Detailed Treatment Process
9 min read
Male, 61 years old Medical record Creation time: February 17, 14:25 Department: Head and Neck Tumor 【Chief complaint】 Enlarged left upper cervical lymph node 【History】 Pending: Enlarged left upper cervical lymph node 【Physical examination】 Approximately 2.5 cm enlarged node palpable in the upper cervical and submandibular region, with good mobility 【Primary diagnosis】 Pending 【TNM staging】 【Management】 Explanation of condition 【Prescription】 Ultrasound requested: parotid gland, submandibular gland, submandibular region, thyroid, neck, supraclavicular area 【Other diagnoses】 Signature time: February 17
Doppler Ultrasound Report Submission date: February 19 Department: Head and Neck Tumor Examination: Parotid glands, submandibular glands, submandibular region, thyroid, neck, supraclavicular areas Clinical diagnosis: Ultrasound findings: Parotid glands: Bilateral parotid glands normal in size and shape, with homogeneous internal echo. CDFI shows roughly normal blood flow distribution. Submandibular glands: Bilateral submandibular glands normal in size and shape, with homogeneous internal echo. CDFI shows roughly normal blood flow distribution. Submandibular region: A hypoechoic mass measuring 45 × 21 × 35 mm detected in the left submandibular region, with relatively clear borders, regular shape, visible hilar structure, heterogeneous echo, and rich blood flow. No obvious mass echo in the right submandibular region; no significant abnormal blood flow signals on color Doppler. Thyroid: Bilateral thyroid lobes and isthmus normal in size and shape, with homogeneous internal echo. CDFI normal. No obvious masses in the bilateral parathyroid regions. Neck: No obviously enlarged abnormal lymph nodes in either side of the neck; no significant abnormal blood flow signals on color Doppler. Supraclavicular areas: No obvious mass echoes in either supraclavicular region; no significant abnormal blood flow signals on color Doppler. Ultrasound impression: 1. Solid mass in the left submandibular region (likely enlarged lymph node; further evaluation recommended) 2. No obvious masses in the bilateral parotid glands, bilateral submandibular glands, right submandibular region, bilateral thyroid, bilateral neck, or bilateral supraclavicular areas Examination date: February 19, 15:03
Medical record 7 Creation time: February 19, 15:29 Department: Head and Neck Tumor 【Chief complaint】 Enlarged left upper cervical lymph node 【History】 Pending: Enlarged left upper cervical lymph node. Ultrasound report (February 19): Solid mass in the left submandibular region (likely enlarged lymph node; further evaluation recommended). No obvious masses in the bilateral parotid glands, bilateral submandibular glands, right submandibular region, bilateral thyroid, bilateral neck, or bilateral supraclavicular areas. 【Physical examination】 General condition satisfactory 【Primary diagnosis】 Pending 【Disease code】 Z00.800A 【TNM staging】 【Management】 Explanation of condition 【Prescription】 Pathology request: Fine-needle aspiration 【Other diagnoses】 Signature time: February 19
Medical record Creation time: February 20, 09:54 Department: Head and Neck Tumor 【Chief complaint】 Left submandibular mass discovered 5 months ago 【History】 Pending. Ultrasound report (February 19): Solid mass in the left submandibular region (likely enlarged lymph node; further evaluation recommended). No obvious masses in the bilateral parotid glands, bilateral submandibular glands, right submandibular region, bilateral thyroid, bilateral neck, or bilateral supraclavicular areas. Fine-needle aspiration showed atypical cells suspicious for malignancy. 【Physical examination】 Left submandibular mass approximately 4 cm, medium consistency, mobile 【Primary diagnosis】 Pending 【Disease code】 Z00.800A 【TNM staging】 【Management】 MRI and CT 【Prescription】 CT request: Contrast-enhanced neck CT. Examination site: Contrast-enhanced neck CT. MRI request: Plain + contrast. Examination site: Oropharynx (plain + contrast) 【Other diagnoses】 Signature time: February 20
Cytopathology Report Submission date: February 20 Submitting hospital: This hospital Department: Head and Neck Tumor Specimen: Fine-needle aspiration of left submandibular mass Pathological diagnosis: Atypical cells present, suspicious for malignancy. Histological examination recommended if necessary.
