It is mainly used for difficult cases and clinical case discussion records for the purpose of clinical teaching, and can be used for case discussion in wards, departments, hospitals or outside hospitals.
1. The discussion of difficult cases should be recorded by the competent physician after the course of the disease is recorded, and the date, time, place, participants, host, medical record reporter and the speeches of the participants (including diagnosis, further examination items and treatment opinions, etc.) should be recorded. ) should be written. After the record is completed, it will be signed and sent to the superior doctor for review, and the reviewer also needs to sign the full name.
2. When the consultation and discussion of special patients need to send messages to the press (newspapers, radio stations and TV stations) due to work, the manuscript must be approved by the Medical Department, and it can only be sent outside after being audited by the department director, the Medical Department and the leaders of the competent hospital.
3. In case of important special rescue or accident, two or more persons shall be appointed to record at the same time, and a special person shall be appointed to conduct a comprehensive review. In addition to keeping one copy of medical records, multiple copies should be made as needed and submitted to relevant departments respectively. Each copy must be signed by the relevant person in charge.
Record time of case discussion: 20 * * August 23rd 10Am.
Venue: Office of the Director of Pediatric Surgery
Participants: xxx (Professor, Chief Physician), XX (Deputy Chief Physician), X ><X (Deputy Chief Physician), XX (Chief Physician)' X X X (Resident)' x x x (Continuing Education, Resident)' xxx (Continuing Education, Resident)' xxx (Continuing Education, Resident)
Moderator: xxx (director)
Medical record reporter: xxx (resident)
Child xxx, male, 2 years old. Five months, Han nationality, from xx county, xx province, lives in Shitougou village, Lianta township, xx county, and was admitted to the hospital on August 20 * * 19, with the hospitalization number of 23 1044.
Chief complaints: progressive abdominal distension, nausea and vomiting. The vomit is absorbed milk, without fever and chills, and there is no yellow stain on skin and sclera. After vomiting, urination and defecation, abdominal distension was not significantly relieved. The frequency, color and character of defecation are normal. Diagnosed as "dyspepsia" in the local hospital, symptomatic treatment (specific drugs and dosage are unknown). Vomiting eased, but abdominal distension did not improve, and it was gradually aggravated.
Physical examination: T38. OC p 160 times/minute Rio! W6kg, with normal development, moderate nutrition, sober mind, poor spirit, no yellow staining on the skin mucosa, high skin temperature, no bleeding spots, rashes and pain points on the whole body, no superficial swelling of lymph nodes, no abnormal skull appearance, black hair, luster, uniform distribution, 2X2cmZ on the front, no obvious depression or protrusion on ID, no congestion and edema on eyelids, and no yellow staining on sclera and cornea. No abnormality is found in ears, nose, lips and mouth, the stomach is soft with trachea as the center, the thyroid gland is not enlarged, the gastric vein is not dilated, the lateral surface of the foot is symmetrical, the breathing is shallow, the rhythm is regular, the lung percussion and auscultation are normal, the heart rate 160 beats/min is regular, no organic murmur is found in each valve area, the abdomen is highly swollen, and no intestinal shape and translational waves are found. Occupy the whole upper abdomen, the upper boundary is unclear, and the lower boundary is 3. 0 cm below the navel. The child who touches it is crying and uneasy, with medium quality and poor mobility. The right inguinal mass is about 4X3cm in size and soft, which can be pushed into abdominal cavity. Intestinal sounds are not excited, and no breathing can be heard. The development of spine and limbs is normal, the external genitalia of anus is normal, and the pills on both sides have dropped to scrotum. Nervous system examination: There are grounding reflex, sucking reflex and grasping reflex, but Babbins shame sign and Hoff sign are not elicited.
Experimental examination: hblog/l, WBC 9. 2 1
1. Abdominal masses to be studied (polycystic, 79 1
2. Intestinal congenital malformation is not exclusive.
3. Intestinal obstruction (partial)
Electrocardiogram: sinus tachycardia (ECG is generally normal)
CT examination: there was a huge mass in the upper abdomen, the stomach was obviously compressed, and the liver J, kidney and stomach were pushed to the right lower abdomen. The mass is12x13x12cm3, and the CT value is 4. 4- 138.8H, with irregular calcification shadow. The opinion is: "giant teratoma of the upper abdomen."
