Come on, Dr. Wu

Chapter 321 What's in the Stomach
The patient had a history of chronic skin eczema for more than 3 years and had used loratadine intermittently for anti-allergic treatment.

Skin eczema, this thing, generally will not appear in normal people after infancy, but in adults, skin eczema may still appear intermittently, which depends on the immune system. Seeing this, Wu Xiaofu suspected that the patient had an immune-related disease.

During the physical examination, there was only mild percussion tenderness in the liver area.

This is consistent with the diagnosis of liver abscess.

Looking at the patient's blood test results, the neutrophil percentage was 86.7%, ALT437U/L, and AST591U/L.

The percentage of neutrophils is an indicator of inflammation, which is generally between 50 and 75 percent. If it exceeds this range, there is a high probability that there is inflammation.

The patient himself confessed that he had repeated and intermittent fever and chills, which were more severe at night, and his body temperature fluctuated between 39.2℃ and 42℃.

Among the symptoms of inflammation, apart from stubborn inflammation, there are few cases of recurrent and intermittent fever and chills, which requires more consideration.

Moreover, it was not just a low-grade fever, it had reached over 39 degrees, or even 42 degrees. Liver abscess usually does not reach this level, it was too high.

ALT and AST are both transaminase indicators. This one is too high. Normally, it will not exceed 100. This time it was directly 400 or 500. However, it can also be explained by liver abscess.

However, after the patient was admitted to the hospital, he was treated with cefoperazone/sulbactam 2.0g, intravenous drip once every 12 hours for anti-infection, and polyene phosphatidylcholine 1mg, once a day for liver protection for one week. The patient's transaminase level decreased, but the problem of repeated intermittent fever and chills was not resolved, and the body temperature remained high.

After using so many drugs, general liver abscesses can be suppressed basically. The drop in transaminase is a clear proof, but the body temperature still does not drop, which means that the patient's inflammation is probably not mainly caused by liver abscess.

At this time, we must be vigilant and see if the patient has any other hidden diseases.

This is how it works when seeing a doctor. No suspicious illness can be overlooked. Otherwise, it is likely to be misdiagnosed. Not only will the patient's superficial illness not be cured, but the treatment of the patient's real illness will also be delayed, causing more serious problems.

If you have doubts, you need to explore.

The patient's previous doctor obviously stopped exploring halfway. The patient underwent blood culture but no bacterial growth was found. Indomethacin was not effective in reducing fever, so dexamethasone was added to reduce fever, which was effective.

A liver biopsy was not performed because the patient refused.

Later, the hospital felt that most of the indications pointed to liver abscess, and there was color ultrasound evidence to support it, so they simply stopped interfering and prepared to treat it as liver abscess and perform surgery directly. During this period, the patient had a high fever at night, and the doctor on duty probably used dexamethasone several times to reduce the temperature in order to save trouble.

Dexamethasone is actually a kind of adrenal cortical hormone, which can also be said to be a panacea. It has pharmacological effects such as anti-inflammatory, anti-endotoxin, immune suppression, anti-shock and enhanced stress response. To be honest, cooling down is only its smallest effect.

Moreover, the cooling effect of dexamethasone is different from the cooling mechanism of commonly used antipyretic drugs.

Commonly used antipyretics, such as ibuprofen sustained-release capsules or acetaminophen, can inhibit the synthesis of prostaglandins, thereby achieving the effect of reducing fever. Moreover, taking antipyretics can also enhance the body's heat dissipation, reduce heat production, and improve the fever phenomenon.

Dexamethasone lowers body temperature by inhibiting the response of the body's temperature center to pyrogens. In other words, after dexamethasone takes effect, it does not mean that the pyrogenic response in the body disappears, but it just makes your body temperature temporarily not as high.

Dexamethasone can reduce fever by inhibiting inflammatory responses. When the body is infected by viruses or bacteria, the immune system will produce a series of inflammatory responses, thereby causing fever. Dexamethasone, as a glucocorticoid, can reduce the production and release of inflammatory factors in the body and the migration of tissue inflammatory cells, thereby reducing the degree of inflammatory response in the body and achieving the effect of reducing fever.

