The secret of the doctor’s diagnosis

When it comes to the diagnosis of diseases, tumors are obviously more complicated than other diseases. Many diseases can be diagnosed by clinical consultation and laboratory or imaging examination, but for tumors, the clinical diagnosis refers to the classification and identification of etiology and pathogenesis according to the patient’s chief complaint, combined with its symptoms, signs, subjective feelings and medical history.

physical examination is a local examination of key organs combined with medical history. Physical examination is mainly aimed at superficial tumors because they are easy to reach, while deep tumors can only be determined by other necessary examinations. During physical examination, doctors will focus on the location, shape, hardness, activity of the tumor and its relationship with surrounding tissues, and carry out regional superficial lymph node examination.

the significance of the above-mentioned clinical diagnosis is that the doctor can have a general judgment on the patient’s condition, which is also convenient for further examination. At this time, the diagnosis can not be made.
for example, physical and chemical examination.

physical and chemical diagnosis is gradually approaching the truth, but still can not be used as a basis for the diagnosis of tumors. Although there are some differences between benign and malignant tumors in imaging performance, the specificity is not significant enough to identify according to photos, and this diagnosis is also closely related to subjective factors such as doctor’s experience and state. As for tumor markers, it is only an auxiliary means for the diagnosis of tumors. Affected by many factors, the false negative and false positive rate is not low, so it can not be used as a means to diagnose tumors.

according to the color and shape of the tumor seen during the operation, experienced doctors can have a more confident understanding and judgment on the benign and malignant tumors. However, after all, nothing seen by the naked eye can not be used as the basis for diagnosis, and there may still be a big gap between it and the truth of the fact.

cytopathological diagnosis is based on the examination of various exfoliated cells and puncture cells. For example, TCT examination of the cervix is to collect exfoliated cells from the cervix by scratching, and then make pathological examination to determine whether there are cancer cells or precancerous lesions; for example, sputum cell examination is to find out whether there are exfoliated cancer cells in the sputum of patients, so as to assist in the diagnosis of lung cancer.

histopathological diagnosis is to obtain tumor tissue by forceps, puncture, cutting and other methods, fix staining, and carry out histological diagnosis under microscope for tumor tissue or living body. If the microscopic features are not clear, it should be combined with immunohistochemical method for identification.

pathological diagnosis is usually regarded as the gold standard of tumor diagnosis and the final diagnosis of tumor. If there is a conflict between clinical diagnosis and pathological diagnosis, pathological diagnosis shall prevail.

as mentioned above, in the diagnosis of tumors, the reliability of the five levels increases in turn, and the fifth level is the most ideal and accurate, with the highest authority and reliability.

Sometimes, because of the particularity of tumor growth site, it is difficult to obtain pathological tissue. In this case, clinical diagnosis, physical and chemical diagnosis can also be used as the final diagnosis basis. Common cases such as pancreatic cancer, because the location is deep, and the upper, lower, left and right are covered by gastrointestinal and other organs, so it is difficult to get tumor tissue through the body surface when surgical treatment has been lost. In this case, clinical symptoms, imaging examination combined with tumor markers can also be used as the basis for diagnosis.

in some cases, even if a pathological diagnosis is made, it is impossible to determine the nature of the disease with 100% accuracy. Because histopathological diagnosis is also man-made, but also has its subjective and objective limitations. At this time, expert consultation or pathological examination is needed.

“the patient is a 53 year old female, married and retired worker. The patient was admitted to the hospital because of painless mass in the left breast for more than 5 months. Since the beginning of January this year, the patient accidentally found a broad bean sized lump in the left breast when taking a bath, which was painless, movable and progressive. Once in the outside hospital, Chinese and Western medicine treatment was ineffective, the mass increased significantly. There was no history of trauma, nipple discharge and obvious weight loss. Admission examination: general condition is good. There was no yellow stain in the skin and sclera. No abnormality was found in heart, lung and abdomen. There was no abnormality in the right breast. The left breast was slightly larger than the right breast, and the nipple was inclined to the upper and outer quadrant. There was a slight “orange peel like” change in the upper outer quadrant. A mass of 5 × 4 × 4cm was palpable. The mass was hard, the surface was not smooth, the boundary was not clear, adhesion with the skin, poor movement, no tenderness. Three enlarged lymph nodes can be palpable in the left armpit. They are hard, no tenderness, no adhesion and fusion, and the movement is fair. The surface is not smooth and the boundary is not clear.

examination: the general condition was ok, and no abnormality was found in heart, lung and abdomen. B-ultrasound and molybdenum target X-ray showed that “the mass in the upper quadrant of left mammary gland has a high possibility of malignant transformation”.

according to the medical history, physical signs and auxiliary examination results, we found that the patient had the following characteristics: middle-aged woman; painless mass in the left breast increased progressively for more than 5 months; the diameter of the mass was 5 × 4 × 4cm; the surface skin of the mass showed “orange peel like” changes, which were hard, not smooth, unclear boundary, and adhered to the skin; the left nipple was elevated, The volume was slightly larger than that on the right side; B-ultrasound and molybdenum target film showed that the mass in the upper quadrant of left breast was more likely to become malignant. Therefore, the diagnosis of left breast cancer should be considered.

1. It is common in young women and rarely occurs in postmenopausal women. The tumor has no adhesion with skin and surrounding tissues, easy to push, slow growth, and no change for many years. It was not consistent with the signs of the patient.

2. Intraductal papilloma. This disease is more common in middle-aged women, after gently pressing the breast, the nipple has bloody liquid overflow, generally can not touch the mass, there is the possibility of canceration. This patient has no history of nipple discharge and does not support this diagnosis.

3. Cystic hyperplasia of breast. It is often seen in 25-40 years old women in menstrual period, and the breast has distending pain before menstruation. The masses were nodular in size, tough but not hard in nature, without adhesion with skin and deep tissues. The patient’s condition is not supported.

4. Breast tuberculosis is relatively rare, and early breast cancer is not easy to distinguish. It can be confirmed by puncture pathology. From the patient’s medical history and physical examination results, there is no basis for the diagnosis of the disease.

5. It often occurs in hypertrophic breast, more than a few days after contusion, and trauma history may not be able to ask. After repeated questioning, the patient had no history of trauma, so the diagnosis was not considered.

operation process: in supine position, the left shoulder is raised about 15cm, the left upper limb abduction is about 90 ° and about 5cm away from the normal skin of the tumor edge. First, draw a fusiform incision with METHYLVIOLET, with the upper end between the pectoralis major and the clavicle, and the lower end to the lower edge of rib arch. 2.5% iodine tincture and 75% ethanol were used to disinfect the skin of chest and right big leg routinely, and the disinfection towel sheet was spread. A radial incision, about 6cm long, was made on the mass in the upper quadrant of the left mammary gland. The skin and subcutaneous tissue were incised. The tumor was completely removed by electric knife and sent to frozen section for examination.

pathological report: invasive ductal carcinoma of the left breast, located in the outer upper quadrant of the breast, with a size of 5x4x4cm and local lymph node metastasis of 2 / 5.

in a word, the diagnosis of tumor is a very serious and complicated matter, and there is no room for ambiguity, because it is the beginning and basis of disease treatment, and it is a major event related to the health and even life of patients. Once diagnosed with malignant tumor, the focus of life of patients and their families is bound to shift, and they may face a completely different life path.

in addition, we always advocate early diagnosis and early treatment. The earlier the diagnosis, the better the treatment effect and the better prognosis. We call for early diagnosis and treatment of cancer. Small habits of pregnancy not only affect the health of pregnant mother, but also delay the development of the fetus, don’t ignore