Gou is practicing medicine in the clinic

Chapter 366: Tumor within a tumor, strange persistent high fever and chest pain
Li Jingsheng carefully checked the patient's detailed information.

The patient is over 50 years old.

Generally speaking, the older you are, the higher your risk of cancer.

When men are over 40 years old, their physical functions decline significantly, and their risk of cancer also rises sharply.This is why many doctors recommend that men after the age of 45 should have a gastrointestinal endoscopy every year as much as possible to screen for various serious diseases.

The male patient reported symptoms of coughing, breathlessness, and sometimes a burning sensation between his chest and back.

The symptoms lasted for almost three months.

After examination by the treating doctor, the patient had paroxysmal and continuous coughing, and would cough up a small amount of white viscous sputum. The patient had a low fever of 37.5 degrees.

A low-grade fever, and a continuous low-grade fever, is a very bad phenomenon.

Every time Li Jingsheng encounters this kind of patient, his heart is always hanging.

Because the final diagnosis is often poor.

In addition to low fever, the man also had a serious problem. Within three months, he lost 4.5kg in weight.

Currently, I also have difficulty breathing when eating.

In particular, it became extremely difficult to breathe in, as if someone was strangling my neck.

No wonder Director Lian Tao suspected that the man's esophageal tumor was not benign.

The patient's pulse was 101 beats per minute, which was considered too fast.

Clinically, the diagnostic criteria for a heart rate of 98 beats per minute are equivalent to 101 beats per minute.The doctor's diagnosis is often that the heart rate is too fast.

Rather than being dogmatic, as long as the heart rate is between 60 and 100 beats per minute, it is considered normal.

At the same time, the patient's blood pressure was also on the high side.

High pressure 145mmhg, low pressure 88mmhg.

This is another blood pressure value for a stuck line.

The standard for identifying high blood pressure in textbooks is that systolic blood pressure exceeds 139 and diastolic blood pressure exceeds 90mmhg.

Even though this patient's blood pressure only exceeded 6 mmhg, it already fell into the category of mild hypertension.

The ideal blood pressure is 120 for high pressure and 80 for low pressure.

Too high or too low is not a good thing.

The patient's lung sound examination showed scattered wheezing.

Regular heartbeat.

Li Jingsheng looked at the patient's blood routine results again and found that the white blood cell count was as high as 13.4 times ten to the ninth power per liter, which was already much higher than the normal value.

The patient's liver function was normal, renal function urea nitrogen was 19.7mmol/L, and other electrolytes, fasting blood sugar, and blood uric acid were all normal.

"Have you had a fiber esophagoscopy?"

"Check! The result should be at the bottom!"

Director Lian Tao replied.

Li Jingsheng checked the microscopic examination results and found a round mass on the front wall 24cm away from the front teeth, about three centimeters in diameter.The surface mucosa is smooth and flat, the wrinkles disappear, and it is light red and translucent.

The mass may move slightly as the patient swallows.

The boundaries are clear.

This tumor should undoubtedly be an esophageal leiomyoma.

Microscopic examination revealed only this tumor.

Li Jingsheng did not find a direct diagnostic basis for malignant tumors. Like Director Lian Tao, he was also confused.

While thinking hard, he couldn't help but think of Secretary Bei's child who was transferred to the People's Hospital for rescue not long ago.

The cause of that child's illness is also extremely obscure.

Cryptococcus is obviously a fungus, but it disguises itself as a virus and sneaks into the child's head to cause trouble.

Could there be something fishy about this tumor?
"Esophageal smooth muscle tumors are usually not particularly large, but the diameter of this tumor is more than three centimeters, and the height of the bulge is different from common esophageal smooth muscle tumors. Do you think it is a tumor within a tumor?"

This was the only thing Li Jingsheng could think of.

Because in the early stages of malignant tumors, the nutrients absorbed by the body are not obvious, and significant weight loss is unlikely to occur.

It is really possible that it is a malignant tumor, either not in the esophagus, but somewhere else in the body.

Or it's a tumor within a tumor.

It looks like a benign leiomyoma on the outside, but there is a malignant tumor hidden inside.

Although this is extremely rare, it can still happen.

Just like some people who hide bad intentions, but appear to be gentlemen on the surface.

"A tumor within a tumor?"

