Come on, Dr. Wu

Chapter 361 Rigorous
the most important is.

"How was yesterday? Were you busy?"

While doing outpatient work, Wu Xiaofu looked at Jiang Bei. This girl also worked the night shift yesterday. He asked her not to come to the outpatient clinic today, but she insisted on following him. She said it was possible last week, so it was possible now.

Wu Xiaofu was also helpless and could only let him follow. The child wanted to make progress and he couldn't stop him.

The most important thing is that these kids, although obviously tired, cannot say they are tired and can only continue to hold on, as if everyone is holding their breath and everyone wants to do something. Well, based on his personal experience, Wu Xiaofu feels that these kids are more tired than he was last season.

Feng Lingling thinks so too.

Last season, at the beginning, they were also very competitive, but then Wu Xiaofu came along and widened the gap between them. After they saw the gap clearly, they started to be less competitive. No matter how strong Wu Xiaofu was, he could be strong, and they just fought for another spot.

Instead, it seems harmonious, which doesn't seem like this season.

The atmosphere was obviously different.

However, it's already Friday, so it's normal to be a little cautious. After all, there will be another test tomorrow. No one knows what the result of this test will be, let alone what unexpected things will happen in this test. We have to be more prepared.

At this time, there were already four people in the clinic besides Wu Xiaofu.

In addition to Cheng Shi and Jiang Bei, there are also You Zhiyi and Liu Lin. Yes, compared to last week, Liu Lin also joined this week. This kid seems to have really recognized that Wu Xiaofu can supervise graduate students. Look, he has become dependent on Wu Xiaofu. It seems that he is not so active in studying and just follows Wu Xiaofu to work.

Wu Xiaofu really wanted to say, if you are like this, even if he can supervise the graduate students, Liu Lin may not be able to pass the written test.

During the morning meeting yesterday, Wu Xiaofu even tested Liu Lin, and it was a rare one. He was going to tell Liu Lin that if she didn't know the answer, she would have to go back and study hard. Unexpectedly, Liu Lin actually knew the answer. This kid really has a solid foundation. No wonder she is so bold.

As for You Zhiyi, to be honest, he is really smart and talented. No wonder Duan Hao took a fancy to him and put him under Wu Xiaofu for training. He can learn quickly whether it is learning diagnosis or performing surgery.

Moreover, he is not the type who studies blindly and does not understand the ways of the world. Instead, he is very good at handling things.

Communicating with patients can not only solve their problems well and make them satisfied, but in Wu Xiaofu's case, he can basically understand what Wu Xiaofu means with just a glance. Wu Xiaofu is willing to adopt this kind of student from Duan Hao.

However, the people he trained will definitely have to work under him in the future and cannot escape. Wu Xiaofu is still confident in his own charm.

"Let the patient in."

Although there are many people, it does not seem too crowded. After all, Wu Xiaofu has many patients, and sometimes he really needs more people to help. With more manpower, he can see patients faster.

The first patient who came in was an elderly man who was pushed in by his family in a wheelchair and looked in pain.

Wu Xiaofu asked questions while Cheng Shi recorded the medical records.

A 70-year-old male patient was admitted to the hospital due to abdominal pain for 12 hours.

This is also a characteristic of the elderly. There are no younger generations around them. Their first reaction after getting sick is to bear it and see if there is any relief. If the symptoms are relieved immediately, then there will be nothing wrong. If the symptoms are relieved after an hour or two, then there will be no problem.

Then use some traditional remedies, such as scraping, bleeding and so on.

If that still doesn't work, you have to take medicine. These elderly people have a full range of medicines at home, including painkillers, fever reducers, stomach remedies, anti-inflammatory drugs, etc.

However, these medicines have another characteristic: they can be used to treat any disease, regardless of their type. Their main claim is that they are omnipotent, so just try them all first.

Then wait for a few more hours. If it feels better, it's fine. But if it really isn't working and you can't stand it for half a day, you have no choice but to come to the hospital, just like the patient in front of you.

Cheng Shi began to record based on Wu Xiaofu's consultation.

The patient had abdominal pain without obvious cause 12 hours ago, mainly in the right lower abdomen, with intermittent stabbing pain, and the frequency of attacks varied. After taking anti-inflammatory analgesics on his own, there was no relief. There were no accompanying symptoms such as palpitations, chest tightness, nausea and vomiting, abdominal distension and diarrhea, tenesmus, and fever. After the onset of the disease, he went to the local health center for treatment. Abdominal B-ultrasound examination showed: a thick liquid dark area of ​​about 5.3mm in the right lower abdomen, and uneven liver echo. Considering "acute appendicitis", he came to our hospital for further diagnosis and treatment.

Physical examination: acute illness, forced bending posture, no obvious abnormalities were found in head, neck, heart and lung examinations, flat and soft abdomen, obvious tenderness and rebound pain in the right lower abdomen, no abdominal masses or cord-like objects were palpable.

