diff --git a/api/controller/CaseItem.go b/api/controller/CaseItem.go
index 3753e71..1698635 100644
--- a/api/controller/CaseItem.go
+++ b/api/controller/CaseItem.go
@@ -7,6 +7,7 @@ import (
 	"case-admin-api/api/responses"
 	"case-admin-api/global"
 	"case-admin-api/utils"
+	"fmt"
 	"github.com/gin-gonic/gin"
 	"strconv"
 )
@@ -288,52 +289,83 @@ func (b *CaseItem) PutCaseItem(c *gin.Context) {
 		return
 	}
 
+	// 检测问题情况
+	var deleteCaseItemQuestions []*model.CaseItemQuestion
+	var addCaseItemQuestions []*requests.CaseItemQuestion
+
+	for _, itemQuestion := range req.CaseItemQuestion {
+		if itemQuestion.QuestionId == "" {
+			addCaseItemQuestions = append(addCaseItemQuestions, itemQuestion)
+		}
+	}
+
+	for _, question := range caseItemQuestions {
+		isExist := false
+		for _, itemQuestion := range req.CaseItemQuestion {
+			if itemQuestion.QuestionId == "" {
+				continue
+			}
+
+			if itemQuestion.QuestionId == fmt.Sprintf("%d", question.QuestionId) {
+				isExist = true
+				break
+			}
+		}
+
+		// 如果没有找到匹配项，则需要删除
+		if !isExist {
+			deleteCaseItemQuestions = append(deleteCaseItemQuestions, question)
+		}
+	}
+
 	statCaseQuestionDao := dao.StatCaseQuestionDao{}
 	caseUserAnswerDao := dao.CaseUserAnswerDao{}
-	for _, question := range caseItemQuestions {
-		if question.QuestionType == 1 || question.QuestionType == 2 || question.QuestionType == 4 {
-			// 删除对应答题记录
+	if len(deleteCaseItemQuestions) > 0 {
+		for _, question := range deleteCaseItemQuestions {
+			if question.QuestionType == 1 || question.QuestionType == 2 || question.QuestionType == 4 {
+				// 删除对应答题记录
+				maps = make(map[string]interface{})
+				maps["question_id"] = question.QuestionId
+				err := statCaseQuestionDao.DeleteStatCaseQuestion(tx, maps)
+				if err != nil {
+					tx.Rollback()
+					responses.FailWithMessage("操作失败", c)
+					return
+				}
+
+				// 删除问题选项
+				maps = make(map[string]interface{})
+				maps["question_id"] = question.QuestionId
+				err = caseItemQuestionOptionDao.DeleteCaseItemQuestionOption(tx, maps)
+				if err != nil {
+					tx.Rollback()
+					responses.FailWithMessage("操作失败", c)
+					return
+				}
+			}
+
+			// 删除用户答题记录
 			maps = make(map[string]interface{})
 			maps["question_id"] = question.QuestionId
-			err := statCaseQuestionDao.DeleteStatCaseQuestion(tx, maps)
+			err := caseUserAnswerDao.DeleteCaseUserAnswer(tx, maps)
 			if err != nil {
 				tx.Rollback()
 				responses.FailWithMessage("操作失败", c)
 				return
 			}
 
-			// 删除问题选项
-			maps = make(map[string]interface{})
-			maps["question_id"] = question.QuestionId
-			err = caseItemQuestionOptionDao.DeleteCaseItemQuestionOption(tx, maps)
+			// 删除问题
+			err = caseItemQuestionDao.DeleteCaseItemQuestionById(tx, question.QuestionId)
 			if err != nil {
 				tx.Rollback()
 				responses.FailWithMessage("操作失败", c)
 				return
 			}
 		}
-
-		// 删除用户答题记录
-		maps = make(map[string]interface{})
-		maps["question_id"] = question.QuestionId
-		err := caseUserAnswerDao.DeleteCaseUserAnswer(tx, maps)
-		if err != nil {
-			tx.Rollback()
-			responses.FailWithMessage("操作失败", c)
-			return
-		}
-
-		// 删除问题
-		err = caseItemQuestionDao.DeleteCaseItemQuestionById(tx, question.QuestionId)
-		if err != nil {
-			tx.Rollback()
-			responses.FailWithMessage("操作失败", c)
-			return
-		}
 	}
 
 	// 新增病例题目
-	if len(req.CaseItemQuestion) > 0 {
+	if len(addCaseItemQuestions) > 0 {
 		for _, question := range req.CaseItemQuestion {
 			caseItemQuestion := &model.CaseItemQuestion{
 				CaseId:         caseItem.CaseId,
diff --git a/api/requests/CaseItem.go b/api/requests/CaseItem.go
index 31b390e..c5e39f1 100644
--- a/api/requests/CaseItem.go
+++ b/api/requests/CaseItem.go
@@ -16,6 +16,7 @@ type AddCaseItem struct {
 
 // CaseItemQuestion 病历表-明细-题目
 type CaseItemQuestion struct {
+	QuestionId             string                    `json:"question_id" form:"question_id" label:"题目标识"`
 	QuestionName           string                    `json:"question_name" form:"question_name" label:"题目名称" validate:"required"`
 	QuestionType           int                       `json:"question_type" form:"question_type" label:"题目类型" validate:"required,oneof=1 2 3 4"`
 	QuestionAnswer         string                    `json:"question_answer" form:"question_answer" label:"答案"`