The Godfather of Surgery

Yang Ping, Song Zimo and Xu Zhiliang rushed to the Department of Traumatology and Orthopedics in the Surgery Building.

Surgeons are used to doing things quickly and swiftly. When Yang Ping rushed to the office of the trauma orthopedic doctor, several directors were already sitting by the computer to check the medical records and research.

Several young doctors helped to bring tea and water to the director who came for consultation.

Professor Zhang and Director Tan were discussing the case in private. When they saw Yang Ping coming, they immediately greeted Yang Ping.

General surgery is Sanbo's main force in solving difficult and miscellaneous surgical diseases. Today, Yang Ping brought two generals to attend the meeting, and Director Tan was quite moved.

In fact, everyone just dropped by. The three of them just happened to finish watching Xiao Guoqiang, so they stopped by to see what kind of strange case happened, and limb necrosis appeared inexplicably.

A few directors have just finished their work and are rushing over. You have to wait for more than ten minutes. You should go and see the patients first. Professor Zhang raised his wrist to look at the old Shanghai brand mechanical watch.

You talk, I'll check the medical records first, and then I'll see the patients. Yang Ping sat down with two assistants, and Gui Peisheng helped to call out the electronic medical records.

Consultation must preview the medical records in advance, and then go to the bedside for medical history and physical examination. This is the basic rule.

There are also doctors who do not see patients in the clinic, but only rely on medical records to diagnose and give opinions in the air, but they are still relatively few.

Clinician, where clinical means standing at the bedside and touching the patient.

Yang Ping browsed the medical records, and after mastering the basic condition, he grabbed some key words from the medical records and recorded them in his mind.

Unexplained erosion and necrosis of the extremities, especially the right hip, accompanied by unbearable headaches and body pains, and frequent cold sweats. Previously healthy, no trauma history, no recent history of infection, no obvious incentives, inexplicable Symptoms appear, probably like this.

The complication of this case is that the necrosis of the extremities is very serious and progressive, but the cause has not been found, even a little clue.

After previewing the medical records, Yang Ping came to the ward. This young man in his twenties was lying on the bed, accompanied by his girlfriend. Even through the mask, a stench of tissue necrosis hit his face.

The patient's girlfriend was sitting far away, so she probably couldn't stand the smell.

The patient lived in a single isolated negative pressure ward. Before the diagnosis was confirmed, some special bacterial infections had to be considered. In order to prevent cross-infection, he could only be placed in the isolation ward.

The right lower extremity was obviously swollen, almost three times the size of the normal limb, and there were blisters in many places. The right hip was almost completely necrotic, and the large trochanter bone was exposed, because the large trochanter belongs to the bony protruding part, which is very superficial, and the skin tendons Once the membrane is necrotic, the bone is easily exposed.

The right upper limb is also swollen, but the lower limb is not exaggerated. Except for a few spots, the right hand still has a normal color, and most of the skin is dull in color, showing the color and texture of lifeless dead flesh.

The left limb is slightly better than the right limb, and the left lower limb is almost twice the size of the normal limb. Several dead gray areas are obviously necrotic areas, and scattered necrotic areas can also be seen in the left upper limb.

In order for the consulting doctor to see the condition of the necrotic area, all the necrotic parts of the limbs were opened, and two regular trainees stood by the bed to assist the consulting doctor to see the wound.

Yang Ping inquired about the medical history. This patient was transferred from Shipo People's Hospital. Seven days ago, for unknown reasons, he felt a little uncomfortable during the day. He felt a burning sensation in his right hip and right hand. I was sweating coldly and couldn't help it. I came to Shipo People's Hospital for treatment. The emergency department temporarily considered mosquito bites, but no other reason was found, so I could only give analgesia and rehydration and other treatments, and I was hospitalized in the General Surgery Department.

On the second day, the patient's limbs began to swell to varying degrees, and blisters appeared in some places, and then the limbs began to appear erosion and necrosis starting from the right hip and right hand.

The general surgery department was at a loss and didn't know what to do. Since the necrosis was in the extremities, it was transferred to the orthopedics department.

In this way, the patient was transferred to the Department of Orthopedics for further treatment. Shipo People’s Hospital also organized a consultation. The directors of the Department of Orthopedics, General Surgery, and Emergency Department thought about it and considered mosquito bites. Shipo is a mountainous area, and the Emergency Department has rich experience in mosquito bites and snakebites. experience.

But this patient was unlike any mosquito bite they had encountered before.

