I can see the status bar

Chapter 1125
Healthy adults are not susceptible to tuberculosis.On the one hand, most of them have been vaccinated with BCG and have immunity to tuberculosis to a certain extent.Tuberculosis itself, on the other hand, is not a very aggressive disease.

People who are in close contact with TB patients, such as children, the elderly, and people with weakened immunity are relatively susceptible to TB.And Ding Huiguo's own Crohn's disease would have too much impact on his immune system-his immune system is attacking the body, not the other way around.

However, in order to treat Crohn's disease, the immunosuppressive treatment doctors used on Ding Huiguo directly led to his low immune level.With such a level of immunity, his risk of contracting tuberculosis rose rapidly.

So, there are three problems facing Sun Lien now - to determine whether Ding Huiguo is still infected with tuberculosis, to determine whether the diagnosis of Crohn's disease is correct, and to choose a more suitable treatment between anti-tuberculosis treatment and Crohn's disease treatment The item about Ding Huiguo's situation.

How troublesome the diagnosis of tuberculosis is... Sun Lien kept it in mind.Anyway, looking at the diagnosis guide again, it is difficult for him to immediately determine whether Ding Huiguo has tuberculosis. Anyway, the status bar is very bad and there is no direct prompt, and it also specially writes "intestinal inflammatory reaction (1482.31.25)" state.

Intestinal inflammatory response can be aseptic inflammation caused by the immune system attacking the intestine, or it can be the result of intestinal tuberculosis formed after tuberculosis invades the intestine.To make matters worse, Crohn's disease is one of the most difficult diseases to differentiate from intestinal tuberculosis.About 17.9% of patients with Crohn's disease had been misdiagnosed as intestinal tuberculosis, and more than 10% of patients with intestinal tuberculosis had been misdiagnosed as Crohn's disease.

In this situation, it seems meaningless to conduct another tuberculosis test on Ding Huiguo - after all, tuberculosis can still be diagnosed after multiple negative tests.But once a patient has TB, the TB that is out of immune system control is likely to progress rapidly and eventually lead to more serious consequences after he is given immunosuppressive therapy again.And if the patient does not have tuberculosis, but Sun Lien still treats him as a tuberculosis patient, the Crohn's disease that now causes his fever is likely to become more serious during the anti-tuberculosis treatment.There may even be very distressing symptoms including intestinal perforation, abdominal abscesses, etc.

But if you think about it bitterly, the chances of local doctors misdiagnosing other diseases as Crohn's disease don't seem too high.This is not because Ding Huiguo was treated by top experts and scholars in the Department of Gastroenterology, but because the possibility of misdiagnosis of other several items is not too high.The differential diagnosis of Crohn's disease includes acute appendicitis, small bowel lymphoma, duodenal retroampullary ulcer, nongranulomatous ulcerative jejunoileitis, ulcerative colitis, ischemic colitis, colonic tuberculosis, amelia Enteritis, colonic lymphoma, and radiation colitis.

Acute appendicitis, radiation enteritis and the patient's course of disease did not match, while intestinal lymphoma did not match the PET-CT results.Other colonic lesions as well as duodenal retroampullary ulcer and multiple colonoscopies with inconsistent results can also be ruled out.Nongranulomatous ulcerative jejunoileitis had been previously denied by pathological findings.

In other words, there are indeed two possibilities for Ding Huiguo's intestinal disease—intestinal tuberculosis or Crohn's disease.At least with Sun Lien's knowledge, there is no third possibility.

"Ding Huiguo, male, 41 years old, positive for T cell spot test (22412.12.36), positive for tuberculin test (22412.12.36), intestinal inflammatory response (1482.31.25), C-reactive protein 18mg/L (1477.14.29. [-])."

The status bar gave out four status reminders very maliciously. Judging from the time, the positive T cell spot test and tuberculin test both occurred about a month after Ding Huiguo received infliximab for the last time.And this state has continued until now—these two states have no reference meaning at all.Even if the tuberculosis infection in Ding Huiguo's body has been completely eradicated, these two experiments suggesting tuberculosis infection may still remain positive for a long time to come.

The increase of intestinal inflammatory response and C-reactive protein coincided with Ding Huiguo's self-reported time of recurrent diarrhea.What does this mean...it means that Ding Huiguo didn't lie about his illness?
Sun Li'en thought about it for a long time, and then decided to send Ding Huiguo to the laboratory for a blood test.And he took advantage of this opportunity to quickly call Director Wu who had introduced the situation earlier - he wanted to ask if Beihu Hospital had the ability to do colonoscopy.

"Colonoscopy? Crohn's disease?" Director Wu was a little confused on the phone, but he quickly gave a definite answer, "Colonoscopy can be done. If you need it, Director Sun, we can do it in about half an hour." can be ready."

