Detailed Treatment Process
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The patient was a 73-year-old woman. Inspection Report Department: Encephalopathy Specimen Type: Venous Blood Submission Date: March 22 Collection Date: March 23 Clinical Diagnosis: Iron-deficiency anemia; hypoproteinemia; lacunar cerebral infarction Test Date: March 23 Report Date: March 23 Release Date: March 23 1. Carbohydrate antigen 199: 10.06 (<39 U/mL) 2. Carbohydrate antigen 724: 2.83 (<6.9 U/mL) 3. Neuron-specific enolase NSE: 40.05↑ (<16.3 ng/mL) 4. CYFRA21-1: 109.60↑ (0~3.3 ng/mL) 5. Serum C-peptide: 1.170 (0.37~1.47 nmol/L) 6. Insulin: 45.81 (10.42~104.2 pmol/L)
Inspection Report Department: Encephalopathy Specimen Type: Venous Blood Submission Date: March 22 Collection Date: March 23 Clinical Diagnosis: Iron-deficiency anemia; hypoproteinemia; lacunar cerebral infarction Test Date: March 23 Report Date: March 23 Release Date: March 23 1. Carcinoembryonic antigen: 14.3↑ (<5 ng/mL) 2. Alpha-fetoprotein: 1.26 (0.89~8.78 ng/mL) 3. Squamous cell carcinoma antigen: 1.10 (0~1.5 ng/mL) 4. Carbohydrate antigen 153: 6.3 (<31.3 U/mL) 5. Carbohydrate antigen 125: 394.4↑ (<35 U/mL)
Gastroscopy Report Department: Encephalopathy Test Date: March 26 Examination Sites: Esophagus; stomach; duodenum Findings: Esophagus: Occupying lesion at the lower esophagus; large occupying lesion with ulceration, covered with dirty fur. From the cardia, gastric fundus, gastric body, and gastric angle to the prepyloric region, the pyloric opening was round with normal opening and closing. The cardia opening was narrowed, with a small amount of turbid mucus but no blood. The gastric cavity was narrowed with poor distension and absent local peristalsis. Gastric body: Mucosal folds were smooth; mucosal arrangement on the greater curvature was orderly, with no obvious abnormalities in color or morphology. Duodenum: A 1.5 cm polypoid protrusion was seen in the bulb; no obvious abnormalities in the descending portion. Conclusion: Advanced gastric carcinoma (Borr. IV type, involving the lower esophagus, cardia, gastric fundus, gastric body, gastric angle, and gastric antrum); duodenal bulb polyp.
CT Report Department: Encephalopathy Clinical Diagnosis: Cerebral infarction Examination Date: March 22 Examination Site: Upper abdominal plain scan Findings: Free fluid in the abdominopelvic cavity with varying degrees of gastric wall thickening. Multiple enlarged lymph nodes in the surrounding area, some measuring approximately 10 mm. The liver had a regular contour with no widening of the fissures; cystic low-density lesions were seen in the liver parenchyma. No obvious dilatation of intra- or extrahepatic bile ducts. The gallbladder was not enlarged, with uniform wall thickness and no abnormal density inside. The pancreas was normal in size and morphology with homogeneous density. Cystic low-density lesions with plaque-like calcifications were noted at the splenic margin. No enlarged retroperitoneal lymph nodes, though some appeared confluent. Both kidneys had regular morphology with no obvious abnormal densities. The uterus had a regular contour with roughly homogeneous density. No obvious occupying lesions in the bilateral adnexal regions. The bladder was moderately filled with unclear contours. Retroperitoneal vascular interfaces were poorly visualized. No obvious enlarged lymph nodes in the bilateral inguinal regions. Conclusion: Abdominopelvic effusion; gastric malignancy highly suspected, with multiple surrounding lymph nodes and enlarged retroperitoneal lymph nodes; hepatic cysts, splenic cystic low-density lesions with calcification. Enhanced scanning is recommended if clinically necessary.