In the past, they also encountered limb infection and necrosis after mosquito bites, bacteria and toxins entered the blood, and finally entered the ICU for rescue.

But this patient had necrosis first, it was aseptic necrosis, and he didn’t have any symptoms of infection at first. As for the mosquito bite, when he was admitted to the hospital, he found that the skin color of his right hip and right hand had changed, but the bite wound was not found, even with a magnifying glass.

Director Miao of the Department of Orthopedics felt that something was wrong, but he couldn't figure out the situation. The disease was a bit strange, so he asked Director Han for help. Director Han couldn't judge what was going on with the medical records, but he knew that the condition was complicated. Serious complications such as toxic shock and acute renal failure can be fatal.

To be on the safe side, Director Han asked Director Miao to send an ambulance to take the patient to Sanbo Hospital, and the Emergency Department was admitted to the Department of Traumatology and Orthopedics.

According to the division of several wards in the orthopedics department of Sanbo Hospital, the trauma orthopedics department not only treats patients with limb and pelvic fractures, but also treats patients with infection and necrosis in the limbs and pelvis that require surgical treatment.

After the patient came to the provincial capital, he stayed in the trauma orthopedics department for three days. The cause of the disease was not found, and the necrosis continued. In order to avoid toxic shock caused by necrotic tissue toxins entering the blood, Director Tan decisively proposed debridement treatment. Partial amputation was performed to save his life.

For a disease, when the conflict focuses on saving lives, saving lives is the first priority, and everything else is sidelined.

However, when the etiology is unknown, amputation, a destructive and disabling operation, requires the medical department to organize a hospital-wide consultation.

After seeing the patients and washing his hands, Yang Ping came to the doctor's office. All the directors came at about the same time. Even the directors who couldn't come for a while sent their agents to attend the meeting.

Director Zhao of the Medical Affairs Department also arrived with the officers at this time, everyone sat down in the doctor's office, the projector was turned on, and the meeting began.

Director Zhao presided over the case discussion. He started the meeting with a few official phrases, and the doctor in charge began to report the medical records.

After reporting the medical records, all the experts frowned. This case was not only unfamiliar, but also a bit out of date and clueless. A young man had no history of trauma, no signs of infection, and suddenly suffered from erosion and necrosis of his limbs.

After the bed doctor finished reporting, Director Tan added some information and shared his opinion:

In this case, I initially considered necrotizing fasciitis, but the bacterial culture of the necrotic tissue did not support it. At first, the bacterial culture of Shipo People's Hospital either did not culture the initial bacteria, or cultured all normal parasitic bacteria on the skin. After our department, we took samples and cultured them. Bacteria were not cultured in many deep samples, and the necrosis was not limited to the skin fascia, but penetrated deep into the bone. The blood lactic acid level was not high, and the distribution width of red blood cells did not increase significantly. The right side Hip necrosis has reached deep into the bone, and the greater trochanter has been exposed, and MRI examinations have also shown that the necrotic tissue in the extremities involves the entire layer of skin, fascia and muscle, and some reach the bone.

Is there any recent history of taking any medicines? Have you considered severe exfoliative dermatitis, have you ever had a history of gout, and have you ever taken allopurinol? Stevens-Johnson syndrome and toxic skin necrosis should be ruled out. Director of the Department of Endocrinology Allergic reactions to allopurinol come to mind first.

Allopurinol is a uric acid-lowering drug, and 1.5% of patients will experience allergic reactions, including a severe allergic reaction called Stevens-Johnson syndrome and toxic skin necrosis, with a probability of 0.1%-0.4 %, that is, 1-4 people will appear in every 1000 people.

This severe allergic reaction can cause skin peeling and mucous membrane damage, and also involves various organs. Once it occurs, the mortality rate can be as high as 20%-50%.

Therefore, if you take allopurinol, you must first do the HLA-B*5801 gene test. If the gene test is positive, you are prohibited from taking allopurinol.

Allopurinol allergy is an allergic reaction mediated by delayed immunity, that is to say, this side effect does not appear when the drug is started, but mostly occurs after 1-2 months of continuous drug use, or even about half a year.

The director of the Department of Endocrinology has encountered such patients, so he put forward his own views.

However, the necrosis in this patient has developed to a deep level, and it is not limited to the skin, but the disease always encounters atypical cases.

I just asked in detail. The patient has no history of high uric acid or gout, has not taken any allopurinol, and has not taken any other drugs. The director of the endocrinology department denied his own judgment.

