MTL - Doctor’s Life Simulator-Chapter 74 Synovial chondrosis or synovial sarcoma, or something else?

Soon everyone came to the conference room of the hand surgery. Li Lianan quickly prepared the materials and made the tea.

"Directors, let me briefly introduce the patient's situation to you, and I'll discuss it with you after Director Tian has comforted the patient."

Li Lian'an is still very knowledgeable and understands the rules. With this level of consultation, how can he be qualified to give opinions.

He handed the printed materials to the big guys respectfully. When he walked past Qin Lang, he frowned slightly, but after all, he gave Qin Lang a copy of the materials. Very well hidden: "Pigs put garlic in their noses, pretending to be an elephant!"

After all, to be able to become Tian Bo's son-in-law, his city is still very deep.

After everything was arranged in an orderly manner, it was time to introduce the patient's situation:

"Experts, this is the case of this patient. The patient, male, is 41 years old. He was admitted to the hospital three days ago because of the discovery of a left wrist mass for one year and numbness in the fingers of his left hand for three months. The mass is soft, non-tender, limited in movement, and the mass gradually increases, so it should not be paid attention to.”

At the same time of the introduction, Li Lianan simultaneously displayed the photos of the patient's wrist, which was clear and organized, and obviously did not cooperate with Director Tian Bo in various reports and consultations.

"Three months ago, the patient developed numbness in the 1st, 2nd, and 3rd fingers of the left hand, and the activities were limited. Later, the symptoms gradually worsened, and the fifth fingers of the left hand were numb and limited in activities. The patient has a history of gout for 3 years and has not taken uric acid-lowering drugs. No special family history."

After hearing Li Lian'an's introduction, in the conference room, several directors also had some guessing directions in their hearts, and then signaled to continue.

Li Lianan nodded, and continued to expand in detail with the reading speed of the experts:

"Specialist examination showed that there was a subcutaneous mass of about 4cmX4cm on the palm of the patient's left wrist. The skin color was normal, the muscle temperature was not high, the texture was firm, the boundary was clear, the position was fixed, and there was no pain when pressing. There was no obvious shrinkage of the left thenar muscle. The left index finger showed extreme flexion deformity, the flexion activities of the left wrist joint were slightly limited, the adduction activities of the left thumb were limited, and the flexion activities of the five fingers of the left hand were limited. Red, the local skin temperature is slightly higher, the texture is tough, the boundary is clear, the position is fixed, there is no pain when pressing, and the movement of the left elbow joint is normal; the blood supply and feeling of the remaining fingers are OK.

Hearing Li Lian'an's introduction, it was obvious that such a large tumor surprised several experts, and the pressure was painless and the position was fixed. Several directors were a little hesitant.

"continue!"

Li Lianan began to introduce laboratory tests:

"...white blood cells 10.55×109·L-1, carbohydrate antigen 72417.55U·mL-1, uric acid 651μmol·L-1, C-reactive protein 13.6mg·L-1, high-sensitivity C-reactive protein 11.1mg· L-1..."

Looking at these data, several experts were still unable to confirm it, but they also aroused their competitiveness, especially Director Tian Hua and Director Qian Mubai in the field of hand surgery.

The two read the information again, and Li Lianan also said the imaging examination at the same time:

"... The mass on the left wrist surface showed an isoechoic mass with a size of about 43mm×36mm×17mm, oval shape, with distinguishable boundary, uneven internal echo, rear attenuation, and dotted blood flow signals in and around the mass. Not rich...”

Then the directors looked at the MRI results of the left wrist joint.

When the directors began to diagnose, Director Tian Bo also rushed back from the ward to the conference room, and when he came in, his tone was sincere:

"It really made you laugh. Thanks to everyone who organized this expert consultation together today, the patient and family members are now emotionally stable, and they are looking forward to us finding out the real cause. On behalf of the hand surgery department, I would like to thank you in advance."

Tian Bo soon came to Li Lian'an's side, asked about the progress, and took over the position of the report, while Li Lian'an was obediently holding the small book and sat on the second row of chairs at the far end of the conference table. , dare not cross the line and line up with the major directors.

Tian Bo also swept Wei Guoqiang and Qin Lang in the middle of his vision, but he was also smirked. This Qin Lang was really ignorant, and pretended to read the case carefully.

