2017-05-31 13:16 First course record

    Patients Li Jiamei, female, 41 years old, mainly due to "found uterine fibroids 5 years" at
2017-05-31 admission.
First, the case features:
    1. middle-aged women, chronic disease;
    2. Patients usually menstrual regularity, 5-6 days / 29-30 days, the amount of dysmenorrhea
(-), the last menstrual 2017-5-14. Patients 5 years ago found uterine fibroids, about 1.2cm in
diameter, after regular review, fibroid nodules gradually increased, 1 week before the review B-
tips showed multiple nodular echo, the larger in the posterior wall, the size of about 7.0 * 6.5 *
8.6cm, check the body: the anterior uterus, such as the size of 11 weeks pregnant, and the
surrounding adhesion, poor activity, the posterior wall of the uterus may be like a size of about
7-8cm mass, hard, no abdominal pain , No nausea, vomiting, no headache, dizziness, no fever,
fatigue, no urinary frequency, urgency, no abnormal vaginal bleeding, fluid and other
discomfort, outpatient consideration "uterine fibroids", the proposed surgical treatment,
    3. Past history: deny the history of hypertension, heart disease, denial of diabetes,
cerebrovascular disease, mental illness history. Denied history of hepatitis, tuberculosis history,
history of malaria. Denied trauma, blood transfusion history, denial of food, drug allergy history,
vaccination history is unknown. Other system reviews No special.
    4. Physical examination: vulva: married type. Vagina: smooth, no abnormal secretions.
Cervical: smooth, medium, blood (-). Uterus: uterine anterior, such as the size of 11 weeks of
pregnancy, and the surrounding adhesion, poor activity, the posterior wall of the uterus may be
like a size of about 7-8cm mass, hard, tenderness (-). Annex: double attachment area was not
significantly thickening and mass, tenderness (-).
    5. Auxiliary examination: syphilis serum antibody determination (2016-9-26, our hospital):
Treponema pallidum antibody (Anti TP) 10.63 * S / CO.
RPR 7 titers (2017-10-13, my hospital): titer (negative), rapid syphilis serum reactive test (RPR)
negative.
B super (2017-5-24, my hospital): the anterior uterus, the palace size of about 6.0 * 7.5 *
10.0cm3, clear boundary irregular, visible multiple nodular echo, the larger located in the back
wall, the size of about 7.0 * 6.5 * 8.6cm, protruding to the film, CDFI shows the inside and the
surrounding visible blood flow signal. More than real echo. Endometrial thickness of about
0.8cm, uterine line showed clear, double ovary is not explored. Ultrasound Tip: uterine multiple
nodules, consider fibroids.
Second, the hospital diagnosis: multiple uterine fibroids
Cesarean section after syphilis carriers

Third, the diagnosis based on:

1, multiple uterine fibroids: patients with middle-aged women, physical examination: uterine
anterior, such as 11 weeks pregnant size, and the surrounding adhesion, poor activity, the
posterior wall of the uterus may be about 7-8cm size, Hard, tender (-). B super Tip: visible
multiple nodular echo, the larger located in the posterior wall, the size of about 7.0 * 6.5 *
8.6cm, protruding to the film, so consider the diagnosis.
2, after cesarean section: past history, diagnosis is clear.
3. syphilis carriers: Treponema pallidum antibody (Anti TP) 10.63 * S / CO, so the diagnosis.
Fourth, the differential diagnosis:
1, adenomyosis: the disease more secondary dysmenorrhea, progressive increase, can increase
the uterus uniformity, and menstrual uterine enlargement, after the narrow features. Uterine
fibroids are manifested as uterine limitations, hard and difficult nodular processes. The patient
found uterine fibroids 5 years, without menstrual changes. Within the clinic: 11 weeks pregnant,
the size of the surrounding adhesion, poor activity, the posterior wall of the uterus may be about
7-8cm size of the mass, hard, tenderness (-). B super Tip: visible multiple nodular echo, the
larger located in the posterior wall, the size of about 7.0 * 6.5 * 8.6cm, protruding to the film, so
do not consider the diagnosis.
2, ovarian cancer: mostly on the side of the cystic mass, pedicle submandibular fibroids can be
mistaken for ovarian tumors. The patient found uterine fibroids 5 years, without menstrual
changes. Within the clinic: 11 weeks pregnant, the size of the surrounding adhesion, poor
activity, the posterior wall of the uterus may be about 7-8cm size of the mass, hard, tenderness
(-). B super Tip: visible multiple nodular echo, the larger located in the posterior wall, the size of
about 7.0 * 6.5 * 8.6cm, protruding to the film, consider the disease is unlikely, can be surgery
and postoperative pathology further Clear diagnosis.
Five, medical treatment plan:
1. Improve the laboratory, review blood, urine, HIV, syphilis, hepatitis B and other tests.
2. patients were married middle-aged women, uterine fibroids persist, diameter greater than 5cm,
with surgical indications.
3. Ask the doctor to check the patient.
[Signature] Nie Shen Si
 

