My medical skills add experience

Chapter 493 The level gap between the director and the deputy director needs to be solved by interventional radiography

"Doctor Zhou is not only skilled, but also has such a sweet mouth! Let's hurry up and discuss the patient's condition. If you delay for a long time, you may get into trouble!"

Director Shang is short-tempered.

After the greetings, Zhou Can was urged to have a consultation together.

It seems that even with the participation of Director Shang and his two graduate students, the cause of the patient has not yet been clearly diagnosed.

He used to call Zhou Can Xiao Zhou, but now that he hasn't seen him for a while, he calls him a lot more.

"Director Shang is right. After taking the medicine, the patient's body temperature dropped a little, but he still had a fever. What is even more worrying is that there may be a large source of bleeding in his body. The first thing to do is to find out the source of the bleeding."

Deputy Director Han is also a practical man.

These senior doctors are definitely worth learning from their serious attitude towards patients and diseases.

The heart of doctors and parents can often reflect these three words in some details.

"After the discussion between the two directors, is there any conclusion?"

Zhou Can asked modestly.

"The specific disease of the patient has not been determined for the time being. However, I think the patient's symptoms are just like upper gastrointestinal bleeding. It is a good way for you to ask Dr. Ai to monitor the patient's gastric juice. It has already been implemented. In addition, I heard that you During the digital rectal examination of the patient, dark red blood was found on the glove, and I think that if it is really upper gastrointestinal bleeding, it is difficult to find dark red blood during the digital rectal examination."

Director Shang should have known about the patient's previous diagnosis and treatment plan.

"Overseas, there is a method specially used to identify upper or lower gastrointestinal bleeding. After clinical comparison, it is found that high plasma urea concentration is a feature of gastrointestinal bleeding, and the degree of increase is related to the amount of bleeding. Through plasma The ratio of urea ammonia concentration to plasma creatinine concentration can infer upper or lower gastrointestinal bleeding."

The level of the chief physician is really not something to brag about.

Zhou Can had also seen the identification scheme proposed by Director Shang in medical journals.

However, he does not know how to use it in clinical practice.

The main reason is that those values ​​​​can't be remembered at all.

And the accuracy rate of this method is not 95%, but about [-]%.

"If the ratio of the two is greater than 100, the probability of upper gastrointestinal bleeding is high. If the ratio is less than 100, the probability of lower gastrointestinal bleeding is high."

Director Shang's proposal is worth a try.

Only by comparing two simple biochemical indicators and calculating the ratio, can the upper and lower gastrointestinal bleeding be distinguished.

Simple and practical, low cost.

"By calculation, the probability of lower gastrointestinal bleeding is high."

Director Shang is really good, he deserves to be the director of Gastroenterology.He personally came here for consultation this time, which also gave the emergency department great face.

"For patients with lower gastrointestinal bleeding accompanied by fever, we need to consider the possibility of inflammation and tumors. The patient has a sudden onset, and the possibility of intestinal bleeding caused by intestinal tuberculosis is very small. Therefore, the main consideration is inflammatory lesions."

Two graduate students have already taken out their small notebooks and are taking notes quickly.

Back then, when Zhou Can was studying with Director Shang, he would often take some notes.

"Dr. Zhou has been away from Gastroenterology for a long time, do you still remember the knowledge about intestinal inflammatory lesions?"

For some unknown reason, Director Shang suddenly wanted to test Zhou Can.

"It's kind of you to call me Xiao Zhou like you did before."

Zhou Can also understood that Director Shang never treated him as a student.

In the Department of Gastroenterology back then, he also received a lot of care and cultivation from Director Shang.

For example, Zhou Can and Deputy Director Shi went to Xinxiang Women's and Children's Hospital for consultation.It was also that opportunity that allowed Zhou Can to be selected into Tuya's famous doctor reserve team.

"Haha, no problem. Isn't it because your status is not what it used to be, and you are worried that calling Ni Xiaozhou will bring you adverse effects!" Director Shang explained with a smile.

"In front of you, I will always be that Xiao Zhou."

Director Shang was very happy to hear Zhou Can's words.

There is no doctor who doesn't like people who are kind and righteous.Director Shang put in a lot of hard work in training Zhou before, and took great care of Zhou Can.

Three years later, Zhou Can is still full of gratitude and respect for him, which naturally made Director Shang feel greatly relieved.

"I still remember a lot of knowledge you taught me. Inflammatory lesions can be divided into specific and non-specific. Inflammatory bowel disease generally refers to inflammatory bowel disease, which is a non-specific chronic intestinal inflammatory disease, mainly including Ulcerative colitis, Crohn's disease, etc., often manifest as abdominal pain, diarrhea, and weight loss."

Zhou Can has already mastered these knowledge points.

"very good!"

Director Shang nodded happily.

