Detailed Treatment Process
Male, 84 years old Painless gastroscopy diagnostic report Department: Gastroenterology Outpatient Source: Outpatient Findings: Cauliflower-like lesion with surface erosion, necrosis, and bleeding visible on the posterior wall of the esophagus from 30 cm from the incisors to the cardia. Gastric fundus and body mucosa smooth and normal in color, with old blood stains. Mucus pool clear and moderate in volume. Gastric angle mucosa smooth, no white coating. Gastric antrum mucosa red and white, predominantly red. Pylorus round and well open. Duodenal bulb unremarkable. Biopsy: 4 pieces from esophagus HP: negative Diagnosis: MT in middle and lower esophagus Note: Please collect biopsy report with this form within seven working days. Fasting and hospitalization recommended. Report date: March 28
Ultrasound examination report (color) Examination time: March 29, 10:00 Department: Thoracic Surgery Ward Examination items: Liver/gallbladder/pancreas/spleen/kidney/ureter/bladder/prostate/neck and supraclavicular Clinical diagnosis: Ultrasound description: Liver: First and second hepatic portals, right interlobar fissure, main interlobar fissure, left interlobar fissure, diaphragmatic top, lateral angle, and inferior margin observed. Portal vein 10 mm, flow velocity 20 cm/s. Liver morphology normal, surface smooth, capsule intact, homogeneous distribution. Parenchymal echo fine and dense, with mild posterior acoustic attenuation. Hepatic veins fairly clear. Intrahepatic bile ducts not dilated. Several hyperechoic spots in right lobe of liver, arranged along bile ducts, largest 9×7 mm, with posterior acoustic shadowing. Gallbladder: Morphology and wall observed. Intra- 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. Intra- and extrahepatic bile ducts not dilated. Pancreas: Normal morphology, clear boundary, homogeneous parenchymal echo. Main pancreatic duct not dilated. No peripancreatic fluid. Spleen: Capsule, parenchyma, and hilar vessels observed. Normal morphology, intact capsule, clear boundary, 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 small in size, capsules intact, clear boundaries. Cortical echo homogeneous, corticomedullary differentiation clear. Renal pelvis not separated. Rich blood supply to both kidneys. Anechoic area in upper pole of left kidney, size 8×8 mm, clear boundary, regular shape, no internal blood flow signal. Ureters: Sections observed. Upper, lower, and intramural segments of both ureters observed. No dilatation of either ureter. Bladder: Mildly filled. Prostate: Base, apex, and capsule observed. Transabdominal size: 41×42×43 mm. Enlarged morphology, clear outline, intact capsule, slightly heterogeneous parenchymal echo. Hyperechoic spots within prostate. Neck: Several hypoechoic nodules in bilateral neck, largest 7×16 mm, long/short axis ratio 0.44, clear boundary, clear corticomedullary differentiation, with punctate blood flow signals inside. Supraclavicular: Several hypoechoic nodules in right supraclavicular region, largest 6×12 mm, long/short axis ratio 0.5, clear boundary, slightly irregular shape, unclear corticomedullary differentiation, with punctate blood flow signals inside. One hypoechoic nodule in left supraclavicular region, size 4×7 mm, long/short axis ratio 0.57, clear boundary, regular shape, clear corticomedullary differentiation, with punctate blood flow signals inside. Ultrasound impression: 1. Hyperechoic spots in right lobe of liver (intrahepatic bile duct stones?) 2. Small bilateral kidneys, 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 in original)
The patient died on the second day after surgery.