Secondly, dexamethasone can reduce fever by suppressing immune response. Some patients with infectious diseases and autoimmune diseases will develop fever due to abnormal reactions of the immune system. As an immunosuppressant, dexamethasone can suppress the body's immune system, regulate and suppress autoimmune reactions, thereby achieving the effect of reducing fever.

This is very scary. Dexamethasone suppresses your immune system. You can imagine how much your body's immune ability will drop. At this time, you may lose the big picture for the small and have a greater impact on your body.

In addition, dexamethasone can also reduce fever through its antihistamine effect. Histamine is a biologically active molecule that can cause vasodilation and tissue edema. Dexamethasone can achieve anti-allergic and anti-edema effects by inhibiting the production and release of histamine, thereby reducing fever.

The legendary use of cannons to kill mosquitoes actually refers to using dexamethasone to reduce fever.

In clinical practice, dexamethasone is generally used as a last resort, just like the use of anti-inflammatory drugs in clinical practice. Vancomycin is only used when the condition has reached a critical point.

Dexamethasone is truly a double-edged sword. If used for minor illnesses, it may actually be harmful.

Generally speaking, large hospitals like the First Affiliated Hospital of Donghai University are very cautious in the use of dexamethasone and basically use it very little. Instead, it is used more frequently in some smaller hospitals or small clinics.

After all, they are eager to let patients see results in order to retain them.

Well, if the outpatient clinic prescribes loose medicine, that is, a small pill wrapped in cloth, for you to take, then you have to be careful not to take hormones, as they can have a significant impact on your body.

In the case of the patient in front of us, the use of dexamethasone only eliminates the patient's superficial symptoms. The deeper symptoms may be covered up by the use of dexamethasone.

If the patient does have an immune-related disease, then the use of dexamethasone and even its examination will be affected.

"Doctor, can I have the surgery?"

Listening to the patient's anxious question, Wu Xiaofu shook his head and said, "It doesn't look like a liver abscess. Let's do some more tests and then we'll take a look."

It doesn't look like a liver abscess!

The patient was stunned when he heard this and looked at the ultrasound report. Wasn't it written as liver abscess? Was the examination wrong?
“Is this inspection wrong?”

"No, it's not. You do have a liver abscess, but the main disease affecting your body may not be the liver abscess, so you have to make sure. Otherwise, even if you remove and drain the liver abscess, you may still have the current symptoms later."

This!
The patient hesitated for a moment, "What other tests should I do?"

The patient was somewhat suspicious at this time. She had already done a lot of tests, and now she was asked to do another test. Even if she had money, it seemed like she was being taken advantage of. Although Wu Xiaofu was well-known, this was her first time to see Wu Xiaofu, and she was not sure if he was really that good.

Wu Xiaofu didn't say much. He just asked Peng Xia to write some prescriptions and handed them to the patient.

Erythrocyte sedimentation rate, serum ferritin, procalcitonin…

Ah!
Just draw blood!

The patient was relieved when she looked at the lists. She had a good memory and remembered that these lists written by Wu Xiaofu had never been done before. In other words, Wu Xiaofu did not want her to repeat the examination.

Moreover, these orders were not for major examinations such as CT or MRI, and the cost was actually limited. This made the patient realize that she might have really misunderstood Wu Xiaofu, and he was probably not trying to cheat her.

"Take the list and go get checked. You should be able to get the results this afternoon. After you get the results, just come over for a follow-up visit."

"Okay, okay, thank you, Doctor Wu."

When the patient heard that the examination results would be out today and that she could come to see Wu Xiaofu again, she felt more relieved. After all, it seemed that Wu Xiaofu was not just trying to fool her. Perhaps she really did not just have a liver abscess.

wrong!

Not just a liver abscess!

The patient, who had been thinking that Wu Xiaofu had not cheated her, now couldn't help but hesitate again. Could she be suffering from some serious illness?

To be honest, she was really troubled by this disease during this period. It was fine during the day, but she would have a fever at night. She couldn't sleep at all and had nightmares all night. She felt like she was dying, and no medicine worked.

I'm using hormones, but they can only last half the night.

The family members also hurried to comfort the patient at this time, saying that they would know the truth after the examination results. After all, what Wu Xiaofu said was just a suspicion. This persuaded the patient to go for the examination and dispelled some of his doubts.

