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

  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 teachers can provide opinions on diagnosis or treatment."

   Next, everyone in the room has 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.

   Beside, Li Yao suddenly whispered: "Lu Chen, you found this case, are there any strange things?"

  Lu Chen raised his brows, and Teacher Li began to ask questions again.

   has started her "room rounds" mode again!

He didn't answer in a hurry, looked at the relevant auxiliary examinations carefully again, and said slowly: "The patient was diagnosed with myocardial infarction, and the descending artery was occluded before coronary angiography. However, after the thrombus was suctioned out, no stenosis was seen in the blood vessel, on the contrary Her veins are so smooth!"

   "Combined with the fact that the patient has no previous risk factors for coronary heart disease such as hypertension, diabetes, and hyperlipidemia, it can be judged that the patient does not have myocardial infarction caused by plaque rupture like the conventional one."

  Acute myocardial infarction, which we often say, is when the blood vessel has underlying disease, the blood vessel narrows, the plaque ruptures, and then a thrombus is formed to block the blood vessel, resulting in cardiac ischemia and hypoxia, and finally myocardial necrosis occurs.

   But this patient is strange.

   There was only thrombosis, and no vascular stenosis and plaque rupture were seen, all of which were not myocardial infarction in the conventional sense.

   "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.

   But as a freshman in the first year of graduate school, Lu Chen was able to judge this, which was not easy.

Lu Chen continued: "Teacher, I also noticed that Mr. Wang Peng didn't say anything, but the PPT he made included the patient's family history. 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."

   Having a family history of bleeding is common, but because of this death, that's rare.

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

   "One more point." Lu Chen paused.

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

Lu Chen nodded and continued: "Although I don't understand the patient's cranial MRI image, we can see from the report that there is no problem with the patient's blood vessels, and only the right occipital lobe and hippocampus have brains. Infarct lesions."

   "In other words, the patient's cardiovascular and cerebral vessels are somewhat similar."

   "What kind of similarity method?" Li Yao smiled.

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

  Lu Chen said sternly: "The thrombus in the heart and brain did not grow by himself, but came from other places!"

   A very simple truth, 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 plaque in 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 comes from elsewhere in the body and comes to this location through the blood circulation.

   This patient had no problems with the blood vessels of the heart and brain, and the results of angiography and MRI showed that the blood vessels were very smooth.

   The only possibility is that the blood clot comes from other parts 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 leads to infarction of the heart blood vessels and brain." Lu Chen frowned, "However, this patient does not have atrial fibrillation, so it should not be caused by atrial fibrillation. Other possibilities, I don't know."

  Lu Chen has very limited clinical experience.

   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, "General residents, or even young attending physicians, may not have as much clinical thinking as yours."

  Lu Chen smiled and scratched his head, then quickly flattered: "The teacher taught me well."

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

   Every time Li Yao rounds the room, he 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 pain and happiness, and his clinical thinking ability was also improving rapidly.

  …

   The time for thinking ends, and the time for collective speaking begins.

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

   He motioned to Wang Peng to hand over the microphone.

   "This patient is obviously caused by ectopic thrombus causing myocardial infarction and cerebral infarction. Could it be a 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 Pengdao, "So the thrombosis caused by atrial fibrillation is unlikely."

   "Have you done a 24-hour Holter? No?" Li Qinghua said.

   "I did, no atrial fibrillation was found."

  Li Qinghua nodded slightly, put down the microphone, and sat back to 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 disease course, recurrent multi-organ arterial thromboembolism (heart, brain), and gastrointestinal bleeding."

   "There are several reasons I am currently considering repeated multiple thrombosis."

  Ouyang Jing's aura was very strong. As soon as he opened his mouth to speak, everyone held their breath and listened carefully.

   shows that in the classroom, it is so quiet that you can hear needles falling.

   "First, vascular disease, such as vasculitis, but the patient has no manifestations of multi-organ involvement such as blood system, muscle joints, liver and kidney function, and immune-related antibodies are all negative, so vasculitis secondary to connective tissue disease is not considered for the time being."

