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For doctors, the beginning of each day seems to be a new beginning. Pen @ fun @ pavilion wWw. ｂｉｑUｇE。 info Routine rounds in the morning, possibly with new patients. Although I am basically familiar with each patient I am responsible for, even if I can't recite the case, I can at least remember the patient's basic condition and treatment plan.

However, every patient cannot be exactly the same every day, so it is very important for residents to make daily ward rounds.

A new patient came in today, and the patient's name was Gillian.

Gillian was admitted to the hospital with swelling of both lower limbs for no apparent cause. Mainly in both ankles, accompanied by fatigue, and many dreams at night. No fever, cough, no history of palpitations, chest tightness, no history of headache, low back pain, hematuria, no history of medication before illness. Edema extends below the umbilicus before 1 month. Accompanied by shortness of breath, chest tightness, and inability to lie flat at night.

On examination, the body temperature was 37 C, the pulse was 140 beats per minute, the breath was 28 times per minute, and the blood pressure was 149 mmHg. Normal development, moderate nutrition, chronic appearance, clear consciousness, slight shortness of breath, passive semi-recumbent position, car sent to the ward, answer relevant questions, check cooperation. There are no yellow staining and bleeding spots on the skin and mucous membranes, no rashes, skin spider angiomatas and palmar erythema. There is no enlargement of superficial lymph nodes. There is no deformity of the facial features of the skull, the facial surface of the bilateral eyelids is slightly puffy, the pupils are equally round and large, and the light reflex is present. There is no resistance in the neck, the trachea is centered, and there is no enlargement of the thyroid gland. Jugular venous distention. Bilateral thoracic symmetry, no edema in both chest walls, equal breathing movements on both sides, clear percussion, clear breathing sounds in both lungs, not 3, ww≠w. There is no bulge in the precordial area, the apical beat is not significant, the heart boundary is enlarged bilaterally, the heart sounds are low and dull, the heart rate is fast, the heart rate is 140 beats per minute, and the rhythm is irregular. A grade II/6 systolic murmur may be heard in the apical area. The abdomen is distended, the mass is not reached, there is no tenderness, there is no rebound tenderness, the liver and spleen are not satisfactory on palpation, and there is no percussion pain in the liver and both kidneys. Moving dullness is suspiciously positive, and bowel sounds are present. There is no deformity of the spine and limbs, normal movement, depressed edema of the abdomen below the umbilicus, perineum, and both lower limbs, the right lower limb is thicker than the left lower limb, and the skin is tight. Mild puffiness of the hands. There were no gunshot sounds, no capillary pulsations. The muscle strength of both upper limbs is level 5, the muscle strength of both lower limbs is level 4+, and the muscle tone of the limbs is normal. Physiological reflexes are present. Pathological reflexes are not elicited.

Chest x-ray: cardiac shadow is markedly enlarged, cardiac insufficiency is considered, congestion in both lungs, and a small amount of pleural effusion on both sides. Abdominal ultrasound: congestive hepatomegaly; Effusion in the peritoneum (small amount); B-ultrasound of both lower extremities: thrombosis of the gastrocnemius vein in the middle and upper part of the right calf. ECG 2 times: low voltage (limb leads), 4:3 atrial flutter; The other is rapid atrial fibrillation.

Dai Lins showed the medical records to everyone before asking questions, "Let's talk about our diagnosis." Why do patients experience such severe puffiness? In addition, let's talk about the next step that requires a thorough examination and a treatment plan. ”

Due to the complexity of the patient's condition and the severity of his condition. Therefore, there are a lot of items to check. This is something that is not very common at Johns Hopkins Hospital. Because the outpatient clinic and the pharmacy and the places of examination and treatment are separated. Any check-up needs to be booked in advance.

Gillian has already been to another hospital and has been hospitalized for a long time. Because nothing worked, he was transferred to Johns Hopkins Hospital. The best hospital in the city of Baltimore, Johns Hopkins Hospital, Natural City. I often receive some difficult diseases that are transferred from community hospitals.

Spacey immediately preemptively said, "I'll come first." ”

Dalins nodded, giving Spacey an encouraging look.