"next."

There were already people waiting at the door, and after Peng Xia called his number, he came in directly.

The patient was a middle-aged man who was supported by his family and holding his stomach.

"Doctor Wu, my dad has had stomach pain for a long time. After a checkup at our local hospital, they said it might be a tumor. We were terrified and rushed to see you."

Tumor!

Wu Xiaofu frowned upon hearing this and looked at the patient's profile card. He was only 47 years old. It was really pitiful for him to have a tumor at this age. "Sit down first. Have you done the local examination?"

"Yes, I did. Look."

The patient handed a film and a CT scan to Wu Xiaofu. Wu Xiaofu took a look. They were abdominal X-rays and CT scans. In the film, there was indeed a dense shadow near the gallbladder and close to the liver, and it seemed to be connected to the liver.

However, calling it a tumor is somewhat strange.

“When did you have your gallbladder removed?”

The patient's gallbladder is no longer visible on the film, but the root of the gallbladder has recovered well. The stomach pain should not be a problem of poor recovery after the gallbladder surgery.

In fact, teachers teach students one way, and when they go to the outpatient clinic to see patients, they use another way.

Normally, students are taught that when they see a patient, they must tell him/her the patient's medical history and then ask questions step by step. But in fact, when doctors see a patient, they mostly go straight to the point and then fill in the blanks slowly. Of course, this is only after gaining experience. When you first start working in the outpatient clinic, you still have to be more disciplined.

"I had it done three months ago, and I started having stomach pain one month after the surgery. When I first started having stomach pain, we thought something went wrong with the surgery. We did it at the local county hospital, and we hired an expert. I think it was an expert from our hospital. His last name was Zuo, Director Zuo."

Ah!
Director Zuo!
Wu Xiaofu was also stunned when he heard this. It seemed that there was only one doctor named Zuo in the hepatobiliary surgery department of the First Affiliated Hospital of Donghai, and that was Wu Xiaofu's current department director Zuo Hui.

However, the operation was performed without any problems, and Zuo Hui's skills were still very good.

Intra-abdominal tumor! Not an organ tumor!

It is possible, and it may not necessarily be a tumor. It may also be a lump or something like that. After all, when diagnosing a tumor, one cannot just look at the density. Wu Xiaofu has seen so many tumors, and the more he looks at this one, the less it seems like one.

Moreover, this examination was done at the local county hospital, and Wu Xiaofu did not think the results were that good.

"Come on, lie down first, let me take a look."

Wu Xiaofu asked the patient to lie down on the treatment bed, and then asked about his medical history while performing palpation.

The patient has had no medical history for all these years, except for a sudden attack of cholecystitis. After conservative treatment, he waited for the expert to come and removed his gallbladder. That was also his first hospitalization, and he usually took few medicines.

"Hey, it hurts!"

Well, Wu Xiaofu looked at the painful area of ​​the patient and felt even more strange.

It's not a liver disease, but the pain is below the liver, towards the original gallbladder area. Wu Xiaofu picked up the film and took another look. Could this be it?

Not right either.

It is better to be cautious. Wu Xiaofu did not say much, but just said that the film taken by the local hospital was not very real, and asked the patient to take another one. Wu Xiaofu also specifically asked the hospital to take the film today and come back for a follow-up visit.

When the patient saw Wu Xiaofu helping him so much, he was very grateful.

Wu Xiaofu also asked the patient to keep the X-rays taken at the county hospital.

After the patient walked out, Wu Xiaofu told Peng Xia to send the film to Zuo Hui for review first.

Peng Xia also noticed that something seemed amiss. After walking out of the clinic, he picked up the film and looked at it carefully, but couldn't see any problem. It looked like an ordinary film. With this density and this shape, it was most likely a tumor or a mass, or perhaps scar contracture after surgery. Further examination and treatment would be enough. Why did he let the film be given to Zuo Hui?
It’s a bit hard to understand, but Wu Xiaofu is so serious, so there must be a reason.

Zuo Hui did not have outpatient clinic today as he had something to do in the morning, so he was not in a hurry to perform surgery. He was there when Peng Xia came over.

Looking at Peng Xia who came in knocking on the door, Zuo Hui was also a little confused.

