"Dr. Zhou is not only good at his skills, but his mouth is still so sweet! Let's hurry up and discuss the patient's condition, if it drags on for a long time, I'm afraid of an accident! ”

Director Shang is an acute person.

After the cold noise, he urged Zhou Can to consult together.

It seems that even with the addition of Director Shang and his two graduate students, the cause of the patient has not been clearly diagnosed.

In the past, he used to call Zhou Can Xiao Zhou, but now he hasn't seen him for a while, but the title is a lot more different.

Director Shang was right, after the patient took the medicine, his body temperature dropped a little, but he was still having a fever. What is even more worrying is that there is likely to be a large source of bleeding in his body. It is imperative that the source of the bleeding be identified. ”

Deputy Director Han is also a doer.

The seriousness of these older doctors towards patients and diseases is definitely worth emulating.

The heart of the doctor's parents can often reflect these three words in some details.

"After the two directors discussed, I don't know if there are any conclusions?"

Zhou Can asked humbly.

"The specific illness of the patient has not been determined for the time being. However, I think the patient's symptoms are just similar to upper gastrointestinal bleeding, and it is a good idea for you to have Dr. Ai monitor the patient's gastric juice. It has now been implemented. In addition, I heard that you found dark red blood on the gloves when you performed a digital rectal examination of a patient, and I think it is difficult to find dark red blood on a digital rectal examination if it is really upper gastrointestinal bleeding. ”

Director Shang should have understood the patient's previous diagnosis and treatment plan.

"There is a method abroad that is specifically used to identify whether it is upper or lower gastrointestinal bleeding. Clinical comparison showed that high plasma urea concentrations were a feature of gastrointestinal bleeding, and the degree of elevation was related to the amount of bleeding. The ratio of plasma urea ammonia concentration to plasma creatinine concentration can be inferred from upper or lower gastrointestinal bleeding. ”

The level of the chief physician is really not blown.

Zhou Can also saw the identification plan proposed by Director Shang in medical journals.

However, he did not know how to use it in clinical practice.

The main thing is that I can't remember those values at all.

And the accuracy rate of this method is not 100%, but about 95%.

"If the ratio of the two is greater than 100, the probability of upper gastrointestinal bleeding is high. If the ratio is less than 100, there is a high probability of lower gastrointestinal bleeding. ”

The approach proposed by Director Shang is worth trying.

By comparing two simple biochemical indicators and calculating the ratio, it is possible to distinguish between upper and lower gastrointestinal bleeding.

Simple and practical, low cost.

"By calculation, the probability of lower gastrointestinal bleeding is high."

Director Shang is indeed powerful, and he deserves to be the director of the Department of Gastroenterology. He came to the consultation in person this time, which also gave the emergency department a big face.

"For patients with this kind of lower gastrointestinal bleeding accompanied by fever, we need to consider the possibility of inflammation and tumors. Patients have an acute onset and are very unlikely to have intestinal bleeding caused by intestinal tuberculosis. So the main consideration is inflammatory lesions. ”

The two graduate students had already taken out their small notebooks and quickly jotted down their notes.

I think back then, when Zhou Can studied with Director Shang, he often took some notes.

"It's been a long time since Dr. Zhou left the Department of Gastroenterology, do you still remember the knowledge of intestinal inflammatory lesions?"

Director Shang didn't know what to think about, and suddenly wanted to take a test for Zhou Can.

"You call me Xiao Zhou like before, which is actually quite kind."

Zhou Can also understood that Director Shang never treated him as a student.

At that time, in the Department of Gastroenterology, he also received a lot of care and cultivation from Director Shang.

For example, when I went to Xinxiang Women's and Children's Hospital for consultation, I asked Zhou Can and Deputy Director Shi to go together. It was also that opportunity that allowed Zhou Can to be successfully selected into Tuya's team of famous doctors and reserve physicians.

"Haha, no problem. Isn't this taking into account that your status is not what it used to be, and you are worried that calling Ling Xiaozhou will have an adverse impact on you! Director Shang explained with a smile.

"In front of you, I will always be that Xiao Zhou."

Zhou Can's words made Director Shang very happy.

There's no doctor who doesn't like people who are affectionate and righteous. When Director Shang cultivated Zhou before, he put in a lot of effort and took great care of Zhou Can.

Three years have passed, and Zhou Can is still full of gratitude and respect for him, which naturally makes Director Shang feel relieved.

"I remember a lot of what you taught me at the beginning. Inflammatory lesions can be classified as specific and nonspecific. Inflammatory enteritis generally refers to inflammatory bowel disease, which is a non-specific chronic inflammatory disease of the intestines, mainly including ulcerative colitis, Crohn's disease, etc., often manifested as abdominal pain, diarrhea, weight loss and other symptoms. ”

Zhou Can has already mastered these knowledge points.

"Very good!"

Director Shang nodded happily.

