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Latest website:    After Wang Peng finished telling the medical history, he began to give the results of various auxiliary examinations.

For example, coronary angiography, chest and abdominal CT, electrocardiogram, and laboratory tests.

Wang Peng said: "It is extremely rare for a patient to have myocardial infarction, cerebral infarction, and gastrointestinal bleeding at the same time. I hope that the teachers can provide a diagnosis or treatment opinion."

Next, everyone present had a short time to think, and then they would start discussing.

Lu Chen quickly read all the auxiliary examination results.

On the side, Li Yao suddenly whispered: "Lu Chen, did you find a few strange things in this case?"

Lu Chen frowned, and Teacher Li began to ask questions again.

She started her "ward rounds" mode again.

He did not answer in a hurry. He carefully looked at the relevant auxiliary examinations again and said slowly: "The patient was diagnosed with myocardial infarction, and the descending branch was occluded before coronary angiography. However, after the thrombus was aspirated, no stenosis of the blood vessels was found. On the contrary, her blood vessels were very narrow. Combined with the fact that the patient had no risk factors for coronary heart disease such as hypertension, diabetes, and hyperlipidemia, it can be judged that the patient did not suffer from a myocardial infarction caused by plaque rupture like the conventional one."

Acute myocardial infarction, as we often say, is when there are underlying lesions in the blood vessels, the blood vessels are narrowed, the plaques rupture, and then a thrombus is formed to block the blood vessels, causing ischemia and hypoxia in the heart, and finally myocardial necrosis.

But this patient is very strange. There is only thrombus formation, and no stenosis of the blood vessels and plaque rupture are found, so it is not a myocardial infarction in the conventional sense.

"Well, not bad." Li Yao nodded.

It is very simple for mature interventional doctors to judge the condition of the blood vessels based on the results of coronary angiography.

But as a student who has just entered the first year of graduate school, it is not easy for Lu Chen to judge this.

Lu Chen continued, "I also noticed one thing that Professor Wang Peng didn't mention, but he wrote about the patient's family history in this PPT. Her sister died of "nose bleeding" at the age of ten. I feel that this should be related to the patient's repeated gastrointestinal bleeding after surgery."

It is common to have a family history of bleeding, but it is rare to die because of this.

Li Yao smiled with satisfaction: "Very good, you look very carefully, this nose bleeding is indeed a problem."

"There is one more thing." Lu Chen paused.

"Huh?" Li Yao showed a hint of surprise in her eyes, "Don't stop, keep talking, tell me everything you know."

Lu Chen nodded and continued, "Although I don't quite understand the patient's brain MRI images, I can see from the report that the patient's blood vessels are fine, only the right occipital lobe and hippocampus have lesions of cerebral infarction."

"In other words, the patient's heart and brain blood vessels are a bit similar."

"How similar?" Li Yao smiled.

She looked at Lu Chen's serious look and was very relieved.

Lu Chen said seriously: "The blood clots in the heart and brain do not grow by themselves, but come from other places!"

It's a very simple truth. There are two possibilities when a blood vessel is blocked.

The first possibility is that there is a problem with the blood vessel itself, such as the plaque on the blood vessel wall ruptures, forming a blood clot and blocking the blood vessel.

The second possibility is that there is nothing wrong with the blood vessel itself. The blood clot came to this location through the blood circulation from other parts of the body.

This patient has no problems with the blood vessels in the heart and brain. The results of angiography and MRI show that the blood vessels are very smooth.

The only possible situation is that the blood clot comes from other parts of the body!

"Then where do you think it came from?" Li Yao asked.

"The most common possibility is that atrial fibrillation causes atrial thrombosis, and the thrombus falls off and causes infarction of the heart, blood vessels and brain." Lu Chen frowned and said, "But this patient does not have atrial fibrillation, so it should not be caused by atrial fibrillation. As for other possibilities, I don't know."

Lu Chen's clinical experience is very limited. All he can think of is the possibility that atrial fibrillation causes blood clots.

"Well, the analysis is already very good." Li Yao smiled, "General residents, even young attending physicians, may not have as good clinical thinking as you."

Lu Chen smiled and scratched his head, and quickly flattered: "The teacher taught well."

Although it was flattering, Lu Chen did learn a lot from Li Yao.

Every time Li Yao made rounds, she would inevitably ask some difficult questions.

Her principle is not to ask simple questions.

If you ask, you must make them difficult!

After this torture, Lu Chen was in pain and happy, and his clinical thinking was also improving rapidly.

……

The time for thinking is over, and the time for collective speaking begins.

Li Qinghua, the chief resident of the Department of Cardiology, was the first to stand up. He signaled Wang Peng to pass the microphone over. .

"This patient obviously has ectopic thrombus causing myocardial infarction and cerebral infarction. Could it be a thrombus caused by atrial fibrillation?"

Li Qinghua's speech was the same as Lu Chen's thought.

"Teacher Li, all the patient's electrocardiograms show that she does not have atrial fibrillation." Wang Peng said, "So it is unlikely that atrial fibrillation will cause thrombosis."

"Have you done a 24-hour dynamic electrocardiogram? No?" Li Qinghua said.

"Yes, and no atrial fibrillation was found."

Li Qinghua put down the microphone and sat back in his seat.

The second speaker was Ouyang Jing, an associate chief physician in the rheumatology and immunology department.

He stood up and took the microphone from Li Qinghua.

"The patient is a middle-aged and elderly woman with a chronic disease course, repeated multi-organ arterial thromboembolism (heart, brain), and gastrointestinal bleeding."