Auxiliary examinations: Whole-abdominal CT scan showed: thickened appendix with fecal stone formation, thickened ileocecal intestinal wall, exudative reaction of surrounding tissues, peritonitis, and a small amount of pelvic effusion; abdominal B-ultrasound showed: a dark area with a thickness of about 3.3 mm was visible in the lower abdomen.

Preliminary diagnosis: Abdominal pain to be investigated, intestinal obstruction?
The diagnosis of abdominal pain to be investigated is a universal diagnosis. As long as the patient suffers from abdominal pain, the initial diagnosis of the outpatient clinic is basically this. Although there is an examination report from the community hospital that suggests appendicitis, this cannot be used as the basis for the outpatient doctor's diagnosis.

What about intestinal obstruction?
The patient suffers from constipation and has not had a bowel movement in the past few days. The CT scan showed fecal stones and fluid level, which are consistent with the diagnosis of intestinal obstruction. Of course, there is also a question mark.

"How is it? What do you think is the disease?"

Wu Xiaofu looked at a few people and asked, Cheng Shi and the others looked at each other, they were actually used to a small test anytime and anywhere, but this was the first question in the outpatient clinic today, so they must treat it seriously.

"appendicitis."

Jiang Bei was the first to speak, and her voice still sounded very calm. After all, the information given was very complete and there was evidence from examinations to support it. Appendicitis was still easy to diagnose, so there should be no problem.

Jiang Bei even explained her reasons.

The others nodded when they heard this, "Intestinal obstruction shouldn't be a problem."

After finishing, I will add a diagnosis. These are the primary and secondary diagnoses. There is no need to explain the other diagnoses in such detail.

"No other opinions?"

Wu Xiaofu looked at the few people nodding, then shook his head and asked Cheng Shi to prescribe an enhanced CT scan for the patient.

Wu Xiaofu continued speaking only after the patient left.

"The patient is 70 years old. Do you want to consider what caused his appendicitis? Appendicitis is very common now, and people generally don't ask why. It seems that appendicitis is normal and anyone can get it. It's not surprising and there's no reason for it.

But in fact, the appendix is ​​actually part of the digestive system, and most of the causes of appendicitis are also the continuation of pathogenic factors in the digestive system. We can save some trouble for young people, but not for the elderly. We must consider whether the patient has the possibility of malignant lesions. "

Everyone realized something after hearing this. Yes, the digestive system of the elderly is a severely affected area. The possibility of malignant gastrointestinal lesions in young people is small and can be ignored, but this cannot be said for the elderly. After all, inflammation does not come easily.

Moreover, the imaging level of community hospitals is indeed a bit poor. For example, the CT films brought by patients do not show many aspects they want to see. "In the outpatient clinic, you must think more, because the diagnosis you make here may be used as the final diagnosis and then treated. For example, if it is just simple appendicitis, then it is okay. If not, we will diagnose it as appendicitis.

The most likely scenario is that you will be admitted to the hospital and have surgery directly. If you cut open the abdomen, you can't close it again. Remember, be rigorous."

rigorous.

Regardless of whether they remembered it before or not, after this moment today, they will be more careful when facing such patients. This is where the teacher's role lies, teaching by words and deeds.

This old man came back for a follow-up visit after his examination in the afternoon.

Looking at the results of the enhanced CT scan, Jiang Bei and her colleagues were relieved. The enhanced CT scan showed that the tumor in the lateral and posterior cavity of the patient's ileocecal colon had occupied more than half of the circumferential diameter. The tumor had affected the opening of the appendix, preventing the contents of the appendix from being discharged.

It turns out that this is the main cause of the patient's appendicitis.

Not to mention, if we don't do an enhanced CT scan, we may not be able to see it. Some examinations really cannot be skipped, like this one. If we really skip it, it will be a big problem. Whether it is for the patient or the doctor, it will probably be a deep-rooted hurt.

Fortunately, Wu Xiaofu ordered further examination. Jiang Bei and the others looked at Wu Xiaofu with admiration in their eyes. This is one of the reasons why Wu Xiaofu has so many outpatients and there are rarely any problems. With Wu Xiaofu, no matter how small the problem is, it will not be missed.

“Let me tell you about a previous case that was shared with me by someone else.

Just recently, a friend of mine in another hospital had a case of chronic appendicitis surgery performed, but ended up falling into a trap.

The situation is actually similar. The patient is an elderly woman in her 70s with a history of cerebral infarction, renal insufficiency, anemia, etc. This kind of patient is really troublesome. After being admitted to the emergency room due to abdominal pain, the CT examination suggested appendicitis.

The CT scan has been done, and it was done in our own hospital, so who would think too much about it? Just go ahead and order it.

