This doctor has a system

Chapter 268 257. Rare ectopic ACTH syndrome

"It's okay. Director, jumping can walk faster than using a cane." Zhang Zheng said.

Director Zhou glared at him, and then started to call, "Hey, Section Chief Zhao? Our department is applying for a new project!"

"What project?" Section Chief Zhao over there asked slowly, "Haven't your department's project plans for this year already been submitted?"

"That was the previous one, and this is the new one." Director Zhou spoke quickly, "Let me tell you briefly, you."

"Let's make a written report." Section Chief Zhao interrupted him, "Give me a brief description. If possible, I will approve it this afternoon."

After hanging up the phone, Director Zhou was a little unhappy, "What! Such a good project has to wait until the afternoon! Shouldn't it be approved immediately?"

Everyone
"Lao Zhou must have injured his head when he got polio before," said Director Guo of the Department of Dermatology.

Zhang Zheng nodded subconsciously and quickly shook his head. Li Youliang also felt that the possibility was very high.

"Don't worry, this matter won't happen in a day or two." Gao Feng said, "Integrate procedures, enter patient information, and coordinate personnel in multiple aspects."

"These things are easy to say, but quite troublesome to do."

"Yes, I'm too anxious." Director Zhou patted his head, "Our allergy department hasn't encountered such a good project for a long time. I'm really a little excited."

"Furthermore, I think the system you mentioned can not only be used on HAE patients, but also other chronic diseases that are prone to acute exacerbations."

Several people talked in the department for a while, and they all felt that they had learned a lot. At around 3 o'clock in the afternoon, Gao Feng and Li Youliang came to the joint rare disease clinic again.

Director Fan from the Department of Endocrinology was talking to the students there and stood up immediately when he saw him coming.

"Director Fan, where are the patients this morning?"

"I have seen them all. They are all chronic diseases and do not belong to the category of rare diseases." Director Fan shook his head, "But they all think they have a serious illness and insist on coming here to join in the fun."

He examined several people, prescribed some medicine and persuaded them to go back.

There was an old lady who farted a lot. She even had gastrointestinal endoscopy 4-5 times and was still worried that she had cancer. She talked to Director Fan for half an hour, and she was exhausted mentally and physically.

"Hahaha, there are patients like this everywhere." Gao Feng laughed. Some people are just idle, especially the elderly. They have nothing to do after retirement and spend all day thinking about their bodies.
While the two of them were talking, the pretty nurse led a patient over.

The patient, a 53-year-old female, came to see a doctor because of "headache accompanied by dizziness for 2 years, which worsened for 1 week."

"What makes your headache hurt? Is it painful or tingling?" Director Fan asked.

“It hurts as soon as I sleep, and it still hurts when I open my eyes,” the patient said.

"Is that swelling or stinging pain?"

"I'm so dizzy that I feel so light when I walk. I really can't stand it!" the patient said.

"Can you see things turning when you are dizzy?" Director Fan took a deep breath and asked.

"I've been comatose for two years. Doctor, do you know how I got here?" Tears filled the patient's eyes.

Director Fan's student couldn't stand it anymore, "Hey, what's wrong with you, auntie? Don't answer questions you don't mean! Just answer whatever you ask!"

"Don't be impatient with the patient." Director Fan asked the students to be gentler, "Family members, who are you?"

"I am her son." The male family member on the side quickly replied.

"Have you ever taken your mother to have her brain checked?" Director Fan asked, "She seems to be in a bad condition."

"After seeing it, the neurologist and psychiatrist both saw it and said it was not mental illness." The patient hurriedly took the medical record. "She is not like this usually. She was chattering as soon as she entered the hospital."

"As long as it's not mental illness!" Director Fan breathed a sigh of relief, "Then let's continue."

After spending a long time, he finally got a rough idea of ​​the patient's condition. Gao Feng was extremely anxious as he sat aside.

The patient had headache, dizziness, no vomiting, and amaurosis 2 years ago without obvious triggers. The blood pressure was as high as "180/100 mmHg." He was given amlodipine besylate (5 mg/d) and benazepril hydrochloride (10 mg). /d), drug treatment with metoprolol tartrate (50 mg/d), blood pressure control was poor and was not taken seriously;
Eight months ago, I visited a hospital in Beijing and my blood potassium was 8 mmol/L. The contrast-enhanced MRI of my head showed a benign space occupation in the sphenoid sinus. The specific diagnosis and treatment were unknown. One week ago, my headache and dizziness symptoms became worse than before, with a feeling of cotton under my feet, chest tightness, Shortness of breath, fatigue, blood pressure measured to "3.12/1 mmHg".The disease started with poor mental health, diet, and sleep, no abnormality in bowel movements, and a weight gain of 180 kg.

