Employed   by

Post

Admission   date

XXX

Discharge   date

XXX

For   total 28 days

Diagnosis   of discharge

Malignant   tumor on superior lobe of right lung (Adenocarcinoma, T1aN0M0)

Discharge summary

Seven months ago, the chest CT showed   the patient had a nodule on the tip segment of superior lobe of right lung   without cough, expectoration, chest distress and shortness of breath, fever,   or blood-stained sputum, and occasionally felt chest pain, which was then   indicated by PET-CT as increased glucose metabolism on the tip segment of superior   lobe of right lung with ground-glass nodular shadows, considering as probably inflammation,   and now the patient consulted in our hospital for further treatment, and the outpatient   service received him for “lung neoplasm” in our department, and he had   completed related examinations and received lobectomy of partial lung under thoracoscope   following anesthesia by intravenous inhalation on May 15, 2018. The   intro-operatively rapid pathological diagnosis prompted the neoplasm was a adenocarcinoma,   and after lobectomy of lung under thoracoscope, the post-operative pathological   diagnosis indicated: neoplasm on superior lobe of right lung; lung   adenocarcinoma, most of which was an alveolar type and a small part of which   was an adherent growth type, not invading into visceral pleura, at size of   about 1.0*0.8*0.6cm, not involving vessels and nerves an without any cancer   at incisal edge of lung tissue, and the PTNM was T1aN0Mx. Then the symptomatic   treatment continued. Now, the general status of the patient was good, his vital   signs were stable without significant discomfort, and the healing of postoperative   incision was ranked as A with good healing, The patient and his family   members requested initiatively discharge due to individual reason, and such   discharge was approved with post-discharged matters needing attention   instructed.

Post-discharged requests and matters   needing attention

1. Periodical dressing change till to   healing;

2. Strengthening nutrition and paying   attention to diet;

3. Periodical re-examination, and follow-up   in case of change of illness.

Seal: XXX University

Unit   one in thoracic surgery department                                 Signed   by attending physician

                                                                                         Signed   by resident doctor

                                                                                         Jun.   05, 2018