Chapter 615 Inexplicable Necrosis
Yang Ping, Song Zimo and Xu Zhiliang rushed to the Department of Traumatology and Orthopedics in the surgical building.
Surgeons are used to doing things vigorously and resolutely. When Yang Ping arrived at the orthopedic trauma surgeon's office, several directors were already sitting at the computer, reviewing medical records and researching.
Several young doctors helped bring tea and water to the director who came for consultation.
Professor Zhang and Director Tan were discussing the case privately. When they saw Yang Ping coming, they immediately greeted Yang Ping.
General surgery is the main force of Sanbo in solving difficult and complicated surgical diseases. Today, Yang Ping and two generals attended the meeting, and Director Tan was very moved.
In fact, we were just dropping by. The three of them happened to be watching Xiao Guoqiang, so they stopped by to see what kind of strange case there was, inexplicable necrosis of limbs.
"A few directors have just finished their work and are on their way over. We have to wait for more than ten minutes. You go and see the patient first." Professor Zhang raised his wrist to look at the old Shanghai brand mechanical watch.
"You guys chat, I'll look at the medical records first, and then I'll look at the patient." Yang Ping sat down with his two assistants, and Guipeisheng helped pull up the electronic medical records.
During the consultation, you must preview the medical history in advance, and then proceed to the bedside for medical history and physical examination. This is the basic rule.
There are also doctors who do not see patients clinically but make diagnoses and give opinions remotely based on medical records, but they are still relatively few.
Clinician, where clinical means standing at the bedside and interacting with patients.
Yang Ping browsed the medical records and after mastering the basic conditions, he grabbed some key words in the medical records and remembered them in his mind.
Unexplained erosion and necrosis of the limbs, most obvious in the right hip of the right hand, accompanied by unbearable headaches and body pain, and frequent cold sweats. He had been in good health, with no history of trauma and no recent history of infection. There was no obvious cause, and it was inexplicable. Symptoms appear on the ground, probably like this.
The complexity of this case is that the necrosis of the limbs is severe and progressive, but the cause has not yet been found, not even a little clue.
After reviewing the medical records, Yang Ping came to the ward. The young man in his twenties was lying on the bed with his girlfriend beside him. Even through the mask, a stench of tissue necrosis hit his face.
The patient's girlfriend was sitting far away and probably couldn't stand the smell.
The patient lives in a single isolation negative pressure ward. Before the diagnosis is clear, some special bacterial infections have to be considered. In order to prevent cross-infection, he can only be placed in the isolation ward.
The right lower limb was obviously swollen, almost three times the size of a normal limb. There were blisters in many places. The right hip was almost completely necrotic and the bone of the greater trochanter was exposed. Because the greater trochanter is a bony protrusion, it is very superficial and the skin tendons Once the membrane becomes necrotic, the bone is easily exposed.
The right upper limb is also swollen, but not as exaggeratedly as the lower limb. Except for a few spots on the right hand, it still has a normal color. Most of the skin is dark in color, showing the color and texture of lifeless dead flesh.
The left limb is slightly better than the right limb. The left lower limb is almost twice the size of a normal limb. Several dead gray areas are obviously necrotic areas. Scattered necrotic areas can also be seen in the left upper limb.
In order to allow the consulting doctor to see the condition of the necrotic parts, all necrotic parts of the limbs were opened, and two medical practitioners stayed by the bedside to assist the consulting doctor in viewing the wounds at any time.
Yang Ping asked about the medical history. This patient was transferred from Shipo People's Hospital. Seven days ago, he felt a little unwell throughout the day for unknown reasons. He had a burning sensation in his right hip and right hand. At night, he developed headaches and body pain, which didn't stop. Breaking out in a cold sweat, I couldn't bear it anymore, so I went to Shipo People's Hospital for treatment. The emergency department temporarily considered mosquito bites, but no other cause was found, so they could only give her analgesia and rehydration, and she was admitted to the general surgery department for hospitalization.
The next day, the patient's limbs began to experience varying degrees of swelling, and blisters appeared in some places. Then the limbs began to suffer from erosion and necrosis starting from the right hip and right hand.
The general surgery department was confused and had no idea. Since the necrosis was in the limbs, they transferred it to the orthopedics department.