"I don't know what happened three months ago when I was moving boxes, and I fractured my thoracic vertebrae," the patient's son added.

"A month ago, I accidentally fell into a pit while walking and broke two ribs. I have just been discharged from the hospital."

It's quite a disaster, Li Youliang thought on the side.

"How is your blood pressure under control now?" Director Fan asked.

"It will feel better when you take antihypertensive medicine. The high pressure in the morning is usually 160, and the low pressure is normal."

"Is the blood pressure still so high even after taking antihypertensive drugs?" Director Fan was very curious. The patient had taken three kinds of antihypertensive drugs, but his blood pressure was still not under control. The blood pressure was so high!

"If you don't eat better," the patient's son smiled bitterly, "My dad has low blood pressure and she has high blood pressure. They both argue and feel dizzy every day, which makes me have a big head."

Gao Feng noticed that the patient was obviously overweight, with a moon face, buffalo hump, central obesity, and facial hairiness. It was naturally impossible for the experienced Director Fan to ignore these signs.

"Cushing's Syndrome?"

"That's right!" said the patient's son, "The doctor over there said the same thing. I have the medical records here."

Cushing's syndrome refers to a group of clinical syndromes caused by abnormal regulation of the hypothalamic-pituitary-adrenal axis and excessive secretion of glucocorticoids by the adrenal cortex.

Typical clinical manifestations include central obesity, moon face, sanguine appearance, purple skin lines, hypertension, hypokalemia, abnormal glucose metabolism, muscle weakness, osteoporosis, etc.

The patient underwent relevant examinations at an external hospital and found that the cortisol (COR) rhythm was disordered, the free COR level in urine was significantly elevated twice, and the 2 mg overnight dexamethasone suppression test was not suppressed.

There is no doubt that Cushing's syndrome (CS) is real.

"Professor Gao, look at the results of her high-dose dexamethasone suppression test (HDDST), which showed that the suppression rate of serum COR levels was <50% (accompanied by hypokalemia). What does this indicate?" Director Fan asked.

"It should be ectopic ACTH syndrome."

"Yes!" After all, this is his own profession. Director Fan exuded a calm confidence, "We must find the lesion and then remove it, otherwise the blood pressure will definitely be uncontrollable!"

Ectopic ACTH syndrome is a relatively rare lesion caused by nonpituitary tumors, mainly located in the lungs, thymus, pancreas, and thyroid.

Several people carefully looked through the medical records and examination materials, but were puzzled. No lesions were found in the patient's lungs, thymus, pancreas and thyroid. "It's unscientific!" Director Fan pinched his chin, "It's usually in these parts."

"There's nothing valuable written on the head MRI report. It's really strange."

"The doctor over there said the same thing." The patient's son said with a worried look on his face, "He told me to come here and have a look."

Gao Feng became interested and picked up the patient's film and started reading it.

"Director Fan, do you think there's something wrong with this?" Gao Feng is accustomed to this. There will always be some gains from high-level reading skills.

"What?" Director Fan stretched his head over. He was dazzled by the medical records.

"This piece of tissue seems to be a little larger than normal tissue." Gao Feng pointed to the patient's head MRI and said, "It feels like edema."

"Is there any?" Director Fan took the film and watched it for a long time. To be honest, he really didn't see it.

"this."

"If that's not possible, let the patient do some enhancement." Gao Feng suggested.

"Well, we can give it a try." Gao Feng's performance in the morning gave him a lot of impression points in Director Fan's mind, and now he promptly expressed his agreement with his proposal.

The family members were very cooperative and quickly took the patient to the imaging department.

"I guess we can't do it today, right?" Li Youliang said, "I heard that MRI here, except for emergencies, usually has to be scheduled for two days later."

"If we can do it, the orders opened by our joint rare disease clinic will have priority." Director Fan said with a smile, "With rare diseases, you have to race against time when diagnosing and treating them."

Sure enough, half an hour later the family members came back with the patient and the film.

"It's very efficient!"

Enhanced MR scan showed a soft tissue mass at the occipital slope with abnormal signal. T1WI showed isointense signal, T2WI showed isointense or mildly hyperintense signal, and the area was 30mm×46mm.The lesion extended anteriorly, completely filling the entire disc sinus, close to the right internal carotid artery.

No obvious infiltration, liquefaction and necrosis were observed in the bilateral cavernous sinuses.The pituitary gland has a normal shape, with an upper and lower diameter of 3.14mm, and the pituitary gland is located in the center.

