Detailed Treatment Process
Male, 61 years old The following is the discharge summary Department: Thoracic and Cardiovascular Surgery, Pediatric Surgery Admission date: May 9 Discharge date: June 8 Hospital 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 lung nodular lesion (upper lobe); 5. Left pleural thickening; 6. Brain atrophy Admission status: The patient was admitted with the 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 Normal chest contour, no tenderness over sternum or chest wall. Symmetric respiratory movement of both lungs. Tactile vocal fremitus increased on the left side. No pleural friction rub. Dullness to percussion over the left lung. Normal upper borders of both lungs. Clear breath sounds on the right, absent breath sounds on the left. No dry or moist rales heard. Auxiliary examinations: Chest CT on May 9 at our outpatient clinic showed: 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 seconds, INR 1.19, APTT 30.6 seconds, FIB 3.75 g/L, TT 12.6 seconds, FDP 6.1 ug/ml. Emergency biochemistry (8 items): Emergency liver function (8 items): Emergency myocardial enzymes (4 items): ALB 33.7 g/L, A/G 1.0, BC (as written in original, likely serum creatinine) 6.1 umol/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 cell percentage 65%, NEU% 35%, dbz 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 ug/L. Acid-fast bacilli smear: negative. TB-DNA: negative. Stool routine normal Pathology on May 12: (Left pleural effusion cell block) Immunohistochemistry showed: moderate to severe nuclear atypia cells CK low molecular +, CK5/6-, TTF-1 (+), NapsinA (-/+), CD57-, D2-40 (-), Ki-67 (+) 5%, consistent with metastatic adenocarcinoma (possibly of lung origin) Chest CT on May 14: Changes after closed chest drainage for left pleural effusion; nodule in left upper lobe, further evaluation recommended; left pleural thickening Chest CT on May 17: 1. Changes after closed chest drainage for left pleural effusion, left hydropneumothorax 2. Left pneumonia 3. Nodule in left upper lobe, further evaluation recommended 4. Left pleural thickening Color Doppler ultrasound of pleural fluid on May 23: Localization for puncture of left pleural effusion (with multiple septations visible inside). Chest CT: 1. Changes after closed chest drainage for left pleural effusion, left hydropneumothorax, similar to previous 2. Left pneumonia, similar to previous 3. Nodule in left upper lobe, further evaluation recommended 4. Left pleural thickening Head and chest CT on May 28: 1. Brain atrophy 2. Changes after closed chest drainage for left hydropneumothorax 3. Left pneumonia, partially absorbed compared with previous 4. Nodule in left upper lobe, considered metastatic tumor (MT), further evaluation recommended 5. Left pleural thickening. Chest CT on June 3: Changes after closed chest drainage for left hydropneumothorax, left loculated hydropneumothorax; left pneumonia, roughly similar to previous; nodule in left upper lobe, considered MT, roughly similar to previous images, 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, bronchodilators, etc. Discharge status: Discharged after improvement in condition. Discharge instructions: 1. Outpatient follow-up, strengthen nutrition, enhance immunity, keep warm, recheck 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 anytime if discomfort occurs
Total cost of first hospitalization approximately $31,000, of which self-pay portion approximately $13,450 (remainder covered by medical insurance or project reimbursement). After discharge, the patient joined the Icotinib clinical validation program and received free Icotinib. At the end of the first year (December): CT imaging showed a nodule in the left upper lobe with multiple lymph node metastases in the left pulmonary hilum, infraclavicular 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 imaging report as follows Examination date: February 13 of the following year Requesting department: Cardiothoracic, General Surgery, Pediatric Surgery Examination site: Chest Description: Left chest wall smaller, left lung showing patchy, patchy-strip like increased density shadows with blurred margins, narrowing of left lower lobe bronchus, progressed compared with previous images from December 18 last year. Multiple nodular increased density shadows in left upper lobe with slightly blurred margins, lesions less clearly defined than before. A nodular high-density shadow now seen in right upper lobe (Img17), about 4 mm in diameter. Multiple enlarged lymph nodes in left supraclavicular fossa and mediastinum, left pulmonary hilum and left axilla, largest about 3.5 cm, some enlarged compared with previous. Heart shadow and great vessels normal in morphology. Pericardial thickening. Arc-shaped and fusiform water-density shadows in left pleural cavity, roughly similar to previous. Left pleural thickening. New arc-shaped water-density shadow in right posterior pleural cavity. Enlarged retroperitoneal lymph nodes noted. Impression: Outpatient diagnosis: Left lung MT with multiple lymph node metastases in left pulmonary hilum, left supraclavicular fossa, mediastinum, and left axilla; nodule in left upper lobe, considered metastatic tumor; small nodule in right upper lobe; narrowing of left lower lobe bronchus, left pneumonia, progressed compared with previous; pericardial thickening; left loculated pleural effusion, left pleural thickening; right pleural effusion; retroperitoneal lymphadenopathy Report date: February 13 of the following year
Death in October of the following year. The entire disease course from diagnosis to death totaled 30 months.