My medical skills add experience

Chapter 491 Inexplicable Hyperthermia, Multiple Sources of Hemorrhage
After an emergency gastroscopy was performed on the patient, the situation was quite bad.

The patient's entire gastric mucosa looked pale, which suggested that the patient had gastritis, and the condition was severe.

This happens only when there is erosion, ulcer or inflammation, edema and exudation on the surface of the gastric mucosa.

No wonder the patient's figure looks thin, and the patient's father said that the child only knows how to play games all day long, go out to fool around, and doesn't eat much at home.If gastritis is so severe, symptoms such as nausea, vomiting, indigestion, acid reflux, and heartburn will definitely occur.

In this case, how can the patient eat food?
However, the formation of gastritis is often due to irregular diet.One meal when you are hungry, one meal when you are full, or drink on an empty stomach, eat spicy food, barbecue, etc.

In short, under normal circumstances, gastritis is self-made.

When you are healthy, you don't cherish all kinds of things.

Eventually the most affected organ becomes overwhelmed and begins to malfunction.That's when you're sick.

Gastroscopy showed that the patient had a line of old mucosal bleeding lesions on the posterior wall of the gastric fundus, superficial erosions were seen on the greater curvature of the gastric body and wrinkled ridges, and flocculent secretions and recent bleeding spots were attached to the surface.

Gastric antrum and duodenal bulb were normal.

A rapid urease test was performed on the patient, which was negative.

After checking this step, the cause of the disease was basically clear.

It's stomach bleeding.

After discussing with Zhou Can, Ai Li decided to use blood transfusion and intravenous infusion of hemostatic drugs for treatment.

Almost all responsible doctors will give priority to drug treatment when treating diseases.Surgical treatment is only considered if medical treatment is ineffective.

Because any operation will cause harm to the patient's body.

"Doctor Zhou, do you think batroxobin can be used as a hemostatic drug?"

"Only one kind is used, it's too thin. Why don't you add tranexamic acid!"

Zhou Can replied.

Batroxobin is an immediate hemostatic drug, and it is often used for this kind of emergency internal bleeding.The hemostatic effect of tranexamic acid is long-lasting and powerful. It is a drug that inhibits the fibrinolytic system and is mainly used for surgical bleeding and obstetrics and gynecology bleeding caused by hyperfibrinolysis.

In addition, it also has a powerful ability to penetrate the blood-brain barrier, so it is often used to stop bleeding in the central nervous system.

After treating the patient, Zhou Can hurried into the operating room.

He told Ai Li that if the above treatment methods are ineffective for the patient, a new treatment plan will be discussed at that time.

……

At around [-] noon, Zhou Can finished the operation and went to the cafeteria to eat with his team members.

As soon as she passed the triage table, she was stopped by Dr. Ellie.

"Doctor Zhou, did you just have an operation?"

"That's right! There are a lot of emergency operations today, so it's a bit late for the operation."

Some surgeries need to be done as quickly as possible without delay.

For example, hemostasis and suturing of traumatic wounds.

There is also replantation of severed fingers.

Replantation of amputated fingers was rarely performed in the emergency department before, because this kind of operation is extremely technically demanding.Only Dr. Xu can complete it.And the operation time is quite long.

If Dr. Xu is performing severed finger replantation on a patient, there will be a shortage of manpower if there is a patient who needs emergency surgery.

Emergency surgery, especially wound suturing, emergency trauma treatment such as dog bites and falls, etc., all need to be handled by the emergency department.If this type of patient is pushed to a specialized department, they will be scolded to death.

Don't look at a few years ago, Director Xie went straight to Deputy Director Ye because he performed a few extra surgeries in the emergency department.

In fact, Tuya has never been short of sources of common minor surgery.

For this famous third-class hospital, which enjoys a certain reputation in the province and ranks first in China, the number of outpatient and emergency departments is increasing at an alarming rate every year.

Each department can be "satisfied", and even many specialized departments have to reject some patients with mild symptoms because of the excessive number of outpatient and emergency patients and "indigestion".

Therefore, specialist departments now have a very contradictory demand. The fewer patients with simple mild symptoms, the better, and the more patients with moderate difficulty, the better.

If hospital departments want to generate income, they mainly focus on critically ill patients and patients with difficult treatment.

Because of this type of patients, the full capacity of the beds in the department can be guaranteed to the greatest extent.

If the emergency department pushes some patients who can be treated with simple treatment to specialized departments, they will definitely be scolded.After all, it's all about profit.

Today's emergency operating room has begun to take shape, with a general operating room, a [-]-level operating room, and an endoscopic operating room under construction.

The surgical team has also directly reached 25 six people from the first few people.

Including more than a dozen surgeons and more than a dozen nurses.

Now, even if Zhou Can or any of the doctors are on vacation, there is no problem that the emergency department cannot function.

"Doctor Zhou, can you please help me to see the patient with upper gastrointestinal bleeding again? After transfusion of 1000ml of blood, the patient has improved. But the bleeding did not stop, but he developed a high fever, and his body temperature rose to 39.4 degrees."

