Detailed Treatment Process
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Male, 84 years old Painless gastroscopy report Department: Gastroenterology Clinic Source: Outpatient Findings: On the posterior wall of the esophagus, from 30 cm from the incisors to the cardia, there is a cauliflower-like lesion with surface erosion, necrosis, and bleeding. The mucosa of the gastric fundus and body is smooth and normal in color, with old bloodstains. The mucus pool is clear with a moderate volume. The mucosa at the gastric angular notch is smooth without white coating. The antral mucosa shows a red-and-white pattern, predominantly red. The pylorus is round and opens well. No abnormalities seen in the duodenal bulb. Biopsy: 4 samples from the esophagus HP: negative Diagnosis: Mid-to-distal esophageal malignant tumor Note: Please collect the biopsy report within seven working days with this form. Remain fasting and proceed with hospital admission for treatment. Report date: March 28
Ultrasound report (color) Examination time: March 29, 10:00 Department: Thoracic Surgery Ward Examination items: Liver/gallbladder/pancreas/spleen/kidneys/ureters/bladder/prostate/neck and supraclavicular region Clinical diagnosis: Ultrasound description: Liver: The first and second hepatic portals, right interlobar fissure, main interlobar fissure, left interlobar fissure, diaphragmatic dome, lateral angle, and inferior margin of the liver were observed. Portal vein 10 mm, flow velocity 20 cm/s. Liver morphology normal, surface smooth, capsule intact, homogeneous distribution. Parenchymal echo is fine with mild posterior acoustic attenuation. Hepatic veins are fairly clear. No intrahepatic bile duct dilatation. Several hyperechoic spots in the right lobe of the liver arranged along the bile ducts, the largest 9 × 7 mm, with posterior acoustic shadowing. Gallbladder: Gallbladder morphology and wall observed. Intrahepatic and extrahepatic bile ducts and first hepatic portal observed. Size 57 × 26 mm, wall thickness 2 mm, common bile duct 5 mm. Gallbladder well filled, wall smooth, bile anechoic. No dilatation of intra- or extrahepatic bile ducts. Pancreas: Normal morphology, clear borders, homogeneous parenchymal echo. Main pancreatic duct not dilated. No peripancreatic fluid. Spleen: Capsule, parenchyma, and hilar vessels observed. Normal morphology, intact capsule, clear borders, homogeneous parenchymal echo, normal blood supply. Kidneys: Coronal, sagittal, and transverse sections of both kidneys observed. Right kidney size: 85 × 42 mm, left kidney size: 83 × 45 mm. Both kidneys appear small. Capsules intact, borders clear, cortical echo homogeneous, corticomedullary differentiation clear. No renal pelvis separation. Rich blood supply to both kidneys. Anechoic area in the upper pole of the left kidney, size 8 × 8 mm, clear borders, regular shape, no internal blood flow signals. Ureters: Sections observed. Upper and lower segments and intramural portions of both ureters observed. No dilatation. Bladder: Mildly filled. Prostate: Base, apex, and capsule observed. Transabdominal size: 41 × 42 × 43 mm. Enlarged, clear outline, intact capsule, slightly heterogeneous parenchymal echo with hyperechoic spots. Neck: Several hypoechoic nodules in both sides of the neck, largest 7 × 16 mm, longitudinal/transverse ratio 0.44, clear borders, clear corticomedullary differentiation, with punctate blood flow signals. Supraclavicular: Several hypoechoic nodules in the right supraclavicular region, largest 6 × 12 mm, longitudinal/transverse ratio 0.5, clear borders, slightly irregular shape, unclear corticomedullary differentiation, with punctate blood flow signals. One hypoechoic nodule on the left, size 4 × 7 mm, longitudinal/transverse ratio 0.57, clear borders, regular shape, clear corticomedullary differentiation, with punctate blood flow signals. Ultrasound impression: 1. Hyperechoic spots in the right lobe of the liver (intrahepatic bile duct stones?) 2. Bilateral small kidneys with left renal cyst 3. Prostatic hyperplasia with calcification 4. Solid nodules in bilateral supraclavicular regions (enlarged right lymph nodes?) 5. Solid nodules in bilateral neck (lymph nodes) Report time: March 29, 09:58 (as stated in original)
The patient died on the second day after surgery.