Lian Tao's eyes lit up slightly.

"It's really possible. I have to communicate with the patient and arrange a needle biopsy."

He needs to take pathological specimens from inside the tumor for testing.

Normally, only some tissue cells on the surface are scraped when taking a specimen.

"Jingsheng, there are two more cases here. They are both difficult cases. You can also help me with the staff. I will go to the ward and I should be back in about half an hour at most. If you are thirsty, you can get some water. There are snacks here. There are a lot of them in this drawer, you can eat whatever you want.”

After saying that, he left in a hurry.

It's comfortable to have your own office.

It is equivalent to a private space.

Ordinary doctors can only share one office, and many doctors don't even have fixed seats.

This is why people who have mistresses in hospitals are often directors or hospital-level leaders.With a separate office, female subordinates can come in to report work, which is easy to create this convenience.

As long as the woman agrees, there is basically no obstacle.

Li Jingsheng watched Lian Tao rush to the inpatient ward and couldn't help but smile and shake his head. Brother Lian Tao's resolute character should be very popular with patients.

It is also a sign of caring about the patient.

He moved on to look at two more cases.

The patient, an 18-year-old male, had severe pain when swallowing and was accompanied by a high temperature of 39.7 degrees.

The consultation information stated that swallowing pain has lasted for more than a month.

However, it was not until the patient developed symptoms of difficulty breathing that his family took him to the hospital.

After being admitted to the local hospital, the patient was given a chest X-ray and no abnormalities were found.

First, the patient was treated as prescribed for strep throat, but to no avail.

Then treat enteric typhoid fever.

Various antibiotics and oral chloramphenicol were used, but no significant improvement was seen.The high fever never went away.

Li Jingsheng also gained knowledge.

The quality of county hospitals varies, but the diagnostic quality of this county hospital is really lame.

In fact, it is also a sad failure of many health centers, county hospitals and other primary medical care. Doctors cannot see patients and can only perform mechanical examinations.

After taking X-rays, blood tests, urine tests, and stool tests, no problem was found, and then the doctor began to doubt his life.

None of the 51 textbooks I read in school taught students how to diagnose patients with normal test results.

Pharmacology talks about medication, medication for various infections and diseases, as well as precautions, pharmacology, etc.

Human parasitology talks about the symptoms of parasitic infection and what methods can be checked...

But if the test results are normal, that means... you are not sick.

Sometimes in the hospital outpatient department, patients can be heard arguing with doctors.

"Why do I come to your hospital for treatment when I'm not sick?"

The patient roared.

The doctor looked aggrieved, "But your test results are all normal, and you are indeed not sick."

Such quarrels are not uncommon.

What happened to this 18-year-old boy in the county hospital is probably a challenge.If he hadn't been suffering from a high fever, the doctor might have said he was fine.

The patient's pulse was 123 beats per minute, and his blood pressure was only 92 high pressure and 68 mmhg low pressure.

Systolic blood pressure is 90-139mmHg, and diastolic blood pressure is 60-89mmHg, both of which are within the normal blood pressure range for adults.

There is something wrong with this big boy's blood pressure, but there is not.

It's just that the high and low pressures are a little on the low side.

What causes this situation is actually a sign that something is wrong with your body, but it's just not very obvious.

Li Jingsheng looked at the admission time. This was already the fourth day of admission.

The first doctor was not Lian Tao.

Probably from his group.

Cases that the attending physician cannot handle will definitely be referred to the chief physician or deputy chief physician.

This boy's situation is actually quite dangerous. If it continues, an accident may easily occur.

Lian Tao must have just taken over, and he hasn't been able to find out the cause yet.

He is so busy all day long that he has very little time to devote to each case, which is indeed not easy.

This time I called Li Jingsheng over to play, and I happened to ask Li Jingsheng to help share some of the burden.

After all, patients cannot afford to wait. The longer the delay, the less likely the patient is to die.

The patient's blood cell count was only 5.7 times ten to the ninth power per liter.

First, this white blood cell count is normal.

But the patient has continued to have high fever for more than a month. Could it be that the body's immune system has simply become a decoration?

Obviously impossible.

High fever itself is a sign that the body's immune system is working overtime.

The most common causes of high fever in the body are viral or bacterial infections, or inflammation somewhere in the body.

