瑞士医疗 - 部分案例

徐女士英文病例


Medical record
 

Name XU ******
Gender Female
Age 40
Date of record August 21th,2017
Chief complaints Blurred vision in the left eye for 9 days
History of Present illness 9 days ago, the patient felt blurred vision without other discomfort. She went to the hospital and underwent CT&MRI,the results showed: a mass in left orbit-choroid melanoma?and exudative retinal detachment in left eye. She is generally in good condition.
Past Medical History History of cesarean section in the year of 2004
 
Personal History No special personal history
Family History No special family history
Physical Examination Height:165 cm,, Weight: 63kg
Visual acuity of naked eye: right 1.0, left 0.25       Intra-ocular pressure: right 15.6mmHg, left 14.3mmHg
Laboratories  
Imaging Studies High-frequency ocular ultrasound (date of August 23th, 2017):
Ultrasound findings: There is an arched oncoides moderate echo area with a size of 6.05*13.98 mm in the temporal side of global wall in the left eye, and the ocular wall is complete. “hollowing sign” (+),“choroidal excavation”(+). Banded echo can be detected in front of the surface and inferior side of global wall, with a distance of 1-2mm to the wall.
Ultrasonic diagnosis:
1.Retinal detachment after suspicious ocular space-occupying lesion of left eye.               2.Choroidal melanoma?
CT,orbits routine scan (date of 25th August, 2017):
Radiology findings:
Bilateral orbital structures are clear and bone wall is continuous. No shadow of abnormal density is seen in orbital cavity. Left sclera is local thickened. A nodular shadow with soft tissue density can be seen in the external upper inner-wall of sclera with a broader base. The size of the mass is about 6*13*15mm.Focal mass protrude into eyeball, and towards to maxillary sinus. No other abnormality.
 
Radiology diagnosis
A nodule is found in the external upper inner-wall of left sclera. Suspicious choroid melanoma.
 
Enhanced MRI,orbit(August 9th, 2017)
Radiology findings;                                 Left fundus retina lift forward without separation from eye ball,the anterior margin of the lesion is like letter“V” in both transverse and sagittal plane. The lesion shows high signal in T1W1, low signal in T2W1 pressure grease and partial high signal in DWI,an enhanced nodule is found at the position of 4 o’clock of left retina after enhancement,anteroposterior diameter of eyeball is increased slightly and transverse diameter is decreased slightly. No abnormal signal is found in retrobulbar muscle cone. Nothing abnormal is found in form and signal of optic nerve. 
Radiology diagnosis:
An enhanced nodule is found at the position of 4 o’clock of left retina. Suspicious choroid melanoma.
Retinal detachment of left eye, please combine with clinical features.
Other Examination Ocular fundus examination (date of 21th August, 2017):
There is no hyperemia in conjunctiva of both eyes ,the cornea is transparent and the anterior chamber is deep with clear aqueous humor. Nothing abnormal is found in right fundus. Left fundus: The margin of optic disk is clear and C/D ratio is about 0.3. The blood vessels routes are clear and macular edema is found. A big highly-uplifted mass is found below retina on the temporal side (2h-4h), the retina is uneven yellow with dispersive,cranny-like,shallow bleeding on the surface. Dark brown pigmentation is seen on the nasal side with a clear margin.
OCT (date of 21th August, 2017):
Neurosensory retina of macular is separated from retinal pigment epithelium in left eye.