"Consider it to be a space-occupying lesion of the occipital slope, with a tendency for low-grade malignant tumors and the possibility of chordoma." Director Fan felt a little strange after reading the report. Why does Professor Gao seem to know everything?

It made him very stressed at the moment.

"Professor Gao, look at this." He handed the report sheet to Gao Feng.

"Could this be an ectopic ACTH pituitary adenoma?" Gao Feng asked, "Director Fan, what should we do next? Excise it directly?"

Hearing Gao Feng ask this, Director Fan finally breathed a sigh of relief. He was really afraid that Gao Feng knew everything.

"Bilateral inferior petrosal sinus vein blood sampling (IPSS) + desmopressin stimulation test can be performed, and the results can be analyzed using the prolactin correction method, which can further locate the tumor." Director Fan said.

Gao Feng knew about the desmopressin stimulation test, but this was the first time he heard about blood collection from the inferior petrosal sinus vein. It seemed that he had never encountered such a patient when he was rotating in the endocrinology department in graduate school.

"Let's wait for the results tomorrow." Director Fan was very excited, "I think we have found the right place."

Gao Feng said goodbye, but Xiong Huaxin was still waiting for him to have dinner with him.

"No need, I already had a meal with others at noon." Gao Feng said.

"Can it be the same? It's not me who invited others." Xiong Huaxin took him to a restaurant that looked high-end. "This is a century-old restaurant that combines the best of the three major cuisines: palace cuisine, Shandong cuisine and halal cuisine." It’s a time-honored Chinese brand, and it’s hard to find a location.”

It's hard to get an appointment with anyone who is even remotely famous. There are too many rich people here. "Li Youliang smiled and said, "Last time we went to eat roast duck, we had to queue for a long time. "

Although it is crowded, the food is served quickly. The three most famous dishes here are Bao Sanyan, Cao Liu San Bai and Xiangyou eel paste.

Gao Feng thinks that the most delicious dish is Cao Liu San Bai. This dish is one of the famous traditional dishes in Shandong. It looks white and elegant in appearance, soft and light in texture, fragrant and has a different aroma.

This dish is named after the cooking method and the color of the ingredients. The chicken breast, mandarin fish slices and winter bamboo shoots are all uniformly white in color, hence the name.

"It's more delicious than Geji braised pancakes." Li Youliang said vaguely.

"That's because you ate too much." Xiong Huaxin said with a smile, "When I first went to your place, I thought the Geji braised cakes were very tasty, but now I'm a little indifferent."

The three of them chatted for a while and drank some wine.

"Alas, my future situation will not be very good." Xiong Huaxin suddenly sighed.

Gao Feng and Li Youliang looked at each other, "Teacher Xiong, aren't you highly regarded by Academician Bao?" Li Youliang asked curiously.

"That was before, but I'm afraid it won't be the case in the future." Xiong Huaxin said a little melancholy, "My senior brother has been selected as a Yangtze River Scholar. My teacher is now planning to focus on training him as his successor."

The "Yangtze River Scholars Award Program" is an important part of China's major national talent projects, and together with the "Youth Talent Development Program" and other programs, form China's national high-level talent training support system.

Starting from March 2012, the Ministry of Education launched the new "Changjiang Scholars Award Program".

Xiong Huaxin's senior brother is currently rated as a young scholar. Academician Bao feels that he is not young anymore and it is time to find a successor. As a disciple of the Yangtze River Scholar, he must be the first choice.

Although Xiong Huaxin has always been his favorite student, in most cases, for the future development of the faction, the disciple who can ultimately inherit the teacher's mantle must be the most capable one.

Otherwise, once Academician Bao retires, everyone will definitely lose their cohesion. This is not a situation he wants to see.

As an academician of the Academy of Sciences, Academician Bao must also hope that his disciples can reach his level. Although the Yangtze River Scholars are still far away from being academicians, they at least have the qualifications to compete in the future. In case of luck in the future, something will happen. The achievements of blind people.

Xiong Huaxin currently has no achievements worthy of praise. I don’t know how long it will take for him to grow up, and it is full of uncertainty.After much thought, Academician Bao decided to choose the most promising disciple as the successor, and planned to invest most of his resources in him in the future.

"The teacher talked to me." Xiong Huaxin sighed, "Actually, I think his decision is the right one, but I'm still a little disappointed."

"What's the point of being disappointed?" Li Youliang advised, "Sometimes there's no need to struggle in the hospital. You might be able to accomplish great things when you come out."

"I still think it's better to stay with my teacher." Xiong Huaxin hesitated and said, "After the project here is over, I will go back to X He and let's talk about the rest."

"Actually, I have a good relationship with my senior brother. He brought me here."

(End of this chapter)