Detailed Treatment Process
Male, 45 years old Involved in a public security dispute requiring injury assessment, during which a subpleural nodule was incidentally discovered on chest imaging. As a result, a lobectomy was performed on August 12.
Radiology Report (CT) Department: Cardiothoracic Surgery Clinical Diagnosis: Left chest trauma Examination Site and Name: Chest Examination Method: Chest CT (plain scan) Radiological Findings: The chest is symmetric. Increased lung markings are seen bilaterally. A high-density nodule is noted in the subpleural region of the posterior segment of the right upper lobe, measuring approximately 1.07 × 0.98 cm, with lobulation and spiculation at the margin and adjacent pleural traction. Scattered small nodules are present in the right upper and middle lobes, some showing calcification. The trachea and bilateral main bronchi are patent. No obvious enlarged lymph nodes are seen in the hila or mediastinum. No pleural effusion bilaterally. No obvious displaced fractures in the visualized chest bones. Radiological Impression: 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: Assist with diagnosis Examination Site and Name: Chest CT Examination Method: Plain scan; baseline at sternoclavicular joint to lung base, inspiratory phase, slice thickness 1 mm, pitch 1 mm, reconstruction thickness 5-10 mm, interval 5-10 mm; 3D reconstruction. Radiological Findings: Bilateral chest walls are symmetric with no obvious abnormalities. Trachea is midline. Tracheobronchial tree is patent. A nodule approximately 1 cm in diameter is seen in the right upper lobe. Calcified nodules are present in both upper lobes and the right middle lobe. Diffuse miliary nodules are also seen in both lungs. Bilateral hilar structures are clear, with normal morphology, size, and position. Mediastinum is midline. Mediastinal great vessels and cardiac silhouette are unremarkable. No abnormal enlargement of mediastinal lymph nodes. Radiological Impression: 1. Nodule in the right upper lobe; further evaluation recommended. 2. Calcified nodules in both upper lobes 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: Assist with diagnosis Examination Site and Name: Chest CT Contrast Agent: Examination Method: Contrast-enhanced; baseline at sternoclavicular joint to lung base, inspiratory phase, slice thickness 1 mm, pitch 1 mm, reconstruction thickness 5-10 mm, interval 5-10 mm; intravenous iodinated contrast 100 ml; 3D reconstruction. Radiological Findings: Bilateral chest walls are symmetric with no obvious abnormalities. Trachea is midline. Tracheobronchial tree is patent. A nodule approximately 1 cm in diameter is seen in the right upper lobe. Calcified nodules are present in both upper lobes and the right middle lobe. Diffuse miliary nodules are also seen in both lungs. Bilateral hilar structures are clear, with normal morphology, size, and position. Mediastinum is midline. Mediastinal great vessels and cardiac silhouette are unremarkable. No abnormal enlargement of mediastinal lymph nodes. Radiological Impression: 1. Nodule in the right upper lobe; no significant change compared with the August 6 prior scan. 2. Calcified nodules in both upper lobes 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/Grade A ASA Classification: II Date of Surgery: August 12 Intraoperative Blood Loss: 50 ml Blood Transfusion: 0 ml Operative Time: 1.5 hours After induction of anesthesia, the patient was turned to the left lateral position. Routine 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 inserted through the trocar. Exploration revealed 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 respectively. The lesions were of medium consistency, without invasion of the visceral pleura or pleural retraction. The pulmonary hilum was mobile. No masses or nodules were seen in the remaining lung. The superior branch of the right superior pulmonary vein (1 branch, 4.5 cm Endo-GIA Stapler), two apical-anterior segmental arteries of the right upper lobe (4.5 cm Endo-GIA Stapler), and two posterior segmental arteries of the right upper lobe (4.5 cm Endo-GIA Stapler) were divided sequentially. The incomplete fissure was opened using 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 cancer at the bronchial stump. Hemostasis was achieved. The chest was irrigated with 3000 ml normal saline. The lung was inflated under water with no air leak. Sponge and instrument counts were correct. Chest tubes were placed through the left 3rd intercostal space anterior axillary line and right 7th intercostal space mid-axillary line, along with one pleural micro-tube. The incision was closed layer by layer.
