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Clinical Pathology Conferences

Case 1 (digital picture)


Clinical data: A 13 years old boy complained that his right thigh began to swell up and felt a fever since
one week ago. Then he found many running sores on his back for 4 days, he went into a coma and was
brought to the closest emergency department and was transported in hospital after coming to his sense.
Physical examination: temperature 39 heart rate 100 beats /minute, moist rales were heard in both
lungs. His right thigh was enlarged without obvious eryth and heat. Many running sores were seen on his
back. The hemorrhage spots scattered on the skin.
Laboratory check: peripheral blood white cells 13.2 109/L, the ratio of neutrophil to lymphocyte was 78 :
22.
Course in hospital: The patient received anti-biotic drug therapy and other emergency treatment. But his
state went worse and died at the third morning of admission.
Autopsy data:
Limbs: right thigh was enlarged. A lot of pale yellow brown pus flowed from the abscess located in the
adductor muscles when it was cut. Biopsy was taken from here and the slide be observed by students.
Lung: observed by the students.
Liver: the liver weighted 1100 grams with dark red color.
SpleenThe spleen weighted 170 grams with dark red color.
Kidney: enlarged and dim. The total weight of two kidneys was 220 grams.
Brain: the brain weighted 1380 grams with obvious congestion.
Question:
(1) Please make the pathologic diagnosis for every organ mentioned above and list out the main evidences.
(2) Please state the boys disease procedure (how did the disease develop?)

Case 2 (digital picture)


Clinical data: The patient is a 47-year-old married female. She palpated a lump() in her left breast by
chance 8 months ago .The lump was the same size of a date and without pain, eryth and heat. The patient
paid no attention to it and did not see the doctor. In late two months, the lump gradually grew to bigger
with a size of about goose egg. So the patient went to see the doctor.
Physical examination: A lump was palpated at the out-upper site of the left breast, the lump size was
655cm, solid and hard, fixed on the chest wall. A 333cm round lump was touched in the left armpit
without pain when it was pressed. The patient was in median nutrition state. No special findings were got
when checking the heart and lungs.
Course in hospital: The patient received left mammectomy. The pathologist checked the dissected left
breast both by gross appearance and under microscope. Please observe the slide from the lesion in the
breast of this patient.
Specimens: Please observe the left breast gross specimen and slide obtained from the lump of the left
breast.
Question:
(1) Please make a diagnosis for this case according to the clinical and pathological data.
(2) Please describe the process of growth of the lump.
(3) Which diseases should be differentiated when you receive such a patient?

Case 3
Clinical data: The patient was a 28- year- old female. She was hospitalized because of a week of
palpitation,() accelerated breathing and low extremity puffiness, and a 3-days chilly and fever. The
patient had suffered palpitation, accelerated breathing after physical labor for two years. She neglected it
because it can recover if she had a rest. In the latest week, she took part in the physical labor in water
reservoir before admission, and she felt severe palpitation, accelerated breathing. She often coughed with
foam sputum while working and had an oliguria and a badly sleep. She had received 3 days therapy for
chilly, fever and cough with mucous sputum before admission.
History of past illness The patient had had pulmonary tuberculosis and arthrositis during childhood.
Physical examination: temperature 38.5 , heart rate 130 beats/minute, respire rate 36 /minute, blood
pressure 120/70 mmHg. The patient was normally developed and in her right senses. Her oral lip color
was cyanotic. She had a jugular varicosity. ()Her heart margin protruded toward left between
the third and fourth rib space. ()Her lungs were dullnessand fremitus vocalis()
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exaggerated at apex of heart. Diastolic heart rumbling murmur and lung diffuse dry and moist rales(
) were heard. The low edge of the liver could be clearly touched 4cm below right rib ( -
3cm)with median hard and tenderness.
Laboratory examination
Hemogram: RBC 3.0109/lL, Hb100gram/L, WBC 11109/L, neutrophil 75%, lymphocyte
20%,macrophage 5%, erythrosedimentation30mm/hour, anti-O-hemolysin 600Unit.
liver function test GTP glutamyl transpeptidase 60IU/L total protein 62.5gram/L, albumin
32gram/L, globulin20.5/L.
ElectrocardiographyMyocardium of left atrium strain() and fibrillation. ()
Barium meal perspective: left atrium presses esophagus.
X ray posterior-anterior film show that Left atrium and right ventricle are enlarged. The pulmonary
vascular markings are exaggerated, with scattered focal shadow lesions.
Course in hospitalpenicillin and streptomycin ()were given to control pulmonary inflammation.
And cardiant ()was given to retrieve congestive heart failure. The patients pathologic
condition improved. At the afternoon of ninth day in hospital, the patient got up and suddenly fall down,
convulsion, coma, though emergency treatment was taken immediately but ineffective, the patient was
died.
Autopsy
appearanceoral lip() and nail bed cyanosis
heart: observed by students.
Liver: observed by students.
Pulmonary: cross section is dark red, and pale red liquid flow out when was pressed. Multiple and yellow
lesions diffused on the section.
Brain: Thromboembolism ( )was seen in right middle cerebroartery and ischemic necrosis lesion on
right temporal lobe.
Kidney: congestion, each kidney weight 200 gram.
Lower extremitylight edema.
Abdominal cavityyellow clear liquid 300 ml.
Tonsil: enlarged to about 32cm(chronic tonsillitis)
Question:
(1) What disease of this case is? Please present your evidences of diagnosis.(
- )
(2) How this disease goes on?
(3) What is the reason of this patient death?
(4) What diseases should be differentiated while on the way of finding the correct diagnosis?