"Then please prepare. After the blood routine is done, I will ask the patient to wait in the colonoscopy examination room." Sun Lien said, "This case will be more troublesome, and it may not be resolved today."

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Sun Lien's feeling was correct. After dealing with a dislocated patient and a patient with diarrhea to hypokalemia, he finally waited for the results of Ding Huiguo's colonoscopy.Of course, Ding Huiguo didn't just stay in the consultation room and stare at Sun Lien to worry. He was once again paid by Sun Lien for chest CT and CT small intestine imaging.

The biopsy specimen of the colonoscopy was sent to the pathology department for further examination, and the direct imaging results of the colonoscopy were very obvious——Ding Huiguo had segmental lesions in the intestine, multiple shallow ulcer lesions in the cecum, and scattered erosions in the transverse colon , while the splenic flexure of the colon——the part of the sigmoid colon mucosa is congested, red and swollen, the vascular texture disappears and shows nodular hyperplasia, and there are a large number of irregular ulcers at the same time.The rectal part also had blurred, disappearing and granular changes in blood vessel texture, as well as scattered punctate erosions.

In other words, almost all of Ding Huiguo's intestines had ulcers and erosions—diarrhea, soft stools and bloody stools are normal under such a severe inflammatory reaction.

Sun Lien sighed when he saw the intestinal examination report, which was completely in line with expectations. What does this mean?Does that mean he's seriously ill?

Therefore, no matter what disease you have, it is best not to get tuberculosis.Sun Lien sighed again, no matter what the disease is, as long as the patient has a tuberculosis—even if it is just a history of tuberculosis—diagnosis will become very difficult.Diagnoses of tuberculosis, like lupus, are universal explanations.And when the omnipotent explanation is combined with other diseases, it becomes the omnipotent confusing condition.

If it is said that God has malice towards the profession of doctors, then tuberculosis is the concrete manifestation of this malice... Sun Lien sneered in his heart, no wonder most of the doctors in the infection department and respiratory department are bald, and they are all worried about tuberculosis.

Although I was worried, I still had to see the disease that should be seen.Based on this colonoscopy alone, the possibility of Ding Hui's state-owned intestinal tuberculosis is not too great.

In the colonoscopy examination of intestinal tuberculosis, the lesions are generally concentrated in the ileocecal part of the colon. In addition to the intestinal mucosal hyperemia, edema and ulcers of the lesions, inflammatory polyps of various sizes and shapes can also be seen under the endoscope. The road narrows.However, these relatively specific signs did not appear in this colonoscopy.

But this does not mean that Sun Lien can declare that the possibility of intestinal tuberculosis has been completely ruled out.Tuberculosis is such a unique disease - intestinal tuberculosis without inflammatory polyps and intestinal narrowing is not uncommon.

Moreover, an important reason why intestinal tuberculosis cannot be ruled out also comes from Ding Huiguo's medical history.

After receiving infliximab treatment, Ding Huiguo developed clear symptoms of tuberculosis.During the treatment of tuberculosis, doctors discontinued all immunosuppressants and switched to an anti-tuberculosis regimen of isoniazid, rifampicin, pyrazinamide, and ethambutol.During the [-] months without any immunosuppressive treatment, Ding Huiguo's "Crohn's disease" did not show any recurrence.This is a very unusual thing.

Crohn's disease is characterized by intractability and a lifelong tendency to relapse.Ding Huiguo's Crohn's disease is obviously very serious.During his continued prednisone therapy, he relapsed only after reducing the dose to 20 mg per day.Infliximab treatment is certainly a very effective treatment option, but it is unlikely to cure Crohn's disease, nor is it possible for patients to achieve a complete remission period of up to a year without the use of hormones.

If it is not intestinal tuberculosis, how to explain the fifteen-month remission period?
If it is intestinal tuberculosis, then how to explain that Ding Huiguo still relapsed after stopping anti-tuberculosis treatment and no longer using immunosuppressants?

Sun Lien felt that his hair hidden under the protective clothing seemed to have fallen out a lot.

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The other clinics are currently very lively.The patients they had to deal with were much more exciting than the few cases Sun Lien had at hand.

Brunn saw a patient with an aortic dissection who was rushed to the hospital by ambulance.Meanwhile, Xu Yourong and Wang Guonan were dealing with four patients with acute abdomen—two of them presented with right upper quadrant cramps, one had knife-like pain, and the other had persistent abdominal pain that aggravated.

Two doctors deal with four acute abdomen patients, which is something that can make a doctor's blood pressure rise rapidly.Through the preliminary examination, Xu Yourong and Wang Guonan agreed that the two patients with right upper quadrant pain were in stable condition, and the pain should be caused by gallstones.The patient with knife pain was sent to the operating room for emergency surgery after a 40-minute examination and preliminary treatment-he had a gastric perforation.