Radiology Report (MRI) Department: Head and Neck Tumor Clinical diagnosis: Pending Requested examination: Oropharynx (plain + contrast) Examination site: Oropharynx (plain + contrast) Examination time: February 20, 22:04:11 Radiological findings: Oropharyngeal cavity symmetric, mucosa generally smooth with clear margins. Left tonsil appears full; right tonsil morphology acceptable. Soft-tissue mass in left upper cervical level IIA, relatively well-defined, measuring approximately 36 × 25 mm, with heterogeneous enhancement post-contrast. Multiple slightly enlarged lymph nodes in the left neck; no obvious enlarged lymph nodes in the right neck. Remaining salivary glands unremarkable. Radiological diagnosis: Mass in the left upper neck, favoring metastatic lymph node; correlate with clinical findings and biopsy. Left tonsil fullness; correlate with clinical findings. Multiple slightly enlarged lymph nodes in the left neck. Report time: February 21, 11:24:53 Verification time: February 21, 11:34:01
Radiology Report (CT) Department: Head and Neck Tumor Clinical diagnosis: Requested examination: Contrast-enhanced neck CT Examination site: Contrast-enhanced neck CT Examination time: February 26, 14:46:13 Radiological findings: Bilateral thyroid glands normal in morphology and density. Oropharynx, hypopharynx, and nasopharynx unremarkable. Neck vessels normal in course. No abnormal soft-tissue shadows in the pharynx or larynx. Enlarged left upper cervical lymph node measuring approximately 26 × 33 mm. Radiological diagnosis: Enlarged left upper cervical lymph node; correlate with biopsy. Report time: February 27, 14:39:25 Verification time: February 28, 09:59:35
Medical record Creation time: February 28, 15:17 Department: Head and Neck Tumor 【Chief complaint】 Left submandibular mass discovered 5 months ago 【History】 Ultrasound report (February 19): Solid mass in the left submandibular region (likely enlarged lymph node; further evaluation recommended). No obvious masses in the bilateral parotid glands, bilateral submandibular glands, right submandibular region, bilateral thyroid, bilateral neck, or bilateral supraclavicular areas. Fine-needle aspiration showed atypical cells suspicious for malignancy. 【Physical examination】 Left submandibular mass approximately 4 cm, medium consistency, mobile 【Primary diagnosis】 Pending 【TNM staging】 【Management】 Referral to head and neck surgery clinic recommended 【Prescription】 【Other diagnoses】 Signature time: February 28
Medical record Creation time: March 3, 09:04 Department: Head and Neck Surgery 【Chief complaint】 Enlarged left cervical lymph node 【History】 Oropharyngeal MRI: Mass in the left upper neck, favoring metastatic lymph node; correlate with clinical findings and biopsy. Left tonsil fullness; correlate with clinical findings. Multiple slightly enlarged lymph nodes in the left neck. Fine-needle aspiration: Atypical cells suspicious for malignancy. Histological examination recommended if necessary. 【Physical examination】 General condition satisfactory 【Primary diagnosis】 Local neck mass 【TNM staging】 【Management】 Explanation of condition; core-needle biopsy recommended; referral to interventional clinic 【Prescription】 【Other diagnoses】 Signature time: March 3
Medical record Creation time: March 3, 11:35 Department: Interventional Treatment 【Chief complaint】 Enlarged left cervical lymph node 【History】 Local neck mass. Oropharyngeal MRI: Mass in the left upper neck, favoring metastatic lymph node; correlate with clinical findings and biopsy. Left tonsil fullness; correlate with clinical findings. Multiple slightly enlarged lymph nodes in the left neck. Fine-needle aspiration: Atypical cells suspicious for malignancy. Histological examination recommended if necessary. Core-needle biopsy requested. 