Case 4 (digital picture)


Clinic data: the patient is a farmer, a 22-year-old male. 15 days ago he went to the local health center
because of headache and fever and received the therapy as common cold, but the condition was not
improved whereas the headache becomes severe especially in forehead. Five days ago the patient was
admitted in the hospital with ejecting vomiting and sequential numbness of both lower extremities.
Physical examination: T38.5HR 85 /minR 20 /minBP128/86mmHg. General status: The patient
was in poor nutrition, sick and drowsy. The breath sounds of bilateral lungs become coarse without rales.
The cardiac rhythm was regular. Tenderness was present on the whole abdomen without rebound. No
stiff neck() and positive kernig sign existed.
History of past illnessThe patient suffered from tuberculosis at childhood.
Laboratory check: peripheral blood white cells 9.2 10 9/L, the ratio of neutrophil was 59% and the
lymphocyte was 41%. Radiographic findings show a nodular and cloudy shadow in the upper lobe of
right lung.
Course in Hospitalization: antibiotic and symptomatic treatment was adopted, but the effect was not
optimistic because of the aggravated fever and headache. CT and lumbar puncture were advised.
Cerebrospinal fluid: pans test (+), WBC 210 6/L, amylaceum 1.79mmol/L, protein1.08/L, chloridate:
110mmol/L. abnormity was not found in brain CT. At the fifth day in hospital the patient still had a fever
with dysphoria ( )and gradually went into a coma. Finally the breath and heart beating stopped
after urgent consultation ()and salvage.
Autopsy data:
Lungs: Grey yellow nodal and small cavities were observed in the upper lobe of right lung.
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Brain: the gyri ()were flattened, the intervening sulci narrowed. Grey white to yellow exudate()
was present in subarachnoid cavity.( ) There was compression trace on the tonsil of
cerebellum. The brain tissue was swollen() and soft obviously. Microscopically slide will be
observed by the students.
Spleen and kidney: there were many millet() grey-white or grey-yellow nodules. Microscopically there
were caseous necrosis() lined by epithelioid cells, multinucleate giant( ) cells
and infiltrating lymphocyte.
Questions:
1. How many diseases were in your consideration? How to distinguish them? Should any other
examinations be taken?
2. Please make final diagnoses and list evidences for each disease.
3. What is the death cause of the patient?
4. What medical faults exist in this case?

