Gou is practicing medicine in the clinic

Chapter 262: Eliminate one by one, diagnose by changing the way of thinking

Through routine blood tests, it has been basically determined that the cause of purpura is thrombocytopenia, which leads to subcutaneous bleeding in the patient.

The possibility of congenital blood diseases has been basically ruled out now.

Then the three common causes of acquired purpura are all questionable.

Because the patient has thrombocytopenia, Henoch-Schonlein purpura can be initially ruled out based on the characteristic that Henoch-Schonlein purpura is generally not accompanied by thrombocytopenia.

That leaves only drug-induced purpura and infectious purpura.

Wanting to determine which type of purpura it was, Li Jingsheng did not rush to apply for a new test, but started with thrombocytopenia and conducted further in-depth analysis.

At this moment, it is really only when the book is used that I hate it less.

The textbooks that medical students learn in school are definitely not enough.

Li Jingsheng usually likes to read books. When it comes to medical knowledge, he considers himself fairly knowledgeable.

But when it comes to clinically encountering such difficult diseases that are not his specialty, he is somewhat stretched.

I racked my brains to recall the common causes of thrombocytopenia.

Primary thrombocytopenic purpura can be divided into acute and chronic types.

In the acute form, severe spontaneous skin and mucosal bleeding may occur.

Platelets are usually less than 20 times ten to the ninth power per liter.

Children are most common.

This patient is nearly 60 years old, and his platelet count is currently around 80.

He initially ruled out the acute type.

Then let’s talk about chronic thrombocytopenic purpura. This disease mostly occurs in young people, and the incidence rate is higher in women than men.

Usually presents with a slow onset, with platelet counts between 30 and 80 being most common.

However, for this disease, those whose platelets are greater than 50 times ten to the ninth power per liter often have no obvious symptoms.

Therefore, there are also discrepancies with this patient.

At this point in Li Jingsheng's diagnosis, he was not in trouble.

Thrombocytopenia is not limited to primary thrombocytopenia, but also secondary thrombocytopenia.

He struggled to recall the relevant medical knowledge about secondary thrombocytopenia.

Fortunately, the doctor's level was upgraded to the deputy director level yesterday. Now, with divine help when making diagnoses, a lot of long-dusted medical knowledge is awakened as soon as I think of it.

The human brain is the most mysterious, less than 10% is developed.

Many are asleep.

And brain cells have their own set of new and old replacement mechanisms.Many memories will gradually become blurred over time. At this time, it is necessary to review or awaken this part of the memory to deepen and consolidate it.

This is why we will never forget the unforgettable moments even after decades.

Because these impressive things are often easily awakened multiple times.

But after the boring knowledge is learned, if it is not used, it may always be thrown in the treasure house of memory regardless of it.

Then as time goes by, it slowly fades away.

Li Jingsheng's doctor level was improved, and he felt that all the medical knowledge he had learned was awakened.These memories are reinforced.

And during diagnosis, that overall view becomes even more prominent.

The diagnosis of the attending physician is generally limited to the field in which he is good at, and at most he occasionally touches on other subdivisions.

The deputy chief physician's diagnosis already has a strong overall view, and he has a clear understanding of the nine major systems and three major circulations of the human body.Often when diagnosing diseases, cross-domain diagnosis can be made and analogies can be drawn.

"Secondary thrombocytopenia can be divided into several categories: drug-induced, infectious, immune-related, and blood diseases."

He succeeded in awakening this category of medical knowledge.

Drug-induced thrombocytopenia can be caused by the suppressive effect of drugs on bone marrow or by immunity.

If it is bone marrow suppression, it is often accompanied by anemia and leukopenia.

If it is immune, it often occurs after re-administration of drugs, usually manifesting as sudden onset and platelet dysfunction.

Such as giant platelet syndrome, thrombothenia, storage pool disease, etc.

This situation is very rare.

Preliminarily rule out the possibility of immune problems.

Then think of the patient's blood routine results showing that the white blood cell count is around 21, and the normal white blood cell count for adults should be between 4 and 10.

This is clearly a substantial increase.

If it is bone marrow suppression, the white blood cells should decrease, but why do they increase significantly?

At this point in the diagnosis, I started to get into trouble.

The difficulty of the cases that can be selected by the panel of judges as examination questions is simply hellish.