【Additional history and signs】 【Physical examination】 General condition satisfactory 【Primary diagnosis】 Local neck mass 【TNM staging】 x 【Management】 Explanation of condition: Risks and complications discussed. Planned core-needle biopsy of left neck mass. 【Prescription】 Interventional request: Lymph node puncture MRT Additional pathology request: Outpatient non-operating room routine pathology Additional pathology request: Interventional cytology Additional laboratory request: HIV antibody, syphilis (specific antibody + serum titer), hepatitis B surface antigen/ antibody/ e antigen/ e antibody/ core antibody (two-and-a-half), HCV antibody (hepatitis C) Laboratory request: Complete blood count (5-classification), coagulation profile (six items) 【Other diagnoses】 Signature time: March 3
Laboratory Report Specimen: Plasma Collection date: March 3, 12:10 Department: Interventional Treatment Clinical diagnosis: Local neck mass Submission date: March 3, 12:11 Test \ Result \ Reference range Prothrombin time 11.1 (9.4-12.5 s) Fibrinogen 2.03 ↓ (2.38-4.98 g/L) Activated partial thromboplastin time 29.9 (25.1-36.5 s) Thrombin time 15.6 (10.3-16.6 s) PT-INR 0.97 (0.80-1.20) D-dimer 0.20 (0.00-0.50 μg/mL) FDP 2.00 (0.00-5.00 μg/mL) Test date: March 3, 12:17 Report date: March 3, 12:50
Laboratory Report Specimen: Venous whole blood Collection date: March 3, 12:09 Department: Interventional Treatment Clinical diagnosis: Local neck mass Submission date: March 3, 12:11 Test \ Result \ Reference range White blood cell count 5.9 (3.5-9.5 × 10⁹/L) Lymphocyte % 43.7 (20.0-50.0%) Monocyte % 7.5 (3.0-10%) Neutrophil % 47.6 (40-75%) Eosinophil % 0.50 (0.4-8.0%) Basophil % 0.70 (0.00-1.00%) Lymphocyte count 2.6 (1.1-3.2 × 10⁹/L) Platelet count 285 (125-350 × 10⁹/L) Monocyte count 0.4 (0.1-0.6 × 10⁹/L) Neutrophil count 2.8 (1.8-6.3 × 10⁹/L) Eosinophil count 0.03 (0.02-0.52 × 10⁹/L) Basophil count 0.04 (0.00-0.06 × 10⁹/L) Red blood cell count 4.86 (4.3-5.8 × 10¹²/L) Hemoglobin 143 (130-175 g/L) Test date: March 3, 12:23 Report date: March 3, 12:23
Laboratory Report Department: Interventional Treatment Clinical diagnosis: Local neck mass Submission date: March 3, 12:11 Test \ Result \ Reference range HBsAg Negative(-) 0.00 (Negative <0.05 IU/mL) HBsAb Negative(-) 1.40 (Negative <10 mIU/mL) HBeAg Negative(-) 0.32 (Negative <1.00 S/CO) HBeAb Positive(+) 0.18 (Negative >1.00 S/CO) HBcAb Positive(+) 4.75 (Negative <1.00 S/CO) HIV antibody Negative(-) 0.19 (Negative <1.00 S/CO) HCV antibody Negative(-) 0.19 (Negative <1.00 S/CO) Syphilis serology Negative(-) (Negative(-)) Syphilis antibody Negative(-) 0.11 (Negative <1.00 S/CO) Test date: March 3, 12:36 Report date: March 3, 14:02
Cytopathology Report Submission date: March 4 Submitting hospital: This hospital Department: Interventional Treatment Specimen: Touch imprint from core-needle biopsy of left neck mass Pathological diagnosis: Atypical cells present, favoring malignancy. Correlate with histological findings.
Medical record Creation time: March 5, 15:43 Department: Head and Neck Surgery 【Chief complaint】 Left upper neck mass 【History】 Local neck mass: Left upper neck mass. Core-needle biopsy: Metastatic carcinoma. MRI: Mass in the left upper neck, favoring metastatic lymph node; correlate with clinical findings and biopsy. Left tonsil fullness; correlate with clinical findings. Multiple slightly enlarged lymph nodes in the left neck. 【Physical examination】 General condition satisfactory 【Primary diagnosis】 Local neck mass 【TNM staging】 【Management】 Explanation of condition. Carcinoma of unknown primary with possible metastatic disease considered. PET-CT recommended for further staging. 【Prescription】 Nuclear medicine request: Whole-body tumor tomography (self-pay item: PET/CT whole-body scan). Examination site: Whole-body tumor tomography. 【Other diagnoses】 Signature time: March 5