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Author: Zhang Qianjin, Director of the Department of Endocrinology, Shuyang Hospital Affiliated to Xuzhou Medical University: Looking for various "clues" in the auxiliary examination, and becoming a glaring endocrine "hunter".
Beginning with an ordinary consultation.
.
.
The Department of Respiratory Medicine, please consult.
It is a 77-year-old woman who was admitted to the hospital for “coughing phlegm and asthma for more than 10 days” and was diagnosed with “acute bronchitis”.
A history of "cerebral infarction" for many years, normal blood pressure control, biochemical showed blood potassium 2.
92mmol/l, hypokalemia symptoms are not obvious, after admission to the hospital, repeated potassium supplements, although blood potassium has increased but still not normal, follow-up medical history has unexplained low He had a history of potassium for many years, so he asked for an endocrine consultation.
I was invited for a consultation and combined the information of the above consultation list.
The first thing I did when I came to the respiratory department was not to go to the bedside to see the patient, but to open the PACS to see the patient’s chest CT.
It is inevitable to have chest CT.
I opened it and checked it out.
Hehe, the first step is to get.
Chest CT scan: However, sorry, the above imaging changes are not my concern.
I am eagerly looking for the corner that belongs to me.
.
.
Sure enough, there is a surprise! Although CT of the entire chest only takes one level (good risk), this is enough.
The last picture of the chest CT: I was lucky to see what I wanted in the last and only picture of the chest CT-the small nodule shadow of the right medial adrenal branch! Most other doctors will not pay attention to this corner, and even imaging doctors will ignore this small detail.
.
.
However, before I have carefully reviewed the case information and face-to-face consultations with the patients, I rely on The three points of "adrenal nodules" have basically locked the diagnosis of "primary aldosteronism: right adrenal aldosterone adenoma", the second step is to get.The third step of get left seems to be logical, sequential perfection of 24h urine potassium, arterial blood gas, orthorenin aldosterone, captopril inhibition test, ACTH and F rhythm and 24hUFC, 24h urine catecholamines, adrenal CT scan and Enhance, everything is as silky as Dove, until finally hit the bullseye, Bingo! Adrenal CT: Be an endocrine "hunter" and look for the words "cue" and "cue", from Qing·Wang Jiaben's "Bie Ya Preface": "Open the door to the same transfer, flood the world with no words.
General, but in fact, clues, original, in ancient books.
"It means that the spider's location can be found from the hanging spider silk, and its whereabouts can be found from the mark of the stove horse (a kind of insect), which is a metaphor for what happened.
Vague traces and clues.
These clues may be of little significance for ordinary seekers, but for advanced hunters, they may be a priceless treasure with a final word to guide the final direction of the prey.
Except for endocrinologists, few people pay attention to the adrenal glands on chest CT.
Although there may only be one or two levels, it may be a surprise to take a closer look.
It may indicate adrenal hypertension, such as primary aldosteronism, Cushing Syndrome.
Few people pay attention to the thyroid on chest CT.
It may be a clue to thyroid nodules, adenomas, or thyroid cancer, suggesting the need for further diagnosis and treatment for diagnosis or exclusion.
The pituitary gland on a large number of cranial MR scans in the neurology clinic and ward is also no one pays attention.
Although only a limited number of aspects are involved in the pituitary gland, for those patients with infarction or hemorrhage caused by hypertension, they have secondary hypertension.
The probability is much greater than that of other people.
An enlarged pituitary may indicate ACTH adenoma or GH tumor, especially in patients with headache and special facial features.
I have encountered many patients who were finally diagnosed with functional pituitary tumors—common Cushing’s disease and acromegaly.
When I retrospectively reviewed the head MR a few years ago, the pituitary gland was significantly enlarged, but unfortunately it was missed.
Lost without timely follow-up, delayed early diagnosis and treatment, and caused more obvious damage to the target organs at present, which is embarrassing (similar cases are as follows).
.
.
Head CT (January 2015) Note: 1 year ago due to "cerebral infarction, "Hypertension" During the hospitalization in the Department of Neurology, a full pituitary gland and a thickened pituitary stalk were visible on the cranial MR scan, which was ignored. Pituitary MR plain scan + enhanced (December 2015) Note: Cushing’s disease was diagnosed in the endocrinology department due to new-onset diabetes and refractory hypertension 1 year later, and imaging revealed irregular adenoma on the left side of the pituitary with increased pituitary stalk Rough, he was transferred to neurosurgery for further transsphenoidal surgery, but the postoperative effect was unsatisfactory and high cortisol was not suppressed.
Head CT (October 2017) Note: Because Cushing’s disease has not been relieved, hypertension has not been controlled, 3 years later, a massive hemorrhage of the right thalamus broke into the ventricle, and he was hospitalized in ICU for 32 days after neurosurgery.
