Detailed Treatment Process
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Male, 61 years old Below is the discharge summary Department: Thoracic and Cardiac General Pediatric Surgery Admission date: May 9 Discharge date: June 8 Length of stay: 30 days Admission diagnosis: 1. Left pleural effusion; 2. Left lung atelectasis; 3. Right middle lobe pneumonia; 4. Hypertension (?) Discharge diagnosis: 1. Left malignant pleural effusion (adenocarcinoma); 2. Left lung atelectasis; 3. Right middle lobe pneumonia; 4. Left upper lobe pulmonary nodule; 5. Left pleural thickening; 6. Brain atrophy Admission status: The patient was admitted with a chief complaint of recurrent cough for half a year. Physical examination: T 36.7℃, P 89 beats/min, R 20 breaths/min, BP 141/80 mmHg Chest wall normal in shape, no tenderness over sternum or chest wall. Respiratory movements symmetric. Tactile vocal fremitus increased on the left. No pleural friction rub. Dullness to percussion over the left lung. Upper borders of lung fields normal. Breath sounds clear on the right; absent on the left. No dry or wet rales heard. Auxiliary examinations: Chest CT on May 9 (outpatient): 1. Left pleural effusion with left lung atelectasis, further evaluation recommended; 2. Right middle lobe inflammation; 3. Upper abdominal CT plain scan showed no obvious abnormalities. Emergency blood routine on May 9: WBC 9.6 × 10⁹/L (4.0-10.0 × 10⁹/L), NEUT% 77.4% (50-70%), LYMPH% 16.1% (20-40%), RBC 4.20 × 10¹²/L (4.0-5.5 × 10¹²/L), HGB 123.0 g/L (120-160 g/L), PLT 237 × 10⁹/L (100-300 × 10⁹/L). Coagulation profile: PT 12.8 s, INR 1.19, APTT 30.6 s, FIB 3.75 g/L, TT 12.6 s, FDP 6.1 μg/ml. Emergency biochemistry (8 items): Emergency liver function (8 items): Emergency cardiac enzymes (4 items): ALB 33.7 g/L, A/G 1.0, creatinine 6.1 μmol/L, CA 2.02 mmol/L, UREA 2.9 mmol/L, OSMO 274 mOsm/kg. Pleural fluid carcinoembryonic antigen (CEA) (chemiluminescence): CEA >1059.00 ng/ml. Pleural fluid routine + protein quantification: Color: bloody red, Transparency: turbid, Clots: none, WBC 835 × 10⁶/L, mononuclear cells 65%, NEU% 35%, protein 53.30 g/L. Chest and abdominal CT: 1. Left pleural effusion with left lung atelectasis, further evaluation recommended; 2. Right middle lobe inflammation; 3. Upper abdominal CT plain scan showed no obvious abnormalities. Squamous cell carcinoma antigen (SCC) on May 11 (instrument method): SCC 0.50 μg/L. Acid-fast bacilli smear: negative. TB-DNA: negative. Stool routine normal. May 12 pathology: (Left pleural fluid cell block) Immunohistochemistry: moderate to severe nuclear atypia cells, CK (low molecular weight) +, CK5/6 –, TTF-1 (+), Napsin A (-/+), CD57 –, D2-40 (–), Ki-67 (+) 5%, consistent with metastatic adenocarcinoma (likely of pulmonary origin). May 14 chest CT: Changes after closed chest drainage for left pleural effusion; left upper lobe nodule, further evaluation recommended; left pleural thickening. May 17 chest CT: 1. Changes after closed chest drainage for left pleural effusion with left hydropneumothorax; 2. Left pneumonia; 3. Left upper lobe nodule, further evaluation recommended; 4. Left pleural thickening. May 23 pleural ultrasound: Localization for puncture of left pleural effusion (with multiple septations). Chest CT: 1. Changes after closed chest drainage for left pleural effusion with left hydropneumothorax, similar to previous; 2. Left pneumonia, similar to previous; 3. Left upper lobe nodule, further evaluation recommended; 4. Left pleural thickening. May 28 head and chest CT: 1. Brain atrophy; 2. Changes after closed chest drainage for left hydropneumothorax; 3. Left pneumonia, improved compared with previous; 4. Left upper lobe nodule, suspected metastatic tumor, further evaluation recommended; 5. Left pleural thickening. June 3 chest CT: Changes after closed chest drainage for left hydropneumothorax with left loculated hydropneumothorax; left pneumonia, largely similar to previous; left upper lobe nodule, suspected metastatic tumor, largely similar to previous, further evaluation recommended; left pleural thickening. Page 1 Treatment course: After admission, relevant examinations were completed. Closed chest drainage was performed. Treatment included anti-tumor therapy, anti-infection measures, expectorants, and bronchodilators. Discharge status: Discharged with improved condition. Discharge instructions: 1. Outpatient follow-up, strengthen nutrition, enhance immunity, keep warm, repeat chest CT in 1 month and regularly thereafter. 2. Chief physician outpatient clinic every Wednesday (full day), attending physician outpatient clinic every Monday afternoon. 3. Seek medical attention immediately if any discomfort occurs.
Total cost of first hospitalization approximately $4,300, of which self-pay portion approximately $1,870 (remainder covered by medical insurance or project). After discharge, the patient participated in a clinical trial of the targeted drug icotinib and received icotinib free of charge. End of first year (December): CT imaging showed left upper lobe nodule with multiple lymph node metastases in the left pulmonary hilum, supraclavicular fossa, mediastinum, and left axilla, along with left loculated pleural effusion and pleural thickening. This indicated that resistance to icotinib had developed. February of the following year: CT report as follows. Examination date: February 13 of the following year Requesting department: Cardiothoracic General Pediatric Surgery Examined region: Chest Description: Left hemithorax smaller, left lung with patchy, patchy-streaky increased density shadows with blurred margins. Left lower lobe bronchus narrowed, progressed compared with previous scan of December 18 last year. Multiple nodular increased density shadows in left upper lobe with slightly blurred margins, lesions less clearly defined than before. New nodular high-density shadow in right upper lobe (Img17), diameter approximately 4 mm. Multiple enlarged lymph nodes in left supraclavicular fossa, mediastinum, left pulmonary hilum, and left axilla, largest approximately 3.5 cm, some enlarged compared with previous. Heart shadow and great vessels normal in morphology. Pericardial thickening. Arcuate and fusiform water-density shadows in left pleural cavity, largely similar to previous. Left pleural thickening. New arcuate water-density shadow in right posterior pleural cavity. Enlarged retroperitoneal lymph nodes noted. Impression: Outpatient diagnosis: Left lung metastatic tumor with multiple lymph node metastases in left pulmonary hilum, left supraclavicular fossa, mediastinum, and left axilla; left upper lobe nodule, suspected metastasis; small nodule in right upper lobe; left lower lobe bronchial narrowing with left pneumonia, progressed compared with previous; pericardial thickening; left loculated pleural effusion and left pleural thickening; right pleural effusion; enlarged retroperitoneal lymph nodes. Report date: February 13 of the following year
The patient died in October of the following year. The entire disease course from diagnosis to death totaled 30 months.