I really thought that I had learned some free flap transplantation operations, so I dared to join the surgery, understand him.

However, Tian Bo's status is there, naturally he won't show it, and he doesn't bother to compete with Qin Lang. Can he pretend to ask Qin Lang's advice?

It's normal for a little doctor of his level to be questioned by a chief director like him, and he can't hold back a fart. It's not shameful, but he looks stingy.

Tian Bo gave several directors some time to think, and he first put forward some of his ideas:

"Everyone, I'll start by throwing some ideas and talking about my views. Combined with imaging data, the left carpal tunnel occupies space, a small amount of effusion in the tendon sheath of the deep flexor digitorum on the left, a small amount of effusion in the lower ulna and radial joint on the left, Median nerve damage, wrist, motor and sensory microscopic involvement, myelin damage mainly with partial axonal damage..."

"So, now I have two inferences, I suspect it is synovial sarcoma, and it may be synovial chondroma. However, the two inferred treatment options are very different. If it is treated according to synovial sarcoma, it is necessary to strive for wide excision, Otherwise, if there is a recurrence, extensive amputation is required, and it may even be easy to metastasize to the lungs through blood, and there are also lymphatic metastases. Once the first-stage treatment is not thorough, the 5-year survival rate after recurrence is only 20% to 50% according to experience!"

"However, if it's just a benign synovial chondroma, a self-limiting lesion, synovectomy or incomplete excision is fine. Destruction is not necessary to fully preserve the patient's tissue function."

Hearing Tian Bo's two completely different diagnosis directions and different treatment plans, several directors in the conference room were also in trouble.

Indeed, for the patient, treating it as a synovial sarcoma, with wide excision, presents the physician with the least risk, but can lead to overtreatment.

After all, once a wide excision is performed, the patient's wrist is basically useless.

However, if it is treated conservatively as a synovial sarcoma, if it is a malignant synovial sarcoma, it will be life-threatening if the treatment is not timely, resulting in recurrence, spread and metastasis.

Tian Hua carefully looked at various materials, and in general, it was similar to Tian Bo's judgment: "It's really not feasible, only the left wrist and left joint tumor can be removed, and the nature of the tumor can be judged during the operation, and the operation can be further adjusted. Program."

Director Qian Mubai had a different opinion:

"Synovial cartilage disease is a rare conscience disease that occurs frequently in the joint cavity and is characterized by the formation of multiple cartilage nodules in the joint synovium, tendon and tendon sheath synovium, and bursa. The general symptoms are pain, swelling and involvement of joint activities In X-ray films and CT images, the free body is shown as single ring calcification or multi-ring calcification, and MRI examination can show synovial and bone erosion.”

"The synovial sarcoma is a highly malignant soft tissue tumor originating from the synovium, bursa, and tendon sheath. It can also appear as a mass in the wrist and cause deformity. The imaging (X-ray or CT) features are mainly soft tissue masses. There may be calcification or ossification within the lesion, and a few cases may be accompanied by extensive osteoid tissue formation."

"However, the physical examination and imaging features of this patient are very similar, but there are very subtle differences, and the differences are only based on years of experience and instinct. So, I was thinking , Is it possible that it is a rarer disease? It's just that I don't have a specific direction for a while, but my proposition is to spend more time and energy before surgery, and under the argument, don't blindly remove it, and try to do it as much as possible. Minimal damage to the patient, preserving the patient's tissue and function as much as possible!"

"Give me some more time, Director Tian, ​​and arrange another enhanced scan."

Hearing Qian Mubai's words, everyone felt ashamed. He was worthy of being the director of hand surgery at Huashan Hospital Affiliated to Aurora University. For his perseverance and tenacity alone, he deserved the title of a famous doctor.

While everyone continued to discuss, an electronic voice appeared in Qin Lang's mind:

[New task: Find out the real cause of the patient through a single case simulation, and guide the directors to confirm the real cause through inferences from minute details. Mission reward: 1 life simulation point. 】

Qin Lang also admired it. As expected of Director Qian Mubai, this patient was really a rare third case.

[Consume 1 life simulation point to start a single case simulation! 】

PS: Thanks to 20170608150747831 for the 100 coins reward!