Detailed Treatment Process
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Male, 53 years old, admitted for gastric cancer surgery. The following is the detailed discharge summary. Department: General Surgery Admission date: July 28 Discharge date: November 27 Outpatient diagnosis: Gastric cancer Admission diagnosis: Gastric cancer Discharge diagnosis: Gastric cancer Main symptoms and signs on admission: Chief complaint: Recurrent dull upper abdominal pain and discomfort for more than one year Physical examination: Alert, breathing normal. No jaundice of skin or mucous membranes. Breath sounds in both lungs were coarse with no dry or moist rales. Heart rhythm regular with strong heart sounds. Abdomen soft and flat, no tenderness, rebound tenderness, or muscle guarding; no palpable masses. Liver and spleen not palpable below the costal margin. No edema in either lower limb. NS (-) Main laboratory results: 10/25 Blood routine with five-classification differential White blood cell count 9.70 × 10⁹/L, neutrophils 56.4%, monocytes 6.90%, lymphocytes 35.20%, eosinophils 0.90%, basophils 0.60%, absolute neutrophil count 5.40 × 10⁹/L, absolute monocyte count 0.70 × 10⁹/L, absolute lymphocyte count 3.40 × 10⁹/L, absolute eosinophil count 0.10 × 10⁹/L, absolute basophil count 0.10 × 10⁹/L, red blood cell count 3.35 × 10¹²/L, hemoglobin 108 g/L, hematocrit 31.80%, mean corpuscular volume 95.1 fL, mean corpuscular hemoglobin 32.3 pg, mean corpuscular hemoglobin concentration 340 g/L, red cell distribution width 16.6%, platelet count 240.00 × 10⁹/L, plateletcrit 0.22%, mean platelet volume 9.00 fL, platelet distribution width 16.1 fL 10/25 Liver function (emergency) + renal function (emergency) + sodium, potassium, chloride (emergency) Sodium (dry slide) 136.0 mmol/L, potassium (dry slide) 3.40 mmol/L, chloride (dry slide) 97.0 mmol/L, urea nitrogen (dry slide) 3.0 mmol/L, creatinine (dry slide) 35.5 umol/L, uric acid (dry slide) 82.20 umol/L, bile acid 10.0 umol/L, alanine aminotransferase (dry slide) 43.0 U/L, aspartate aminotransferase (dry slide) 48.0 U/L, alkaline phosphatase (dry slide) 130 U/L, GGT (dry slide) 79 U/L, total bilirubin (dry slide) 16.3 umol/L, direct bilirubin (dry slide) 0.00 umol/L, total protein (dry slide) 64 g/L, albumin (dry slide) 30.2 g/L, albumin/globulin ratio 0.89 07/29 Blood routine with five-classification differential White blood cell count 7.50 × 10⁹/L, neutrophils 61.2%, lymphocytes 28.00%, monocytes 7.70%, eosinophils 2.40%, basophils 0.70%, absolute neutrophil count 4.60 × 10⁹/L, absolute monocyte count 0.60 × 10⁹/L, absolute lymphocyte count 2.10 × 10⁹/L, absolute eosinophil count 0.20 × 10⁹/L, absolute basophil count 0.10 × 10⁹/L, red blood cell count 4.49 × 10¹²/L, hemoglobin 141 g/L, hematocrit 43.80%, mean corpuscular volume 97.7 fL, mean corpuscular hemoglobin 31.4 pg, mean corpuscular hemoglobin concentration 321 g/L, red cell distribution width 13.8%, platelet count 212.00 × 10⁹/L, plateletcrit 0.19%, platelet distribution width 16.5 fL, mean platelet volume 9.10 fL 07/29 DIC panel Prothrombin time 10.50 s, prothrombin time INR 0.97, activated partial thromboplastin time 36.5 s, fibrinogen 3.05 g/L, thrombin time 13.60 s, D-dimer 0.13 mg/L, antithrombin activity 124%, fibrin (ogen) degradation products 0.70 mg/L 07/29 Pre-transfusion testing