Doctor's Life Simulator

Chapter 77 Qin Lang's Surprising Thoughts: Carpal Tunnel Syndrome Caused by Tophi
[A patient with a rare tumor in the left wrist and left hand joint was admitted to the Department of Hand Surgery.Tian Bo invited Shen Jiachen, Qian Mubai, Tian Hua, Wu Xin, and Wei Guoqiang who licked his face and led you.After some demonstration and discussion, it is still difficult to choose directly between synovial chondroma and synovial sarcoma.Director Qian Mubai was puzzled, but because of the special symptoms of this patient, even enhanced CT and MRI still 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 schedules, but they still pay close 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, about 12cm.Cut the skin, subcutaneous area, and carpal tunnel, and see an oval-shaped tumor at the distal end of the second finger on the left wrist, about 5cmX3cm in size. The superficial flexion tendons are thickened and surrounded by plaster-like deposits.The situation is more complicated, intraoperative decision, extensive resection. 】

【Postoperative report of left wrist tumor case: tophi formation in fibrous tissue accompanied by foreign body giant cell reaction.The real cause of the patient turned out to be that the extremely rare tophi caused extreme flexion contracture deformity of the fingers and carpal tunnel syndrome. 】

[Director Qian Mubai regretted and blamed himself after communicating with Director Tian Bo 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, causing the median nerve to be entrapped in the carpal tunnel and causing paresthesia in the radial fingers. A syndrome with main features.It is more common in women, and the ratio of male to female patients is about 1:9.Since it is more common in females and rare in males, there are few discussions on the etiology and clinical features of CTS in males.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 to move, and the flexion and extension of fingers were not satisfactory.In response to this misdiagnosis, Director Qian Mubai made a summary and review, and gave a lecture in their department.A small wrist incision surgery treatment plan was proposed. Of course, this surgery requires extremely high requirements for incision, exposure, stripping, and tendon repair in a small field of view. The release of the median nerve is only available in the top hospitals in Shanghai or Hangzhou. possible development. 】

[Summary of classic diagnostic schemes: The value of imaging in the diagnosis of gout and tophi is still very limited. X-ray, routine CT, and MRI have low specificity for tophi.This is also the reason why the directors misdiagnosed. 】

[The typical ultrasound imaging findings of tophi include anechoic halo and multiple hyperechoic centers, and the surrounding anechoic rings may represent histologically fibrovascular areas, with synovial hyperplasia with central hyperechoes.However, the field of view of ultrasound is small, the operator is highly dependent, and the experience requirements for physicians are extremely high. 】

[After the simulation is over, you can retain 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 the carpal tunnel syndrome is caused by tophi actually relieved Qin Lang. After all, as long as this disease is properly operated, the impact on the patient is very small. Alcohol, drink more water, etc.

Removal of lesions, functional reconstruction, combined with comprehensive treatment such as medication and diet conditioning, can generally restore finger function well and prevent recurrence.

In the conference room, Qin Lang put down the materials, and he relaxed, and his subtle actions caught the attention of Director Shen Jiachen who was beside him.

Deputy Director Shen Jiachen has always been very open-minded and brainstorming. As long as he participates in his consultation, no matter who he is, he will give them a chance to speak freely, so he asked softly:
"Qin Lang, what thoughts and ideas do you have, if you have something to say, bring it up, let's discuss it?"

When Deputy Director Shen Jiachen said this, the other chief executives also looked at the little doctor with some interest.

Tian Bo squinted his eyes, and also showed his demeanor:

"Doctor Qin, don't be under psychological pressure. It doesn't matter if you have no ideas. After all, this is the field of hand surgery. If you have some ideas, you can share them. Maybe we senior doctors are limited by habitual thinking, but a novice like you, There will be fresh angles."

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

Li Lian'an, who was on the second row of seats, looked at Qin Lang gloatingly, wondering how he would behave in such a suffocating chief director's consultation.

After all, if he was suddenly named, his head would be blank and his face would be flushed.

When Wei Guoqiang saw Qin Lang being killed like this, he naturally wanted to protect the calf, so he made a rescue:
"With such a complicated case, even Director Tian is in a dilemma. What does a young doctor like Qin Lang know? Let him come to participate in the consultation today, just let him bring his ears and eyes. That's fine, Qin Lang, just take care of yourself." Just listen, and we won't show our ugliness."

Hearing Wei Guoqiang's words, the rest of the people also smiled slightly. It's true that this little doctor has such a talent clinically. on the dog.

Li Lian'an in the second row was a little disappointed when he saw that Wei Guoqiang resolved Qin Lang's predicament.After all, being robbed of his establishment, if he could see Qin Lang make 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 want to raise, and I hope everyone can correct me."

Several directors looked at this young man in surprise, and saw him, neither humble nor overbearing, with a calm demeanor:

"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. In our community hospital, I followed Dr. Zhou to see several patients. It's gouty arthritis."

Hearing Qin Lang talk 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 feeling of enlightenment.

And Qin Lang continued to tell calmly: "Dr. Zhou explained the principle to me in detail before. Gouty arthritis is a foreign body granuloma caused by the deposition of urate crystals. 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 is mostly deposited in the joints of the extremities, including tendons, ligaments, articular cartilage, bone, joint capsule, synovium and subcutaneous tissue, so I think again, is it possible that the cyst in this patient is also related to the patient's ventilation? "

Qin Lang's words were resounding, and when such a unique point of view was thrown out, everyone felt a little weird 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 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. Moreover, the tophi you mentioned is on the left wrist and joint, and it is also It's such a big tumor, I've never heard of it before."

Just after Tian Hua finished speaking, Qian Mubai interrupted:
"No, Director Tian, ​​I have seen this kind of patient before. It's just that last time my patient was a female patient, and her exact illness was carpal tunnel syndrome."

"Carpal tunnel syndrome?"

Tian Bo was startled suddenly, and then recalled:

"However, the incidence of carpal tunnel syndrome among men is very low, and I have only encountered one or two cases. Moreover, they are all caused by occupational factors and long-term physical labor. Carpal tunnel syndrome caused by tophi Zheng, it’s unlikely, right?”

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

Qian Mubai's experience and knowledge are not comparable to these directors of Hecheng, and his instinct tells him that Tian Bo's two diagnoses are problematic.

So, what Qin Lang proposed made him agree with it. After thinking about it, he quickly re-drawn the plan based on 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 from scratch. If carpal tunnel syndrome caused by tophi, X-rays, conventional CT, and enhanced MRI are not too big worth it."

"Come on, let's go and do another examination on the patient. I will personally perform an ultrasound examination and an electromyography examination on the patient."

Qian Mubai acted vigorously and resolutely. It can be said that he is the most authoritative on hand surgery diseases among all the people present. Naturally, Tian Bo did not dare to disobey.

"Qin Lang, you go with me."

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

(End of this chapter)