Spacey was ecstatic, and it seemed that the future American doctor finally got the opportunity to get ahead, "I think the following possibilities can be considered." 1. Chronic cardiac insufficiency: elderly women, accompanied by increased heart rate, chest tightness, edema of both lower limbs, and cardiac insufficiency are more likely. Perfecting BNP, cardiac ultrasound, etc. can help with diagnosis. 2. Chronic renal insufficiency: patients have protein in urine (+), and have obvious symptoms such as edema and fatigue, and chronic renal insufficiency generally has no special symptoms in the early stage, which can be considered. Renal function tests and quantitative urine protein measurements can help diagnose the disease. 3. Hepatic origin, the patient's liver function is mildly impaired, and the total protein is not particularly low, and edema is considered to be caused by non-hypoproteinemia, and it is excluded. 4. Hyperthyroidism: Hyperthyroidism and hypothyroidism can be accompanied by edema, but thyroxine can be ruled out. 5. Venous thrombosis of the lower limbs: often manifested as limb edema, and edema is more serious, generally not accompanied by systemic symptoms, can be ruled out. 6. Tumor: due to the obstruction of venous return of the lower limbs caused by pelvic tumors, edema, ascites or even pleural effusion produced by tumors can produce corresponding symptoms. 7. Infection: Not considered at this time. 8. Autoimmune diseases. The reason why the edema is still serious is that on the one hand, the cause has not been removed, and the kidney function is indeed impaired, and thirdly, in the long-term state of hyperdynamic circulation, it is hoped that the short-term method of reducing blood volume and tissue fluid volume will cause the body to cause relevant reactions. Complete examination, BNP, cardiac ultrasound, coagulation function, renal function, 24-hour urine protein quantitative measurement, pelvic MRI, chest and abdomen CT, etc. Cannot be used β receptor blockers, on the one hand, it is easy to induce arrhythmia, on the other hand, it is easy to induce pulmonary edema due to the slowing of the heart rate. ”

After Spacey finished speaking, he looked at everyone with some triumph.

"You say so much, but there are not many words that are really useful. What kind of disease do you say directly, how can it be cured soon? "Deborah is a little unaccustomed to the swaggering appearance of a future American doctor.

Spacey laughed, "Deborah, if you think I have a bad diagnosis, you can tell me your opinion." Dr. Dalins must have been willing to see how serious we were about diagnosing the disease. ”

"What's the big deal?" Deborah pouted and said, this girl was angry with the future famous doctor in the United States.

"Everyone, be quiet, Deborah has something to say." Spacey clapped his palms.

"I was diagnosed with heart failure. In the symptomatic treatment of cardiac diuresis and edema continues to worsen, first consider kidney function, at the beginning should ask how much urine output per day to consider kidney function, renal failure will of course edema will be aggravated, the next step is to check kidney function first, consider what causes heart failure, is kidney failure caused by heart failure. Deborah spoke her mind. But before Deborah could finish speaking, Spacey was already laughing.

"You call that the answer? Dr. Dalins's question, you still have a few questions that you haven't answered. Spacey had a sarcastic look on his face.

My answer is very short, but intuitive. It's not like someone who says a lot and only knows that he's endorsing. I don't even know what I'm talking about. Deborah immediately fought back.

Dai Linsi looked at the two second-hand goods he brought with him a little helplessly: "You also talk about your opinions." ”

The situation in this case is really complicated, so the diagnosis of the disease by several trainees is very different. Western medicine relies on advanced instruments and equipment. Gillian has a wide range of tests, but the results are not enough for the doctor to make the right judgment. So there was a little more uncertainty in everyone's answers.

"Qin, why don't you tell me your opinion?" Deborah asked.

"Although the case is described in great detail, after all, it is a medical record, and I think it is better to do some simple examinations on the patient, and it does not necessarily need to rely on instruments and equipment. We say that the patient's complexion may tell the patient's condition, and some routine tests can also help us make the right choice. Qin Chuan said.

Dai Lins nodded: "Okay, let's go over and see this patient with our own eyes." ”

Both Spike and Deborah are puzzled.

"Didn't you already see that patient just now? Why do you need to do it? Spacey asked, puzzled.

Deborah didn't understand it originally, but since someone didn't understand it anymore, she naturally couldn't show it.

"Qin, you're not mistaken, are you? Even if you check it yourself, will you be able to get more detailed results than that? Emerson asked.

Qin Chuan shook his head: "Although I can't get more detailed results than this, there are advantages to hand-to-hand inspection." ”

This is Qin Chuan's advantage, he used to work in the emergency department, and there was a time when he went out of the emergency department, before the universal first aid kit appeared, Qin Chuan and his colleagues had to rely on experience to judge the patient's condition in advance. Buy time for your patient's treatment.

Tajira was also unimpressed by Qin Chuan's words: "What we learn in school is how to use advanced medical equipment, rather than relying on personal experience to see a doctor. Because personal experience will always have a certain degree of subjectivity, it is easy to lead to misdiagnosis due to personal subjective awareness. When we judge a disease, there will always be specific conditions, which are very strict. This strict procedure, while seemingly dogmatic, allows us to make fewer mistakes. ”

Dai Linsi seemed to want to say something, but he took it back, but he still gave Qin Chuan a chance, "Qin, diagnose it according to your method." ”

Qin Chuan gave Ji Lian some simple examinations and took Dai Linsi's pulse with his hand.

Spike didn't understand what Qin Chuan meant by taking the pulse. But it can be seen that Qin Chuan's inspection method is much stranger than ordinary inspection.

"Qin, have you checked out anything?" Spacey was a little curious about Qin Chuan's inspection.

The rest of the trainees, as well as Dai Linsi and the others, all their attention was on Qin Chuan. They were eager to know Qin Chuan's diagnosis.

Qin Chuan didn't say anything, he wrote a lot of things in the notebook.

Gillian didn't ask questions, as she could already see that everyone except Dalins was a trainee. Their results were naturally less convincing.

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