It is estimated that if this kind of patient is thrown into an ordinary tertiary hospital, he can directly wipe out several "bricks".

Li Jingsheng raised his head and looked at the doctors at the venue. Many of them had already chosen to give up with a look of defeat.

It's like asking a history student to answer economic questions. This is pure abuse.

No one likes to be abused.

Except for people like Li Jingsheng and Lian Tao who are naturally interested in studying medicine and really love medicine.

The vast majority of doctors choose to practice medicine, perhaps not because they love it at first, but because they just think that doctors have high income, good social status and stability.

Later, after working, I gradually discovered that treating diseases and saving lives can bring a great sense of accomplishment, which makes people very happy, and gradually fell in love with this profession.

Li Jingsheng lowered his head and stared at the tablet again. The diagnosis had reached this point. Seeing that there were only one or two steps left, there was no reason to give up halfway.

He finds it difficult, and others find it difficult too.

"We have to change our perspective and not dwell on the factor of thrombocytopenia."

After Li Jingsheng's diagnosis fell into trouble, he immediately made adjustments.

Change the diagnostic direction.

Digging into the wrong facts is the most common thing that happens when diagnosing difficult cases.

After all, every doctor is naturally full of confidence in his own diagnosis and knowledge.

Even if this self-confidence may be blind self-confidence, it will still lead to self-interest and cannot extricate itself.

Doctors who run clinics are different.

Especially when he is both the boss and a doctor, he always tries his best when diagnosing various cases.

Every effort must be made to find out the cause of the disease.

Because as long as the cause of the disease is found, accidents can be avoided and a large amount of treatment expenses can be earned.If it is a difficult case, it can also enhance the clinic's reputation and reputation.

With so many reward mechanisms, clinic owners will try their best to improve diagnosis efficiency when diagnosing various diseases.

"The patient's initial cause of illness was headache, sore throat, and fever. These symptoms are very similar to influenza. So could he be infected by a virus?"

Li Jingsheng decided to try it based on the patient's symptoms.

He stared at photos of patients' skin, zooming in so he could see the details.

The backs of the hands and legs were all covered with purple bruises of varying sizes.

He used to focus on the large purple spots, but now after changing his mind, he stared at some small purple spots.

"It is also possible that this is not subcutaneous bleeding but disseminated intravascular coagulation."

At this moment, cardiovascular disease diagnosis is somewhat useful.

"If it is really disseminated intravascular coagulation, it must be acute."

His ideas continue to make new breakthroughs.

On the second day after taking the medicine, the patient began to develop subcutaneous purpura on the face and limbs, varying in size.

It shows that the onset of illness is very urgent.

"Sudden purpura, acute disseminated intravascular coagulation, upper respiratory tract infection, pharyngeal pain and congestion, taking antibiotics and antipyretic analgesics before onset, headache, fever, mild tenderness around the umbilicus, mild thrombocytopenia, white blood cells and Neutrophils were significantly increased..."

He combined all the information with the results of the initial diagnosis, and then began to look for diseases that matched the symptoms of these diseases.

This method is actually very practical.

It is somewhat similar to a computer's intelligent search. The more comprehensive information provided, the more accurate the search results will be.

"Septicemia caused by meningitis seems to have more similar symptoms."

The most familiar one is meningococcal septicemia.

Li Jingsheng's eyes became brighter little by little.

"There is another doubtful point. The patient is accompanied by mild tenderness around the umbilicus, joint and femoral muscle soreness. These symptoms are very consistent with allergic purpura."

However, according to his medical knowledge and clinical experience, for patients with systemic extensive bleeding of skin and mucous membranes, the number of platelets is usually very low and generally cannot be higher than 50 times ten to the ninth power per liter.

In most cases of extensive bleeding, the platelet count is below 30.

"Would you like a chest X-ray?"

If possible, you can also check an electrocardiogram.

It's just that one or two points will be deducted for each additional inspection. He seems very cautious.

He still suspected that viral meningitis was more likely.

If this is the case, it would be a waste to check ECG and chest X-ray.

It's better to check for blood gas analysis.

Even though its name sounds very technological, it is actually just a routine inspection.

Blood gas analysis mainly extracts a portion of arterial blood to check related indicators.

Including oxygen partial pressure, carbon dioxide partial pressure, lactic acid and other indicators.

It is mainly used to evaluate the microcirculation metabolic function status of the human body.

