I can see health

Chapter 205
After Wang Peng told the patient's medical history, he began to give the results of various auxiliary examinations.

Such as coronary angiography, chest and abdomen CT, electrocardiogram and laboratory tests and other indicators.

Wang Pengdao: "It is extremely rare for a patient to have myocardial infarction, cerebral infarction, and gastrointestinal bleeding at the same time. I hope all the teachers can provide a diagnosis or treatment opinion."

Next, everyone here will have a short time to think, and then they will start to focus on the discussion.

Lu Chen quickly finished reading all the auxiliary examination results of the patient.

On the side, Li Yao suddenly whispered: "Lu Chen, did you find anything strange about this case?"

Lu Chen frowned, and Teacher Li started asking questions again.

She started her "ward rounds" mode again!
He did not answer in a hurry, but carefully looked at the relevant auxiliary examinations again, and said slowly: "The patient was diagnosed with myocardial infarction, and the anterior descending artery of the coronary angiography was occluded. However, after the thrombus was sucked out, there was no stenosis of the blood vessel. On the contrary Her veins are smooth!"

"Combining the patient's previous risk factors for coronary heart disease such as hypertension, diabetes, and hyperlipidemia, it can be judged that the patient is not like the conventional myocardial infarction caused by plaque rupture."

The acute myocardial infarction we often refer to is when the blood vessels have basic lesions, the blood vessels are narrowed, the plaques rupture, and then a thrombus is formed to block the blood vessels, resulting in cardiac ischemia and hypoxia, and finally myocardial necrosis.

But this patient is strange.

Only thrombosis, and no vascular stenosis or plaque rupture was seen, so it was not a conventional myocardial infarction.

"Well, not bad." Li Yao nodded.

It is very simple for mature interventional doctors to judge the condition of blood vessels through the results of coronary angiography.

However, as a student who has just entered the first year of graduate school, it is not easy for Lu Chen to judge this point.

Lu Chen continued: "Teacher, I also noticed one thing. Teacher Wang Peng didn't mention it, but he wrote the patient's family history in this PPT. Her sister died of "nosebleed" when she was ten years old. I feel that this should be related to the patient's repeated gastrointestinal bleeding after surgery."

A family history of bleeding is common, but with this death, it is rare.

Li Yao smiled with satisfaction: "Very well, look carefully, there is indeed a problem with this nosebleed."

"One more thing." Lu Chen paused.

"Huh?" There was a trace of surprise in Li Yao's eyes, "Don't stop, keep talking, and tell what you know."

Lu Chen nodded and continued: "Although I don't understand the patient's brain MRI images, I can see from the report that there is nothing wrong with the patient's blood vessels, only the right occipital lobe and hippocampus have cerebral palsy. focus of infarction."

"In other words, the blood vessels of the patient's heart are somewhat similar to the blood vessels of the brain."

"What kind of similarity?" Li Yao smiled.

She was very relieved to see Lu Chen's serious appearance.

Lu Chen said seriously: "The thrombus in the heart and brain didn't grow on me, but came from other places!"

A very simple reason, a blood vessel is blocked, there are two possibilities.

The first possibility is that there is a problem with the blood vessel itself, such as the rupture of the plaque on the blood vessel wall, the formation of thrombus, and the blockage of the blood vessel.

The second possibility is that there is nothing wrong with the blood vessel itself.The thrombus came to this location through the blood circulation from other places in the body.

There is no problem with the blood vessels of the heart and brain of this patient, and both angiography and MRI results show that the blood vessels are very smooth.

The only possibility is that the clot came from another part of the body!
"Then where do you think it came from?" Li Yao asked.

"The most common possibility is that atrial fibrillation causes atrial thrombus, and the thrombus falls off and causes infarction of the heart and brain." Lu Chen frowned, "But this patient does not have atrial fibrillation, so it should not be caused by atrial fibrillation. As for Otherwise, I don't know."

Lu Chen's clinical experience is very limited.

All he could think of was the possibility of atrial fibrillation causing blood clots.

"Well, but your analysis is already very good." Li Yao smiled, "Ordinary residents, even young attending doctors, may not be as strong as your clinical thinking."

Lu Chen scratched his head with a smile, and quickly flattered him: "It's better that the teacher taught me well."

Although it was flattering, Lu Chen did learn a lot from Li Yao.

Every time Li Yao makes rounds, she will inevitably ask some difficult questions.

Her principle is not to ask simple questions.

If you want to ask, you must make it difficult for them!
After this kind of torture, Lu Chen felt both pain and happiness, and his clinical thinking ability also improved rapidly.

……

The time for thinking is over, and the time for group speaking begins.

Li Qinghua, chief resident of the Cardiology Department, was the first to stand up.

He motioned for Wang Peng to pass the microphone over.

"This patient obviously had myocardial infarction and cerebral infarction caused by ectopic thrombus. Could it be the thrombus caused by atrial fibrillation?"

Li Qinghua's speech was exactly what Lu Chen thought.

"Mr. Li, all the patient's electrocardiograms show that she does not have atrial fibrillation." Wang Peng said, "so the thrombus caused by atrial fibrillation is unlikely."

"Have you had a 24-hour dynamic electrocardiogram? No?" Li Qinghua said.

"It did, and no atrial fibrillation was found."

Li Qinghua nodded slightly, put down the microphone, and sat back in his original position.

The second doctor who spoke was Ouyang Jing, a deputy chief physician of the Department of Rheumatology and Immunology.

He stood up and took the microphone from Li Qinghua's hand.

