Detailed Treatment Process
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Male, 45 years old. The patient underwent a medical evaluation for an injury related to a public security dispute, during which a subpleural nodule was incidentally discovered on chest imaging. He subsequently underwent lobectomy on August 12. Radiology Report (CT) Department: Cardiothoracic Surgery Clinical Diagnosis: Left chest trauma Examination Site and Name: Chest Examination Method: Non-contrast chest CT scan Radiological Findings: The thorax is symmetric. Increased lung markings are noted bilaterally. A high-density subpleural nodule is seen in the posterior segment of the right upper lobe, measuring approximately 1.07 × 0.98 cm, with lobulated margins and spiculation. Adjacent pleura shows retraction. Scattered small nodules are present in the right upper and middle lobes, some with calcification. The trachea and bilateral main bronchi are patent. No enlarged lymph nodes are visible in the hila or mediastinum. No pleural effusion. No obvious displaced fractures in the visualized chest bones. Radiological Diagnosis: Subpleural nodule in the posterior segment of the right upper lobe; close follow-up or contrast-enhanced CT is recommended to rule out neoplastic lesion. Scattered small nodules in the right upper and middle lobes; follow-up recommended. Examination Time: August 1, 14:43 Report Written: August 1, 14:58 Report Verified: August 1, 15:11
Radiology Report Clinical Diagnosis: Pulmonary nodule to be investigated Requesting Physician Requirement: Assist with diagnosis Examination Site and Name: Chest CT Examination Method: Non-contrast scan from sternoclavicular joints to lung bases, inspiratory phase, slice thickness 1 mm, pitch 1 mm, reconstructed slice thickness 5-10 mm, interval 5-10 mm; 3D reconstruction. Radiological Findings: The bilateral chest walls are symmetrical with no obvious abnormalities. The trachea is midline and the tracheobronchial tree is patent. A nodule is seen in the right upper lobe, measuring approximately 1 cm. Calcified nodules are present in the upper lobes of both lungs and the right middle lobe. There are also diffuse miliary nodules throughout both lungs. Bilateral hilar structures are clear, with normal morphology, size, and position. The mediastinum is midline. The great vessels and cardiac silhouette appear normal. No abnormal enlargement of mediastinal lymph nodes. Radiological Impression: 1. Nodule in the right upper lobe. Further evaluation is recommended. 2. Calcified nodules in the upper lobes of both lungs and right middle lobe. 3. Diffuse miliary nodules in both lungs. Examination Time: August 6, 11:06 Report Written: August 7, 10:31 Report Verified: August 7, 15:31
Radiology Report Clinical Diagnosis: Pulmonary shadow Requesting Physician Requirement: Assist with diagnosis Examination Site and Name: Contrast-enhanced chest CT Examination Method: Contrast-enhanced scan from sternoclavicular joints to lung bases, inspiratory phase, slice thickness 1 mm, pitch 1 mm, reconstructed slice thickness 5-10 mm, interval 5-10 mm; 100 ml intravenous iodinated contrast; 3D reconstruction. Radiological Findings: The bilateral chest walls are symmetrical with no obvious abnormalities. The trachea is midline and the tracheobronchial tree is patent. A nodule is seen in the right upper lobe, measuring approximately 1 cm. Calcified nodules are present in the upper lobes of both lungs and the right middle lobe. There are also diffuse miliary nodules throughout both lungs. Bilateral hilar structures are clear, with normal morphology, size, and position. The mediastinum is midline. The great vessels and cardiac silhouette appear normal. No abnormal enlargement of mediastinal lymph nodes. Radiological Impression: 1. Nodule in the right upper lobe, showing no significant change compared with the August 6 study. 2. Calcified nodules in the upper lobes of both lungs and right middle lobe. 3. Diffuse miliary nodules in both lungs. Examination Time: August 11, 15:37 Report Written: August 12, 13:41 Report Verified: August 12, 13:59
Operative Record Ward: Thoracic Surgery Preoperative Diagnosis: Pulmonary shadow; pulmonary infection Postoperative Diagnosis: Benign lesion of the right upper lobe Procedure: VATS right upper lobectomy Anesthesia: General anesthesia Incision and Healing Grade: II/Primary ASA Grade: II Date of Surgery: August 12 Blood Loss: 50 ml Blood Transfusion: 0 ml Operating Time: 1.5 hours After induction of anesthesia, the patient was placed in the left lateral decubitus position. Standard skin preparation and draping were performed. Operating ports were created in the right 7th intercostal space at the mid-axillary line and the 4th intercostal space at the anterior axillary line. A thoracoscope was introduced via trocar. Exploration showed no pleural adhesions or effusion. Two lesions were identified in the posterior segment of the right upper lobe, measuring 0.7 cm and 0.5 cm in diameter respectively. The lesions were of moderate consistency, without invasion of the visceral pleura or pleural retraction. The pulmonary hilum was mobile. No other masses or nodules were seen in the remaining lung. The superior branch of the right upper pulmonary vein (1 branch) was divided with a 4.5 cm Endo-GIA stapler. Two apical-anterior segmental arteries and two posterior segmental arteries of the right upper lobe were divided with 4.5 cm Endo-GIA staplers. The incomplete fissure was divided with a 4.5 cm Endo-GIA stapler. The right upper lobe bronchus was transected and the stump closed with a 4.5 cm Endo-GIA stapler. The right upper lobe was removed. Intraoperative frozen section showed no malignancy in either nodule of the right upper lobe and no carcinoma at the bronchial margin. Hemostasis was secured. The pleural cavity was irrigated with 3000 ml normal saline. The lung was inflated under water with no air leak. Sponge and instrument counts were correct. One chest tube was placed in the left 3rd intercostal space anterior axillary line and another in the 7th intercostal space mid-axillary line, along with a pleural microcatheter. The chest was closed in layers.