Cerebrospinal fluid
Item Value Normal value
pans test (+), (-) (qualitative test of protein)
WBC 2106/L < 0.01106 /L
amylaceum 1.79mmol/L 3.6-4.5mmol/L
protein 1.08g/L 0.15-0.45g/L
chloridate 110mmol/L 119-129mmol/L

Case 5 (digital picture)


Clinical data: female, 28years old, married. 4 days ago she felt light to mild abdominal pain around the
umbilicus. The abdominal pain gradually shifted to right lower quadrant of the abdomen. At the fourth
day she felt the abdominal pain become severe with fever and diarrhea for 2 times. So she went to see the
doctor and was admitted in the hospital.
Physical examination: The patient was in median nutrition and conscious state. Her temperature was 38.5
heart rate 100 beats /minute, respiratory rate 24time/minute. Abdomen was evenness. Abdominal
palpation: There was no lump at patients abdomen. The liver and spleen were not palpable. Her
abdominal muscle at right lower quadrant was slight tense with obvious tenderness and rebound
tenderness. ()At the McBurney point, ()the symptoms mentioned above
were heavier. Rovsings sign() was positive. No abdominal shifting dullness was touched(
). Auscult: Hypoactive bowel sounds.
Laboratory check: peripheral blood white cells 12 109/L, the ratio of neutrophil to lymphocyte was 82 :
18; RBC 4.5109/L, Hb130g/L. Urine routine was normal. Stool routine was normal and occult
blood-.
Clinical diagnosis: acute appendicitis ()
Course in hospital: The patient received appendectomy soon. What be seen in operation: the appendix
located in the right pelvic cavity with 20ml purulent fluid ( )in the cavity. The size of appendix was
6cm long and 1cm diameter. Some yellow white fibroid membrane covered on the serosal surface.
Perforation could be seen at the distal end of the appendix.
Biopsy data:
Please observe the excisional appendix and slide from it carefully. Make some notes on your notebook.
Question:
1. Please make a precise diagnosis for this patients disease, give out the evidence to support your
diagnosis.
2. What diseases should be included in your thought before you make up the ultimate diagnosis?
3. How do you distinguish and exclude these diseases?
(Hint: in right lower quadrant of the abdomen, what organs are there?)

Case 6
teaching aim
Clinic data A 36-year-old man, who was a long-distance coach driver, complained with fever, malaise,
headache, diarrhea and abdominal pain for several days. He was received in hospital. The doctor found
that he had a hyperpyrexia with relative bradycardia.
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History of past illness: no significant past medical history
Personal history: He had no travel history to a malarial endemic area, and not contact with soil water. He
consumed alcoholic beverages only for social intercourse and denied any recent binges. He did not take
any medication including antibiotics before admission and denied blood transfusions, promiscuity or
intravenous drug abuse.

Physical Examination: The patient shown fatigue appearance with mild dehydration. The temperature was
40 and continued for whole day, the pulse was 85 times per minute. There was tender firm
hepatomegaly with moderately enlarged soft spleen. some rose-rash appearing on his chest without
pruritusno evidence of encephalopathy was found. No lymphadenopathy was detected. Respiratory
examination was normal.

Laboratory test: Full blood count showed a borderline leucopenia - 4.8 109/L with 51% neutrophils and
44% lymphocytes. The platelet count was 175 109/L and never dropped significantly throughout his
hospital stay. The initial ESR was 35 mm/h and the CRP was elevated 96 mg/L. The liver biochemistry
showed normal albumin levels with elevation of AST and ALT which were 120 units/L and 240 units/L
respectively. The serum electrolytes and renal function were within normal limits.

Blood culture, urine culture, serology studies for viral hepatitis, leptospirosis and dengue were dispatched.
The leptospira microscopic agglutination test was equivocal and hepatitis serology was negative for
Hepatitis A, B and C.

Image examination: The ultrasound scan of the abdomen showed an enlarged liver at 17.5 cm with a
coarse echo pattern. The intra and extra-hepatic bile ducts were not dilated, no calculi was visualized.
There was splenomegaly at 15.5 cm. The patient refused to give consent for a percutaneous liver biopsy.

Therapy: he was empirically treated with IV penicillin as leptospirosis was endemic in the region despite
the negative test.

Questions

1. Please make diagnosis for the patient depending on documents mentioned above.

2. How many diseases should be included in the differentiation diagnosis? Could you exclude these
diseases according to the data offered in the case?