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\beta2-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 Staining Results: Acid-fast (+), reticulin (-), PAS (-), hexamine silver (-) Special Stains 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 section; 2. Pulmonary infection Main Symptoms and Signs on Admission: Right lung abnormality discovered one week earlier Key Laboratory Results: August 11 Complete Blood Count: Hemoglobin 146 g/L, red blood cells 4.80 × 10¹²/L, white blood cells 4.66 × 10⁹/L, neutrophils 50.7%, lymphocytes 32.2%, monocytes 12.0%↑, eosinophils 4.9%, basophils 0.2%, neutrophil absolute count 2.36 × 10⁹/L, lymphocyte absolute count 1.50 × 10⁹/L, monocyte absolute count 0.56 × 10⁹/L, eosinophil absolute count 0.23 × 10⁹/L, basophil absolute count 0.01 × 10⁹/L, platelets 175 × 10⁹/L, hematocrit 0.440, mean corpuscular volume 91.7 fL, mean corpuscular hemoglobin 30.4 pg, mean corpuscular hemoglobin concentration 332 g/L, red cell distribution width 13.3%, red cell distribution width SD 44.5 fL, plateletcrit 0.190, platelet distribution width 11.8 fL, large platelet ratio 29.6%, mean platelet volume 10.6 fL August 11 Biochemistry Report: γ-glutamyl transferase 18 IU/L, alanine aminotransferase 27 IU/L, aspartate aminotransferase 24 IU/L, aspartate aminotransferase isoenzyme 10 IU/L, alkaline phosphatase 82 IU/L, total bilirubin 11 umol/L, direct bilirubin 4 umol/L, total bile acid 3.3 umol/L, total protein 70 g/L, albumin 43 g/L, globulin 27 g/L, albumin/globulin ratio 1.6, prealbumin 257 mg/L, α-L-fucosidase 26 U/L, uric acid 286 umol/L, urea 4.0 mmol/L, creatinine 66 umol/L, cystatin C 0.99 mg/L, glucose 5.0 mmol/L, potassium 4.0 mmol/L, sodium 142 mmol/L, chloride 103 mmol/L, calcium 2.36 mmol/L, phosphorus 1.02 mmol/L, magnesium 0.80 mmol/L, retinol-binding protein 37 mg/L, total cholesterol 3.65 mmol/L, triglycerides 0.62 mmol/L, high-density lipoprotein 1.00 mmol/L↓, low-density lipoprotein 2.86 mmol/L, apolipoprotein A1 0.91 g/L↓, apolipoprotein B 0.59 g/L↓, apolipoprotein E 25.35 mg/L↓, lipoprotein(a) 90.0 mg/L. Special Examinations and Important Consultations: August 11 ECG Report: 1. Sinus rhythm 2. Essentially normal ECG. August 11 Ultrasound Report: Fasting liver, gallbladder, pancreas, spleen, and kidneys unremarkable; bilateral adrenal glands unremarkable. August 11 Ultrasound Report: Cardiac/vascular – 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 Echocardiography Report: Cardiac/vascular – resting echocardiogram shows no obvious segmental wall motion abnormalities. August 12 Endoscopy Report: Bronchoscopy. August 12 CT Report: 1. Nodule in the right upper lobe; no significant change compared with the August 6 prior scan. 2. Calcified nodules in both upper lobes and right middle lobe. 3. Diffuse miliary nodules in both lungs. August 12 Pathology – Frozen Section Report: ① Frozen nodules (1-3): No malignant lesion. ② Frozen nodules (4-5): No malignant lesion. Time: 19:15 Course and Treatment Outcome: After admission, examinations were completed. No surgical contraindications were found. On August 12, VATS right upper lobe posterior segment resection was performed under general anesthesia. Postoperative supportive care included intravenous fluids, antibiotics, and expectorants. Recovery was uneventful. Incision healed Grade II/A. Complications: None Condition at Discharge: Vital signs stable, general condition good Treatment Outcome: Improved Date: August 15