This doctor has a system

Chapter 531 594. Let’s verify it
"Now, please allow Mr. Gao to give a speech!"

"Please invite Mr. Li to say a few words to everyone."

"Now, please welcome Mr. Zhao, the general manager of the company, to give us the first

Qi Siyuan in the audience was confused at the moment. He remembered what he had said: It is difficult for you to become my colleague with your qualifications.

But if you think about it carefully, it seems to be true. Leaders are not considered colleagues.

"Did you see that person?"

"I saw it. It seems to have just arrived this year." Hu Jiaran said.

"Qi Siyuan, from Group 3." Yue Penghui added.

"Find a reason to scold him for me." Li Youliang said, "This kid was acting so arrogant at the door just now."

Qi Siyuan was scolded that day.

"You can't recognize any of the top three leaders in the company? Are you blind?" Yue Penghui said helplessly, "What do you do every day?"

"Doing an experiment." Qi Siyuan replied weakly.

"Everyone is doing experiments, what? Are you the only one who does the best?"

"I am indeed the best in our group," said Qi Siyuan.

"Get out! You are hopeless." Yue Penghui drove him out. "Just do experiments for the rest of your life! Don't even think about getting promoted!"

"Oh my god, I thought you were going to fire me." Qi Siyuan breathed a sigh of relief and left happily.

As for promotion?

Who in their right mind would want that?
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"Director Gao, please come and have a consultation with us." Director Ding from the Department of Gastroenterology called.

"Okay, I'll go there now." Gao Feng agreed straightforwardly.

Director Ding from the Department of Gastroenterology is quite familiar with him, because the gastrointestinal endoscopy and bronchoscopy rooms are next to each other, and the two often meet.

Director Ding looked a little older than before, his hairline had receded again, and he looked terribly strong. At the moment, he was frowning.

"My dear niece." Director Ding sighed, "We have not been able to find out the cause of the disease." This put him under a lot of pressure.

The patient, Xiao Meng, female, 15 years old, was admitted to the hospital with abdominal pain as the main symptom.

This was not the first time Xiao Meng had experienced abdominal pain. The patient had experienced similar symptoms twice before, but there was no clear diagnosis.

Five months ago, the patient first experienced abdominal pain, and the local hospital suspected that it was intestinal obstruction caused by fecal obstruction. The second episode of abdominal pain was mainly manifested by abdominal pain, constipation, limb pain and hypertension.

According to the patient and his family, the patient was generally in good health 6 days before admission.

The patient reported that the abdominal pain was of acute onset, originating from the left lower abdomen. The pain was non-radiating, colic-like and burning in nature, with fluctuating pain intensity, accompanied by multiple vomiting, with no bile or blood in the vomitus, and loss of appetite.

He had intermittent constipation for the past five months, with only one bowel movement per week. He had no history of fever, cough, chest pain, weight loss, lower limb edema, hematuria, or loss of consciousness.

"When I came in, my blood pressure was very high, so I was given urapidil." Director Ding pulled up the medical records. "During my hospitalization, I had a generalized tonic-clonic epilepsy, and I was given anti-epileptic drugs."

"There are a lot of problems." Gao Feng said.

"Who said it wasn't true?" Director Ding was so worried. The patient was his niece. His elder brother and sister-in-law came to the office every day to criticize him, saying that he was not paying enough attention if the child was not being cured.

It's very annoying.

At the beginning, when my brother called him, Director Ding didn't take it seriously at all. It's just a stomachache. I called Ping'an County.
The most common symptom is abdominal pain!

"Do you still need to come to me for such a minor illness? Go to the county hospital and see a doctor."

Why use a butcher knife to kill a chicken? Director Ding thought.

My niece stayed in the county hospital for a few days. The doctor in charge had several white hairs and saw no improvement at all, so she finally came to the provincial hospital.

Gao Feng looked at the medical records carefully and found that the patient's examination was very thorough, and all the necessary and unnecessary examinations were checked.

入院的体格检查显示：血压（190/100 mmHg）、呼吸频率（21次/分钟）、SpO2（93%）、脉搏（100次/分钟），呼吸系统和心血管系统检查正常。

Abdominal examination revealed mild tenderness but no organomegaly or renal artery bruits.

Central nervous system examination was unremarkable, and the Glasgow Coma Scale (GCS) was 15/15.

The complete blood count was within normal range at admission, and mild anemia was present, with a hemoglobin of 12 g/dl. After admission, amlodipine was given to lower blood pressure, polyethylene glycol was given to treat constipation, and 3% sodium chloride infusion and oral salt replacement were given to correct the sodium level.