In this way, the patient was transferred to the Orthopedics Department for continued treatment. Shipo People's Hospital also organized a consultation. The directors of the Orthopedics Department, General Surgery Department and Emergency Department thought about mosquito bites. Shipo is a mountainous area, and the Emergency Department has rich experience in mosquito bites and snake bites. experience.
But this patient was unlike any mosquito bite they had encountered before.
In the past, they have also encountered infection and necrosis of limbs after mosquito bites, bacteria and toxins entering the blood, and finally being admitted to the ICU for rescue.
But this patient first suffered from necrosis, which was aseptic necrosis. There were no symptoms of infection at first. As for the mosquito bites, when he was admitted to the hospital, he noticed a change in the color of the skin on his right hip and right hand, but no bite wound was found, and he couldn't see it even with a magnifying glass.
Director Miao of the Department of Orthopedics felt that something was wrong, but he could not figure out the situation. The disease was a bit strange, so he asked Director Han for help. Director Han could not judge what the situation was based on the medical records, but he knew that the condition was complicated and if the necrosis continued like this, it would be possible. Severe 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 Sanbo Hospital and transfer the patient to the Department of Traumatology and Orthopedics from the emergency department.
According to the division of several wards of the Department of Orthopedics of Sanbo Hospital, the Department of Traumatology and Orthopedics not only treats patients with limb and pelvic fractures, but also patients with infections and necrosis in the limbs and pelvis that require surgical treatment.
After the patient came to the provincial capital, he stayed in the Department of Traumatology and Orthopedics for three days. The cause of the disease was not found and the necrosis continued. In order to prevent toxins from the necrotic tissue from entering the blood and causing toxic shock, Director Tan decisively proposed debridement. The right hand and right lower limb were treated. A partial amputation was performed to save his life.
In a disease, when conflicts focus on saving lives, saving lives is the first priority, and everything else is put aside.
However, when the cause of the disease is unknown, a destructive and disabling surgery such as amputation requires the medical office to organize a hospital-wide consultation.
After Yang Ping saw the patients, washed his hands, and came to the doctor's office, the directors were also there. Even the director who couldn't come temporarily sent his agent to attend the meeting.
Director Zhao of the Medical 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 confusing and clueless. A young man with no history of trauma and no signs of infection suddenly developed erosion and necrosis of his limbs. After the doctor in charge finished his report, Director Tan added some information and expressed his own opinions:
"In this case, I initially considered necrotizing fasciitis, but the bacterial culture of the necrotic tissue did not support it. The initial bacterial culture from Shipo People's Hospital either did not culture the original bacteria, or the cultured bacteria were all normal parasitic bacteria on the skin, and they were transferred to After our department, we took samples for culture. Many deep samples did not culture bacteria and were necrotic. It is not limited to the skin fascia, but goes deep into the bone. The lactic acid level in the blood test is not high, and the red blood cell distribution width is not significantly increased. The necrosis of the right hip has reached deep into the bone, and the greater trochanter has been exposed. MRI examination It also shows that the necrotic tissue in the limbs involves the entire layer of skin, fascia and muscles, and some reaches the bone.”
"Have you taken any medications recently? Have you considered severe exfoliative dermatitis? Do you have a history of gout? Have you taken allopurinol? Stevens-Johnson syndrome and toxic skin necrosis must be ruled out." Director of the Department of Endocrinology The first thing that comes to mind is allergic reactions caused by allopurinol.
Allopurinol is a uric acid-lowering drug. 1.5% of patients will experience allergic reactions. Among them, there is a severe allergic reaction called Stevens-Johnson syndrome and toxic skin necrosis. The probability is 0.1%-0.4 %, that is, 1-4 people will appear in every 1,000 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, when taking allopurinol, you must first do HLA-B*5801 gene testing. If the gene test is positive, you are prohibited from taking allopurinol.
Allopurinol allergy is a delayed immune-mediated allergic reaction, that is to say, this side effect does not appear when starting the medication, but mostly occurs after 1-2 months of continuous medication, or even about half a year.
The director of the Department of Endocrinology has encountered this kind of patient, so he put forward his own opinions.
However, this patient's necrosis has developed to a deeper level and is not limited to the skin, but the disease always encounters atypical moments.
