北京海淀医院出院报告翻译

入院情况:

患者:陈，男，74岁，主因“发现肺部结节一年余”于2025年07月01日08时39分诊，以“1部阴影2.高血压3.陈旧性脑梗死4.糖耐量异常5.冠状动脉粥样硬化6.冠状动脉狭窄。”收入我科。一年余简患者体检于北京大学人民医院行胸部CT(2025-05-12)示:右肺上叶后段磨玻璃结节，大小约9*8mm，纵隔内

未见明显肿大淋巴结。患者未行进一步治疗。2025年6月18日，患者于北京大学人民医院复查购部CT示;右肺上叶后段结节较前稍增大，大小约12*8mm，双肺散在多发肺结节，纵未见明显肿大淋巴结。入院查体:T:36.2℃P:76次/分:18次/分BP:100/55mmHg发育正常，营养良好，身高170厘米，体重60公斤，神志清晰，自主体位，而无异常，与医生合作。二、入院诊断:1.肺部阴影2.高血压3.陈旧性脑梗死4.精形量异常5.冠状动脉粥样硬化6.冠状动脉狭窄三、诊疗经过:患者因肺部结节入院，入院后完善相关检查，肺部结节符合手术适应症，无明显手术禁忌，于2025-07-03于全麻下行VATS右肺上叶后段切除术，术后病理:术后病理:在肺上叶后段，微漫性腺癌，大小为1.8*1cm*0.8cm，未见明确脉管内癌栓及气腔播散，未侵犯胜层胸膜，肺断端未见，送检4/7/9/10/11/12组淋巴结未见癌转移(0/2,0/1,0/1，0/1，0/1，0/1)。患者术后恢复较好，伤口愈合良好，生命体征平稳，未诉特殊不适症状，查体未见明显异常，拔除胸腔闭式引流管后未诉不适，目前于我科

已无特殊处理，可予其今日出院，出院后按时拆线、换药，术后定期复查，不适随诊，出院带药，执嘱四、出院情况:患者一般情况可，无恶心、呕吐，无腹痛、腹泻，无发热、乏力。请示上级医师后予以出院。五、出院诊断:1.肺恶性肿瘤(T1a(mi)NOMOIA1期)2.糖耐量异常3.陈旧性脑梗死4.高血压5,冠状动脉粥样硬化6.冠状动脉狭窄7.胃食管反流。

六、出院医嘱:

1、口服药物

2、按时换药拆线;

3、定期复查，不适随诊;

4、复方鲜竹沥液[10mlx8支/盒]X6/KF20m三次/日(8-12-16)阿斯美[60粒/盒]X1/KF2粒三次/日(8-12-16)通关藤1服液[10mlx10支/盒]X5/KF10m1三次/日(8-12-16)

Beijing Haidian Hospital

Department: Thoracic Surgery Department  Name: Chen Kangmei  Page 1  Inpatient No.: 516796

Discharge Record

Name: Chen       Gender:                Age: 74 years old

Admission Date: July 1, 2025  Discharge Date: July 11, 2025  Hospital Stay: 10 days

I. Admission Details:

Patient: Chen , male, 74 years old. The main reason for admission was "discovery of pulmonary nodules for over one year". He was admitted to the outpatient department at 08:39 on July 1, 2025, and admitted to our department due to "1. Pulmonary shadow; 2. Hypertension; 3. Old cerebral infarction; 4. Abnormal glucose tolerance; 5. Coronary atherosclerosis; 6. Coronary artery stenosis". Over one year ago, the patient underwent a chest CT examination at Peking University People's Hospital (2025-05-12), which showed that a ground-glass nodule in the posterior segment of the right lung, approximately 9*8 mm in size, and no obvious enlarged lymph nodes were found in the mediastinum. The patient did not receive further treatment. On June 18, 2025, the patient underwent a chest CT re-examination at Peking University People's Hospital, which showed that the nodule in the posterior segment of the right lung was slightly larger than before, approximately 12*8 mm, and multiple scattered pulmonary nodules were found in both lungs, with no obvious enlarged lymph nodes in the mediastinum.

Physical examination upon admission: T: 36.2℃, F: 76 beats/min, R: 18 beats/min, BP: 100/55 mmHg.

Normal development, good nutrition, height 170 cm, weight 60 kg, clear consciousness, able to maintain an independent position, no abnormality in appearance, cooperating with the doctor.

II. Admission Diagnosis: 1. Pulmonary shadow; 2. Hypertension; 3. Old cerebral infarction; 4. Abnormal glucose tolerance; 5. Coronary atherosclerosis; 6. Coronary artery stenosis.

III. Medical History and Treatment Process: The patient was admitted to the hospital due to pulmonary nodules. After admission, relevant examinations were completed. The pulmonary nodules met the surgical indications and there were no obvious surgical contraindications. On July 3, 2025, under general anesthesia, a VATS right upper lobe posterior segment resection was performed. Postoperative pathology: Right upper lobe posterior segment, minimally invasive adenocarcinoma, size 1.8*1 cm*0.8 cm. No clear intravascular cancer emboli or air cavity dissemination was observed. No invasion of the visceral pleura was found. No cancer was found at the lung stump. The 4/7/9/10/11/12 groups of lymph nodes sent for examination showed no cancer metastasis (0/2, 0/1, 0/1, 0/1, 0/1, 0/1). The patient recovered well after surgery, the wound healed well, the vital signs were stable, no special discomfort symptoms were reported, no obvious abnormalities were found during physical examination. After removing the closed thoracic drainage tube, no discomfort was reported. Currently, there is no special treatment in our department, and the patient can be discharged today. After discharge, the stitches will be removed and the dressing changed on time, regular postoperative follow-up will be conducted, any discomfort will be followed up, and the prescribed medication will be taken.

IV. Discharge Status:

The patient's general condition is acceptable. There is no nausea, vomiting, abdominal pain, diarrhea, fever or fatigue. After consulting with the senior physician, the patient was discharged.

V. Discharge Diagnosis: 1. Malignant lung tumor (T1a (mi) N0 MO IA1 stage); 2. Abnormal glucose tolerance; 3. Old cerebral infarction; 4. Hypertension; 5. Coronary atherosclerosis; 6. Coronary artery stenosis; 7. Gastroesophageal reflux.

VI. Discharge Instructions:

1. Take oral medications;

2. Replace dressings and remove stitches on time;

3. Regularly undergo check-ups; if experiencing any discomfort, consult a doctor;

4. Fufang Xinzhu Liye [10 ml x 8 vials/box] * 6 / KF, 20 ml, three times/day (8-12-16); Compound Methoxyphenamine Capsules (Asimei) [60 pills/box] * 1 / KF, 2 pills, three times/day (8-12-16); Tongguanteng Oral Liquid [10 ml x 10 vials per box] * 5 / KF, 10 ml, three times/day (8-12-16)

Doctor's Signature: Wang Xiaoyu (Signature)

Case Statistics Department of Beijing Haidian Hospital (Sealed)