Case 7 (digital picture)


Clinical data: The patient was a 45 years old male who taught in element school. He was admitted for
poorly appetite and haematemesis twice. In the past 5 months, he began to feel fatigued and abdominal
distention, diarrhea and bloody stools occasionally were seen. In the latest one month he began to feel
abdominal pain especially on right upper abdomen. Gradually, he became emaciation and his urine became
decreased and yellow.
History of past illness: T he patient had infective hepatitis 3 years ago, he thought that he had recovered.
Physical examination: temperature 37pulse 90/minute, blood pressure 116/80mmHg. The patient was
poorly nourished and depressed. His skin and cornea opaca were not yellow. There was a spider
telangiectasia on the left skin in front of the chest. Superficial absorbent gland could not be touched. No
positive sign in heart and lung. Abdominal distension and superior belly wall vein was seen with shifting
dullness. The borderline of liver was between the right third rib and 4cm below right rib. The liver was hard
with unsmooth surface. The spleen was located at 6cm blow left rib.
Laboratory examination:
Hemogram : RBC 3.5109/L, Hb115g/LWBC8.5109/L(N70%L20%M8%E2%).
Urine: yellow and clearing, protein (-), WBC1-2/ high power.
Stool: furvous, occult blood (+).
Abdominal fluid: green-yellow color, specific gravity 1.011, Rivalta test (+). Total cells 90106/L.
Liver function test: bilirubin total 30umol/L, bilirubin direct 5.2umol/L, hemobilirubin 24.8umol/L,
AFP(+), total protein 65.7g/L, albumin 22.1g/L, globulin 43.6g/L. Electrophoresis(filter paper): albumin
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43.4%, 1globulin 7%2 globulin 11.7%globulin 11.8%globulin 26.1%.
X ray: many round shadows scattered in the lung field.
Course in hospital: the patient was given flowing treatments: non per os; transfusion; haemostat and aid to
liver. Hemorrhage (by mouth and stool) was stopped gradually. By the tenth afternoon, at 5 oclock, the
patient suddenly complained that right abdomen agonia, nausea. His face turned to pale, acrotism, blood
pressure descend. Emergence salvage was ineffective, the patient died soon.
Autopsy:
Liver: observed by students (gross and slide)
Lung: there were many round or orbicular-ovate solid lesions on the cross section.
Spleen: enlarged and congestion (600 gram in weight)
Esophagus: the mucous membrane edema, varices was seen at its lower segment.
Abdominal cavity: bloody ascites 4500ml.
Question:
(1) What disease did this patient suffer from?
(2) How many pathologic changes occur in this patients body? Can you find the relations between these
pathologic changes?
(3) Please explain the clinical manifestation with pathologic changes?

Case8 (digital picture)


Clinical data: male, 53 years old, married. The patient complained repeatedly right upper abdominal pain
for 2 years and the pain became severe to be not tolerated. He was admitted in the hospital at September
16th, 2007.
Physical examination: general station: The patient was in median nutrition and conscious state. No yellow
was seen on the patients skin and mucosa. His temperature was 37.0 heart rate 80 beats /minute,
respiratory rate 20 time/minute. Special station: the patients abdomen was evenness and soft. No
subcutaneous varicos vein of abdominal wall was seen. No lump was palpated on patients abdomen. The
liver and spleen were not touched below the rib. The upper boundary of liver was at right sixth fib. The
tenderness existed on the right upper abdomen without rebound tenderness. Mophys syndrom (+). No
abdominal shifting dullness was touched. There were no sensitive to percussion on bilateral renal region.
Bowel sounds 4 times / minute and no vascular murmur was found by auscult.
history of past illnessThe patient suffered from cholelithiasis for many years and negated hepatitis,
post-operation blood infusion, hypertension and heart disease.
personal historyThe patient was local native, negated having been in epidemic area of schistosome and
touching toxin.
Laboratory check before opration(16th, September): peripheral blood white cells 7.3109/L, neutrophil
3.8109/L , lymphocyte 3109/L , nertrophil percentage was 51.3%. RBC 5.081012/L, HGB144g/L,
HCThematocrit44.7%. Urine routine: WBC 0/ul, prorein 0g/L, bilirubin -urorubin was
normal. Stool routine was normal and occult blood-. Blood biochemistry: show in the table.
Pathogen test: HBs-AG(-),HBs-AB(+), HBe-AG(-), HBe-AB(-), HBc-AB(-), HC-AB(-), HIV(-),
syphilis-AB preliminary screening-.
MRCP: choledocholithiasis (magnetic resonance cholangiopancreatography)
Clinical diagnosis: 1. Cholelithiasis
2. Choledocholithiasis
Course in hospital: At the fourth day of admitted, the patient received the operation (cholecystectomy +
choledocholithotomy + T-Tube Drain). What be seen in operation: the cholecyst was 74cm, congestion
and edema, there were over 10 pieces calculus in the cholecyst. The calcules was about 0.8040.4cm..
The diameter of bile commen duct was 1.2 cm, in the lumen of the duct several calculi were seen. The
doctor resected the cholecyst and pick out the calculi from the bile commen duct, laid a T-tube in the
operation site.
Laboratory check after operation (22th, September): peripheral blood white cells 10.8 109/L,
neutrophil 8.4109/L , lymphocyte 1.8109/L , neutrophil percentage was 77.3%. RBC 4.861012/L,
HGB141g/L, HCThematocrit43.5%. Blood biochemistry: show in the table.

