 U/ml ↑; CA125 194.80 U/ml ↑; CA15-3 5.20 U/ml; CA72-4 66.40 U/ml ↑; CYFRA21-1 49.50 ng/ml ↑; NSE 17.30 ng/ml ↑; ProGRP 114.97 pg/ml ↑; SCC 0.30 ng/ml; T3 0.39 nmol/L ↓; T4 79.70 nmol/L; FT3 1.4 pmol/L ↓; FT4 16.77 pmol/L; TSH 0.25 μIU/ml ↓; thyroglobulin 12.1 ug/ml ↓; calcitonin 1.66 pg/ml August 3, 14:53:23: CA50 479.00 U/ml ↑; CA242 200.00 U/ml ↑ August 15, 07:50:11: WBC 5.43 × 10⁹/L; neutrophils 87.7% ↑; lymphocytes 7.2% ↓; monocytes 3.8%; eosinophils 1.2%; basophils 0.1%; neutrophil count 4.75 × 10⁹/L; lymphocyte count 0.4 × 10⁹/L ↓; monocyte count 0.21 × 10⁹/L; eosinophil count 0.07 × 10⁹/L; basophil count 0.01 × 10⁹/L; RBC 2.43 × 10¹²/L ↓; hemoglobin 58 g/L ↓ (moderate or greater anemia suggested, recommend anemia workup); hematocrit 19.1% ↓; MCV 78.7 fL ↓; MCH 24.0 pg ↓; MCHC 306 g/L ↓; RDW 19.4% ↑; platelets 96 × 10⁹/L ↓; MPV 10.1 fL; plateletcrit 0.1% ↓; PDW 15.7 fL; large platelet ratio 0.31 August 15, 07:52:44: PT 11.0 s; APTT 34.3 s; TT 12.7 s; fibrinogen 4.84 g/L ↑; FDP 11.72 ug/mL ↑; D-dimer 5.43 mg/L ↑; PT-INR 0.91 August 15, 07:50:09: BNP 1900.61 pg/ml ↑ August 15, 08:32:06: CK-MB mass 0.74 ng/ml; myoglobin 78.63 ng/ml; high-sensitivity troponin I 0.144 ng/ml ↑ August 15, 08:40:45: Procalcitonin 0.66 ng/ml ↑ Special examinations and important consultations Echocardiography: Left ventricular ejection fraction (LVEF) 61.8%; no atrial or ventricular level shunt; mild-to-moderate MR, moderate AR, mild-to-moderate TR; left atrial enlargement; widened aortic sinus and ascending aorta; focal aortic valve calcification with mild stenosis and moderate regurgitation; moderate pulmonary hypertension; mild-to-moderate tricuspid regurgitation; mild-to-moderate mitral regurgitation; trace pericardial effusion Ultrasound: Varicose left great saphenous vein (calf segment), please correlate clinically; bilateral lower extremity arterial sclerosis with multiple plaques; no obvious abnormalities in bilateral lower extremity deep veins at present; bilateral carotid atherosclerotic plaques; increased resistance index in right carotid and bilateral vertebral arteries; reduced flow velocity in bilateral carotid arteries, please correlate clinically Colonoscopy: Ascending colon cancer with obstruction; multiple colonic polyps; internal hemorrhoids; poor bowel preparation ECG: 1. Sinus rhythm 2. Complete right bundle branch block 3. Left axis deviation 4. Left ventricular high voltage X-ray: Enlarged cardiac silhouette, right lower lung exudative shadow, please correlate with history. CT: Scattered small nodules in right upper and lower lobes, suggest follow-up. Scattered fibrous foci in both lungs. Calcified mediastinal lymph nodes, aortic and coronary artery calcification, please correlate clinically. Possible multiple liver metastases, bilateral adrenal metastases to be excluded, suggest contrast-enhanced study. Ascites. Specimen collection site: Other histological changes: Pathology: Histological diagnosis: (Ascending colon) adenocarcinoma. Ascending colon cancer gene detection report Specimen information Ascending colon: diameter 0.2 cm Method: Fluorescence quantitative PCR Pathological diagnosis (Right hemicolon) adenocarcinoma Test item \ Locus \ Result KRAS EXON-2 G12S, G12D wild-type KRAS EXON-2 G12C, G12R, G12V, G12A, G13C