Hospital Discharge Summary

First Affilliated Hospital of Zhejiang University Faculty of Medicine

NameMeihui Jiang Gender: Male DOB: 11-09-1958 Patient ID #: 00699306
DOA: 08-12-2010 DOD: 11-01-2011 HS: 34 Days Att. Physician: Dr. Peng Ye
Ad. Dx: 1. Carcinoma in the right mandibular post-molar region;
2. Hypertension;
L. Dx: 1. Adenocarcinoma and bronchioloalveolar carcinoma of right upper lung T1bN0M0;
2. 1. Squamous cell carcinoma in the right mandibular post-molar region;
3. 2. Hypertension;
Note: DOB= Date of Birth; DOA= Date of Admission; DOD= Date of Discharge; HS= Hospital Stay; Att. Physician = Attending Physician;
Ad. Dx= Admitting Diagnosis; L. Dx= Leave Diagnosis;
General Conditions on Admission:
The patient has a history of having a chronic ulcer in the right mandibular post-molar region for about one and
half years. He reported that the size of the ulcerative lesion is gradually increased in size, from its diameter of 0.5
cm to 2.0 cm. He was experiencing sleep disturbance, poor appetite and weight loss. Two weeks after worsening
his conditions, he was referred to a stomatologist and was admitted to the Department of Stomatology at First
Affiliated Hospital of Zhejiang University School of Medicine.
Procedures and Treatment Provided:
After he was admitted to the department of stomatology, the patient experienced a biopsy of ulcerative lesion
the right mandibular post-molar region, the post-operative pathological examination revealed that the tumor was
squamous cell carcinoma. Thereafter, patient had chest CT scan, it showed a peripheral nodule in right upper
pulmonary lobe. He was immediately undergone a CT-guided FNA, biopsy showed the nodule was primary
adenocarcinoma in entity. The Patients was transferred to the Department of Thoracic Surgery for further
treatment. No metastatic sites were detected, and the patient was received right upper lobectomy plus
mediastinal lymph node sampling through right posterolateral thoracotomy. The tumor was located in the
anterior segment of right upper lobe, approximately 2*2cm in size without any association of atelectasis,
obstructive pulmonary pneumonia or carinal envolvement. although mediastinal lymph node enlargement was
not significant, lymph nodes at prevascular , upper and lower paratracheal, subcarinal, and interlobar lymph node
stations were sampled. The post-operative pathological findings were described as adenocarcinoma and partly
bronchioloalveolar carcinoma of right upper pulmonary lobe.
Patients Discharge Condition:
At the time of discharge, the patient had no further signs of bleeding. His respiratory status did slowly improve to
baseline. He complained of some mild chest discomfort, CXR did not reveal any gas fluid in the thoracic cavity. He
is discharged and given the medications below. Followup with Dr. Peng Ye of thoracic surgery, in the outpatient
setting.
Discharge Medications:
Cefuroxime (Zinnat) 0.25g po twice a day;
Mucosolva Transbrocho 30mg po three times a day;
Attending Physicians Signature Date: ___ /___ /______