Ai Li made a request to Zhou Can with some embarrassment.

She, an attending doctor who is nearly 20 years old, has asked a resident doctor in her [-]s for help. This has been N times.

In other words, she has long been used to it.

"Let me go with you to see that patient!"

Zhou Can can only put patients first.

"Doctor Zhou, I'll make dinner for you first, can I wait for you?" Qiao Yu took care of Zhou Can silently in life.

Now the time itself is relatively late, she is worried that it is too late, and the food in the cafeteria has been sold out.

"Eat first! I'll finish my work in a while and go get dinner by myself."

Zhou Can realized that this patient with gastrointestinal bleeding was more difficult to deal with.

I don't know how long it will take yet.

Why did high fever appear in just three or four hours after taking the medicine?
Following Ellie to the emergency room, the patient was lying on the bed with his eyes closed, his face still a little pale.However, compared with when he was first admitted to the hospital in the morning, the situation has improved significantly.

The amount of blood transfusion is as high as 1000ml, which is actually quite amazing.

"Did you take ranitidine?"

After seeing the patient's condition, Zhou Can asked Dr. Ai Li.

For such rescue patients admitted to the emergency department, the first-visit system is currently implemented.Whoever receives the diagnosis is responsible.

Novice doctors are especially afraid of receiving critically ill patients.

However, as long as there are doctors above the attending level on duty, they will immediately rush over to take over the patients when they hear that there are patients in need of rescue.There is no such thing as asking a novice doctor to rescue a critically ill patient, and the superior doctor will let it go.

"used!"

Allie nodded.

Ranitidine is commonly used in the treatment of duodenal ulcer, gastric ulcer, reflux esophagitis, Zoller syndrome and other diseases of high gastric acid secretion.Sometimes it is also used to treat Helicobacter pylori.

The cause of the patient's current fever is a major problem that bothers Elle.

This is also the main reason why she asked Zhou Can to help with the consultation.

"The patient's other vital signs were fairly stable. There was no chills, only high fever, which is really weird. The possibility of intestinal infectious diseases cannot be ruled out."

Zhou Can frowned slightly, and began to try his best to diagnose the patient's cause.

Blood transfusion is unlikely to cause high fever, this factor can basically be ruled out.

Ai Li was very cautious in administering drugs to the patient, and only used the two hemostatic drugs discussed with Zhou Can.Ranitidine is commonly used to treat stomach ulcers.

It stands to reason that the possibility of high fever caused by medication is also very low.

But the patient did have a high fever after three or four hours of treatment in the hospital.

From the record of the patient's body measurement by the nurse, it can be clearly seen that the patient's body temperature showed a relatively stable slope within four hours.

It didn't come on suddenly.

The first thing to suspect is still the problem of medication.

Zhou Can's current pathological diagnosis is level five, which is close to the advanced level of the deputy chief physician.Pharmacological syndrome differentiation is also at the fifth level, and not long ago, it has just reached the intermediate level of the deputy chief physician.

Compared with the pathological diagnosis, there is a significant gap.

The patient had a blood transfusion of 1000 ml, and the hemoglobin barely recovered to a more ideal level.But his anemia has not been significantly improved.

Zhou Can couldn't help picking up the patient's emergency gastroscopy report again.

It stands to reason that the amount of bleeding caused by gastric mucosal erosion is unlikely to be large. Even if the bleeding continues for as long as a month, it is impossible to cause severe anemia or even sudden shock in the patient.

Where is the problem?
At this time, Zhou Can had begun to suspect that the patient was not simply bleeding from gastritis.

In addition, erosive and hemorrhagic gastritis usually stops bleeding quickly, and the disease is relatively self-limiting.However, the patient continued to have black stools for more than a month, and there was a contradiction between these two points.

It was further confirmed that the patient was not simply gastritis bleeding.

His brain was running fast, thinking hard whether there were other parts of the patient's bleeding source?

It can cause severe anemia and even shock in patients, indicating that the amount of bleeding is very large.

If there is a large amount of bleeding in the stomach or duodenum, the blood will flow back into the stomach. At this time, the patient will vomit coffee-like stomach contents, or even vomit blood directly.

For example, in the records of the Three Kingdoms, Zhuge Liang scolded Wang Lang directly before the battle until he vomited blood and died on the spot.

In the novel, it is believed that Wang Lang died of a broken heart, which is definitely unscientific.

The heart is in the chest cavity, and the rupture of the cardiovascular system is also difficult to cause direct vomiting of blood.Usually only the upper gastrointestinal tract and upper respiratory tract bleeding will directly vomit blood.

Upper respiratory tract bleeding is more blood foam appears.

For example, when encountering an emergency patient who suddenly vomits blood and falls to the ground, doctors often judge the specific source of bleeding based on the color of the blood spit out from the patient's mouth and nose and whether there is foam.

Bleeding into the lungs, usually with blood foam, accompanied by coughing.Mainly coughing up blood.

Stomach and duodenal bleeding are directly vomiting blood.

