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 recommended
surgical 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 to right lower abdomen this morning. He
was sent to our emergency department. Ensuantly, tenderness and rebound pain in
the right lower abdomen were depicted; so were WBC 15,400/mm 2 and C-reactive
protein 150 mg/dL in the blood tests and local bowel dilatation in the right lower
quadrant in 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 distress at 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 tube into the mouth failed.(?) 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 fever and 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/mm2 and 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 in the 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. Repeated manual reduction after sedation failed
before 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 gentamicin lessened
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