For example, the most common tonsil inflammation will soon cause a body fever.

The patient's urine protein was obviously abnormal, which was two +.

The white blood cells were also abnormal, much higher than the normal value.

Feces were common but no abnormalities were found.The blood non-protein nitrogen was 48mmol/L, the carbon dioxide binding capacity was 22mmol/L, and the erythrocyte sedimentation rate was 26mm/H.

Chest X-ray examination revealed a hydropneumothorax on the left side of the chest.

and pneumomediastinum is present.

Judging from the film, the left lung was compressed by at least 30%.

It is also accompanied by a small amount of effusion.

This illustrates a problem. The patient had a chest X-ray taken at the People's Hospital and found a problem. Why did the chest X-ray taken at the county hospital show normal?
Is it because the patient's chest was normal when he went to the county hospital for treatment, but his condition has progressed continuously in recent days, which led to the abnormality detected in the chest X-ray? Or is it because the county hospital's examination equipment is backward and the doctor who took the X-ray is poor, so the problem was not detected ?

Based on Li Jingsheng’s experience in opening a clinic, it is likely the latter situation.

The equipment is backward, the doctors are of poor quality and have insufficient experience.

After reviewing all the patient's symptoms, medical history, examination results and other information, he began to make a comprehensive diagnosis for the patient.

Whether it's diagnosis in respiratory medicine, gastroenterology, or cardiovascular medicine, Li Jingsheng is good at it.

The first thing he suspected was whether the patient had sepsis?
Judging from the patient's current symptoms, they are very similar to gram-negative bacilli sepsis.

But how to explain the left hydropneumothorax and accompanying pneumomediastinum?

If air wants to enter the mediastinum, without obvious trauma, it usually enters the mediastinum from the pulmonary interstitium to the hilus, causing pneumomediastinum.

Li Jingsheng has fairly rich clinical experience in this area.

Causes pneumomediastinum, usually due to pneumothorax.

So what causes pneumothorax?

He began to quickly form a counterargument in his mind.

From the analysis of the film taken by the patient, it is likely that pneumothorax was caused by emphysema and ruptured bullae.The patient's high fever lasted for more than a month, and it was inevitable that the body would show obvious symptoms of poisoning.

The possibility of sepsis may be considered.

So what causes sepsis?

Moreover, the real cause of pneumothorax requires further investigation, and the diagnosis cannot be made entirely by inference.

At least some favorable evidence needs to be obtained.

"Brother Lian Tao is really not easy. None of the cases brought to him are easy."

The key is that Lian Tao is also a dual-disciplinary director.

Not only responsible for the Department of Respiratory Medicine, but also responsible for difficult cases in the Department of Gastroenterology.

If this patient's condition is accurate, it is no longer a simple respiratory medicine department, but more appropriately called a thoracic medicine department.

Li Jingsheng reviewed the patient's various examination results again.

The white blood cell count is normal, even on the low side.

At the same time, among the patient's symptoms, many symptoms such as cough, purulent sputum, and chest pain were not obvious.

This disease is so weird.

"Perhaps if you go to the ward and find out more about the situation from the patients and their families, you will find out more."

Li Jingsheng took the patient's basic information and left the office.

He closed the door easily.

Although there are no valuable items inside, you must be aware of precautions.

It is already evening, and many doctors and nurses have gone off work long ago, leaving only the medical staff on duty.

They are still very busy.

The main reason is that the number of patients admitted here is overloaded, and all the temporary beds are full.It is estimated that there are many patients outside who want to move in, but they have to wait for beds.

Only when new beds become available can new patients be admitted.

Li Jingsheng found bed No. 73 based on the information on the list.

The patient is still living in the hallway.

A middle-aged couple was standing beside the hospital bed. Judging from their clothes, they seemed to be in ordinary condition.

The patient lies on the hospital bed in a semi-recumbent position.

It is estimated that the patient's current symptoms are very severe, and lying down will make it more difficult to breathe.

Lying in this semi-recumbent position can make him more comfortable.

He looked like a skinny boy with a sickly look on his face.

"Xu Jie, is that you?"

Li Jingsheng did not wear a white coat. Fortunately, he now has a successful career, good love, and good conditions in all aspects, so he is in very good spirits.The presentation is also excellent.