2017-05-31 13:19
    The patient has no complaints.
    Physical examination: body temperature: 36.7 ℃, pulse: 76 times / min, breathing: 18 times /
min, blood pressure: 110 / 70mmHg, the general situation is good, heart and lung auscultation
without exception, abdominal soft, no tenderness, rebound tenderness and muscle tension, Liver
and spleen ribs not touched, no vaginal bleeding.
    Ask the physician to see the patient.
[Signature] Nie Shen Si
2017-05-31 13:33 Golden shadow deputy chief physician ward round
    The patient has no complaints.
    Physical examination: body temperature: 36.7 ℃, pulse: 76 times / min, breathing: 18 times /
min, blood pressure: 110 / 70mmHg, the general situation is good, heart and lung auscultation
without exception, abdominal soft, no tenderness, rebound tenderness and muscle tension, Liver
and spleen ribs not touched, no vaginal bleeding.
    1, according to the history, physical examination and auxiliary examination: multiple uterine
fibroids, cesarean section, syphilis carriers; 2, middle-aged women, uterine fibroids, the largest
diameter> 5cm , Surgical indications clear. 3. is to improve preoperative preparation, elective
surgery.
[Signature] Nie Shen Si
2017-06-01 08:02
    The patient has no complaints.
    Physical pressure: 36.5 ℃, pulse: 75 times / min, breathing: 18 times / min, blood pressure:
110 / 70mmHg, the general situation is good, heart and lung auscultation without exception,
abdominal soft, no tenderness, rebound tenderness and muscle tension, Liver and spleen ribs not
touched, no vaginal bleeding.
    Please go to the superior physician.
[Signature] Nie Shen Si
2017-06-01 08:34 Hao Zengping chief physician rounds
    Patients Li Jiamei, female, 41 years old, mainly due to "found uterine fibroids 5 years" at
2017-05-31 admission.
    Physical examination: body temperature: 36.5 ℃, pulse: 75 times / min, breathing: 18 times /
min, blood pressure: 110 / 70mmHg, the general situation is good, cardiopulmonary auscultation
without exception, abdominal soft, no tenderness, Muscle tension, liver and spleen ribs not
touched, no vaginal bleeding. Internal consultation: vulva: married type. Vagina: smooth, no
abnormal secretions. Cervical: smooth, medium, blood (-). Uterus: uterine anterior, such as the
size of 11 weeks of pregnancy, and the surrounding adhesion, poor activity, the posterior wall of
the uterus may be like a size of about 7-8cm mass, hard, tenderness (-). Annex: double
attachment area was not significantly thickening and mass, tenderness (-).
    1, according to history, physical examination and auxiliary examination: multiple uterine
fibroids, cesarean section, syphilis carriers; 2, middle-aged women, uterine fibroids, the largest
diameter> 5cm, surgery 3, to the patients and their families account for the condition: 1)
according to the situation, if the pelvic adhesions are serious, there may be laparotomy surgery
may be The Intraoperative injury to the bladder, ureter, intestine and other surrounding organs
may be. 2) line of uterine fibroids nucleus surgery, there may be myometrial fibroma may be
postoperative fibroid recurrence may be. 4) the final diagnosis based on postoperative
pathological results, postoperative additional treatment may be. 5) postoperative pelvic infection,
intestinal obstruction, deep vein thrombosis may be. Patients and their families expressed their
understanding of the condition, requiring surgery and signature. Improve the preoperative