"The patient is a middle-aged and elderly woman with a chronic course of disease, repeated multi-organ arterial thromboembolism (heart, brain), and gastrointestinal bleeding."

"I am currently considering the following reasons for repeated multiple thrombosis."

Ouyang Jing's aura was very strong. When he spoke, everyone held their breath and listened carefully.

In the classroom, it was so quiet that a needle could be heard.

"First, vascular disease, such as vasculitis, but the patient does not have multiple organ involvement such as blood system, muscle joints, liver and kidney function, and all immune-related antibodies are negative, so secondary vasculitis of connective tissue disease is not considered for the time being."

"The patient's gastroscope showed duodenal plexus telangiectasia and microvascular involvement. In systemic vasculitis, it is more common in ANCA-associated vasculitis, polyarteritis nodosa, and Behcet's disease. The patient had no systemic involvement. ANCA is negative, and ANCA-associated vasculitis and polyarteritis nodosa are not considered for the time being. The patient has multi-level vascular involvement, and thrombus and hemorrhage exist at the same time. The possibility of Behcet’s disease is considered high. It is necessary to ask the patient about oral ulcers and genital ulcers Condition……"

Lu Chen just thought of the possibility of atrial fibrillation thrombus.

But the teacher of the rheumatology and immunology department immediately cited such a large differential diagnosis.

The Department of Rheumatology and Immunology can be said to be the department most prone to intractable diseases.

Lu Chen listened very carefully, although he didn't quite understand some parts.

Vasculitis, polyarteritis nodosa, Behcet's disease...

He still wrote it down in his little notebook.

"In addition, the patient may have antiphospholipid syndrome. The patient's anticardiolipin antibody is negative and the platelets are normal, but the disease cannot be ruled out. It is necessary to inquire whether the patient has a history of recurrent miscarriage, and complete the ESR, anti-β2-GP1, lupus Anticoagulants are further clarified."

"In addition, there are other thrombophilias. The patient has a family history of epistaxis and death. Anticoagulation factor III and coagulation factor XII should be checked to further rule out hereditary abnormal coagulation and fibrinolysis or vascular disease."

"Okay, that's all I've said." Ouyang Jing, deputy chief physician of the Department of Rheumatology and Immunology, finished his speech.

His analysis aroused heated discussions among the crowd.

At this time, Wang Peng stood on the podium again and said: "Teacher Ouyang's speech was very good. He sorted out the differential diagnosis of thrombophilia. Among them, we asked the patient's relevant medical history. She did not have oral ulcers, genital ulcers, etc. Ulcers, no history of recurrent miscarriage, and related rheumatic immune indicators are normal, and rheumatic immune-related diseases are preliminarily ruled out."

Ouyang Jing's speech was wonderful and opened up everyone's thinking.

But Wang Peng's words directly ruled out immune-related diseases.

Everyone present fell into deep thought again.

At this time, Chief Physician Xu Zhonghuang of the Department of Hematology got the microphone.

"I see that everyone is analyzing the possible causes of the embolism, have they forgotten to analyze the causes of the patient's multiple gastrointestinal bleeding?"

Lu Chen pricked up his ears and listened.

His intuition was that the patient's multiple gastrointestinal bleeding must be problematic.

But no one mentioned it just now.

Xu Zhonghuang continued: "The patient is a 54-year-old female with no history of liver cirrhosis and repeated upper gastrointestinal bleeding. The results of gastroscopy showed that there was no ulcer or erosion in the esophagus-gastric duodenum, gastric antrum, duodenum Plexiform telangiectasia with local old hemorrhage can be seen in the proximal end of the bulb. The patient's elder sister also had a history of epistaxis. Based on the above clinical features, it is considered that the cause of the patient's upper gastrointestinal bleeding is HHT."

Hearing this, Lu Chen was slightly taken aback.

"HHT, what is this?"

Li Yao whispered: "HHT is hereditary hemorrhagic telangiectasia. It is clinically manifested as multiple clustered telangiectasia in the skin and mucous membranes. Often the nasal mucosa is involved. It can be manifested as epistaxis, or even intractable epistaxis. Viscera can also be involved, and digestive tract involvement is more common."

Lu Chen suddenly realized.

He has only seen this disease in the text, and has never encountered it in clinical practice.

Xu Zhonghuang paused, and continued: "HHT can also involve blood vessels in the brain, manifested as intracranial telangiectasia, which is generally asymptomatic and is often found accidentally during autopsy, but it can also cause cerebrovascular disease, which is prone to bleeding The formation of a hematoma manifested as spontaneous cerebral hemorrhage. According to the patient's sister's medical history of epistaxis, the diagnosis of the patient's hemorrhage should be HHT."

Lu Chen, who was in the audience, felt admiration in his heart when he heard everyone's speech.

New content is constantly instilled into his mind.

Lu Chen felt that he had many blind spots in his thinking and was being stripped away a little bit.

A medical diagnosis is like investigating a case. You have to peel back the cobwebs, step by step through a little clue, and finally get the most reasonable explanation.

This is different from reading a book, which is just memorizing knowledge mechanically.

But this kind of large-scale discussion in the whole hospital is a collision of various thoughts in one case!
……

However, although everyone had heated discussions and each department gave their own unique opinions, in the end, they still did not get a reasonable diagnosis.

At this moment, Lu Chen suddenly noticed.

He has been silent on the system panel, and a prompt pops up suddenly.

"Congratulations, you have received clinical comprehension and obtained the clinical thinking skills book (primary)!"

　There are two more chapters, which will be published after revision.

　　
　
(End of this chapter)