However, the serum sodium (109 mEq/L) and magnesium (range, 1.1 to 2.4 mg/dl) could not be corrected after treatment, so a disorder of the renin-angiotensin-aldosterone system was considered.

进一步检查血清醛固酮为49 ng/dl（直立位3.1-35.1 ng/dl），直接肾素为181IU/ml（直立位4.67-47.60IU/ml），醛固酮肾素比（ARR）为0.28，尿钠排泄量也升高（169 mEq/L）。

Therefore, unilateral renal artery stenosis (RAS) was suspected. To confirm RAS, abdominal Doppler and pelvic CT were performed, but the reports showed normal results, excluding the diagnosis of renal artery stenosis.

"I did two gastrointestinal endoscopies and found no hair."

I tried some antispasmodic and gastrointestinal motility-promoting drugs, but the effects were minimal.

As soon as they arrived at the door of the ward, they heard an argument coming from inside.

"I think we should go to Beijing," said Director Ding's sister-in-law. "We've been here for so long, but we haven't found anything. It's just a waste of time."

"What do you know!" A male voice sounded. It should be Director Ding's elder brother. "The main reason is that our girl's condition is a bit complicated. Besides, can you rush to see a doctor? Is rushing useful? If you can, go ahead! If not, stop talking!"

"Then go talk to your brother and ask him to worry more and find a few more experts to take a look."

"Okay, I'll put some more pressure on him," said Director Ding.

"Stop putting pressure on me!" Director Ding pushed the door open and walked in unhappily. "This is Director Gao from our hospital. He's the best at treating difficult and complicated cases."

"Xiao Meng!" He walked forward and nudged the sleeping girl, "What time is it? Wake up!"

Xiao Meng is a little fat, but she is very tall and looks like a cute big fat girl. This should be inherited from her mother.

Gao Feng conducted a detailed physical examination and found only mild tenderness in the left lower abdomen, and no other valuable findings, which was a bit disappointing. As the saying goes, internal medicine is afraid of fever, and surgery is afraid of abdominal pain.

Unexplained abdominal pain is indeed worrying. Director Ding even thought of a surgical laparotomy, but the general surgery doctors were reluctant to do it.

"It doesn't look like a surgical disease. Besides, your niece is too fat. It would be troublesome if the fat liquefies."

"Director Gao, do you think we need to do other examinations?" asked Director Ding.

"I have no idea yet." Gao Feng said honestly, "I'll take a closer look later."

"Okay, call me directly if you have anything." Director Ding was not overly disappointed when he heard this. His niece's problem was obviously very complicated, and it was impossible to draw a conclusion at a glance. He was mentally prepared for this.

After Gao Feng returned, he carefully read all of Xiao Meng's medical records and found many problems. First of all, this medical record was definitely written by an intern or resident.

"Director Ding Hua's ward rounds on July 7. Today the weather was fine. I followed Director Ding to make ward rounds. The patient's vital signs were stable. Director Ding asked: "Are you feeling better, niece?" The patient shook her head. Director Ding's face suddenly darkened."

However, although it is written in a mess, it also has its advantages, that is, it records in great detail.

"The patient complained of severe pain in both lower limbs, which she had never experienced before. The pain lasted from 2pm to 4:pm. The doctor on duty came to see her and said she should take some painkillers. The patient didn't want to eat because of the pain, which posed a huge challenge to her obese body."

"Today the patient had abdominal pain again, and Director Ding asked me to tell her not to eat first. But the patient said in the afternoon that not eating would make the abdominal pain worse. I quickly ran to tell Director Ding, and he frowned and said: You are being pretentious!"

"I asked if the patient could eat, but Director Ding waved his hand at me impatiently and said, 'Eat, eat, eat as much as you want!'"

"I immediately informed the patient of the latest instructions from the senior doctor. She was very happy and told me that her abdominal pain had improved a lot after drinking a cup of porridge. The family members said that doctors in large hospitals are serious and responsible."

A teacher once told me that a student wrote his chief complaint like this: I couldn’t urinate for three days.

The two have the same effect.

After laughing, Gao Feng fell into deep thought. It was really strange that a young woman, who had been in good health before, suddenly developed abdominal pain accompanied by so many complex symptoms.

Is there a disease that can combine all these symptoms?
Director Ding had previously considered allergic purpura as the abdominal pain, but the patient had not developed skin purpura, and the treatment for this disease had no effect after several days.

Gao Feng thought hard for a long time but couldn't figure it out.

Three days passed quickly. Gao Feng had just finished his ward rounds that day when Li Youliang came over and told him about the situation.