"Xiao Peng, aren't you on a clinic visit with Doctor Wu? What's going on? Did something happen?"

Peng Xia handed the film to Zuo Hui. Zuo Hui thought that Wu Xiaofu had encountered some difficult problem and couldn't even handle it himself, so he came to ask him for help. To be honest, at this moment, he couldn't help but feel a little excited, after all, this was the first time.

"Director, our boss asked me to bring it to you."

After hearing what Peng Xia said, Zuo Hui became even more certain. Wow, he never thought that one day Wu Xiaofu would take the initiative to ask him for help.

But after opening the film, his face became strange. It didn't seem like a bad film. He still believed in Wu Xiaofu's level. He thought he couldn't even handle this.

"Is the patient difficult to deal with? Or is there some special situation?"

Peng Xia shook his head and said, "No, by the way, the patient seemed to say that it was you, Director, who performed the surgery on him."

Ah!
Upon hearing this, Zuo Hui's face froze and his muscles tensed. Many thoughts flashed through his mind. Could it be that his surgery was done wrong? He quickly looked at the film again. Hmm, it was familiar. This technique looked like his. It must have been done by him.

Look at the roots after the operation, hmm, it seems to be pretty good. What does Wu Xiaofu mean? Does he think the shadow is caused by his operation?

After looking at it carefully, I still couldn't figure it out, so I just called Wu Xiaofu.

Wu Xiaofu was seeing other patients at the time, and when he received the call, he picked up the phone immediately.

"Doctor Wu, what do you mean by bringing me this film?"

"Director, what does that shadow look like?"

Like what!
Zuo Hui seemed to have thought of something when he heard this, and looked carefully at the shadow, which was a small long strip.

Zuo Hui actually realized what Wu Xiaofu meant. Was it that something fell into his stomach during the operation?
But there is nothing else of this shape except the strip of gauze torn to wrap the root of the gallbladder.

However, gauze has a developing function. This was not captured in the photo, so it shouldn’t be the case.

"Director, I'll have the patient take another photo. Please take a look at it on the computer later."

After Peng Xia saw that the two had communicated well, he left.

In the consulting room.

The patient with liver abscess came back near the end of the outpatient clinic. Wu Xiaofu looked at the additional tests the patient had undergone and his guess became even more certain.

Erythrocyte sedimentation rate: 84 mm/h, serum ferritin: 846 μg/L, procalcitonin: 0.114 ng/ml…

"What you need to see right now is not liver abscess, but adult Still's disease."

Adult Still Disease!
The patient was stunned when he heard this. What kind of disease is this?

Adult Still's disease is a clinical syndrome with long-term intermittent fever, transient polymorphic rash, arthritis or joint pain, and sore throat as the main clinical manifestations, accompanied by systemic involvement such as increased total white blood cell count and granulocytes in the peripheral blood and impaired liver function.

In 1943, there was a description of adult Still's disease. As the number of cases gradually increased, the information about the disease became more complete. Wu Xiaofu had seen this disease when he was reading a book before. However, similar patients were generally in the rheumatology and immunology department. This was the first time Wu Xiaofu had seen such a patient.

However, Wu Xiaofu's current brain processor is definitely top-notch, so when he first looked at the patient's medical records and examinations, he had some doubts. Now that these test results are out, he is even more certain.

Adult Still's disease is also called "allergic sub-sepsis" because its clinical features are very similar to sepsis or allergic reactions caused by infection. After 1987, it was uniformly named adult Still's disease.

Wu Xiaofu explained it to the patient, and the patient was relieved. It turned out to be just rheumatism. He didn't even need surgery. The patient felt quite fortunate.

Wu Xiaofu knew from the patient's expression that he was wishful thinking. However, after thinking about it, Wu Xiaofu did not say anything else. He just asked the patient to go to the Rheumatology and Immunology Department for another check-up. Wu Xiaofu also enthusiastically introduced the patient to Dr. Feng, the most professional doctor in this field in the Rheumatology and Immunology Department, and called him directly.

You don't have to make an appointment tomorrow, you can just go there now. There are actually not that many cases of adult Still's disease. Director Feng was also very interested when he heard about such a case.

(End of this chapter)