Doctor’s Life Simulator

[Hand surgery admitted a patient with a rare left wrist and left hand joint mass. Tian Bo invited Shen Jiamo, Qian Mubai, Tian Hua, Wu Xin, and Wei Guoqiang who licked his face and took you with him. After some argumentation and discussion, it is still difficult to choose between synovial chondroma and synovial sarcoma. Director Qian Mubai was puzzled, but due to the special symptoms of this patient, even enhanced CT and MRI could not confirm the cause. 】

[In the end, several chief physicians disagreed, and Tian Bo decided to perform tumor resection. Several directors left early because of their busy affairs, but they still pay attention to the follow-up. 】

【Tian Bo presided over the operation. During the operation, a longitudinal incision was made on the midline of the left wrist tumor, the length was 12 cm. The skin, subcutaneous and carpal tunnel were incised, and an oval mass was formed at the distal end of the superficial flexion of the second finger of the left wrist. The size was about 5cm×3cm. The superficial flexion tendons are thickened and surrounded by plaster-like deposits. The situation is more complicated, and intraoperative decision, wide excision. 】

【Postoperatively, case report of left wrist mass: formation of tophi in fibrous tissue with foreign body giant cell reaction. The patient's real cause turned out to be an extremely rare tophi causing extreme flexion contracture deformity of the fingers and carpal tunnel syndrome. 】

[Director Qian Mubai and Director Tian Bo regretted and blamed themselves after the operation. Carpal tunnel syndrome (CTS) is one of the common peripheral nerve entrapment diseases in hand surgery. Due to various reasons, the volume of the carpal tunnel decreases and the pressure increases, so that the median nerve is compressed in the carpal tunnel, causing paresthesia in the radial fingers. A syndrome with the main feature. It is more common in women, and the ratio of male to female patients is about 1:9. Because it is more common in women, the disease is rare in men, and there is less discussion on the etiology and clinical characteristics of CTS in men. And those caused by tophi are even rarer. 】

[This patient missed the best treatment plan due to misdiagnosis. After surgery, the recovery was not ideal, the left wrist and hand joints were inconvenient, and the flexion and extension of the fingers were not ideal. In response to this misdiagnosis, Director Qian Mubai made a follow-up summary and review, and gave a lecture exchange in their department. A treatment plan for small wrist incision surgery is proposed. Of course, this surgery has extremely high requirements for incision, exposure, dissection, and tendon repair under small field of view, and median nerve release, which is only available in top hospitals in Modu or Hangzhou. may develop. 】

[Summary of classic diagnostic schemes: The value of imaging in the diagnosis of gout and tophi is still very limited. X-ray, conventional CT, and MRI are not very specific for tophi. This is also the reason for the misdiagnosis by the directors. 】

[Typical sonographic findings of tophi include anechoic halos and multiple hyperechoic centers, and the surrounding anechoic rings may represent histologically fibrovascular areas with central hyperechoic synovial hyperplasia. However, the ultrasound field of view is small, the operator is highly dependent, and the experience of the physician is extremely demanding. 】

...

[The simulation is over, you can keep the clinical experience of the disease. 】

Seeing the patient's real condition, Qin Lang was also very surprised. The culprit turned out to be tophi!

However, knowing that it was carpal tunnel syndrome caused by tophi actually made Qin Lang relax. After all, as long as the operation is done properly, this condition will have very little impact on the patient, such as lowering uric acid after surgery, avoiding high-purine foods, and quitting. Alcohol, drink plenty of water, etc.

Removal of lesions, functional reconstruction, and comprehensive treatments such as drug and dietary conditioning can generally restore finger function well and prevent recurrence.

In the conference room, Qin Lang put down the materials, and the whole person relaxed, and the subtle actions caught the attention of Director Shen Jiamo, who was on the side.

Deputy Director Shen Jiayang has always been very open-minded and brainstorming. As long as he participates in his consultation, no matter who it is, he will give them the opportunity to speak freely, and he asked softly:

"Qin Lang, what are your thoughts and ideas? If you have anything you want to say, bring it up and let's discuss it?"

Deputy Director Shen Jiachang said this, and the other principals also looked at the little doctor with some interest.

Tian Bo narrowed his eyes and showed his demeanor:

"Dr. Qin, don't be under psychological pressure. It doesn't matter if you don't have any ideas. After all, this is the field of hand surgery. If you have some ideas, you can share them. Maybe we senior physicians are limited by habitual ideas, but newbies like you, There will be new angles.”

Tian Bo said so, of course he didn't think Qin Lang could really say one, two, three.