Items
Date 17-9 22-9 24-9 Normal Chinese name
ALT 411 157 97 5-46 U/L alanine aminotransferase

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AST 409 61 29 8-46 U/L aspartate aminotransferase
GGT 204 159 123 5-54 U/L -glutamyltransferase-
TBA 43.69 0.06 0-10 umol/L total bile acid
TB 63.9 34.5 13.7 0-6 umol/L total bilirubin
UDB 19.3 8.8 5 0-6 umol/L direct bilirubin
IBI 44.6 25.7 8.7 1.7-17 umol/L indirect bilirubin
TPm 60 56.1 55.8 60-80 g/L total protein
ALB 38.4 31.4 31.3 35-55 g/L Albumin
GLB 21.7 24.7 24.5 20-35 g/L Globulin
A/G 1.77 1.27 1.28 1.09-2.5

Biopsy data:
Please observe the removed cholecyst and the slide from the operation carefully. Make some notes on
your notebook.
Question:
(1) Please make diagnosis for this patient depend upon both clinical and pathologic data.
(2) How does the calculus form in the cholecyst and bile commen duct?
(3) Has the patient had jaundice? Which kind of jaundice it is? How do you distinguish hepatic and
obstructive jaundice? It is better if you list the differentiating points in table form.

Normal field of part of medical test


items Subitems Normal field
Blood routine WBC (white blood cell) 4-10 109/L
Neutrophil 2-7109/L
Lymphocyte 2-4109/L
Neutrophil % 50-70 %
Lymphocyte % 20-40 %
RBC 4-51012/L
HGB (Hemoglobin) 120-160g/L
HCT (haematocrit) 40-50 %
Urine routine WBC 0/ul
Protein 0/L
Bilirubin negative
Urorubin negative
Stool routine

Case 9 (A) (digital picture)


Clinical data: A female patient, 25 years old, unmarried, Han nation, student, Hainan native.
Present Illness: The patient had hyperhidrosis, palpitation, polyphagia, and fatigue and no significant
mitigation =relieve after rest for half a year. She had no chill, fever, oppressed feeling in chest,
dyspnia. She went to the hospital and received treatment of PTU. Her symptoms abated =relieve by
PTU but recurred after suspension of the drug for several time. So she went to see doctor again and was
admitted on August 11th, 2007. Since onset, her weight dropped 5 kilogram, she slept well, her
defecationand urinationare normal.
Past history: the patient denied hypertension, heart disease and tuberculosis. She had no history of surgery,
trauma, transfusion, allergy to any food and drug.
Personal history: No history of contact with infected areas and contaminated water. No special hobbies.
Menstrual History: Her menarche was in 14 years old, 28 days of menstrual cycle in that the menstrual
periodwas 4-5days with dysmenorrhea. Her last menstrual period (LMP) was on 25 th, July, 2007.
Family History: no family member has the same diseases. No history of family genetic diseases.
Physical ExaminationT37HR 80 /minR 20 /minBP110/84mmHg. She is well developed and
in well conscious state and active position. Her skin was moist. Superficial lymph nodes were not
palpable. Her heart, lung and abdomen are normal. Her spine and limbs are normal. Her genitourinary

