1.Certificate of Clinic Diagnosis
No. 4921656
Name: Xxxx Gender: Female Age: 76y Dept. VIP clinic
Visiting Date: Contact No.: xx
Clinic diagnosis: Primary hepatic cancer of left lobe. After resection of the left lobe of liver.
Right hepatic metastatic carcinoma
Hepatic failure
Hereby certify that
Signature of physician: Xxxx
Issuing date: Oct.26, 2016
(Seal)
Peking University Shenzhen Hospital
Special seal for outpatient medical certificate
Notes:
1.This certificate must be consistent with medical records.
2.It is valid with the special seal.
(Medical Record preservation) Peking University Shenzhen Hospital
Peking University Shenzhen Hospital
2.Discharge Summary
Dept. Endoscopic Hepatobiliary Surgery Bed No. GDY70 Inpatient No.364191
Name: Xxxx Occupation :retired
Gender: Female Work units:
Age: 76 Address: xxxx Da Xia, Futian District, Shenzhen, Guangdong,
Marriage£ºWidowed Contact No.:xxx
X-ray No. N/A CT No. N/A Pathology No. N/A
Date of admission: Jan. 27, 2016 at 11:32 Date of discharge: Feb.14, 2016 at 8:22
Total inpatient stay: 18 days
Admission information: The patients was admitted into the hospital due to ¡°Appetite became worse more than 3 months ¡°, Admission Examination: T: 36.5¡æ P: 86 times/minute, R: 19 times/minute, BP: 158/69mmHg. Skin and sclera without yellow dye. Abdomal is plain. No intestinal type and intestinal peristaltic wave. No abdomen varicose vein. Liver and spleen was not palpable under the ribs. Whole abdomen is no tenderness, rebound tenderness and muscle tension. Murphy's Disease (£)£¬there is not knock pain in the liver and kidney area and shifting dullness (£), borborygmus 5 times/minute. Contrast ¨C Enhanced of ultrasound on Jan.26, 2016: Substantial mass in the left lobe of liver, considered that it is Hepatocellular Carcinoma with contrast - enhanced ultrasound images.
Admitting diagnosis: 1. the left lobe of liver occupied lesions. Hepatocellular Carcinoma?
2. After tubal ligation. 3. After resection of bilateral annex.
Treatment: After admission, the patients is complete the relevant checks. Blood routine of five categories ( fast ), routine urine analysis, kidney functions analysis five items ( biochemistry ) + electrolyte four items biochemistry ) + liver functions six items, blood coagulation four items, hepatitis exams and immune functions two items etc. Those results are normal. ECG and chest X-ray are normal. Upper abdominal CT: 1. the left lobe of liver occupied lesions, the possibility of Hepatocellular Carcinoma is great. 2. There are multiple hepatic cysts. 3. Bilateral renal have multiple small cysts. Therefore, on February 4, 2016 under general anesthesia laparoscopic resection of the left lobe of liver. Prevention of infection, prevention of stress ulcer by treatment of acid, sedation and analgesia, rehydration treatment and symptomatic treatment etc. Now the patient's condition is stable. Permitting to discharge.
Discharge conditions£ºNo complain with special discomfort. Examination: Vital signs are stable. Auscultation of heart and lung are normal. The dressing of abdominal wound is drying. Bilateral Lung respiratory sound is clear, and no obvious rales. Rhythm is tidy and abdomen isl plain and soft. The peristaltic sound was normal.
Discharge diagnosis: 1. the left lobe of liver with primary Hepatocellular Carcinoma. 2. After tubal ligation. 3. After resection of bilateral annex.
Discharge instructions: 1. Take more rests, low-fat diet.
2. Outpatient follow-up 3 months later, visit at any time when discomfort.
3. Taking medicine at discharge:
Shdan tablet 5.7g oral T.i.d
Diammonium glycyrrhizinate and Enteric coated capsules 100mg oral T.i.d
The attending physician: xxx Signature of physician: xxx
Date: On February 14, 2016 at 08:27
Notes: Sign with a dark blue pen in ¡°discharge summary", "the hospital diagnosis proof" and "Introduction to the hospital" on each page.
Peking University Shenzhen Hospital
3.Ultrasound Examination Report
Name: Xxxx Gender: Female Age: 76 years Exam No. xxx
Source: Outpatient Dept. Endoscopic Hepatobiliary Surgery Inpatient No. Bed No.
Exam equipment: IU22 (VIP 3) Exam site: Color Ultra, liver, gallbladder and pancreas
Exam imaging:
Ultrasonic description:
After left lobe hepatectomy: Shapes and sizes of the right lobe of Liver is in normal range. The echo of envelope structured. Tiny light point of Liver parenchymal echo is low, and uneven distribution. Multiple sizes of anechoic mass in hepatic are visible. The larger is located in the right posterior lobe of the Liver, the size is 59X57mm, a round, and boundary is clear, smooth coated, sound transmission is good. Posterior acoustic enhancement. In the right frontal lobe of the liver, there are more hypoechoic masses of different sizes. Sizes of several larger about 25X19mm, 21X18mm, 19X18mm, 21X18mm, a round boundary is clear, some are integrated, echo in uniform. The main portal vein is not wide. CDFI: Liver mass have no obvious blood flow signal around. Portal venous flow is positive.
Shapes and sizes of the Gallbladder are normal. The wall is thin and smooth. No significant abnormalities indicated therein. No dilatation of intrahepatic and extrahepatic bile ducts.
Shapes and sizes of Pancrea is normal, uniform echoes. No abnormal echo.
Ultrasonic tips:
After left hepatic surgery, there are hypoechoic masses in the right hepatic lobe, considered metastatic carcinoma (the number and size are increase than the previous examination).
Multiple cyst of the right Liver.
Diagnostician:
Print time: xxx at 8:57:08 |