Li Lian'an in the second row of seats looked at Qin Lang with some schadenfreude, what would he do in such a suffocating chief director's consultation.

After all, if he was suddenly named, he would definitely have a blank head and a flushed face.

When Wei Guoqiang saw Qin Lang being killed like this, he naturally wanted to protect the calf, so he made a relief:

"With such a complicated case, even Director Tian is in a dilemma. What does a young doctor like Qin Lang know? To let him participate in the consultation today is to let him bring his ears and eyes. It's alright, Qin Lang, you are fine. Just listen, we won't be ugly."

Hearing Wei Guoqiang's words, the rest of the people also smiled slightly. Yes, this little doctor has such a talent in clinical practice, which is already incredible. If he is also accomplished in diagnosis, wouldn't these old guys live to their age? on the dog.

Li Lian'an in the second row was a little disappointed when he saw Wei Guoqiang's action to resolve Qin Lang's dilemma. After all, if he was robbed, if he could see Qin Lang making a fool of himself, it would relieve him a little.

When all the directors were about to start discussing again, they heard a very clear and calm voice.

"Directors, I do have a few ideas that I would like to propose, and I hope you will correct me."

Several directors looked at this young descendant with some surprise, and saw him, neither humble nor arrogant, with a calm bearing:

"In addition to these imaging data, I found that this patient had a history of gout for up to three years, and had not taken uric acid-lowering drugs. Before in our community hospital, I followed Dr. Zhou to see several patients, It's gouty arthritis."

Hearing Qin Lang talking about gouty arthritis and the history of gout, Qian Mubai, who was still thinking hard, was struck by lightning. Many thoughts passed through his mind, and he seemed to have a sense of clarity.

And Qin Lang calmly continued to tell: "Old Dr. Zhou told me the principle in detail before, gouty arthritis is a foreign body granuloma caused by the deposition of urate crystals, and the center of the lesion is composed of amorphous urate crystals. , surrounded by inflammatory tissue formed by histiocytes, lymphocytes, fibroblasts and foreign body giant cells, also known as tophi."

"Tophi deposits on the limbs and joints, including tendons, ligaments, articular cartilage, bone, joint capsule, synovium and subcutaneous tissue, so I think again, is it possible that this patient's cyst is also related to the patient's ventilation? "

Qin Lang's words were loud, and when such a unique point of view was thrown out, everyone felt a little bizarre and absurd, but think about it carefully. It doesn't seem entirely impossible.

Tian Bo frowned and didn't know what to say for a while, because he wanted to refute, but there was no absolute reason.

Wei Guoqiang has been immersed in the field of burns all these years, so he has no idea at all.

It was Tian Hua, another senior expert in hand surgery: "Qin Lang, although your proposal is possible, the possibility is too low. Also, the tophi you mentioned is on the left wrist and left joint, and the It's such a big lump, I've never heard of it."

Tian Hua just finished speaking ~www.readwn.com~ when Qian Mubai interjected:

"No, Director Tian, ​​I have seen this kind of patient. It's just that the last time my patient was a female patient, and her exact condition was carpal tunnel syndrome."

"Carpal tunnel syndrome?"

Tian Bo was shocked, and then recalled:

"However, the incidence of carpal tunnel syndrome in men is very low, and I have encountered one or two cases. Moreover, they are all caused by occupational factors and long-term physical labor. Carpal tunnel syndrome caused by tophi It's not possible, is it?"

"No, there is a chance. In our Huashan Hospital affiliated to Aurora University, there have been carpal tunnel syndrome caused by gout, hemodialysis, diabetes, and even old radial fractures and rheumatoid arthritis."

Qian Mubai's experience and knowledge were not comparable to those of Hecheng's directors, and his instinct told him that Tian Bo's two diagnoses were faulty.

At the end, what Qin Lang proposed made him somewhat agree. After thinking about it, he quickly re-drawn the plan with years of experience:

"I think the idea proposed by Qin Lang can be tried. Since Director Tian Bo's direction has fallen into a dead end, then we will start anew. If carpal tunnel syndrome caused by tophi, then X-ray, conventional CT, and enhanced MRI will not be much. worth it."

"Let's go, let's go to the patient for another examination. I will perform an ultrasound examination and an EMG examination on the patient myself."

Qian Mubai acted resolutely. It could be said that he was the most authoritative in the field of hand surgery among all the people present. Tian Bo naturally did not dare to disobey.

"Qin Lang, you go with me."

Qian Mubai invited Qin Lang to conduct further inspections. While the rest of the directors were anxiously waiting, the inspection results finally came out.