"According to the patient's medical history, symptoms, and biochemical results, bacillary dysentery and amoebic dysentery can be basically ruled out. I suggest checking the patient's phyticosis reaction, which is now about the fifth week of illness, and it is the right time to check the phyticosis reaction. ”

"Does Director Shang suspect that the patient is enteric typhoid fever?"

Zhou Can's eyes lit up slightly.

Director-level diagnostic thinking is too powerful.

Compared with Director Shang, he could clearly feel the gap.

His current pathological diagnosis is at the level of deputy chief physician, and it will take some time to be promoted to the level of director.

Especially in the recent period, in order to enter the graduate school, the sitting time has been compressed, the number of patients diagnosed has decreased, and the growth of pathological diagnosis experience has also slowed down.

Fortunately, the recent business of cardiothoracic surgery has been on the rise, and the number of difficult cases has increased, which has given him the opportunity to earn a large amount of experience in pathological diagnosis.

Zhou Can suspected that the patient might have intestinal malignant histiocytosis, and he barely touched the edge.

He even thought of doing a bone marrow exam on his patient.

If it is enteric typhoid fever, bone marrow culture is done, and most of them can be detected.

As for blood cultures, because the course of the disease has progressed to four weeks later, the peak of bacteremia has passed, and the test results are likely to be negative.

"It's only a preliminary suspicion of enteric typhoid fever. Digestive tract diseases like this with obscure etiology and long progression time, after excluding malignant tumors, there are more than a dozen rare and refractory diseases. Such as Crohn's disease, ulcerative colitis, and so on. However, most of these conditions have a slow onset and are often accompanied by intestinal obstruction and an abdominal mass, and this patient has obvious multiple inconsistencies. ”

"Ulcerative colitis also has an acute onset, and some severe ulcerative colitis will have high fever and blood in the stool. However, it is more consistent with the patient's condition. The patient has just been admitted to the hospital today, and even if he wants to have an emergency colonoscopy, it will take some time for the intestinal lumen to be prepared. In particular, the residual blood in the intestinal lumen is estimated to be quite serious, which will seriously affect the examination effect. ”

Director Shang was very cautious in diagnosing the cause.

From his various statements, it has been basically diagnosed that the patient is enteric typhoid fever. There may also be lower gastrointestinal bleeding.

It is not the first time that Zhou Can has seen director-level diagnostic thinking, and he is very yearning for this high level.

Over the next two days, the patient was given further examinations.

Includes aspiration of gastric juice monitoring.

The patient's body temperature was always between 37.7 and 38.9 degrees, and the fever never went away.

The gastric juice drawn from the first day was pale yellow and turbid, and a little old blood streaks were found in the gastric juice.

The gastric juice that was withdrawn the next day turned clear.

At this point, major upper gastrointestinal bleeding can basically be ruled out.

Yesterday, the patient's stool was still black. Indicates that blood in the stool is still present.

There is no bleeding in the upper gastrointestinal tract, and the patient still has black stools, so there is no need to think about it, it must be that there is still large bleeding in the lower gastrointestinal tract.

After the black stool, the patient arrived this morning and had two more dark red bloody stools.

This is consistent with the situation when Zhou Can first gave a patient a digital examination.

At that time, it was discovered that the gloves were stained with dark red blood.

The patient's blood culture was negative.

After the peak period of blood bacteria, this is basically the result of re-examination.

The results of the patient's bone marrow routine examination also came out, and no abnormal naïve cells and histiocytes were found. This is only the results of routine examination of bone marrow, and the specific diagnosis depends on the results of bone marrow culture.

This morning, the patient's blood pressure has dropped to 60/42mmHg, his pulse has become very weak, and his heart rate is about 120 beats per minute.

This is a very bad sign.

It means that the bleeding is not under control and has been bleeding.

If the source of the bleeding is not immediately found and stopped, the patient may not be saved.

This morning happened to be the day when Zhou Can was in the emergency department, because the patient was in shock again, the emergency room was worried that something would happen to the patient, so he invited Zhou Can over in desperation.

AFTER ZHOU CAN ARRIVED AT THE EMERGENCY ROOM, HE IMMEDIATELY PERFORMED MUSCLE VENOUS PUNCTURE AND CATHETERIZATION ON THE PATIENT, AND THE CENTRAL VENOUS PRESSURE WAS MEASURED, WHICH WAS ONLY 0.78KPA.

I didn't expect the patient's condition to deteriorate so quickly.

Only two days later, after 1000 ml of blood had been transfused and several treatments were given, shock reappeared. And the blood pressure has dropped to an extremely worrying level.

At this time, the source of bleeding is unknown, and there is no effective means to stop bleeding, and the use of vasopressors can only accelerate bleeding.

Zhou Can quickly instructed the nurses and doctors to expand the patient's capacity and transfuse blood to fight shock, and after transfusing three bags of blood in a row, he finally pulled his blood pressure up again.