preparation; intraoperative attention to avoid damage to the ureter, separation of the bladder
when the anatomical relationship, careful operation, to avoid injury, pay attention to strict
hemostasis; postoperative attention to gastrointestinal function recovery, pay attention to prevent
deep vein thrombosis. Improve preoperative preparation, next Monday surgery.
[Signature] Nie Shen Si
2017-06-01 14:03 Preoperative Summary
    Patients Li Jiamei, female, 41 years old, mainly due to "found uterine fibroids 5 years" at
2017-05-31 admission. Physical examination: body temperature: 36.5 ℃, pulse: 75 times / min,
breathing: 18 times / min, blood pressure: 110 / 70mmHg, the general situation is good,
cardiopulmonary auscultation without exception, abdominal soft, no tenderness, Muscle tension,
liver and spleen ribs not touched, no vaginal bleeding. Internal consultation: vulva: married type.
Vagina: smooth, no abnormal secretion. Cervical: smooth, medium, blood (-). Uterus: uterine
anterior, such as the size of 11 weeks of pregnancy, and the surrounding adhesion, poor activity,
the posterior wall of the uterus may be like a size of about 7-8cm mass, hard, tenderness (-).
Annex: double attachment area was not significantly thickening and mass, tenderness (-). 2,
patients with middle-aged women, uterine fibroids, the largest diameter> 5cm, surgical
indications clear, and now have a history of uterine fibroids, cesarean section Improve the
preoperative preparation, intended to laparoscopic uterine fibroids, 3, to patients and their
families account for the disease: 1) according to the situation, if the pelvic adhesions are serious,
there may be laparotomy. Intraoperative injury to the bladder, ureter, intestine and other
surrounding organs may be. 2) line of uterine fibroids nucleus surgery, there may be myometrial
fibroma may be postoperative fibroid recurrence may be. 4) the final diagnosis based on
postoperative pathological results, postoperative additional treatment may be. 5) postoperative
pelvic infection, intestinal obstruction, deep vein thrombosis may be. Patients and their families
expressed their understanding of the condition, requiring surgery and signature. Improve the
preoperative preparation; intraoperative attention to avoid damage to the ureter, separation of the
bladder when the anatomical relationship, careful operation, to avoid injury, pay attention to
strict hemostasis; postoperative attention to gastrointestinal function recovery, pay attention to
prevent deep vein thrombosis. Improve preoperative preparation, next Monday surgery.
Anesthesia options for general anesthesia, preoperative surgery have seen patients.
[Signature] Nie Shen Si
2017-06-02 08:20
    The patient has no complaints.
    Body pressure: 36.6 ℃, pulse: 78 times / min, breathing: 19 times / min, blood pressure: 110 /
70mmHg, the general situation is good, heart and lung auscultation without exception,
abdominal soft, no tenderness, rebound tenderness and muscle tension, Liver and spleen ribs not
touched, no vaginal bleeding.
    Following the view.
[Signature] Nie Shen Si
2017-06-03 09:51
    The patient has no discomfort.
    Examination: T 36.4 ℃, Bp 110 / 70mmHg, the general situation is good, belly soft, no
tenderness, no bleeding vagina.
    Following the view.
[Signature]
2017-06-04 10:12
    The patient has no discomfort.
    Examination: T 36.2 ℃, Bp 110 / 70mmHg, the general situation is good, belly soft, no
tenderness, no bleeding vagina.
    Following the view.
[Signature]
 