People can tell by looking at him that he is a social elite.

"Correct!"

The boy opened his eyes and looked at him.

The child's parents looked at Li Jingsheng with wary eyes.

There are often money scammers, salespeople, and even medical consultants sneaking into hospitals.

The deceptive methods and routines are really hard to guard against.

The key is that many of these scammers appear in nurses' uniforms or doctor's white coats, making it difficult for ordinary patients and family members to tell the truth from the lies.

They are very good at understanding the feelings of family members and patients, and they will also pin a work ID card on their chest or above their pocket.

Of course, if you look carefully at their work ID cards, you can find some tricks.

"You took a chest X-ray at the county hospital, but I didn't see it. Did you bring the X-ray here?"

Li Jingsheng asked.

"Take it, take it, your doctor Liu here has seen it once and said that the film taken by the county hospital has no reference value and asked us to take it again."

the patient's mother replied.

"Show it to me!"

Li Jingsheng nodded. Almost most large hospitals operate this way and do not recognize the films and examination results from other hospitals.

There are indeed certain differences in the laboratory level and the advanced level of instruments between the two parties.

The patient's mother took out the information bag from under the bed. After Li Jingsheng took it, he took it out and looked at the light.

The X-rays taken in the county are indeed not of high definition.

But it's much better than Li Jingsheng's old grandfather machine.

At that time, he used his grandfather's machine once and wanted to smash it once.

I accidentally developed the ability to watch such unclear movies.

In the eyes of the doctor at the People's Hospital, this was a film made with junk equipment. In his opinion, it was pretty good.

At least there is some basis for reference.

After carefully watching the film, no shadow of lung inflammation was found.

That can basically rule out the possibility of Staphylococcus aureus pulmonary infection.

"Have you ever had vomiting symptoms?"

"no!"

"Where did you feel uncomfortable when you first got sick? Do you still remember it?"

"I felt a little sore in my throat at first. Later, whenever I ate, I felt severe pain in my chest. It still hurts even if I don't eat, but it's not as painful as before."

The patient describes the onset of the disease.

The sore throat he was referring to was probably a sore throat.

Pain occurs only when swallowing, indicating that the lesion may be red, swollen and inflamed, or that the lesion is not actually in the throat, but in the area below the throat.

There will be a lifting movement when swallowing, especially the chest will move along with it, and the lesion is likely to be in the chest.

Li Jingsheng made a judgment based on clinical experience.

As for the patient who said that the pain is not as painful as before, it may be that the lesion area is seriously infected and the pain continues to numbness.Or the terminal nerves at the lesion site have been damaged.

The human body feels pain because prostaglandins, a hormone substance, stimulate nerves.

Taking cold medicine such as ibuprofen will reduce pain, which takes advantage of this mechanism.

"Can I see your breasts?"

"can!"

The patient agreed to let his mother help him unbutton his clothes.

He seemed to be in extreme pain whenever he raised his arm, and during the conversation, the patient was breathing very heavily.There is severe wheezing.

Li Jingsheng observed the patient's chest and abdomen and found no obvious problems such as depression or bulge.

He tried to press the patient's chest and abdomen, and found an obvious tenderness response in the middle of the sternum.

After the patient was admitted to the People's Hospital, he has undergone a number of infection control treatments, but the high fever has not gone away.

It shows that infection control has no obvious effect.

When this happened, Li Jingsheng, based on his own surgical experience, suspected that there might have been a purulent infection in the patient's chest.

He couldn't help but think of the latest chest X-ray, which showed a small amount of fluid accumulation.

Could that be pus?

The results of the X-ray showed that the lesion should be in the left lung.

This is also consistent with the patient's current symptoms of difficulty breathing and severe wheezing.And the left lung is squeezed, which makes it extra difficult to inhale.

However, based on the patient's current condition, the possibility of blood disease cannot be ruled out.

Because some blood diseases may also cause these symptoms in patients.

He decided to start with the lungs.

The first thing that comes to mind is tuberculosis.

This disease is the most annoying. It is not only difficult to treat, but also difficult to diagnose.

It’s just that tuberculosis usually starts in the upper lungs.

But this patient's lesion was obviously in the left lower lung.

With this clinical experience alone, Li Jingsheng was able to initially rule out tuberculosis.

(End of this chapter)