After clicking on this check application, he was deducted another point.Two points have been deducted.

So far, a blood routine and a blood gas analysis have been checked.

After clicking on the blood gas analysis, the results came out quickly.

This shows that this examination item has been done during the diagnosis and treatment of the patient.

He was secretly happy that the path should be right.

It seems that more than a year of training in the clinic has not been in vain.

Of course, the main thing is that I gained the most in the three months after I obtained the attribute panel.

It's hard for a good woman to make a meal without straw. If it hadn't been for the increasing number of patients seeking treatment in the past three months, which gave him ample opportunities to practice, he wouldn't have been able to improve so quickly.

Blood gas analysis results: metabolic acidosis was decompensated, the partial pressure of carbon dioxide was 27.6mmhg, the partial pressure of oxygen was 132.7mmhg, serum potassium was 2.7mmol/l, and sodium and chloride were all within the normal range.

The urea nitrogen is 29.9mg/dl, the hemoglobin is 163g/l, and the white blood cells are 18 times ten to the ninth power per liter.

Neutrophil spot 89%.

Platelets 43 times ten to the ninth power.

Seeing this result, Li Jingsheng's lips twitched.

It's just a BUG.

The patient's platelet count was around 80 when he was first admitted to the hospital, and now it's 43.

It means that the result was found after the patient was admitted to the hospital and treated.

In this short period of time, the patient's platelet count dropped by nearly half.

Is this a problem after medication?
Or has there been a major change in the condition?
Li Jingsheng smiled like a thief and thought to himself.

He looked up at the venue again and found that someone had the same thief smile as him.

It seems that these doctors also thought of requesting a blood gas test.

You have to hurry up, otherwise it would be a pity if someone takes the lead.

He was confident that so far, there were only a handful of doctors like him who had only used up two routine examination opportunities.

We do not rule out big names in the field of blood diseases, because they have extremely rich clinical experience and may have used fewer examination opportunities than him.

Experts with real strength can really be so perverted in their fields of expertise.

You can even diagnose the cause just by listening to the patient's description of the condition.

He took a look at the blood gas analysis time and saw that it was only more than two hours before the patient was admitted to the hospital for initial diagnosis.

In such a short period of time, the patient should not have had time to go through the hospitalization procedures.

When a hospital receives this kind of patient, it is impossible to just admit the patient to the hospital without doing any examination.

Otherwise, the hospital would have gone bankrupt 800 years ago.

Not every family member is easy to talk to.

If one person dies, the compensation will be at least hundreds of thousands.Even in a larger hospital, if one or two patients die every day, the hospital's day is basically in vain.

Moreover, the mortality rate is too high, which will trigger a variety of supervision and assessment.

This patient went to the hospital for treatment at around eight o'clock in the evening because he was afraid because he had a lot of purpura on his body.

What if I fall asleep at night and become warped?
The patient himself is not afraid, but his family members are too.

I must have rushed to the hospital overnight.

In the evening, all specialist outpatient clinics are off duty, and only the emergency department and emergency center are on duty 24 hours a day.

The patient only has purpura on his skin, and it is impossible to go to the sudden attack center to call the center.

Even if you go there, they won't accept it.

Because this is not chest pain or cardiovascular disease at all.

So I can only go to the general emergency department.

The emergency department does not have the authority to admit inpatients, so specialists must be hired to recruit patients.

Based on this analysis, Li Jingsheng estimated that the patient had been queuing up and undergoing various examinations for two hours after being admitted to the hospital.

Many of the emergency doctors who work at night are young doctors with little experience.

Is it possible to skip the inspection?
What young doctor wouldn't feel trembled when he saw the purpura all over his patient's body?
Then you must do all the tests that need to be done!

Therefore, the patient should not have received any treatment for these two hours.In just two hours, the condition changed so quickly that ordinary viral meningitis is not capable of this.

All Li Jingsheng could think of was fulminant meningitis, the acute kind.

The patient's platelets suddenly doubled, which would definitely be unbearable.

At this time, he was probably in a state of shock.

He secretly speculated on the patient's condition at that time.

The examiner was also a thief and deliberately did not tell everyone the information about the progress of the disease.Let the participants make their own diagnosis and make up their own minds.

Those experienced doctors have a great advantage.