He is still bedridden for a long time.
There are many such small experiences, such as: ➤ For a patient with long-term fatigue, the increase of eosinophils in the blood routine may indicate adrenal cortex insufficiency; ➤ For a patient with repeated hypokalemia, blood biochemical carbon dioxide Reduced binding capacity (indicating metabolic acidosis) combined with urine routine PH>6.
0 (indicating abnormal alkaline urine) indicates distal renal tubular acidosis; ➤For patients with weight loss and palpitations, low blood lipids will point to hyperthyroidism.
.
.
When we are outpatients, we quickly combine the medical history, physical signs and small details that are easy to overlook, and firmly tell the patient: your pituitary is likely to have a small adenoma (major physical signs, etc.
), your adrenal glands are likely to have problems, and your kidneys There may be a problem with the tubule, your thyroid may have a problem, and you need to check it further, balabala.
.
.
the patient’s conviction and gratitude from the initial suspicion to the final diagnosis of the disease adds joy to the often boring path of practicing medicine.
.
It is not easy to identify the "clues and horses", and it takes a long time to accumulate.
This reminds us that doctors should pay attention to the "bundled" clues of auxiliary examinations in clinical diagnosis and treatment.
Once caught, they may be important directions for the diagnosis of other diseases, and these are all What seems to be a routine inspection, whether you pay attention or not, it is there, waiting for an experienced "hunter.
"
Once those seemingly illusory "clues" reach the hunter's hands, they become strong ropes, and the ropes that come from different directions but point to the same prey will gather into a solid net, and finally the prey will be firmly locked.
However, the search for clues does not depend on luck.
For hunters, it is the accumulation of long-term theory and wild hunting experience.
It is also true for doctors.
If there is no thorough understanding and practice of a certain disease from basic to clinical, even if there are thousands of clues.
I can't feel it in my hands as if there is no spider silk, let alone forming a solid web of various seemingly single clues to catch the disease.
The author introduces Dr.
Zhang Qianjin, director of the Department of Endocrinology, Shuyang Hospital Affiliated to Xuzhou Medical University, deputy chief physician, lecturer, postgraduate, deputy director of the Endocrinology Branch of the Suqian Medical Association, and deputy director of the Suqian Medical Association of Integrated Traditional Chinese and Western Medicine.
Especially difficult, rare/rare diseases keep a keen interest, personal public account "endocrine regulator".
Beginning with an ordinary consultation.
.
.
The Department of Respiratory Medicine, please consult.
It is a 77-year-old woman who was admitted to the hospital for “coughing phlegm and asthma for more than 10 days” and was diagnosed with “acute bronchitis”.
A history of "cerebral infarction" for many years, normal blood pressure control, biochemical showed blood potassium 2.
92mmol/l, hypokalemia symptoms are not obvious, after admission to the hospital, repeated potassium supplements, although blood potassium has increased but still not normal, follow-up medical history has unexplained low He had a history of potassium for many years, so he asked for an endocrine consultation.
I was invited for a consultation and combined the information of the above consultation list.
The first thing I did when I came to the respiratory department was not to go to the bedside to see the patient, but to open the PACS to see the patient’s chest CT.
It is inevitable to have chest CT.
I opened it and checked it out.
Hehe, the first step is to get.
Chest CT scan: However, sorry, the above imaging changes are not my concern.
I am eagerly looking for the corner that belongs to me.
.
.
Sure enough, there is a surprise! Although CT of the entire chest only takes one level (good risk), this is enough.
The last picture of the chest CT: I was lucky to see what I wanted in the last and only picture of the chest CT-the small nodule shadow of the right medial adrenal branch! Most other doctors will not pay attention to this corner, and even imaging doctors will ignore this small detail.
.
.
However, before I have carefully reviewed the case information and face-to-face consultations with the patients, I rely on The three points of "adrenal nodules" have basically locked the diagnosis of "primary aldosteronism: right adrenal aldosterone adenoma", the second step is to get.The third step of get left seems to be logical, sequential perfection of 24h urine potassium, arterial blood gas, orthorenin aldosterone, captopril inhibition test, ACTH and F rhythm and 24hUFC, 24h urine catecholamines, adrenal CT scan and Enhance, everything is as silky as Dove, until finally hit the bullseye, Bingo! Adrenal CT: Be an endocrine "hunter" and look for the words "cue" and "cue", from Qing·Wang Jiaben's "Bie Ya Preface": "Open the door to the same transfer, flood the world with no words.
General, but in fact, clues, original, in ancient books.
"It means that the spider's location can be found from the hanging spider silk, and its whereabouts can be found from the mark of the stove horse (a kind of insect), which is a metaphor for what happened.