"Director Ding's niece was transferred to a critically ill patient today."

"Why?" Gao Feng was a little surprised. He seemed to be in good condition a few days ago.

"Since yesterday afternoon, the patient has had frequent epileptic seizures and his state of consciousness does not seem to be very good."

Gao Feng always remembered Director Ding's niece and asked Li Youliang to visit her every day. She was fine yesterday morning, but he didn't expect her condition to deteriorate so quickly.

"Let's go and see."

Director Ding was there when the two of them arrived at the intensive care unit. When he saw Gao Feng, he forced a smile on his face.

"I don't know what happened, it suddenly became not working." Director Ding was under a lot of pressure. He regretted letting his elder brother and sister-in-law come here. He should have let them go directly to Beijing.

Even though they are relatives, it would be more difficult to explain if something really went wrong.

Xiao Meng is in a sedated state at this time. The neurologist has just given her some medication, and her vital signs have stabilized.

Abdominal pain, high blood pressure, epileptic seizures, lower limb pain. One symptom after another flashed through Gao Feng's mind.

For some reason, he suddenly remembered the medical record written by the intern, which mentioned that the patient's abdominal pain worsened when he was fasting, but eased after drinking porridge.

Does carbohydrate intake affect the condition?
Gao Feng vaguely felt that he seemed to have grasped something.

He immediately walked to the doctor's office in the intensive care unit and sat down. There were several doctors inside. When they saw him, they greeted him with a smile, and Gao Feng responded.

"Could it be porphyria?!" Five minutes later, Gao Feng suddenly stood up and Li Youliang who was standing next to him was startled.

"No way." Director Ding was a little hesitant. He was quite familiar with this disease.

Porphyria is a type of disease caused by a lack of enzyme activity in the heme biosynthesis pathway, which leads to an abnormal increase in the concentration of porphyrin or its precursors, such as δ-amino-r-ketovaleric acid (δ-ALA) and porphyrinogen (PBG), and their accumulation in tissues, causing cell damage.

Patients may commonly experience skin symptoms, digestive system symptoms, and neuropsychiatric symptoms.

Some patients will develop chronic blistering photosensitivity reactions after their skin is exposed to sunlight, including congenital erythropoietic porphyria, tarda cutaneous porphyria, hepatoerythropoietic porphyria, etc.

"Director Gao, my niece doesn't seem to have any symptoms like this."

"Director Ding, you may not have a comprehensive understanding of this disease." Gao Feng explained, "Porphyria cutanea tarda is the most common porphyria, but your niece should be suffering from acute intermittent porphyria."

The prevalence of acute intermittent porphyria (AIP) is estimated to be 10-5 cases per 10 people. Females are more likely to be affected by the disease, symptoms usually appear during adolescence, and about 90% of patients may remain asymptomatic throughout their lives.

Common clinical manifestations of AIP include altered consciousness and unexplained abdominal, chest, and back pain. Dark or red urine, new-onset hypertension, hyponatremia, proximal muscle weakness, and pain related to the menstrual cycle may also be present.

“A low-carb diet can make the condition worse!”

Gao Feng felt that his guess was correct. He reviewed all of Xiao Meng's symptoms and found that they could all be explained by this disease.

"Let's verify it."

How to verify it?
In fact, the method is very simple, that is the urine exposure experiment: urine porphyrin sun exposure test.

The colorless porphyrin in the patient's urine can be converted into colored porphyrin compounds under light. Therefore, if the patient's fresh urine is placed in the sun for several hours, it will turn brown-red. This is a characteristic manifestation of patients with acute intermittent porphyria (AIP).

Xiao Meng has been given a urinary catheter by the nurse, so it is very convenient to collect urine.

Most patients admitted to the intensive care unit have two tubes: a urinary catheter and a subclavian vein catheter. If they are unfortunate, they will also have to have a tracheal intubation, a gastric tube, a jejunal fistula tube, a PTCD drainage tube, a femoral artery ECMO catheter, and an intra-aortic balloon counterpulsation tube.
Some people always want to take care of this and that, so why not live there for a few days?

Once you get in here, you’ll have enough!
The results of the urine drying experiment confirmed Gao Feng's judgment. Xiao Meng's urine turned brown-red after being exposed to the sun for several hours, which is a characteristic manifestation of patients with acute intermittent porphyria.

Another urine sample was taken for the Watson-Schwartz test, which was also positive, indicating the presence of porphyrinogen in the urine, further confirming the diagnosis of acute porphyria.

Although the diagnosis was clear, Director Ding was still a little unhappy.

(End of this chapter)