"According to the patient's medical history, symptoms, and biochemical results, bacillary dysentery and amoebic dysentery can be basically ruled out. I suggest checking the patient's Vita reaction. It is almost the fifth week of the patient's onset, and it is the right time to check the Vita reaction. .”

"Director Shang suspects that the patient has typhoid fever?"

Zhou Can's eyes brightened slightly.

Director-level diagnostic thinking is too powerful.

Compared with Director Shang, he can clearly feel the gap.

His current pathological diagnosis is at the level of deputy chief physician, and it will take some time to be promoted to director level.

Especially in the recent period, for the postgraduate entrance examination, the consultation time has been compressed, the number of diagnosed patients has decreased, and the growth of pathological diagnosis experience has also slowed down.

Fortunately, the business of cardiothoracic surgery has been increasing recently, and the number of difficult cases has increased, giving him the opportunity to earn a large amount of experience points for pathological diagnosis.

Zhou Can suspected that the patient might have intestinal malignant histiocytosis, and he barely touched the edge.

He even thought of doing a bone marrow test on the patient.

If it is typhoid fever, do bone marrow culture, most of them can be found out.

As for the blood culture test, because the course of the disease has developed to four weeks later, the peak period of bacteremia has passed, and the test result is likely to be negative.

"It is only tentatively suspected to be typhoid fever. The etiology of this kind of digestive tract disease is obscure and the course of disease progresses for a long time. After excluding malignant tumors, there are only a dozen rare and intractable diseases. For example, Crohn's disease , ulcerative colitis, etc. However, most of these diseases have a slow onset, often accompanied by intestinal obstruction and abdominal mass, and this patient obviously has many inconsistencies."

"Ulcerative colitis also has acute onset. Some severe ulcerative colitis will have high fever and blood in the stool. It is more consistent with the patient's condition. The patient was just admitted to the hospital today. Even if he wants to do an emergency colonoscopy, the preparation of the intestinal cavity needs A certain period of time. Especially the residual blood in the intestinal cavity is estimated to be quite serious and will seriously affect the results of the examination."

Director Shang was very cautious when diagnosing the cause.

From his various statements, it has been basically diagnosed that the patient is typhoid fever.May also be associated with lower gastrointestinal bleeding.

It is not the first time that Zhou Can has seen director-level diagnostic thinking, and he is very yearning for this high level.

In the next two days, further corresponding examinations were performed on the patient.

Including aspirated gastric fluid monitoring.

The patient's body temperature has always been between 37.7 degrees and 38.9 degrees, and the fever has not subsided.

The gastric juice extracted on the first day was light yellow and turbid, and a little old blood was found in the gastric juice.

The gastric juice extracted the next day turned clear.

At this point, upper gastrointestinal bleeding can basically be ruled out.

Yesterday, the patient's stool was still black.It shows that the blood in the stool still exists.

There is no bleeding in the upper gastrointestinal tract, but the patient still passes black stools. Without even thinking about it, there must be a large bleeding in the lower gastrointestinal tract.

After passing black stools, the patient passed two dark red bloody stools this morning.

This is consistent with the situation when Zhou Can performed the digital examination on the patient for the first time.

At that time, it was found that the gloves were stained with dark red blood.

The patient's blood bacterial culture was negative.

After the peak period of blood bacteria, the re-examination is basically the result.

The patient's bone marrow routine examination results also came out, and no abnormal immature cells and tissue cells were found.This is just the result of a routine examination of the bone marrow. The specific diagnosis depends on the results of bone marrow culture.

This morning, the patient's blood pressure has dropped to 60/42mmhg, the pulse has become very weak, and the heart rate is about 120 beats/min.

This is a very bad sign.

It shows that the bleeding cannot be controlled and has been bleeding.

If you don't immediately find a way to find out the source of the bleeding and stop the bleeding, the patient may not be saved.

This morning happened to be the day when Zhou Can was in the emergency department. Because the patient suffered shock again, the emergency room was worried about the patient's accident, so they had no choice but to invite Zhou Can over.

After Zhou Can arrived at the emergency room, he immediately performed a muscular venous catheterization on the patient, and measured the central venous pressure, which was only 0.78KPA.

Unexpectedly, the patient's condition deteriorated so quickly.

In just two days, even though 1000 ml of blood had been transfused and multiple therapeutic measures were given, shock still occurred again.And the blood pressure dropped to an extremely worrying level.

At this time, the source of bleeding is unknown, and there is no effective means of hemostasis, and the use of vasopressors can only accelerate bleeding.

Zhou Can quickly instructed the nurses and doctors to expand the patient's volume and transfuse blood for anti-shock. After transfusing three bags of blood in a row, the blood pressure was finally raised again.

"Doctor Zhou, the patient must be bleeding all the time. Please help me find a way! I think it is difficult to stop the bleeding with medical treatment. I'm afraid surgical treatment is needed to stop the bleeding."