"I am currently considering the following reasons for repeated thrombosis."

Ouyang Jing's aura was very impressive. As soon as he spoke, everyone listened attentively.

The classroom was so quiet that you could hear a pin drop.

"First, there are vascular lesions, such as vasculitis, but the patient does not have symptoms of multiple organ involvement such as blood system, muscle joints, liver and kidney function, etc., and immune-related antibodies are all negative, so vasculitis secondary to connective tissue disease is not considered for the time being."

"The patient's gastroscopy showed duodenal plexiform telangiectasia and microvascular involvement, which are common in systemic vasculitis such as ANCA-related vasculitis, polyarteritis nodosa, and Behcet's disease. This patient has no systemic involvement. ANCA is negative, and ANCA-related vasculitis and polyarteritis nodosa are not considered for the time being. This patient has multiple levels of vascular involvement, and coexistence of thrombosis and bleeding. Behçet's disease is likely, and the patient needs to be questioned about oral ulcers and genital ulcers. Condition……"

The Department of Rheumatology and Immunology can be said to be the department most prone to difficult and complicated diseases.

Lu Chen listened very carefully, although he didn't understand some parts.

Vasculitis, polyarteritis nodosa, Behcet's disease...

Lu Chen quickly wrote it down in his notebook.

He had just thought of the possibility of atrial fibrillation and thrombosis.

But the teacher in the Department of Rheumatology and Immunology immediately cited so many differential diagnoses.

"In addition, the patient may also have antiphospholipid syndrome. The patient is negative for anticardiolipin antibodies and has normal platelets. However, the disease is still not ruled out. The patient needs to be asked whether he has a history of recurrent miscarriage, and the patient's erythrocyte sedimentation rate, anti-β2-gp1, and lupus Anticoagulants are further clarified.”

"In addition, there are other thrombophilias. The patient has a family history of epistaxis and death. Anticoagulation factor 3, coagulation factor XII and other tests should be completed to further rule out hereditary coagulation and fibrinolysis abnormalities or vascular lesions."

"Okay, that's all I have to say." Deputy Chief Physician Ouyang Jing of the Department of Rheumatology and Immunology finished his speech.

His analysis aroused heated discussion among everyone.

At this time, Wang Peng stood on the podium again and said: "Teacher Ouyang's speech was very good. He sorted out the differential diagnosis of thrombophilia. Among them, we asked the patient's relevant medical history. She did not have oral ulcers or genital ulcers. There are no ulcers and no history of recurrent miscarriage. The relevant rheumatic and immune indicators are normal, and rheumatic and immune-related diseases have been preliminarily ruled out.”

Ouyang Jing's speech was wonderful and opened up everyone's thinking.

But Wang Peng's words directly ruled out immune-related diseases.

Everyone present fell into deep thought again.

At this time, Chief Physician Xu Zhonghuang from the Department of Hematology got the microphone.

"I see that everyone is analyzing the possible causes of embolism. Have they forgotten the patient's multiple gastrointestinal bleeding?"

Lu Chen pricked up his ears and listened.

His intuition was that there must be something wrong with the patient's multiple gastrointestinal bleeding.

But no one mentioned it just now.

Xu Zhonghuang continued: "The patient is a 54-year-old female with no history of liver cirrhosis and recurrent upper gastrointestinal bleeding. The results of the gastroscopy showed that there were no ulcers or erosions in the esophagus-gastroduodenum, gastric antrum, and duodenum. Plexiform telangiectasia and local old bleeding lesions were seen in the proximal part of the bulb. The patient's sister also had a history of epistaxis. Based on the above clinical characteristics, the cause of the patient's upper gastrointestinal bleeding was considered to be hht."

When Lu Chen heard this, he was slightly startled.

"hht, what is this?"

Li Yao whispered: "hht is hereditary hemorrhagic telangiectasia. The clinical manifestations are multiple clustered telangiectasia in the skin and mucous membranes. The nasal mucosa is often affected. It can manifest as nosebleeds or even intractable nosebleeds. Internal organs can also be affected, with the digestive tract being more common.”

Lu Chen suddenly realized that he had only heard about this disease and had only seen it in texts.

Xu Zhonghuang paused and continued: "HHT can also involve blood vessels in the brain, manifesting as intracranial telangiectasia. It is generally asymptomatic and is often discovered accidentally during autopsy. However, it can also cause cerebrovascular disease, and the lesions are prone to bleeding. The formation of hematoma showed spontaneous cerebral hemorrhage. According to the patient's sister's history of epistaxis, the patient's diagnosis should be hht."

Lu Chen in the audience was filled with admiration when he heard everyone's speeches.

There is constantly new content being fed into his mind.

Lu Chen felt that UU Reading www. uukａnshu.net I have many blind spots in my thinking, which are being peeled off little by little.

Medical diagnosis is like investigating a case, peeling off the cocoons, gradually deliberating through little clues, and finally getting the most reasonable explanation.

This is different from reading a book, which only mechanically memorizes knowledge.

But this kind of large-scale discussion in the whole hospital happened in a case, where various thoughts collided!

…

However, although everyone had a heated discussion and each department gave their own unique opinions, in the end, they still did not get a reasonable diagnosis.

It was then that the clinic suddenly noticed.

His system panel, which had been silent all this time, suddenly popped up a prompt.

"Congratulations, I received clinical insights and obtained the Clinical Thinking Skills Book (Elementary)!"

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