Detailed Treatment Process
Female, 13 years old Consultation date: December 16, 14:00 Consulting department: Orthopedics Chief complaint: Abnormal back posture discovered for several months Present history: Several months ago, asymmetry of the shoulders and back was accidentally discovered. The shoulders and wrists were asymmetrical. There was no local pain or swelling, no impact on movement, but slight effect on appearance. She therefore sought medical evaluation. Physical examination: Back examination showed upper thoracic and thoracic segments deviated to the right, thoracolumbar and lumbosacral segments slightly deviated to the left. No local pain or swelling. Joint mobility not affected. Lumbar, back, and shoulder movements were acceptable. Past history: No allergy history, history of resuscitation at birth, or major disease history Diagnosis: Scoliosis; other forms
Consultation date: July 1, 08:28 Consulting department: Thoracic Surgery Outpatient Clinic Chief complaint: Sternum depression for more than 6 months, follow-up Present history: Sternum depression discovered 6 months ago. No fever, no chest tightness or chest pain, no headache or dizziness. Physical examination: Alert, breathing stable, no skin rash over the body. Coarse breath sounds in both lungs. Heart rhythm regular, heart sounds strong, no murmurs heard. Soft abdomen, no tenderness. Sternum depression. Past history: Nothing particular Diagnosis: Pectus excavatum; Treatment plan: Regular follow-up in thoracic surgery outpatient clinic
Examination item: CT chest plain scan and three-dimensional reconstruction Findings: Lung window showed acceptable transparency of both lungs, clear lung markings. A small amount of blurred patchy high-density shadow was seen in the right upper lobe. No obvious abnormal density lesions in the remaining lung fields. Trachea and bronchi were patent. Mediastinal window showed no obvious enlarged lymph nodes or soft tissue masses in the mediastinum. Diaphragm normal. No pleural effusion. Depression in the xiphoid process and lower central chest wall area. Heart slightly compressed and displaced. Haller index approximately 4.14. Anterior margin of the left second rib relatively wide. Diagnosis and recommendations: Consistent with pectus excavatum changes. Small blurred patchy shadow in the right upper lobe. Anterior margin of the left second rib relatively wide. Please correlate with clinical findings. Report date: July 1, 09:12 Review date: July 1, 09:19
Discharge record Admission date: July 15 Discharge date: July 20 Admission diagnosis: 1. Chest wall depression 2. Pectus excavatum Discharge diagnosis: 1. Chest wall depression 2. Pectus excavatum Admission status: 1. Admitted due to “discovery of anterior chest wall depression deformity, diagnosed as pectus excavatum for 5 months.” 2. The patient discovered anterior chest wall depression deformity 5 months ago. The deformity gradually progressed. Usual symptoms included poor immunity, frequent colds, and easy pulmonary infections. Mild chest tightness and fatigue after activity. No chest pain, no hemoptysis, no cough, no sputum, no blood-streaked sputum, no shortness of breath or dyspnea, no fever. In February this year, she visited a local hospital outpatient clinic and was diagnosed with chest wall depression deformity. She came to our hospital for surgical treatment and was admitted with “chest wall depression.” Since onset, the patient has been conscious, with fair spirit, normal appetite, fair sleep, normal bowel movements, normal urination, and no significant weight change. 3. Chest wall deformity with sternum depression. Chest wall basically symmetric. Breath sounds symmetric in both lungs, no dry or wet rales. Heart rhythm regular. No pathological murmurs in any valvular areas. Abdomen flat and soft, no tenderness or rebound tenderness. Normal bowel sounds. No edema in both lower limbs. Physiological reflexes present, pathological reflexes not elicited. Treatment course: After admission, relevant examinations were completed. After ruling out surgical contraindications, chest wall deformity correction surgery was performed. Postoperative condition was stable, and she was discharged. She was advised to change dressings on the wound actively. Return promptly if fever, obvious wound redness, swelling, or increased exudate occurs. Main laboratory and examination results during hospitalization: July 15 emergency blood gas analysis: Total carbon dioxide 22.3 mmol/L↓, chloride 107 mmol/L↑, ionized calcium 1.14 mmol/L↓, anion gap 7.8 mmol/L↓ July 15 emergency liver function, emergency kidney function, emergency electrolytes, glucose determination, emergency myocardial injury: Total protein 66 g/L↓, anion gap 7.90 mmol/L↓. July 15 preoperative infectious disease screening: Hepatitis B surface antibody 55.800 mIU/mL (positive)↑, hepatitis B core antibody 0.883 Index (positive)↑. July 16 emergency blood routine 2: White blood cell count 18.1 × 10⁹/L↑, neutrophil percentage 81.3%, lymphocyte percentage 17.6%↓, monocyte percentage 0.8%↓, neutrophil absolute count 14.66 × 10⁹/L↑, mean corpuscular volume 93.1 fL↑. July 17 blood routine 1: White blood cell count 15.4 × 10⁹/L↑, neutrophil percentage 82.7%↑, lymphocyte percentage 10.2%↓, neutrophil absolute count 12.76 × 10⁹/L↑, monocyte absolute count 1.08 × 10⁹/L↑, red blood cell count 4.15 × 10¹²/L↓, C-reactive protein 11.52 mg/L↑, procalcitonin 1.16 ng/mL↑, serum amyloid A 149.31 mg/L↑. July 17 electrolytes, kidney function 1, liver function 1: Total protein 63.20 g/L↓, albumin 40 g/L↓, aspartate aminotransferase 43 U/L↑, alanine aminotransferase 71 U/L↑ July 17 bedside chest X-ray: Post-pectus excavatum surgery with internal fixation in place. Small bilateral pneumothorax. Exudation in right lower lung field. July 15 chest CT scan (plain): Pectus excavatum changes. July 15 color Doppler echocardiography, left heart function measurement, TDI examination: 1. No obvious abnormalities in segmental systolic activity at rest. 2. No obvious abnormality in left ventricular systolic function. 3. No obvious abnormality in left ventricular diastolic function. July 17 routine electrocardiogram (computerized multi-lead ECG): Sinus arrhythmia Discharge status: No special discomfort complaints. Physical examination: Alert, general condition fair, wound dry with no exudate, no chest wall deformity, breath sounds symmetric in both lungs, soft abdomen, no tenderness or rebound tenderness, NS(-) Discharge orders and post-discharge advice: Rest well, change wound dressings actively. Return promptly if fever, obvious wound redness, swelling, or exudate occurs. Regular follow-up in thoracic surgery outpatient clinic.