Has the patient been exposed to any chemicals recently?

The director of the general surgery department asked while looking at the medical records in his hand.

I've asked many times, but I haven't even touched the detergent. Director Tan replied.

You see, combining the medical records of Shipo People's Hospital and ours, his skin changes and necrosis started from the right hip and right hand, indicating that the right hand and right hip were the starting sites, and the order of onset is consistent with the history of exposure. case-onset logic.”

A doctor's diagnosis of a disease is somewhat similar to the police's handling of a case, relying on logical reasoning.

If you consider vascular embolism, it is impossible for such extensive vascular embolism to not be found by color Doppler ultrasound, and it is impossible for D-dimer to be so low. The results of vascular color Doppler ultrasound and D-dimer do not support this diagnosis. The director of the Department of Hematology spoke a little to himself Soliloquy.

The extensive vascular embolism he considered could be ruled out by color Doppler ultrasound and blood tests.

trauma? Bug bites? allergic reaction? History of exposure to chemical poisons? Vascular embolism?

Trauma can be ruled out, and it is impossible for the patient to not know about the crush injury, and there is no need to hide it when life and death are at stake.

Several other situations can also be ruled out for the time being, so that common causes are ruled out.

Is there any problem with the medical history? For intractable diseases, a true and complete medical history is very important, but due to various reasons, it is often difficult for doctors to obtain a true and complete medical history.

For example, the patient conceals the medical history, or misses some key information due to memory reasons.

The medical history can still be excavated. The medical history is a bit simple. I remember a patient with an oral ulcer went to the emergency department. The ulcer continued to bleed. The emergency department received simple hemostasis and was sent to the stomatology department. The ulcer was found to be something wrong. Please go to the consultation. At first glance, this is not an oral ulcer, but a condyloma acuminatum that occurred on the oral mucosa. The patient may have removed the wart with a sharp instrument, causing the mucosa to be damaged and bleeding. The patient refused to admit it, saying that there was no. Only when it is confirmed that it is genital warts does the patient admit that he has some special hobbies. Director Kang of the dermatology department is a woman, a quiet beauty, in her forties, and looks like a young man in her twenties.

Medical history is something that can always be explored. Whether it is intentional or unintentional, patients often conceal or miss it.

After everyone finished speaking, the venue fell into a brief silence.

Xiao Yang, what's your opinion? How could Professor Zhang let Professor Yang of General Surgery go, and let Yang Ping speak by name.

Yang Ping sorted out the medical history, physical examination and auxiliary examination, and just wanted to say a few words.

The whole process of the disease is very special, that is, the disease starts from the right hip of the right hand, and the right hand and right hip are the most obvious, indicating that the pathogenic factors are most closely related to these two places, and even the earliest related parts, agree Director Kang’s opinion, in the medical history, we can develop a little bit more, we can center all the possibilities we have considered, list a divergent chart, and ask questions according to the chart, the effect will be better.” Yang Ping said his own view.

Sometimes for difficult and miscellaneous diseases, the most important thing is the medical history. Try to grasp the true and complete medical history as much as possible, find out the characteristic things, and then think about it.

I agree with Professor Yang. Judging from the current medical history, this is the most special point. The necrosis starts from the right hip of the right hand, and the right hip is the most serious. If mosquito bites are considered, these two parts are the bite sites , or the most severe part of the bite. So we ask the patient's medical history again, at least two weeks before the onset, where he has been, what he has done, what people and objects he has come into contact with, what hobbies he has, etc. Xiong Sihai from the emergency department Still prone to mosquito bites.

Everyone is also paying close attention. In this way, the contact factor is still considered, and the right hand and right hip have certain clues.

Everyone spoke very enthusiastically and divergently, saying what came to mind.

Professor Zhang is the oldest and most experienced among the experts present. He eats more salt than others eats rice, and crosses more bridges than others. He said in a summary:

There is a formula for the emergence of diseases: fatal factors + disease-causing conditions = disease. In terms of etiology, the curative factors are nothing more than two major factors: internal and external factors. External factors include physical, chemical, and biological factors. Factors, endocrine, mental and psychological factors, etc., we will investigate one by one.

When encountering difficult and miscellaneous diseases, it is very useful to check the ideas, and rare diseases will not be missed.

Screening generally starts with common diseases and then shifts attention to rare diseases.

After all, there are very few rare diseases, and there are more rare symptoms of common diseases than rare diseases themselves.