However, because the patient had a cerebral infarction and was still taking oral anticoagulants at the time, even if appendicitis was confirmed, he could only be treated conservatively. You should know this situation. Oral anticoagulants, especially those with a history of long-term use of anticoagulants, must not be treated with surgery.

The probability of bleeding is almost 100%. Don't say that you are fast and precise. With so much blood and at such an old age, even if you have X-ray vision, the patient will not be able to bear it.

The patient's condition improved and he was discharged from the hospital after conservative treatment.

But appendicitis is not so easy to treat. You have been in clinical practice for quite some time, and you have seen several patients who responded well to conservative treatment. Basically, they relapsed shortly after being discharged from the hospital because they did not pay attention to their diet, sleep, or exercise.

This patient's abdominal pain has not been completely relieved after being discharged from the hospital, but because of the doctor's instructions, he can only take medicine in the outpatient clinic many times. By the way, let me ask you a question. What is generally used to eliminate inflammation in conservative treatment of appendicitis?"

Ah!
So sudden?

Cheng Shi and the others were listening with great interest, but Wu Xiaofu's move really caught them off guard.

"I usually use cefixime + metronidazole when I see outpatients?"

Fortunately, this problem is not too difficult. After all, they have been working in the clinic for some time and have always seen the use of medicines.

However, they will have to be more careful and think more from now on, otherwise who will be able to bear it next time.

"Well, this is a tried and tested combination. You can study it later. However, the results of conservative treatment are mixed. The treatment effect on this patient is not very good. Three months after being discharged from the hospital, the pain attacks became more and more frequent. In the end, there was really no other way. The patient could only request to be hospitalized again for surgery to get rid of the pain as soon as possible.

There is no way to treat this kind of situation. Conservative treatment is ineffective. We can't let people die in pain. In this kind of situation, painkillers are of little effect in the end. What's more, anti-inflammatory drugs and painkillers cannot be taken frequently. After admission to the hospital, an abdominal CT scan was performed again. The appendicitis remained unchanged and the inflammation was even better than before.

Let's prepare for the surgery. After he was discharged from the hospital last time, I stopped taking anticoagulants. This time, I don't have to worry so much. I will complete routine preoperative examinations to see if there are any contraindications. Then, considering that the patient is old, thin, and has many diseases such as cerebral infarction, I am worried that endotracheal intubation and general anesthesia will have a greater impact on the heart, lungs, and brain, so I plan to perform an open appendectomy under epidural anesthesia.

Well, it's a detailed consideration. My friend has actually thought of everything very carefully.

However, the operation was a joke to him. After opening it at the beginning, they found that the appendix was indeed enlarged and the wall was thickened, which was consistent with the changes of chronic appendicitis. But soon they unexpectedly discovered a tumor with a diameter of about 7 cm in the greater omentum in the right upper abdomen of the patient.

My friend felt a little nervous at the time, but after looking at the tumor, he considered the possibility of omental inflammatory wrapping, so he directly removed the tumor completely.

Moreover, there is no obvious ascites in the abdominal cavity, nor any other metastatic nodular lesions, so the possibility of malignancy should be low.

but.

The problem is, when the pathology came out, everyone was dumbfounded.

"Appendix adenocarcinoma."

Appendiceal adenocarcinoma!

Cheng Shi and the others were also shocked when they heard this. This was not common. You know, this was a disease that was only briefly mentioned in textbooks.

Appendiceal adenocarcinoma is difficult to diagnose before surgery. Many patients are hospitalized for appendicitis, and the diagnosis is confirmed by pathology after surgery. After all, for appendicitis surgery nowadays, basically only a color ultrasound is performed before the operation, and a CT scan like this is considered rigorous.

Don’t try to detect appendiceal adenocarcinoma using color Doppler ultrasound. That’s wishful thinking.

At this time, they also understood the root cause of the case that Wu Xiaofu mentioned.

In fact, there are still some suspicious aspects of this patient. For example, the patient's anti-infection treatment has not been effective in the past three months. At first, it was thought that an appendectomy abscess had formed and was not completely cured, so he had repeated abdominal pain. In fact, at this time, appendiceal cancer should be considered.

After all, as Wu Xiaofu said, he is seventy years old, and when considering things, he cannot afford to neglect malignant diseases.

Also, during the operation, they found a tumor in the omentum, but without giving it much thought, they thought based on experience that it was a corpuscular inflammatory mass caused by chronic appendicitis, and did not consider that it was metastatic cancer.

You should know that this kind of direct resection does not follow the standard resection of the tumor, and there are many hidden dangers after the operation. Apart from anything else, according to the standards of appendiceal adenocarcinoma, the surrounding lymph nodes must be routinely cleared.

It's all closed, I can't open it and clean it.

Moreover, they now have to consider whether it is metastatic cancer. Just thinking about it makes them worry about Wu Xiaofu's friend.

"Boss, what did your friend do afterwards?"

(End of this chapter)