小兒外科標準病歷範本
Case 1:Inguinal hernia
Chief complaint: right groin bulging, off and on, for 2 weeks
Present illness:
The 2-month-old male was noted to have intermittent bulging in the right inguinal area since 2 weeks ago. As the baby cried or strained,the bulging mass was obvious; as he slept, it disappeared. Sometimes the mother manually reduced the bulging. He was taken to the local pediatric clinic 3 days ago before referred to our pediatric surgery department which diagnosed right inguinal hernia and recommendedsurgical treatment. Hence, he was admitted for operation.
Impression: right inguinal hernia
Plan: 1. Preoperative evaluation including consultation of anesthesia department
2. Operation(herniorrhaphy)
3. Postoperative care
Case 2:Acute appendicitis
Chief complaint: abdominal pain for 2 days
Present illness:
The 7-year-old boy noted periumbilical pain associated with nausea and mild diarrhea since 2 days ago. The pain shifted toright lower abdomen this morning. He was sent to our emergency department. Ensuantly, tenderness and rebound pain in the right lower abdomen were depicted; so wereWBC 15,400/mm 2 and C-reactive protein 150 mg/dL in the blood tests and local bowel dilatation in the right lower quadrantin the plain abdominal film. For acute appendicitis, he was admitted for operation.
Impression: acute appendicitis
Plan: 1. Operation
2. Postoperative care
Case 3: Imperforate anus
Chief complaint: absence of anal orifice noted since birth
Present illness:
The newborn was just via normal vaginal delivery this morning in a local obstetric hospital. Absence of anal orifice was found. There was no obvious fistula opening for meconium passage over the perineum. He was transferred to our emergency department before admitted for further management.
Impression: imperforate anus, high or intermediate type
Plan: 1. Newborn screening including cardiac echo, renal echo, spine X-ray and urinanalysis.
2. Operation(sigmoid colostomy)
3. Postoperative care
四.【Hirschsprung’s disease】
Chief complaint: chronic constipation for 2 years
Present illness:
The 2-year-old boy has had abnormal bowel habits since 1 month old. Delayed meconium passage(over 24 hours) was noted in the newborn period; so were the stool passage once or twice in a week and poor appetite and abdominal dullness frequently. Occasionally glycerin balls were required for stool passage. He was brought to our pediatric surgery clinic recently. Resultantly, digital rectal examination revealed increased anal tone and narrow rectum; lower GI series, dilated sigmoid colon and small-caliber rectum with a transitional zone. For megacolon, he was admitted for operation.
Impression: Hirschsprung’s disease, rectosigmoid type
Plan: 1. Preoperative preparation including fluid and electrolyte supplement, colon preparation and consultation of anesthesia department
2. Operation(Duhamel’s pull-through operation)
3. Postoperative care.
Case 5: Idiopathic hypertrophic pyloric stenosis
Chief complaint: projectile vomiting for 1 week
Present illness:
The 1-month-old baby was noted to have projectile vomiting since 1 week ago. The appetite was normal and stool passage was regular once per day. He was brought to a local pediatric clinic yesterday where a movable mass was palpated in the right upper abdomen and echo revealed hypertrophic change of the pylorus with luminal stenosis. He was referred to our pediatric surgery clinic before admitted for operation.
Impression: Idiopathic hypertrophic pyloric stenosis
Plan: 1. Preoperative preparation including fluid and electrolyte supplement and consultation of anesthesia department
2. Operation(Ramstedt pyloromyotomy)
3. Postoperative care
Case 6: Esophageal atresia with tracheoesophageal fistula
Chief complaint: respiratory distress with cyanosis since birth
Present illness:
The newborn was just delivered via cesarean section due to fetal distressat our obstetric department. The birth weight was 2,580 grams. Respiratory distress with cyanosis was found soon. Immediate endotracheal intubation was performed. However, to coil the NG tubeinto the mouthfailed.(?) For probable esophageal atresia, she was transferred to PICU for further management.
Impression: esophageal atresia with tracheoesophageal fistula
Plan: 1. Preoperative evaluation and resuscitation including chest X-ray, antibiotics, fluid/electrolyte supplement and consultation of anesthesia department
2. Operation(esophagoplasty with repaire of TE fistula)
3. Postoperative care
Case 7: Intestinal perforation
Chief complaint: fever and abdominal pain for 5 days
Present illness:
The 5-year-old boy was noted to have feverand abdominal pain, associated with watery diarrhea,since 5 days ago. He was brought to a local pediatric clinic where acute gastroenteritis was told and some medications were prescribed. The symptoms became milder initially. However, high fever with abdominal distension happened this morning. He was sent to our pediatric emergency department. Resultingly, plain abdominal X-ray revealed pneumoperitoneum; blood tests, WBC 21,500/mm2and CRP 210 mg/dL. For hallow organ perforation, he was admitted for operation.
Impression: intestinal perforation
Plan: 1. Preoperative resuscitation including antibiotics and fluid/electrolyte supplement
2. Operation(exploratory laparotomy)
3. Postoperative care
Case 8: Incarcerated inguinal hernia
Chief complaint: painful mass in right scrotum noted since this morning
Present illness:
The 5-month-old baby was found to have a tender mass inthe right scrotum since this morning; so was irritating crying with vomiting. He was transferred to our pediatric emergency department where incarcerated inguinal hernia was impressing. Abdominal X-ray revealed ileus. Repeatedmanual reduction after sedation failedbefore admitted for operation.
Impression: right incarcerated inguinal hernia
Plan: 1. Operation(reduction and repair of inguinal hernia)
2. Postoperative care
Case 9: Vesicoureteral reflux
Chief complaint: repeated urinary tract infection in recent 6 months
Present illness:
The 5-year-old boy had two episodes of UTI presented with fever and pyuria in recent half a year(6 and 2 months ago respectively) after previously admitted to our pediatric ward where right pyelonephritis was diagnosed by renal echo and DMSA,urine culture yielded E. coli, and administrating ampicillin and gentamicinlessened the infection. During the follow-up in the pediatric nephrology clinic, a VCUG was arranged(1 week ago) and bilateral vesicoureteral reflux(right grade V; left grade IV) was found before referred to the pediatric surgery clinic and admitted for operation.
Impression: bilateral vesicoureteral reflux, right side grade V, left side grade IV
Plan: 1. Operation(bilateral intravesical ureteroneocystostomy)
2. Postoperative care
Case 10: Ureteropelvic junction obstruction
Chief complaint: progressive left hydronephrosis since birth
Present illness:
The 2-month-old baby was found to have left hydronephrosis during the prenatal screening. After birth, he was followed up regularly in our pediatric nephrology department. Progressive enlargement of left renal pelvis was noted from 1.5 cm at birth to 3.4 cm 1 week ago. DTPA revealed total obstruction (right: 65%; left: 35%) of the left renal outlet and split renal function. Owing to left ureteropelvic junction obstruction, he was admitted for surgical treatment.
Plan: 1. Operation(Dismembered pyeloplasty)
2. Postoperative care