The next thing to deal with is this patient with persistent and worsening abdominal pain.According to the patient's complaint, Xu Yourong and Wang Guonan tend to think that the patient may have acute pancreatitis.But first of all, it is still necessary to take an electrocardiogram to rule out the involved pain caused by myocardial infarction.

Xu Yourong has worked in the emergency department for so long, if there is anything she has learned, then "always suspect myocardial infarction" must be a very high ranking item.The year before last, not long after he partnered with Sun Lien, Xu Yourong received a patient with radiating pain in the right upper abdomen.The patient himself had a history of cholecystitis, plus the pain occurred after eating, Xu Yourong very naturally thought that this patient should have a relapse of cholecystitis.

However, just as Xu Yourong asked the patient to take a B-ultrasound, Sun Lien appeared in the consultation room.And directly stopped the patient who had half stepped out of the emergency room.Then, with a very strong attitude, he asked the patient to take an electrocardiogram immediately and draw blood for myocardial injury markers.

Although Xu Yourong was a little puzzled by Sun Lien's actions, practice many times had proved that Sun Lien's judgment was accurate most of the time.What's more, at least it's not too unacceptable to take an electrocardiogram at this time.

Results Half a minute later, the patient was ordered to lie still on the bed under the classic posterior wall infarct changes suggested by the electrocardiogram.Dr. Cao Yanhua, who is in charge of the Chest Pain Center, was urgently called to the patient's bedside.

That was a very atypical case of myocardial infarction.

Gaining wisdom from a pitfall, Xu Yourong's first reaction to patients with acute abdomen is to get an electrocardiogram first.It can be seen that the condition of the previous patient really impressed her very much.

Ma Yongfang's current problem is relatively trivial. She is dealing with a patient with ketoacidosis. The patient's blood sugar is as high as 54.2mmol/L, unconsciousness and breath smell like rotten apples. This symptom is very typical.

Although typical... But it is very difficult for one person to treat a patient with ketoacidosis. What is even more troublesome is that this 37-year-old male patient has no history of type [-] or type [-] diabetes. .The last time he checked his body was at the end of November last year. At that time, his random blood sugar and glycated hemoglobin levels were normal.

This is what makes Ma Yongfang more worried.Ketoacidosis generally occurs in patients with type 37 diabetes who are first diagnosed, and it is indeed very rare to be diagnosed for the first time at [-] years old.

What's more, it often takes about six months for patients with type [-] diabetes to progress from onset to diagnosis.From the decrease of insulin secretion by pancreatic islets to the complete manifestation of hyperglycemia symptoms, this process takes time.

However, it has only been four months since the end of November last year. Even type [-] diabetes, which has a relatively rapid onset, takes time to develop.

While pumping insulin into the patient, Ma Yongfang urgently opened the intravenous channel to rehydrate the patient, and at the same time called the nurse to help.There are still several patients waiting for consultation in her consulting room, which is really too busy.

First control blood sugar and ketosis, and then have a headache about what is going on with this patient's diabetes-it must not be easy anyway.

Yuan Pingan and Chen Xuerong are the only ones who can see patients now.After Chen Xuerong transferred the patient with aortic dissection to Brunn in the emergency room, the next patients he encountered were anaphylactic shock, hemoptysis and intracranial hypertensive crisis.The patient in anaphylactic shock is relatively easy to deal with. Emergency subcutaneous injection of epinephrine, 400 mg of hydrocortisone and oxygen inhalation will do.The patient who coughed up blood was given 10 units of 5% vasopressin for rapid treatment due to the large amount of hemoptysis.No other checks were done.

Patients with intracranial hypertensive crisis are even more troublesome. In addition to the 20ml intravenous infusion of 200% mannitol, they also received furosemide injections and rapidly injected 10 mg of dexamethasone.Now he doesn't dare to let the patient get away for some CT examinations, first let the intracranial pressure drop--the pupils of the patient's left and right sides are not equal in size, and the pupil's light reflex is not very good.

Yuan Ping'an assigned several patients with fractures one after another. Fortunately, he was lucky and did not encounter any cases of periosteal compartment syndrome.After treating the last patient this morning, he immediately rushed to the emergency room without stopping—the patient with intracranial hypertensive crisis in Chen Xuerong's hand needed consultation, and it had been 3 minutes since the consultation request was sent.

The entire emergency room of Beihu Hospital was in chaos.

　Chapter 64 is temporarily unavailable due to some reasons, and it is expected to be released on the 8th.

　　
　
(End of this chapter)