"The patient's gastroscopy showed duodenal plexiform telangiectasia and microvascular involvement. In systemic vasculitis, ANCA-associated vasculitis, polyarteritis nodosa, and Behcet's disease were more common. The patient had no systemic involvement. ANCA is negative, and ANCA-related vasculitis and polyarteritis nodosa are not considered for the time being. The patient has multi-level vascular involvement, coexistence of thrombus and bleeding, and the possibility of Behçet's disease is high. Happening……"

  Lu Chen just thought of a possibility of atrial fibrillation thrombosis.

   But the teacher of the Department of Rheumatology and Immunology immediately mentioned such a big differential diagnosis.

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

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

   Vasculitis, polyarteritis nodosa, Behcet’s disease…

   He still wrote it down in his notebook.

"In addition, the patient has the possibility of antiphospholipid syndrome. The patient has negative anticardiolipin antibodies and normal platelets, but the disease is still not excluded. It is necessary to ask the patient whether there is a history of repeated miscarriage, and to improve the erythrocyte sedimentation rate, anti-β2-GP1, lupus Anticoagulants are further clarified."

   "In addition, there are other thrombophilias. The patient has a family history of epistaxis and death, and tests such as anticoagulation factor III and coagulation factor XII should be improved to further exclude hereditary abnormal coagulation and fibrinolysis or vascular disease."

   "Okay, that's all I have to say." 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: "Mr. Ouyang's speech was very good, and he sorted out the differential diagnosis of thrombosis. Among them, we asked the patient's relevant medical history, and she did not have oral ulcers or genitalia. Ulcers and no history of repeated miscarriages, and related rheumatic immune indicators are all normal, preliminarily ruling out rheumatic immune-related diseases.”

  Ouyang Jing's speech was very exciting and opened up everyone's ideas.

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

   Everyone present fell into contemplation 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 embolism. Did you forget to analyze the cause of the patient's repeated gastrointestinal bleeding?"

  Lu Chen pricked up his ears and listened.

   His intuition, the patient's repeated gastrointestinal bleeding must be a problem.

   But no one mentioned it just now.

Xu Zhonghuang continued: "The patient, a 54-year-old female, has no history of liver cirrhosis, and has recurrent upper gastrointestinal bleeding. The results of gastroscopy showed that there were no ulcers or erosions in the esophagus-gastroduodenum, and there were no gastric antrum and duodenum. Plexiform telangiectasia with local old bleeding foci can be seen at the proximal end of the bulb. The patient's sister also has a history of epistaxis. Based on the above clinical features, the cause of the patient's upper gastrointestinal bleeding is considered to be HHT."

   Lu Chen was slightly taken aback when he heard the words.

   "HHT, what is this?"

Li Yao whispered: "HHT is a hereditary hemorrhagic telangiectasia. The clinical manifestations are multiple tufted telangiectasias on the skin and mucous membranes, often involving the nasal mucosa, which can manifest as epistaxis or even persistent epistaxis. Internal organs can also be affected, with the digestive tract being more common.”

  Lu Chen suddenly realized.

   He had only seen this disease in the text, and had never encountered it clinically.

Xu Zhonghuang paused and continued: "HHT can also affect the blood vessels of the brain, manifesting as intracranial telangiectasia, which is generally asymptomatic and is mostly discovered accidentally during autopsy, but it can also cause cerebrovascular disease, and the lesions are prone to bleeding A hematoma was formed, which manifested as spontaneous intracerebral hemorrhage. According to the patient's sister's history of epistaxis, the diagnosis of the patient's bleeding should be HHT."

   Lu Chen in the audience was very impressed when he heard everyone's speech.

   Constantly instilling new content into his mind.

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

  Medical diagnosis is like investigating a case. It takes a little bit of clues and scrutinizes it step by step, and finally gets the most reasonable explanation.

  This is different from reading a book~www.novelmt.com~ is just memorizing knowledge mechanically.

   And this kind of large-scale discussion in the whole hospital is in one case, there are collisions of various thoughts!

  …

   However, although the discussion was heated 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 had been silent on the system panel, and a prompt popped up suddenly.

   "Congratulations, received clinical insights and obtained the clinical thinking skills book (primary)!"

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

   (end of this chapter)