"I just asked in detail that the patient has no history of high uric acid or gout, and has not taken any allopurinol or other drugs." The director of the endocrinology department denied his 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 come into contact with detergents," Director Tan replied.
"You see, combined with the medical records of Shipo People's Hospital and our medical records, his skin changes and necrosis started from the right hip and right hand, indicating that the right hand and right hip are the starting sites. The sequence of onset is consistent with a history of contact. Case onset logic ”
Doctors diagnose diseases, which is somewhat similar to police handling cases, relying on logical reasoning.
"If we consider vascular embolism, such extensive vascular embolism cannot be detected by color ultrasound, and D-dimer cannot be so low. The results of vascular color ultrasound and D-dimer do not support this diagnosis." The director of the Department of Hematology said a bit self-proclaimed Talk to yourself.
The extensive blood vessel embolism he considered could be ruled out by color ultrasound and blood tests.
trauma? Mosquito bites? Allergic reaction? History of exposure to chemical poisons? Vascular embolism?
Trauma can be ruled out. It is impossible for the patient to not know that there has been a crush injury. There is no need to hide it in a life-or-death situation.
Several other situations can also be ruled out for the time being, so that the common causes are ruled out.
Is there any problem with the medical history? For difficult and complicated diseases, a true and complete medical history is very important. However, due to various reasons, it is often difficult for doctors to obtain true and complete medical records.
For example, the patient conceals his or her medical history, or misses some key information due to memory reasons.
"You can also dig into the medical history. The medical history is a bit simple. I remember that a patient with oral ulcers went to the emergency department before. The ulcer kept bleeding. I went to the stomatology department for simple hemostasis in the emergency department. I found something was wrong with the ulcer in the mouth. I asked for consultation. I At first glance, it turns out that this is not an oral ulcer, but a condyloma acuminata that occurs on the oral mucosa. The patient may have used a sharp instrument to remove the warts, causing damage to the mucosa and bleeding. The patient refused to admit it and said it was not true. In the end, the pathological examination and pathogenic examination showed that it was not the case. Only when it was confirmed that it was genital warts did the patient admit that he had some special hobbies. "Director Kang of the dermatology department is a female, a quiet beauty, in her forties, who looks like a young man in his twenties.
Medical history is something that can always be explored. Whether intentionally or unintentionally, 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 go of Professor Yang from the Department of General Surgery and ask Yang Ping to speak by name.
Yang Ping sorted out the medical history, physical examination and auxiliary examinations, and just wanted to say a few words.
"One thing that is very special about the whole pathogenesis is that 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 causative factors are most closely related to these two places, or even the earliest parts. Agreed Director Kang’s opinion is that we can expand on the medical history. We can center on all the possibilities we consider, 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 complicated diseases, the most important thing is the medical history. Try to have a true and complete medical history, find out the characteristic things, and then start thinking about it.
"I agree with Professor Yang. Judging from the current medical history, the most special thing is this. The necrosis starts from the right hip of the right hand, and the right hip of the right hand is the most serious. If mosquito bites are considered, these two parts are the bite sites. , or the most serious part of the bite. So we re-ask the patient’s medical history, at least two weeks before the onset of the disease, where they have been, what they have done, who and what they have been exposed to, what their hobbies are, etc.” Still prone to mosquito bites.
Everyone is also paying closer attention. In this way, it is better to consider the contact factor. The right hand and right hip have certain clues.
Everyone spoke very enthusiastically and divergently, saying whatever they thought of.
Professor Zhang is the oldest and most experienced among the experts present. He eats more salt than others and has crossed more bridges than others. He said in a summary manner:
"There is a formula for the occurrence of diseases: fatal factors + pathogenic conditions = disease. In terms of etiology, the treatment factors are nothing more than internal and external factors. The external factors include physics, chemistry, and biology, and the internal factors include genetic factors, nutritional factors, and immunity. Factors, endocrine, mental and psychological factors, etc., we will investigate them one by one.”
When encountering difficult and complicated diseases, troubleshooting ideas are very useful and rare diseases will not be missed.
The investigation usually starts with common diseases and then shifts attention to rare diseases.
After all, rare diseases are rare, and common diseases have more rare symptoms than rare diseases themselves.
(End of chapter)