Dr. Allie has been haggard for the past two days.

For this patient, she was heartbroken.

Every doctor is afraid of receiving difficult patients.Especially for this extremely difficult patient with gastrointestinal bleeding, she is really unable to handle it with an ordinary attending physician.

I saw the patient go into shock again just now. She is 50 years old and still stomps her feet anxiously.

"Don't worry, it's basically confirmed that it's lower gastrointestinal bleeding. The blood in the patient's stool is dark red, which should be hemorrhage in the ileum and colon. It's just that the patient's current physical condition does not allow barium radiography of the colon, nor can colonoscopy be done. Even for a laparotomy, the bleeding point must be identified before it can be targeted."

Zhou Can has relatively rich experience in dealing with such difficult patients.

"I can't do the checkup. The patient's bleeding point can't be locked, but he keeps bleeding. What should I do?" Ellie said with a sad face.

The level of general doctors is limited, and it is really difficult to deal with this kind of patients.

"Celiac arteriography may be a better way. Although radiological intervention is somewhat invasive, it is very effective in locating this kind of gastrointestinal bleeding of unknown etiology. The harm of the two phases is the lesser, in order to save the patient's life." I think it is worth taking some risks to do a celiac angiography. However, this examination needs to be done at a good time, and it must be performed when the patient is bleeding."

Zhou Can gave a better solution.

When doing abdominal angiography, timing is very important.

If the patient's bleeding is temporarily stopped during the examination, it is difficult to find out the bleeding point.

At this time, Zhou Can's sixth-level hemostasis technique came into play again.

He can basically judge whether the patient is in the bleeding stage from the patient's skin color, complexion, appearance, and physical condition.

In addition, the patient had just discharged liquid bloody stools twice recently, indicating that he was in a state of heavy bleeding.

Not to be missed.

Zhou Can decisively asked Ai Li to report to Deputy Director Han, and then contacted the intervention room to perform emergency selective celiac angiography on the patient.

The doctor in the intervention room saw that the patient's condition was very bad, and was worried that the patient would hiccup and die during the intervention operation, so he invited Zhou Can to help.

Zhou Can is also well-known, and now many doctors in Tuya Hospital know that he is good at endoscopic surgery and interventional surgery.

Every now and then someone would ask him to help.

The intervention room invited him over this time, saying that he was asking for help, but in fact, he was afraid of taking responsibility.

Zhou Can didn't expose it, and just passed by.

Performing celiac angiography on the patient was originally an examination plan proposed by him.

Someone has to carry the burden of defending life for the patient.

Of course, the consent form that should be signed by the family must be signed.

It's okay to ask him to work hard to save people, but he can't be asked to take all the risks.

If the family members only want to save people, but are unwilling to take any risks, they will let the doctors bear all the responsibilities.Then I'm sorry, Zhou Can has never been a virgin, and when he should be ruthless, he must be ruthless.

Fortunately, the patient's parents were reasonable and quickly signed the agreement.

In the intervention room, wearing a heavy lead coat, Zhou Can carefully sent contrast tubes into the patient's femoral artery, then into the celiac aorta, and then into the first-level branches, celiac trunk, superior mesenteric artery, and inferior mesenteric artery.

He seemed particularly focused throughout the operation.

The celiac trunk and branches of the inferior mesenteric artery were recorded by TV, and no abnormalities were found.

His heart sank involuntarily.

Is the timing of the selected angiographic examination wrong?
Through the TV image, it can be seen that the diameter of the superior mesenteric artery generally becomes thinner, and the contrast medium overflows at the end of the ileocolic artery branch.

Zhou Can was overjoyed immediately.

Finally found the source of the bleeding.

"Quick, quick, this is the part."

Zhou Can motioned to quickly locate the source of bleeding on the patient.

It can be clearly seen that the contrast agent overflowing from the end of the arterial artery branch is extremely concentrated and gathers into a ball.

After the bleeding was identified, vasopressin 20U was slowly injected through the catheter, and then the catheter was extubated.

It turned out to be active bleeding from the ileocolic artery, no wonder the amount of bleeding was huge.

Bleeding from just about any larger artery can be horrific.

And it's hard to stop the bleeding automatically.

I finally understood why the combined use of two hemostatic drugs still failed to stop the bleeding.

"This patient must be operated to stop the bleeding immediately. Let's push it back first! I will discuss it with Dr. Xu to see if the emergency department can perform this operation directly."

Zhou Can actually already had a surgical plan in his mind.

But this matter needs to be discussed with Dr. Xu first.

After all, Zhou Can was the one who performed the surgery, but Dr. Xu was the one who took the responsibility.

After discussion, Dr. Xu agreed to take over the operation after seeing the replay of the angiography image.

For Zhou Can, this is a very good training opportunity.

(End of this chapter)