Gastroscopic Pathology Report Department: Encephalopathy Clinical Diagnosis: Malignant tumor of the gastric body Test Date: March 26 Examination Site: Gastric body Findings: Four tissue fragments, each 0.2 cm in diameter. Conclusion: (Gastric body, biopsy) Poorly differentiated carcinoma; in combination with immunohistochemical results, neuroendocrine differentiation is considered. Immunohistochemistry: A: Syn(+), AE1/AE3(+), Ki-67(80%+), C-erbB-2(0), CgA(-), CD56(-), Cam5.2(+), P40(-) Histocytology: HP(−) AB(−) PAS(+) HID(−)
Discharge Summary Department: Encephalopathy Admission Date: March 22 Discharge Date: March 29 Outpatient Diagnosis: Iron-deficiency anemia; hypoproteinemia; lacunar cerebral infarction; secondary epilepsy; status post artificial knee meniscus replacement; lumbar vertebral compression fracture Admission Diagnosis: Iron-deficiency anemia; hypoproteinemia; lacunar cerebral infarction; secondary epilepsy; status post artificial knee meniscus replacement; lumbar vertebral compression fracture Discharge Diagnosis: Gastric malignancy; upper gastrointestinal bleeding; iron-deficiency anemia; hypoproteinemia; lacunar cerebral infarction; secondary epilepsy; status post artificial knee meniscus replacement; lumbar vertebral compression fracture Main Symptoms and Signs on Admission The patient presented with dizziness and generalized edema. She had no chest tightness or shortness of breath, poor appetite, normal urination, and no bowel movement. Physical Examination: BP 104/70 mmHg, alert, poor mental status, anemic appearance, pale bilateral conjunctiva and face. No enlarged supraclavicular lymph nodes. Breath sounds diminished bilaterally with no obvious moist rales. Heart rate 100 beats/min, regular rhythm, no pathologic murmurs. Abdomen distended with active bowel sounds, tenderness in the upper middle abdomen, left upper abdomen, and left lower abdomen, no palpable masses. Tympanic percussion note over the abdomen. Sacrococcygeal pitting edema (++), bilateral lower limb pitting edema (+++). Negative neurologic signs. Main Examination Results March 22 emergency laboratory reports showed ammonia (dry) <9 μmol/L↓. Outpatient reports: plasma antithrombin activity 67%↓, fibrin degradation products 6.8 μg/mL↑, D-dimer 1.97 mg/L↑. Arterial blood gas: pH 7.460↑, potassium 2.5 mmol/L↓, sodium 135.0 mmol/L↓, standard bicarbonate 27.3 mmol/L↑, base excess 3.2 mmol/L↑, HCO3 27.0 mmol/L↑. BNP 781.00 pg/mL↑. Procalcitonin 0.57, white blood cell count 10.08 × 10⁹/L↑ (4.00-10.00 × 10⁹/L), neutrophils 75.9%↑, absolute neutrophils 7.65 × 10⁹/L↑, lymphocytes 17.8%↓, absolute monocytes 0.64 × 10⁹/L↑, eosinophils 0.0%↓, absolute eosinophils 0.00 × 10⁹/L↓, red blood cell count 1.31 × 10¹²/L↓, hemoglobin 39 g/L↓, hematocrit 11.8%↓, RBC distribution width 18.6%↑, platelets 190 × 10⁹/L, high-sensitivity CRP 211.65 mg/L↑. Myoglobin 111.9 ng/mL↑, total protein (dry) 51.1 g/L↓, albumin (dry) 22.6 g/L↓, AST (dry) 133 U/L↑, cholinesterase (dry) 1617 U/L↓, urea (dry) 20.77 mmol/L↑, creatinine (dry) 130.7 μmol/L↑, uric acid (dry) 640 μmol/L↑, potassium (dry) 2.9 mmol/L↓, inorganic phosphorus (dry) 1.78 mmol/L↑. Blood type Rh(+)P. Additional same-day results: plasma antithrombin activity 58%↓, fibrin degradation products 13.6 μg/mL↑, prothrombin time 10.7 s, APTT 29.0 s, D-dimer 4.23 mg/L↑. Procalcitonin 0.31, WBC 7.32 × 10⁹/L, neutrophils 72.2%, lymphocytes 22.0%, eosinophils 0.0%↓, absolute eosinophils 0.00 × 10⁹/L↓, RBC 2.01 × 10¹²/L↓, hemoglobin 61 g/L↓, hematocrit 18.3%↓, RDW 16.9%↑, platelets 118 × 10⁹/L↓, MPV 11.3 fL, hs-CRP 181.96 mg/L↑. Glycated hemoglobin 5.6%. Blood type A, Rh positive. Anti-HCV negative. Anti-HBc positive. AFP variant <0.5%. Reticulocyte percentage 2.8%↑, absolute reticulocytes 55.0 × 10⁹/L, no abnormal cells on peripheral smear. Triglycerides 1.34 mmol/L, total cholesterol 3.24 mmol/L, HDL-C 0.49 mmol/L↓, VLDL-C 0.42 mmol/L↑, apoA1 0.36 g/L↓, apoA2 0.10 g/L↓, apoB 0.065 g/L↓, glucose 6.03 mmol/L. CEA 14.3 ng/mL↑, AFP 1.26 ng/mL, SCC 1.10 ng/mL, CA153 6.3, CA125 394.4↑. Total 25-OH vitamin D 11.0 nmol/L↓. CA199 10.06, CA724 2.83, NSE 40.05↑, CYFRA21-1 109.60 ng/mL↑. Thyroid function low. Stool black, occult blood ++++ positive, fecal transferrin positive. March 25: unsaturated iron-binding capacity 6.80 μmol/L↓. Antithrombin 65%↓, FDPs 11.2 μg/mL↑, D-dimer 3.73 mg/L↑. BNP 464.00 pg/mL↑. WBC 6.50 × 10⁹/L, hemoglobin 81 g/L↓, platelets 73 × 10⁹/L↓, hs-CRP 78.32 mg/L↑. Albumin 22.9 g/L↓, prealbumin 0.06 g/L↓. AST 45 U/L↑. Ferritin later elevated. March 26-27: Additional tumor markers and coagulation parameters consistent with ongoing inflammation and bleeding. Stool remained black with positive occult blood. Special Examination Results and Consultations (with dates) March 22 chest CT: Scattered inflammation in both lungs, multiple fibrotic lesions, mild bronchiectasis in right lower lobe, small bilateral pleural effusions, small