Pectus Excavatum\Scoliosis\Triage and Management in Adolescents

Female, 13 years old Date of visit: December 16, 14:00 Department: Orthopedics Chief complaint: Abnormal back appearance noted for several months History of present illness: Several months ago, the patient incidentally noticed asymmetry in the shoulders and back. There was no pain or swelling, and the condition did not affect movement but slightly impacted appearance. She presented for evaluation. Physical examination: On examination of the back, the upper thoracic and thoracic segments deviated to the right, while the thoracolumbar and lumbosacral segments showed slight deviation to the left. No local pain or swelling was noted, and joint mobility was unaffected. Lumbar, back, and shoulder movements were satisfactory. Past history: No history of allergies, resuscitation at birth, or major illnesses. Diagnosis: Scoliosis; other forms

Date of visit: July 1, 08:28 Department: Thoracic Surgery Outpatient Clinic Chief complaint: Follow-up for sternal depression for over 6 months History of present illness: Sternal depression was noted 6 months ago. No fever, chest tightness, chest pain, headache, or dizziness. Physical examination: Alert and oriented, breathing stable, no skin rash. Coarse breath sounds in both lungs. Regular heart rhythm with strong heart sounds and no murmurs. Soft abdomen, no tenderness. Sternal depression noted. Past history: Unremarkable Diagnosis: Pectus excavatum Management plan: Regular follow-up in the thoracic surgery outpatient clinic

Examination: Chest CT scan (plain) with three-dimensional reconstruction Findings: Lung window shows relatively normal lung transparency with clear lung markings. A small area of faint patchy high-density shadow is visible in the right upper lobe. No other obvious abnormal density lesions in the remaining lung fields. The trachea and bronchi are patent. Mediastinal window shows no obvious enlarged lymph nodes or soft tissue masses in the mediastinum. The diaphragm is normal, and there is no pleural effusion. Depression is noted in the lower sternal and inferior chest wall midline region, with mild compression and displacement of the heart. The Haller index is approximately 4.14. The anterior margin of the left second rib appears relatively wide. Diagnosis and recommendations: Consistent with pectus excavatum. Small faint patchy shadow in the right upper lobe and relatively wide anterior margin of the left second rib. Please correlate with clinical findings. Report date: July 1, 09:12 Verification date: July 1, 09:19

Discharge summary 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. The patient was admitted for “chest wall depression deformity diagnosed as pectus excavatum 5 months earlier.” 2. Five months previously the patient had noticed progressive anterior chest wall depression. She reported generally poor immunity with frequent colds and respiratory infections. Mild chest tightness and fatigue occurred after activity, but there was no chest pain, hemoptysis, cough, sputum, blood-streaked sputum, shortness of breath, dyspnea, or fever. After a clinic visit at a local hospital in February, she was diagnosed with chest wall depression deformity and came to our hospital seeking surgical treatment. She was admitted under the diagnosis of “chest wall depression.” Since onset, the patient had been alert and oriented with fair spirits, normal appetite and sleep, regular bowel and urinary habits, and no significant weight change. 3. Chest wall deformity with sternal depression was noted. The chest wall was generally symmetric. Breath sounds were equal bilaterally without crackles or wheezes. Heart rhythm was regular with no pathologic murmurs. The abdomen was soft and nontender with normal bowel sounds. No lower-limb edema. Physiologic reflexes were present and pathologic reflexes absent. Hospital course: After admission, necessary preoperative evaluations were completed. Once surgical contraindications were ruled out, the patient underwent corrective surgery for chest wall deformity. Her postoperative condition was stable, and she was discharged. She was advised to perform regular wound care and to return promptly if fever, marked wound redness, swelling, or increased drainage developed. Key laboratory and imaging results during hospitalization: July 15 emergency arterial blood gas: 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, renal function, electrolytes, glucose, and myocardial injury markers: total protein 66 g/L↓, anion gap 7.90 mmol/L↓. July 15 preoperative infectious disease screen: 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, renal 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 radiograph: postoperative appearance of pectus excavatum repair with internal fixation in place. Small bilateral pneumothoraces. Exudative changes in the right lower lung field. July 15 chest CT (plain scan): pectus excavatum. July 15 echocardiography, left ventricular function, and tissue Doppler imaging: 1. No obvious segmental wall motion abnormalities at rest. 2. Normal left ventricular systolic function. 3. Normal left ventricular diastolic function. July 17 routine electrocardiogram (computerized multichannel): sinus arrhythmia. Discharge status: No specific discomfort. Physical examination: Alert and oriented, general condition satisfactory, wound dry with no exudate, chest wall without deformity, breath sounds symmetric, abdomen soft and nontender, no rebound tenderness, neurologic signs negative. Discharge instructions and recommendations: Rest adequately, perform regular wound care, and return promptly for fever, obvious wound redness, swelling, or increased drainage. Schedule regular follow-up in the thoracic surgery clinic.