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system was not examined. Neural reflexes existed. Neck: Trachea was in midline, thyroid was diffusely
enlarged (), soft, mobile, nontender, but vascular murmur could be heard , regional node were not
palpable, fine tremor could be seen when she lifted evenly her hands.
Laboratory Data:
(1) Tests of Thyroid function:
Testing time Item value Unit normal Reference
2007.3.5. TSH 0.04 mIU/L 0.3-5.0
FT3 9.34 pmol/L 3.8-6
FT4 26.3 pmol/L 7.5-21.1
2007.7.23. TSH 0.07 mIU/L 0.3-5.0
FT3 4.92 pmol/L 3.8-6
FT4 6.87 pmol/L 7.5-21.1
TMAb* 37.5 % 0-15
TGAb* 71.7 % 0-30
TotT3 1.66 nmol/L 1.34-2.73
TotT4 89.35 nmol/L 78.38-157.4
RT3 0.49 nmol/L 0.46-1.05
*TMAb [][=thyroid microsomal antibody] TGAb [][=thyroglobulin antibody]
T3: Triiodothyronine T4: tetraiodothyronine RT3: Resin T3
(2) Blood routine: WBC 8.3109/L, MC 0.7109/L LC 3.4109/L, N:4.2109/LWBC%: LC40.9%,
MC: 9.6%N50%PLC303109/LMPV 9.4fLRBC 4.61012/L,HGB131g/L.
(3) Blood biochemistry: Normal. Stool and Urine routine: Normal.
EKGNormal.
X-ray: The heart and lung were normal.
Course in Hospitalization: The patient accepted the resection of most of thyroid on August 18, 2007.
What was seen in operation: Bilateral thyroids diffuse enlarge to the medial margin of sternocleidomastoid
muscle but not press the trachea, moderate hardness. Regional nodes were not palpated. After operation
her symptoms abated. She stopped taking the drug and was discharged on 8-24-2007.

Case 9 (B) (digital picture)


Clinical data: A male patient, 49years old, Haikou native, occupation: Cadres, Han nation.
Present Illness: The patient touched a painless lump like a soybean in size at his right front of the neck a
week ago. The size of tumor was not increased in the past week. He had no chill, fever, cough,
expectoration, polyphagia, exophthalmos, palpitation, insomnia, hyperhidrosis, and hand-foot-trembling.
His diet, sleep, defecation and urination are normal. His weight did not significantly drop. Attendance to
the hospital, CDFI (Color Doppler Flow Imaging) of thyroid showed Parathyroid adenoma, so he was
admitted in the hospital on 8-17-2007.
Past history: the patient denied the history of hepatitis, tuberculosis, hypertension, coronary heart disease
and diabetes. He had no allergy history to any food and drug, no history of surgery, trauma and
transfusion. The history of vaccination is unclear.
Personal history: No history of living out of hometown. No history of contact with infected areas and
infective water. No special life hobbies.
Family History: No history of family genetic diseases.
Physical Examination T 36.8CP76/minR 28/minBP 120/80mmHg. The patient was well built
and in consciousness and active position. His skin was normal. His heart, lung and abdomen were normal.
His spinal and limbs were normal and neural reflexes were present. Superficial lymph nodes were not
palpable. Neck: Trachea was in midline of his neck. A number of painless and mobile nodules could be
palpated on the right lobe of thyroid. Among that the biggest nodule was about 32cm and hard in
consistency. The realm of nodules is clear. The nodules move on swallowing. A number of smaller nodules
could also be palpated on the left lobe of thyroid. Vascular murmur could not be heard.
Laboratory Data:
(1) Tests of Thyroid function:
Item value Unit Normal parameter

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TSH 1.13 mIU/L 0.3-5.0
FT3 4.59 pmol/L 3.8-6
FT4 11.05 pmol/L 7.5-21.1
TMAb 2.9 % 0-15
TGAb 4.5 % 0-30
TotT3 1.88 nmol/L 1.34-2.73
TotT4 109.95 nmol/L 78.38-157.4
RT3 0.8 nmol/L 0.46-1.05