"Doctor Zhou, the patient must have been bleeding, please help me think of a way! I think it is difficult to stop the bleeding by relying on internal medicine treatment, and I am afraid that surgical treatment will have to be used to stop the bleeding. ”

Dr. Elle was emaciated for the past two days.

She broke her heart for the sake of this patient.

Every doctor is afraid of receiving a refractory patient. Especially for this extremely difficult gastrointestinal bleeding patient, she is an ordinary attending physician, and she really can't handle it.

Just now I saw the patient go into shock again, she is fifty years old, and she is still anxious to stomp her feet.

"Don't worry, it's basically a lower gastrointestinal bleeding now. The patient's blood in the stool is dark red in color, which should be ileal or colonic bleeding. It's just that the patient's current physical condition does not allow for barium colonography, and colonoscopy cannot be done. Even if it is a laparotomy, the bleeding point must be determined before it can be targeted. ”

Zhou Can has a lot of experience in dealing with this kind of tricky patient.

"I can't do the examination and I can't do it, the patient's bleeding point can't be locked, but he keeps bleeding, what should I do?" Ellie's face was sad.

The level of ordinary doctors is limited, and it is really impossible to deal with this kind of patient.

"Celiac angiography may be a better approach. Interventional radiology, although invasive, is very effective in localizing this type of gastrointestinal bleeding of unknown etiology. I think it's worth taking some risks to do a celiac arteriography in order to save the patient's life. However, this test needs to be done at the right time and must be done when the patient is bleeding. ”

Zhou Can gave a better solution.

Timing of celiac angiography is very important.

If the bleeding happens to be temporarily stopped at the time of the examination, it can be difficult to detect the bleeding point.

At this time, Zhou Can's sixth-level hemostatic technique came into use again.

He only needs to judge whether the patient is in the bleeding stage from the skin color, complexion, appearance, and physical state of the patient.

In addition, the patient had just passed liquid blood twice recently, indicating that he was in a state of heavy bleeding.

Don't miss the opportunity, and never miss it.

Zhou Can decisively asked Ai Li to report to Deputy Director Han, and then contacted the interventional room to do emergency selective celiac angiography for the patient.

The doctor on the other side of the intervention room saw that the patient's condition was very bad, and he was worried that the patient would burp directly during the interventional operation, so he invited Zhou Can over to help.

Zhou Can is also famous, and now many doctors in Tuya Hospital know that he has done a good job in endoscopic surgery and intervention.

Every now and then, someone asks him for help.

The intervention room invited him over this time, saying that it was asking him to help, but in fact he was afraid of taking responsibility.

Zhou Can didn't expose it, and went straight over.

Giving patients celiac angiography was an examination plan he proposed.

Someone has to take on the burden of protecting the lives of the patients.

Of course, the consent form that should be signed by the family must be signed.

It's okay for him to work hard to save people, but he can't take all the risks.

If the family only wants to save people, they are not willing to take any risks, but let the doctor take all the responsibility. Then I'm sorry, Zhou Can has never been a virgin, and when it should be ruthless, he must be ruthless.

Fortunately, the patient's parents were reasonable and signed quickly.

In the interventional room, Zhou Can wore a heavy lead suit and carefully sent the contrast tube into the patient's femoral artery, then into the celiac aorta, and then into the first-order branches, the celiac trunk, the superior mesenteric artery and the inferior mesenteric artery.

During the whole operation, he seemed very focused.

Visualizations of the celiac trunk and branches of the inferior mesenteric artery were recorded on television, and no abnormalities were found.

One of his hearts couldn't help but sink.

Could it be that the timing of the imaging test was wrong?

Through the television video, it can be seen that the diameter of the superior mesenteric artery is generally tapered, and the end of the ileocolic artery branch has a spill of contrast agent.

Zhou Can was immediately overjoyed.

Finally found the source of the bleeding.

"Quick, quick, this is it."

Zhou Can signaled to quickly determine the location of the bleeding source on the patient.

It can be clearly seen that the contrast agent overflowing from the end of the arterial branch of the nodular vein is extremely concentrated and gathers into a ball.

After bleeding is identified, a 20 unit of posterior pituitary lobe is slowly bolus injected through the catheter and then extubated.

It turned out to be active bleeding from the ileocolic artery, so it was no wonder that the bleeding was huge.

Almost all slightly larger arterial bleeding can be scary.

And it's hard to stop the bleeding automatically.

I finally understood why the combination of two hemostatic drugs still failed to stop the bleeding.

"This patient must be operated on to stop the bleeding as soon as possible, so let's push it back first! I discussed with Dr. Xu to see if the emergency department could do the surgery directly. ”

Zhou Can actually already had a surgical plan in his head.

However, this matter needs to be discussed with Dr. Koh first.

After all, the person who did the operation was Zhou Can, but the person who took responsibility was Dr. Xu.

After discussion, Dr. Xu looked at the image playback and agreed to take the surgery.

For Zhou Can, this is a very good opportunity to exercise.

(End of chapter)