Vague traces and clues.
These clues may be of little significance for ordinary seekers, but for advanced hunters, they may be a priceless treasure with a final word to guide the final direction of the prey.
Except for endocrinologists, few people pay attention to the adrenal glands on chest CT.
Although there may only be one or two levels, it may be a surprise to take a closer look.
It may indicate adrenal hypertension, such as primary aldosteronism, Cushing Syndrome.
Few people pay attention to the thyroid on chest CT.
It may be a clue to thyroid nodules, adenomas, or thyroid cancer, suggesting the need for further diagnosis and treatment for diagnosis or exclusion.
The pituitary gland on a large number of cranial MR scans in the neurology clinic and ward is also no one pays attention.
Although only a limited number of aspects are involved in the pituitary gland, for those patients with infarction or hemorrhage caused by hypertension, they have secondary hypertension.
The probability is much greater than that of other people.
An enlarged pituitary may indicate ACTH adenoma or GH tumor, especially in patients with headache and special facial features.
I have encountered many patients who were finally diagnosed with functional pituitary tumors—common Cushing’s disease and acromegaly.
When I retrospectively reviewed the head MR a few years ago, the pituitary gland was significantly enlarged, but unfortunately it was missed.
Lost without timely follow-up, delayed early diagnosis and treatment, and caused more obvious damage to the target organs at present, which is embarrassing (similar cases are as follows).
.
.
Head CT (January 2015) Note: 1 year ago due to "cerebral infarction, "Hypertension" During the hospitalization in the Department of Neurology, a full pituitary gland and a thickened pituitary stalk were visible on the cranial MR scan, which was ignored. Pituitary MR plain scan + enhanced (December 2015) Note: Cushing’s disease was diagnosed in the endocrinology department due to new-onset diabetes and refractory hypertension 1 year later, and imaging revealed irregular adenoma on the left side of the pituitary with increased pituitary stalk Rough, he was transferred to neurosurgery for further transsphenoidal surgery, but the postoperative effect was unsatisfactory and high cortisol was not suppressed.
Head CT (October 2017) Note: Because Cushing’s disease has not been relieved, hypertension has not been controlled, 3 years later, a massive hemorrhage of the right thalamus broke into the ventricle, and he was hospitalized in ICU for 32 days after neurosurgery.
He is still bedridden for a long time.
There are many such small experiences, such as: ➤ For a patient with long-term fatigue, the increase of eosinophils in the blood routine may indicate adrenal cortex insufficiency; ➤ For a patient with repeated hypokalemia, blood biochemical carbon dioxide Reduced binding capacity (indicating metabolic acidosis) combined with urine routine PH>6.
0 (indicating abnormal alkaline urine) indicates distal renal tubular acidosis; ➤For patients with weight loss and palpitations, low blood lipids will point to hyperthyroidism.
.
.
When we are outpatients, we quickly combine the medical history, physical signs and small details that are easy to overlook, and firmly tell the patient: your pituitary is likely to have a small adenoma (major physical signs, etc.
), your adrenal glands are likely to have problems, and your kidneys There may be a problem with the tubule, your thyroid may have a problem, and you need to check it further, balabala.
.
.
the patient’s conviction and gratitude from the initial suspicion to the final diagnosis of the disease adds joy to the often boring path of practicing medicine.
.
It is not easy to identify the "clues and horses", and it takes a long time to accumulate.
This reminds us that doctors should pay attention to the "bundled" clues of auxiliary examinations in clinical diagnosis and treatment.
Once caught, they may be important directions for the diagnosis of other diseases, and these are all What seems to be a routine inspection, whether you pay attention or not, it is there, waiting for an experienced "hunter.
"
Once those seemingly illusory "clues" reach the hunter's hands, they become strong ropes, and the ropes that come from different directions but point to the same prey will gather into a solid net, and finally the prey will be firmly locked.
However, the search for clues does not depend on luck.
For hunters, it is the accumulation of long-term theory and wild hunting experience.
It is also true for doctors.
If there is no thorough understanding and practice of a certain disease from basic to clinical, even if there are thousands of clues.
I can't feel it in my hands as if there is no spider silk, let alone forming a solid web of various seemingly single clues to catch the disease.
The author introduces Dr.
Zhang Qianjin, director of the Department of Endocrinology, Shuyang Hospital Affiliated to Xuzhou Medical University, deputy chief physician, lecturer, postgraduate, deputy director of the Endocrinology Branch of the Suqian Medical Association, and deputy director of the Suqian Medical Association of Integrated Traditional Chinese and Western Medicine.
Especially difficult, rare/rare diseases keep a keen interest, personal public account "endocrine regulator".