Laboratory Report Item \ Result \ Reference Range AFP \ Alpha-fetoprotein \ 7.35 (0-20 ug/L) CEA \ Carcinoembryonic antigen \ 1.45 (0-10 ug/L) NSE \ Neuron-specific enolase \ 11.27 (0-20 ng/ml) β-MG \ Beta-2 microglobulin \ 2.25 (0.25-4.4 ug/ml) SF \ Ferritin \ 159.3 (20-240 ng/ml) CA-242 \ Carbohydrate antigen CA242 \ 9.05 (<25 U/ml) CA153 \ Carbohydrate antigen CA153 \ 5.80 (0-30 U/ml) CYFRA21-1 \ Cytokeratin 19 fragment \ 0.90 (0-3.3 ng/ml) CA50 \ CA50 \ 18.92 (0-25 U/ml) CA199 \ Carbohydrate antigen CA199 \ 11.36 (<37 U/ml) Test Date: August 13 Report Date: August 13
Pathology Report Department: Thoracic Surgery Special Stains: Acid-fast (+), Reticulin (-), PAS (-), Hexamine silver (-) Special stain results suggest tuberculous lesion. Report Date: August 20 ******** Discharge Summary Department: Thoracic Surgery Admission Date: August 9 Discharge Date: August 15 Outpatient Diagnosis: 1. Right pulmonary shadow; 2. Pulmonary infection Admission Diagnosis: 1. Right pulmonary shadow; 2. Pulmonary infection Discharge Diagnosis: 1. Right pulmonary shadow, pending paraffin sections; 2. Pulmonary infection Main Symptoms and Signs on Admission: Right lung abnormality discovered one week earlier Key Laboratory Results: August 11 Blood Routine: Hemoglobin 146 g/L, RBC 4.80 × 10¹²/L, WBC 4.66 × 10⁹/L, neutrophils 50.7%, lymphocytes 32.2%, monocytes 12.0%↑, eosinophils 4.9%, basophils 0.2%, neutrophil count 2.36 × 10⁹/L, lymphocyte count 1.50 × 10⁹/L, monocyte count 0.56 × 10⁹/L, eosinophil count 0.23 × 10⁹/L, basophil count 0.01 × 10⁹/L, platelets 175 × 10⁹/L, hematocrit 0.440, MCV 91.7 fL, MCH 30.4 pg, MCHC 332 g/L, RDW 13.3%, RDW-SD 44.5 fL, plateletcrit 0.190, PDW 11.8 fL, large platelet ratio 29.6%, MPV 10.6 fL. August 11 Biochemistry: ... (results as documented) Special Examinations and Consultations: August 11 ECG: Sinus rhythm, roughly normal ECG. August 11 Ultrasound: Liver, gallbladder, pancreas, spleen, kidneys unremarkable; bilateral adrenals unremarkable. August 11 Vascular Ultrasound: No obvious deep vein thrombosis in bilateral lower limbs; right lower limb deep vein valve incompetence; suspected left lower limb deep vein valve incompetence. August 11 Echocardiogram: No obvious segmental wall motion abnormalities at rest. August 12 Bronchoscopy. August 12 CT: 1. Right upper lobe nodule, no significant change from August 6. 2. Calcified nodules in upper lobes bilaterally and right middle lobe. 3. Diffuse miliary nodules in both lungs. August 12 Frozen Section: ① Frozen nodules (1-3): No malignancy. ② Frozen nodules (4-5): No malignancy. Time: 19:15. Hospital Course and Treatment Outcome: After admission, preoperative evaluation was completed. There were no contraindications to surgery. On August 12, VATS right upper lobectomy (posterior segment) was performed under general anesthesia. Postoperative intravenous fluids, antibiotics, and mucolytics were administered. The patient recovered well. The incision healed by primary intention (Grade II). No complications. Condition at Discharge: Stable vital signs, good general status. Treatment Outcome: Improved. Date: August 15