Teratoma of upper abdomen (huge)
2. Right groin disease.
Purpose of discussion:
1. confirmed
Decide on a treatment plan
Xxx Intern: Abdominal distension and vomiting occurred immediately after delivery. Vomiting may be due to incomplete obstruction caused by tumor pressing the gastrointestinal tract. The tumor may be congenital or it may exist before birth. The most common tumors in children's upper abdomen are; (1) nephroblastoma; (2) Retroperitoneal teratoma; (3) Wilms' tumor, which is mixed by B-ultrasound and has nothing to do with both kidneys, can be ruled out. Treatment should actively prepare for surgical treatment, remove teratoma and reduce its oppression on gastrointestinal tract. In order to improve children's sucking and nutritional status.
Residents of Xx: Abdominal distension and vomiting are the most prominent symptoms. Physical examination found that the upper abdomen was a huge mass with medium mass, unsmooth surface and poor mobility. In addition to the nephroblastoma, hepatoblastoma and teratoma mentioned above, there may be common bile duct cyst, hepatic hydatid cyst and pancreatic cyst. Although "choledochal cyst" can be huge, children lack jaundice (that is, abdominal pain, abdominal mass and jaundice "triad"), which is not supported by B-ultrasound and CT. Therefore, "retroperitoneal teratoma" should be ruled out first, and surgery should be performed as early as possible in the treatment to reduce the oppression on the digestive tract.
Xxxx Resident: I agree with the analysis of the above doctors. There is almost no possibility of hepatic echinococcosis. Although echinococcosis is one of the widely prevalent parasitic diseases in our province, the only way for children to be infected is placenta. Even if the child is infected through the placenta in the womb, the child is only 2 years old. Five months old. If the hydatid cyst grows 4cm a year on average, it is impossible to grow that big and can be ignored. Polycystic liver formed in fetal period can be considered, but neither CT nor B-ultrasound found any abnormality in the liver, so we can also ignore the diagnosis of "retroperitoneal fetal tumor". The child has been vomiting for a long time, so we should pay attention to reexamining and correcting the disorder of serum ion and acid-base balance, replenish enough liquid, and be sure to operate as soon as possible.
Attending physician xxx: Such a small baby has never encountered a huge abdominal mass. Without the assistance of B-ultrasound and CT, it is difficult to make a diagnosis, because there are many things to consider, such as nephroblastoma, hepatoblastoma, multiple hepatic cysts, polycystic kidney, sponge kidney, solid tumor or cyst of pancreas, retroperitoneal teratoma and so on.
Attending physician xxx: The child is only 2. 5 months old, progressive abdominal distension and vomiting. Abdominal distension caused by the gradual growth of intra-abdominal tumors, followed by gastrointestinal compression symptoms, and the child vomited, which was caused by frequent vomiting and fear of aspiration.
Because of acquired pneumonia, the original meaningful air barium radiography of the upper digestive tract and even the whole digestive tract could not be carried out. In addition to what everyone said, there can also be "gastric cystic lymphangioma" and "mesenteric cyst". We have encountered several cases of gastric cystic lymphangioma, which can be large, multilocular and calcified. Because the examination is not thorough, it cannot be ruled out, but the activity of mesenteric cyst is generally large, smooth and unobstructed. Retroperitoneal teratoma is very likely, followed by retroperitoneal neuroblastoma, with irregular calcification, but hard and fixed texture. Unless retroperitoneal infiltration, intestinal wall diffuse metastasis, generally there will be no intestinal obstruction symptoms. At present, I consider: (1) retroperitoneal teratoma, (2) multilocular cystic lymphangioma of the stomach. Because children often vomit and can't eat anything, they should be treated as soon as possible and actively supported.