2017-06-05 08:19 Preoperative discussion

Participants: Mr. Hao Zengping chief physician, deputy chief physician of the shadow, snow,
Nie Shensi, Dong Xu resident physician
Report case: Nie Shensi resident physician
Discussion speech: patients Li Jianmei, female, 41 years old, the main reason "found uterine
fibroids 5 years" at 2017-05-31 admission. Physical examination: body temperature: 36.5 ℃,
pulse: 75 times / min, breathing: 18 times / min, blood pressure: 110 / 70mmHg, the general
situation is good, cardiopulmonary auscultation without exception, abdominal soft, no
tenderness, Muscle tension, liver and spleen ribs not touched, no vaginal bleeding. Internal
consultation: vulva: married type. Vagina: smooth, no abnormal secretions. Cervical: smooth,
medium, blood (-). Uterus: uterine anterior, such as the size of 11 weeks of pregnancy, and the
surrounding adhesion, poor activity, the posterior wall of the uterus may be like a size of about
7-8cm mass, hard, tenderness (-). Annex: double attachment area was not significantly
thickening and mass, tenderness (-). 2, patients with middle-aged women, uterine fibroids, the
largest diameter> 5cm, surgical indications clear, and now have a history of uterine fibroids,
cesarean section Improve the preoperative preparation, intended to laparoscopic uterine fibroids,
3, to patients and their families account for the disease: 1) according to the situation, if the pelvic
adhesions are serious, there may be laparotomy. Intraoperative injury to the bladder, ureter,
intestine and other surrounding organs may be. 2) line of uterine fibroids nucleus surgery, there
may be myometrial fibroma may be postoperative fibroid recurrence may be. 4) the final
diagnosis based on postoperative pathological results, postoperative additional treatment may be.
5) postoperative pelvic infection, intestinal obstruction, deep vein thrombosis may be. Patients
and their families expressed their understanding of the condition, requiring surgery and
signature. Improve the preoperative preparation; intraoperative attention to avoid damage to the
ureter, separation of the bladder when the anatomical relationship, careful operation, to avoid
injury, pay attention to strict hemostasis; postoperative attention to gastrointestinal function
recovery, pay attention to prevent deep vein thrombosis. Improve preoperative preparation, next
Monday surgery. Anesthesia options for general anesthesia, preoperative surgery have seen
patients.
[Signature] Nie Shen Si
  

2017-06-05 16:37 The first course of the disease after surgery

First, preoperative diagnosis: multiple uterine fibroids, cesarean section, syphilis carriers
Second, the surgical name: laparoscopic uterine fibroids under the nucleus surgery + intestinal
adhesions
Third, after surgery: anesthesia satisfaction, routine disinfection, shop towels, at the top of the
umbilical at the edge of the skin 1 cm, pneumoperitoneum needle puncture smooth,
pneumoperitoneum after successful, line Trocar puncture smooth, into the laparoscopic
examination see: uterus Increase the size of 12 weeks pregnant, the posterior wall of the muscle
wall between the sudden protrusion of a fibroid nodule diameter of about 8cm, fibroids on the
surface of vascular dense, uterine left anterior wall of the anastomosis of the fibroid nodules of
about 4cm, double Side of the annex no abnormalities, uterine left rear and intestine membrane
adhesions, line under the abdomen of the first 2,3,4 incision puncture, sharp separation of the
uterus and intestinal adhesions, uterine fibroid nodules at the base of injection of pituitrin ( 6U +
saline 100ml dilution), with a single pole electric hook to cut the uterine fibroids on the surface
of the uterine fibrous nodules, clamp tumor, visible tumor and uterine muscle layer gap,
separation of fibroids around the organization, the nucleus Fibroids nodules, myofascial soft,
wound bleeding serious, local bleeding with bipolar coagulation hemostasis, nuclear fibroids
wound with V-LOC absorbable line 2 layers of continuous suture muscle layer, with the same
Law out of the uterine anterior fibroid nodules 1, check no bleeding. Rotate the tumor nodules
with a peeler to remove the nodules. Check the wound without bleeding, wound a chitosan one,
abdominal placement of a disposable drainage tube, suture abdominal small incision surgery.
Large tumor, surgical difficulties, intraoperative blood pressure stable, anesthesia satisfaction,
bleeding 30ml, urine color clear, the amount of 200ml, the patient back to the ward.
General specimens: peeling fibroids 2, slightly soft texture, cut surface was swirling.
Fourth, postoperative diagnosis: multiple uterine fibroids, cesarean section, syphilis carriers
5, postoperative doctor's advice: 1. Monitoring of life