wild-type KRAS EXON-2 G13D wild-type KRAS EXON-3 Q61L, Q61R, Q61H wild-type KRAS EXON-4 K117N, A146T, A146V, A146P wild-type NRAS EXON-2 G12D, G12S wild-type NRAS EXON-2 G13R, G12C, G12V, G12A, G13V wild-type NRAS EXON-3 Q61R, Q61K, Q61L, Q61H wild-type NRAS EXON-4 A146T wild-type PIK3CA EXON-20 H1047R, H1047L wild-type BRAF EXON-15 V600E, V600K, V600D, V600R mutant Conclusion BRAF Exon 15 mutation detected; other items wild-type. Other histological changes: Histological diagnosis: (Ascending colon) adenocarcinoma Specimen type: Right hemicolectomy Tumor location: Ileocecal region Resected specimen length: 31 cm Gross type: Protruding Tumor size: 6.5 cm × 6 cm × 4 cm Proximal margin: (-); distal margin: (-) Histology: Adenocarcinoma with necrosis, focal mucin secretion Tumor budding: Bd3 (≥10 buds) Invasion depth: Full-thickness intestinal wall to extraserous fibroadipose tissue Differentiation: Poorly differentiated Lymphovascular invasion: (+); perineural invasion: (+) Lymph node metastasis: Peritumoral lymph nodes (2/3 +), mesenteric lymph nodes (1/3 +), additional 20 cancer nodules. Other: Appendix with full-thickness adenocarcinoma involvement Immunohistochemistry: CK7(-), CK20(+), Ki67(80%+), CDX2(+), P53(+), Villin(+), MLH1(+), MSH2(+), MSH6(+), PMS2(+), HER2(1+), CD34(+) Special stains: AB-PAS (focal +), reticulin (-); additional CDX-2(+), reticulin (+) (Liver) adenocarcinoma consistent with metastatic colorectal adenocarcinoma, cauterized margin (-) Comorbidities: None Discharge status: Not alert, normal breathing, no jaundice. Abdomen soft and flat, no tenderness, rebound, or guarding. Negative succussion splash, liver percussion tenderness, or Murphy sign. No palpable masses. Negative shifting dullness. Bowel sounds not hyperactive. No succussion splash or vascular bruits. Flatus and stool passed. Tolerating liquid diet without discomfort. Dry incision without exudate, healing II/primary. Discharge instructions and health education provided. Discharge medications Cefaclor sustained-release tablets (II) (H) (3 boxes, 1 tablet orally twice daily) Clostridium butyricum live bacteria powder (self) (2 bags, 0.5 pack orally three times daily) Torasemide tablets (1 box, 1 tablet orally once daily at 8 am) Spironolactone tablets (1 bottle, 2 tablets orally twice daily) 1. Rest adequately, soft diet, avoid overeating, consume soft and easily digestible foods, maintain regular bowel movements. 2. Seek prompt medical attention for high fever, abdominal pain, or other discomfort. 3. Follow up at General Surgery outpatient clinic as scheduled. Return promptly if unwell. Appointment: Gastrointestinal Surgery specialist clinic Appointment time: August 21, 09:00:00--09:30:00
88 years old, colon cancer with liver metastases, multiple enlarged retroperitoneal lymph nodes, stage IV cancer Anemia, elevated troponin, BNP 1900, LVEF 62%, moderate pulmonary hypertension Postoperative state: coma + small bowel obstruction The doctor told the family that surgery would allow longer survival than no surgery Most family members agreed to proceed with surgery No contrast-enhanced CT or MRI performed preoperatively. Discharge summary does not specify timing of examinations including echocardiography, ECG, ultrasound, CT, and colonoscopy.