(2) Blood routine: WBC number: total WBC 6.410 9/L, among that LC 2.310 9/L, MC 0.4 109/L, N
3.7 109/L; WBC percent: LC 35.6%, MC:6.6%, N 57.8% ; RBC 5.2310 12 /L HGB 151g/LPLT
238109/L.
(3) Blood biochemistry: Normal. Urine routine and stool routine: Normal.
(4) Inspection of Pathogens: HBsAg-, HBsAb+, HBeAg-, HBeAb+, HBcAb-, HCAb-, HIV-,
SyphilisAb-.
EKG: Normal.
X-ray: The heart and lung were normal.
Color ultrasound check to thyroid: The thyroid enlarged asymmetrically, the right lobe of thyroid
enlarged more significantly. The size of the right lobe was about 523629mm, while the size of the left
lobe was about 441617mm. The thickness of isthmus of thyroid is about 4mm.The thyroid capsule was
smooth. Two solid hypoechoic nodules were seen in the left lobe of thyroid, their size were 8 7mm and
76mm respectively, the borders of these nodules were clear and regular. The echo in these nodules was
uneven. CDFI showed no abnormal color flow signal in the nodules. An oval-shaped mixed mass was
seen in the right lobe of thyroid, the size of mass was about 3830mm with a clear border, the distribution
of echo in which was uneven, many strong points of echo can be seen on it. The echo from the part of
thyroid parenchyma out of those nodules was even.
Course in hospitalization: The patient underwent the resection of part of thyroid under general anesthesia
status on August 20, 2007. The part of resection of the right lobe of the thyroid was 5 3 2 cm 3, the left
was 1.3 1 0.5cm3. Surgical incision healed well after the operation. He was discharged on August 27,
2007.
Biopsy data:
Please carefully observe the excisional specimens from two patients respectively. Pay special attention
to the differences between two cases at both gross and histological morphology. Make some notes on your
notebook. That will be helpful in your diagnosis.

Questions:
1. According to clinical and laboratory data, the observation of surgical specimens, what are your diagnosis
for two patients? Please list the basis of diagnosis. Has there any clinical feature not supporting your
diagnosis in each case?
2. In the process of diagnosis, what diseases should be distinguished with?