pericardial effusion. March 22 abdominal CT: Abdominopelvic fluid, suspected advanced gastric malignancy with surrounding and retroperitoneal lymphadenopathy; liver and splenic cysts. Enhanced scan recommended. March 26 gastroscopy: Advanced gastric carcinoma (Borr. IV), duodenal bulb polyp. March 27 echocardiography: Mitral and aortic valve thickening with calcification, mild mitral and tricuspid regurgitation, reduced left ventricular diastolic function. March 27 vascular ultrasound: Normal lower limb venous flow, no thrombosis. Residual urine 210 mL. Course and Treatment Results (including surgery dates, blood transfusion, resuscitation) After admission, relevant examinations were completed. On March 22, hemoglobin was 39 g/L↓; the patient received 4 units of A Rh(+) suspended red blood cells on March 22 and 23. Black stools and severe anemia led to a supplemental diagnosis of upper gastrointestinal bleeding on March 23. Gastroscopic biopsy was performed on March 26 after contraindications were ruled out, confirming advanced gastric carcinoma. Pathology results were pending at discharge. Abdominal tenderness and CT findings supported the diagnosis of gastric malignancy on March 26. The patient requested discharge for further treatment elsewhere and was discharged with approval. Complications: None Condition at Discharge (Symptoms and Signs) Dizziness, generalized edema, poor appetite, black stools. BP 98/56 mmHg, anemic appearance, abdominal distension and tenderness, bilateral lower limb edema (+++). Discharge Medications and Advice 1. Discharge prescriptions: None 2. Self-provided medications: (omitted) Discharge Orders: (omitted) Treatment Outcome: Improved Date: March 29
Medical Record Date: March 26 Chief Complaint: Advanced gastric cancer with ascites History: Cardia cancer with metastasis and ascites. Outside CT showed abdominopelvic fluid and suspected advanced gastric malignancy with lymphadenopathy. Gastroscopy showed advanced gastric cancer involving lower esophagus and cardia. Pathology pending. Physical Examination: Poor general condition, ECOG 3-4 Preliminary Diagnosis: Cardia cancer with metastasis; ascites Management: Explained condition; recommended feeding tube placement for nutrition and obstruction relief, pathology consultation, followed by chemoradiotherapy. Prescription: Pathology consultation requested.
Medical Record Date: March 27 Chief Complaint: Anemia for half a year History: Anemia for half a year. Recent imaging and labs as above. Hb improved to 72 g/L after transfusion, albumin 22.9 g/L. Physical Examination: Proxy consultation Preliminary Diagnosis: Gastric occupying lesion; gastrointestinal bleeding Management: 1. Recommend active supportive care, hemostasis, and gastric mucosal protection. 2. Given poor performance status (mostly bedbound), provide symptomatic, supportive, analgesic, hemostatic, and transfusion therapy. 3. If condition improves sufficiently to allow ambulation for about half the day, consider FU/LV or FOLFOX chemotherapy.
CT Report Department: Internal Medicine Examination Date: April 8 Site: Upper abdominal enhanced CT Findings (with 3D): Marked thickening of gastric body and antrum walls with heterogeneous enhancement, blurred surrounding fat planes, omental bursa involvement, pancreatic invasion, enlarged gallbladder. Low-density cysts in liver, spleen, and right kidney without enhancement. Enlarged lymph nodes at hepatic hilum and retroperitoneum. Abundant intraperitoneal fluid. Conclusion: Gastric cancer invading omental bursa and pancreas, with multiple enlarged lymph nodes. Hepatic, splenic, and right renal cysts; enlarged gallbladder. Abdominal effusion.
CT Report Department: Internal Medicine Examination Date: April 9 Site: Lower abdominal enhanced CT Findings: No obvious pelvic masses; mesenteric stranding; pelvic fluid. Uterus and bladder unremarkable. Conclusion: Mesenteric stranding and pelvic effusion.
CT Report Department: Internal Medicine Examination Date: April 10 Site: Chest enhanced CT Findings: Emphysematous lungs, bronchial wall thickening, patchy and linear opacities (worse on right), right lower lobe nodule with bronchial narrowing, mediastinal and hilar lymphadenopathy, pleural thickening. Conclusion: Pulmonary emphysema, multiple inflammatory and fibrotic lesions (right-sided predominant), possible metastases. Right hilar nodule, right lower lobe obstructive inflammation/atelectasis. Enlarged hilar and mediastinal lymph nodes, pleural thickening.
The patient was admitted to the geriatric (encephalopathy) department for dizziness and generalized edema. Advanced gastric cancer with diffuse spread was later discovered. Pathology showed poorly differentiated carcinoma. She was hospitalized for 7 days at a total cost of $2,870, including approximately $920 for laboratory tests and over $460 for medications, with $310 out-of-pocket. The patient died four months later.