For example, Li Jingsheng was one of them. When he thought that the patient's platelets had dropped by half in two hours, to nearly 40, he could immediately predict that the patient was in a state of shock.

It is impossible for a hospital to just watch a patient die, and emergency doctors will definitely start rescuing the patient immediately.

Blood gas analysis revealed acidosis.

But were the blood gas analysis results taken before the patient went into shock or after the shock?

It is estimated that most of them were emergency replacements after shock.

When a patient goes into shock, most of the doctors who treat him will panic. If the cause of the disease is unknown, how can he be rescued?

Although the patient had signs of respiratory infection before admission, who can be sure that pneumonia caused the shock?

The rescue measures at this time must be conservative.

Strengthening antibiotics and actively replenishing blood volume are routine operations.

Large hospitals are most likely to give such patients first aid, replenish blood volume, and transfuse crystalloids and plasma.

And a catheter should be inserted to maintain the urine output at about [-] ml.

In order to make the rescue effect more ideal, booster drugs should also be used.

After taking the vasopressor, Li Jingsheng predicted that the patient's purpura might get worse, and the possibility of the small flakes turning into a large one was very high.

This case was selected for the examination questions, indicating that the patient was definitely cured in the end.

Otherwise, wouldn’t the hospital and the attending doctor who received the patient be slapped in the face?

Besides, if the patient dies, the answers to the test questions will be full of uncertainty.

Many treatments can only be used on patients, and you will only know whether they work after trying them.Instead of just predicting based on experience, you can get the answer.

After figuring it out, Li Jingsheng began to make inferences based on the results.

In the end, it was still determined that fulminant meningitis was the most likely case.

Idiopathic thrombocytopenic purpura was completely abandoned by him because of some inconsistencies.

Without any further hesitation, he directly wrote in the answer column. Because the patient's platelets dropped sharply about two hours after being admitted to the hospital, he suspected that the patient was in shock, indicating that the condition was progressing rapidly and fiercely.There are many discrepancies in idiopathic thrombocytopenic purpura. The patient had symptoms such as respiratory tract infection, headache, and fever before admission. Blood gas analysis showed acidosis. Therefore, I believe that fulminant meningitis is most likely to be caused by viral infection.

After writing, he gave treatment measures.

It is recommended that after anti-shock treatment, a large dose of 1100 million units of penicillin should be given intravenously, and fluid and potassium should be added to correct the acidosis.Endotracheal intubation and ventilator-assisted first aid can be performed if necessary.

After writing the answer, submit it.

He let out a soft breath.Although he was only answering a question, it still felt like he was on the battlefield in person, carrying out a life-and-death rescue for a purpura patient.

Vice Dean Jin, who was leading the team, looked at Li Jingsheng in surprise.

Because there are so many doctors coming to the Second Hospital, many of them just clicked on the tablet computer to have a look, and then gave up quickly.

The only person who persisted until the end and wrote the answers on the tablet was Li Jingsheng.

"Newborn calves are not afraid of tigers! No matter whether the answer is correct or not, at least the attitude of actively participating in the competition is very good."

Dean Jin felt that the score was also zero, and it was better to write down the answers than hand in a blank paper.

But he felt that the first test question was indeed a bit difficult, because he secretly observed the entire venue, more than 3000 contestants, and more than 95% of the doctors could not persist for more than 5 minutes.

Time passes little by little.

The host switched the large screen on the stage to show a countdown screen.

And there was a ticking sound of time.

This is to remind the contestants to take the time to answer the questions.

Because it is a competition with thousands of people participating, it is impossible to allow the contestants to answer questions without time limit.

"Okay, time's up! Thank you to every participating doctor for your active participation. Please see the system scores and rankings below."

As soon as the host finished speaking, the picture on the big screen changed again.

"Scoring is in progress!"

These days, high technology is good.

If the scores were scored manually, the judges would be exhausted on the spot.And being able to produce results within one day is considered very efficient.

More than 3000 pairs of eyes were glued to the big screen.

Many people held their breath and watched nervously.

Especially those contestants who successfully submitted their answers were nervous and looking forward to it.

Who doesn’t want to show off in the first game?

Everyone wants to win glory.

Li Jingsheng looked indifferent, because this was not his area of ​​expertise.It's natural to be happy to get the ranking and get off to a good start.

If he failed to enter the rankings, this diagnosis also brought him great progress.

(End of this chapter)