Dr. xxx: In the past, there was little surgical contact, even less infants, and even less knowledge about abdominal tumors in children. I have been engaged in B-ultrasound diagnosis for many years. According to the analysis of B-ultrasound, there are two mixed masses, 79 > & lt74c. And 8 1 X 7 1cm, with liquid dark area, CT reported irregular calcification. Through the above comprehensive analysis, teratoma is very likely, because children are too young, have serious symptoms, can't stand more and more complicated examinations, and parents have limited financial ability, so they should prepare for surgical exploration as soon as possible.
Attending physician of Xxx: the child developed progressive abdominal distension with vomiting 50 days before admission, and the child developed symptoms 25 days after birth, suggesting that there was a tumor at birth. B-ultrasound showed mixed tumor with irregular calcification. This means that teratoma is the most likely. Because teratoma tissue comes from three germ layers, there may be teeth, bones,
Hair, bones, etc. It can be shown on X-rays, so it is irregular calcification because it is immature. Intraperitoneal calcification can also be seen in meconium peritonitis. Meconium overflows from the perforated intestine and enters the abdominal cavity to form calcification, which can make the intestines stick together, causing obstructive symptoms and fever. However, on the X-ray plain abdominal film, there was no sign that the intestine was pushed to the right lower abdomen by tumor and adhesion, and the children with meconium peritonitis spit out green water. In this case, the child vomits. Different from the manifestation of complete obstruction of small intestine, the grave of meconium ileus can be ruled out. There are also retroperitoneal neuroblastoma with calcification, but it is more common in children over 2 years old, and it is hard and fixed, generally not in the middle and upper parts, and does not cause intestinal obstruction symptoms. As far as pregnancy tumors are concerned, they are mostly found in the Russian tail and mediastinum, followed by retroperitoneum. Teratomas in liver, brain and stomach are rare. In this case, it is a baby boy. Of course we can rule out ovarian teratoma. Then, it is most likely to be a retroperitoneal fetal tumor. It is helpful to do a whole gastrointestinal barium radiography, but the child can't tolerate it, which may lead to aspiration chemical pneumonia. Therefore, we should actively prepare for surgical exploration and strive to completely remove and relieve intestinal obstruction.
Doctor xxx: I have never seen such a small baby in the tomb hospital, and there is such a big lump in the abdomen. This is a good learning opportunity. In the diagnosis of diseases, common diseases should be considered first, so I agree with the above doctor's analysis that teratoma is possible and should be treated by surgery as soon as possible.
Dr. xxx: I agree with the above analysis and agree with the surgical treatment. I work in a cemetery hospital, which I have never met before. This is a good learning opportunity.
Professor xxx (Summary): Everyone has expressed many good opinions on the diagnosis and treatment of this baby's abdominal tumor, involving many aspects, which is a good opportunity for mutual learning and communication. Now I will talk about my personal views for further discussion and diagnosis.
The child is two years old. 5 months old, 50 days before admission (that is, 25 days after birth). Parents found that the child's abdomen gradually swelled. With vomiting, vomiting is sucking milk. Because there is no history of vomiting "green water", stool is normal, intestinal tumor itself is unlikely, and vomiting and other incomplete obstruction manifestations are mostly considered to come from exogenous oppression. During physical examination, a huge abdominal tumor was found, which was not smooth, slightly tender and relatively fixed. The sources of epigastric tumors in infants are:
1. Liver: hepatoblastoma, hepatic hemangioma, hepatic non-parasitic multilocular cyst, hepatic hydatid cyst and bullous echinococcosis, hepatic actinomycosis, hepatic teratoma, etc. All the above liver tumors can be very large and produce compression symptoms, with liquefaction in the center (cystic lesions themselves produce such results), cystic degeneration and multilocular, but liver tumors can be completely ruled out.
2. Biliary duct: congenital cystic dilatation of common bile duct, spontaneous biliary perforation in infants, etc. Cysts can be very large, leading to obvious compression symptoms of duodenal descending part and other gastrointestinal compression symptoms. A few months ago, 3 cases (29 cases in total) were treated by surgery in our department. Among them, 1/3 is a giant cyst. In March, a 25-day-old child with spontaneous common bile duct rupture and multiple septa was surgically treated, and the results of B-ultrasound examination were similar to those of this child. But the child has jaundice, which is different from this case. Can't consider it.