This patient had no clinical symptoms of vomiting.

The possibility of massive upper gastrointestinal bleeding in a short period of time can basically be ruled out.

However, before this shock, the patient had a sudden nosebleed, which is also a place worthy of vigilance.

The structure of the human pharynx and nasal cavity is very complex.

The nasal mucosa is rich in blood vessels, and people are prone to nosebleeds when they get angry or their noses are attacked.

Sometimes the bleeding is profuse and scary.

However, the patient and his family did not respond to frequent nosebleeds.This reason can be postponed.

The most urgent task is to quickly find out the real source of bleeding in patients.

Although the patient's vital signs are still stable after rescue, if the real cause of the massive bleeding is not found out, danger can occur in an instant.

After the patient was admitted to the hospital, he developed high fever symptoms through infusion and blood transfusion.

Is this a coincidence, or is there another reason?
There are only three kinds of drugs for the infusion. Whether it is ranitidine for gastric ulcer, batroxobin or tranexamic acid for hemostasis, none of them will cause high fever in a short period of time.

At least based on Zhou Can's clinical experience and knowledge of pharmacology, it is impossible to have a hyperthermic reaction.

Does blood transfusion cause high fever?
This is the first time I've heard of such a thing.

"Dr. Ai, call the nurses who give the patient infusion and care to the office to discuss the condition."

Zhou Can needs to rule out the possibility of hyperthermia caused by infusion and blood transfusion.

For example, there is a problem with the saline used for infusion.

This must be checked first.

Some normal saline may have problems during storage or manufacturing due to various reasons.

For example, flocs appear in the bottle.

Experienced and careful nurses will not only check three times and seven pairs before giving patients infusions, but also deliberately shake the infusion bottle to see if there is any problem after the saline in it is mixed with the medicine.

Physiological saline is the largest category of medicines consumed in hospitals.

When the hospital purchases, each manufacturer also uses its own magic.

It is not ruled out that after some unscrupulous manufacturers get the order from the hospital, the quality of the salt water sold to the hospital is substandard.

Of course, manufacturers are also afraid of accidents and want to do long-term business, so in terms of quality, especially safety, they will definitely try their best to ensure it.

It's just that the workers doing the work, or the manufacturer's technology is not up to standard, and the hardware facilities are outdated or malfunctioning, which may cause problems with the produced brine.

Not every bottle is faulty.

As long as there is a quality problem in one of the ten thousand bottles, it is a ticking time bomb.

If it is used on a patient, that unlucky patient will probably have an accident.

In the office, the nurse who gave the patient infusion, Dr. Ai Li, and Zhou Can began to discuss the patient's condition.

Zhou Can is the leader.

"Did Mr. Zhao check the medicine bottle when he gave the patient infusion?"

Zhou Can would never ask such words in front of patients and their families.

That's why Ellie and the nurse were called to the office.

"I checked carefully at the time, and found no problems. Director Niu gave us repeated orders, asking us to be careful and careful in clinical nursing and changing dressings, with safety as the most important thing. We will be very careful when giving infusions to every patient."

Zhao Qian and Zhou Can are also old acquaintances.

She works really hard.

At present, I have been promoted to a nurse, but there is still a long way to go before I want to be promoted to a nurse in charge.

The promotion of nurses is not easier than that of doctors.

It is relatively easy for a doctor to be promoted to an attending physician.

Nurses now want to be promoted to supervisor nurses, either through qualifications or postgraduate entrance examinations.Of course, related households are not included in this list.

Society is a society of human relations, especially in our country, where human relations are particularly rampant in some units.For example, a certain railway head office, or a hospital, management positions with high wages and easy work basically belong to the world of the second generation.

Zhou Can still understands Zhao Qian's work style.

She usually works hard and works hard.

Since she checked carefully before the infusion and there was no problem, the possibility of problems with the infusion medicine itself can basically be ruled out.

After thinking about it, Zhou Can felt that the patient probably had multiple sources of gastrointestinal bleeding.

What is multisource bleeding?

It means that there is bleeding in multiple places.

The patient's bleeding site is likely to be more than the upper gastrointestinal tract.

The upper part of the small intestine and colon should be the focus of investigation.In addition, gastric juice should be monitored.

Because the patient had black stools for more than a month, the possibility of massive gastric bleeding cannot be completely ruled out.

Unless there is a solid basis for diagnosis in medicine, any possibility should not be ruled out.At most, a certain possibility is higher, and the investigation is prioritized.

In particular, such difficult cases, which are extremely difficult to diagnose, are often caused by reasons that are easily overlooked.

The essence of difficult cases is that they are relatively rare causes and diseases, which cannot be solved by borrowing the contents of textbooks.

Doctors need to make a flexible diagnosis based on actual clinical experience.

"Doctor Ai, I suggest that the gastric juice should be drawn regularly to monitor the gastric bleeding. At the same time, some auxiliary examination methods should be used to further check the possibility of bleeding sources in the small intestine and colon."

Specific recommendations for further diagnosis given by Zhou Can.

(End of this chapter)