Case 10
Clinical data: A male patient, 58 years old, worker, Hainan native. The patient had left dull ahce in the loin
without any obvious cause for 4 months. The pain did not radiate to anywhere. He had no nausea and
vomiting, no chills and fever, no frequent or urgent micturition. He is well conscious. His appetite, sleep,
stool and urine were normal. In other hospital, he was diagnosed by USG (ultrasound graphy): Left upper
ureter single stone/calculus; Right renal multiple stone. He was given ESWLextracorporeal shock-wave
lithotripsy treatment in other hospital, but there is no any stones discharged. He came to our hospital for
further treatment and was admitted in hospital on 18th, March, 2007.
Past history: the patient denied hypertension, diabetes, heart disease, hepatitis, tuberculosis but have
chronic gastric peptic ulcer.
Personal history: the patient born and live in hometown without long term leaving and contacting
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infective water.
Family history: No similar disease was found in his family.
Personal hobby: The patient consumed a packet of cigarettes and 100g alcohol daily.
Physical Examination T 36.8HR 80/minR 20/minBP 130/85mmHgThe patient was well
built and in conscious state with active position. His abdomen was flat and soft, no mass was palpated and
no shifting dullness was found by percussion. His liver and spleen could not be palpated No bulge was
observed over kidney area where no tender and sensitive to percussion were examined. The area of ureter
was normal and no tenderness. The area of bladder not expanded. His external genital organs, anal, spine
and extremities are normal. The nerve reflexes were normal.
Color ultrasonography Check to kidney: Left kidney was 18585mm with enlarged pelvic (about 78mm
in width)and cortex was very thin z(normal: 8mm), no strong echo was detected in kidney (normal kidney
size: 10-125-63.5cm). The upper part of the left ureter was enlarged, about 13mm in diameter (normal
4-5mm, nearly cannot be seen). A strong echo mass about 1710mm with shadow was detected at the site
far from 35mm of pelvis outlet. The right kidney was normal in shape and size (2150mm) with smooth
capsule. The cortex layer was 10mm, no obvious enlargement was observed in pelvis. many strong echo
masses were observed in upper, middle and lower renal calices with shadow, in which the biggest one was
96mm. The right ureter was not enlarged. The bladder wall was smooth and no feeling defect, no
abnormal echo mass was observed. Color Doppler showed that blood stream signals were rare in left
kidney while abundance and in branches shape in right kidney.
X ray check: shape
Plain film: Left kidney was obviously enlarged. A 1.5x1cm hyperdense shadow was observed at forth
lumber vertebrae in left side. No obvious lesion was observed in other ureter passage.
Excretory urogram: The photos of urinary system were taken after injection of contrast agent 15min
and 20min.The visualization of right kidney and ureter were good but left could not be seen. The bladder
was filled well without any filling defect sign.
Chest film: The aorta was tortuous. The heart and lungs were normal.
Laboratory finding:
Blood routine: WBC number: total WBC 6.210 9 /L lymphocyte 2.2109 /L intermedial cell
0.8109 /L neutrophile 3.2109 /L. WBC percent: lymphocyte 36.01% intermedial cell
12.2% N51.7% RBC 5.111012/L HGB161g/L, PLT210109/L; HCT(hematocrit) 48.6%,
MCV(mean cell volume)95.3fL, MCH(mean corpuscular hemoglobin)31.5pg/.
Stool routine: normal. Urine routine: yellow, clear, WBC-, Glu-, specific gravity=1.030.
Inspection of pathogens : HBsAg +HbsAb -HBeAg -HBeAb + HBcAb +HCAb - HIV
-Syphilis Ab -.
Blood biochemistry:
Item Value Unit Normal parameter Chinese item
K 4.81 mmol/L 3.5-5.4 potassium
Na 142.4 mmol/L 135-148 natrium
Cl 102 mmol/L 96-106 chloride
Ca 2.35 mmol/L 2.2-2.8 calcium
BuNm 6.3 mmol/L 1.78-7.14 Urea nitrogen
CO2CP 26.9 mmol/L 22-27 carbon dioxide combining power
CREm 107.1 umol/L 44-133 creatinine
URIC 356 umol/L 90-420 acidum uricum
BUN/Cr 0.05 umol/L Urea nitrogen / creatinine /
Glu 4.6 mmol/L 3.89-6.11 Glucose
ALT 3.2 U/L 5-46 alanine aminotransferase
AST 26 U/L 8-46 aspartate aminotransferase
AST/ALT 0.81
GGT 26 U/L 5-54 -glutamyltransferase-
ALP 89 U/L 35-134 aspartate aminotransferase
UCHE 16016 IU/L 5400-13200 pseudocholine esterase
UTBA 0.1 umol 0-2 total bile acid
TPm 69.3 g/L 60-80 total protein
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ALBm 35.1 g/L 35-55 Albumin
GLB 34.2 g/L 20-35 Globulin
A/G 1.03 1.09-2.5
TB 17.6 Umol/L 1.7-20 total bilirubin
UDB 5.0 umol/L 0-6 direct bilirubin
lBI 12.6 umol/L 1.7-17 indirect bilirubin
PABI 247.35 mg/L 170-420 Prealbumin
AG 13.5 mmol/L 10-14 Anion gap
OSM 276.37 mosm 280-320 Osmole ,
Mmol: millimol(e) mosm: ['mzm] milliosmol
Umol: ['ju:ml] U: unit IU: international unit
Course in hospitalization: The patient received the left nephrectomy by posterior belly abdominoscope.
An incisional drainage tube was set. What was seen in operation: left kidney enlarged like a water sac
with 600ml hydrops, the renal parenchyma is very thin. The drainage tube was taken out on 23 th, March,
2007. The operative incision dermal sutures out was taken on 27th, March, 2007. Wound healing was
good. The patient was discharged on 29th, March, 2007.
Biopsy data:
Please observe the removed kidney and the slide from it carefully. Make some notes on your notebook.
Questions:
1. How did the renal calculi develop? Where dose (do) the renal calculi frequently occur?
2. What consequences can the renal calculi cause? Which among that occurred in this patient? (Clue:
please infer according what you see on the macro and micro biopsy specimen)
3. What diseases should be differentiated from renal calculi?

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