3. Pancreas; Pancreatic tumors, especially pseudocysts and true cysts, are similar to this case, and most of them protrude from the omental sac above the gastric curvature, which can be huge, but B-ultrasound and CT confirm that the pancreas in this case is normal.
4. Kidney: polycystic kidney, hydronephrosis, Wilim tumor, etc. Although the child did not receive intravenous nephrography, B-ultrasound and CT showed normal kidneys.
5. Stomach: Cystic lymphangioma of the stomach, which can be huge, multilocular and oppressive. Three cases of this disease were treated by surgery in our hospital, including 1 case reported by Chinese Journal of Surgery. This is possible, but the texture is harder than cystic limbal tumor. Gastric leiomyoma or sarcoma: but children are generally not too bad. After admission, they saw a coffee-colored solution vomiting, but such a huge leiomyoma or sarcoma is rare, and the situation of ordinary children is much worse than this; Gastric teratoma; This is a rare part of teratoma. Can grow into the stomach, can also grow out of the stomach, or grow into a dumbbell. If the superficial mucosa in the stomach is destroyed, it can bleed. The outside of the stomach adheres to the liver and colon, which is relatively fixed, the surface is not smooth, and the fluidity becomes smaller. Because of teratoma, the texture can be slightly hard. B-ultrasound and CT can show mixed tumors with irregular calcification. This is beneficial to these situations, so it is likely to be a teratoma.
6. Mesenteric tumor: generally smooth and active, different from this case (mostly mesenteric tumor, fibroma, etc.). ).
7. Retroperitoneal tumor: Wilims tumor, neuroblastoma, lipoma, fibroma, teratoma, etc. Among them, Wi 1 1ns tumor is more common, but the child's kidney is normal; Neuroblastoma is usually hard and fast-growing, and it is more common in children aged 2-6 years. Lipoma and fibroma have no cystic manifestations; Retroperitoneal teratoma is possible, and CT shows that retroperitoneum is normal and complete, so it is unlikely.
8. Meconium peritonitis: There may be calcification, but the performance of intestinal obstruction is obvious, such as vomiting "green water", intestinal dilatation and limited activity. But in this case, the small intestine stays in the right lower abdomen, and there is no sign of adhesion, which can be ignored.
9. Intestinal tumor: Such a huge person is bound to be completely obstructed, so it cannot be considered.
10. Repeated stomach or intestine: Although the tumor can be found, it is Huai, but it is not calcified.
To sum up: I think the child is diagnosed as: ① gastric teratoma. ② Cystic lymphangioma of stomach. ③ Retroperitoneal teratoma (unlikely). ④ Eggplant with oblique right groin.
Treatment should be given:
1. Actively support the whole body, correct dehydration, electrolyte and acid-base balance disorder, and give TPN,
2. If vomiting improves, barium meal radiography of upper digestive tract is feasible to observe whether there is tumor (insufficient filling) on the stomach wall.
3. Prepare for surgical treatment and try to remove the tumor during the operation. Because the tumor is tightly attached to the intestine, it is likely to break, so it is necessary to prepare the intestine.
4. Right inguinal oblique myopathy can be repaired by abdomen during operation.
5. Because the child is too young and the tumor is huge, it may not be removed, and the child's tolerance for bleeding is poor. During the operation, there is more bleeding, even acute massive bleeding, which is more dangerous. So be sure to make it clear to your parents, get understanding, cooperate and sign.
6. Prepare enough blood, and establish an unobstructed infusion channel during operation.
7. Fine operation during operation, general anesthesia of seeding tube, unobstructed gastrointestinal decompression after operation, powerful broad-spectrum antibiotics, high nutrition (TPN), etc.
Maintain respiratory tract after operation. Pay attention to oxygen inhalation and sputum aspiration at ordinary times to prevent lung infection.
Record xxx