【Tomorrow 10-11 o'clock】

The phone call with Lu Zishan ended with Qi Jing's repeated agreement. Compared to the phone call with Xiao Yu in the afternoon, it was much calmer.

The mother acted very restrained and just asked Qi Jing how she was doing recently and when she would go back to Danyang. She didn't lose her temper, nor did she curse, and her tone was extremely calm. After learning about Qi Jing, she had to leave the country, so Xiao Yu didn't say much, just took care of her health and took protective measures, and then the following was gone.

Qi Jing was speechless for a moment and didn't know what to say with his cell phone.

Finally, after hesitating for a long time, I could only make some promises as I said when communicating with Lu Zishan. I heard my mother say a few "yes", which made me feel better.

Parental shortcomings are not Qi Jing’s strengths.

In his previous life, his family relationship was quite poor. He worked day and night, and he ignored his health and had a very strange temper. In the end, he broke up with the two elders and moved out alone. For him, he would rather live in the lounge than be nagged about his daily life.

It seemed that it was around 11-12 years ago, when Qi Sen was still worried about his promotion, Xiao Yu happened to be in menopause. Qi Jing was the main infectious disease department, and after moving out, he still stayed in the same hospital with them.

However, he often avoided the two of them and rarely met on weekdays. It would be fine if he was calm when he met. If his temper became stronger, he would be quarrel.

In the next year or so, Qi Jing didn't even say a word to them, and he was relieved until he was a few years older.

But even so, his stubborn son and his parents were hard to get close to each other. This move basically left the possibility of living, and he only went home two or three times a year to have a meal together. It was not until Qi Sen went to work in Beijing that Qi Jing often went home to see Xiao Yu.

During those days, the relationship between mother and son was pretty good. Xiao Yu often reminded him to find a girlfriend, get married early, and stop dragging him out. Qi Jing was not as violent as he was at the beginning, and just fooled him with coaxing and deceiving.

Qi Jing himself knew very well that when he reached the original state, he basically couldn't find his other half.

Even if you really find it, it will be a pain for the other party.

He only had Lu Zishan's good memories in his mind, and he was already missing a piece of it. In addition, he had a bad temper, had irregular daily life, and had no possibility of taking care of his family at work. He was still taking the route of infectious diseases, and he would bring the germs home if he was accidentally...

These are things that need to be considered after getting married. Qi Jing was afraid of trouble, so he simply put his head on his work.

This also laid the groundwork for the support line in the first place, but in the end it was too exhausted to cause cerebral hemorrhage caused by hypertension.

Now Qi Jing recalls all the past. When he is reborn, he not only takes a shortcut in work, but also gives himself a chance to make up for his family relationship. Now everything has returned to the beautiful life he envisioned before he is reborn, and he has got what he always wanted before he is reborn.

But these are just family matters.

After all, family affairs are family affairs, and his primary goal is to deal with the next wave of love. As long as they can handle them and make the truth hidden behind them public, it should be a warning to people.

"The symptoms are so strange..."

Qi Jing looked at the photos and matching introduction text, not knowing where to start. He didn't need any correct answers from others, just to expand his thinking. Qi Jing looked at his phone, then looked at the time, and decided to call the diagnostic department.

......

At this time, the diagnostic department was still holding a meeting, and the focus of the meeting was still Ult. The previous several additional examination reports were all obtained, and the people have been living in for two days. They need to find the root cause of the disease as soon as possible.

Qi Jing dared to send people back to China and put people in his own diagnosis department, which means he had confidence in Hu Dongsheng and Gao Jian.

The two of them knew very well that if they could not find the cause and could not solve Ult's problem, the consequences would be very serious. Not only did the diagnosis department smash the sign, the person in charge after the diagnosis department might have to change it.

Their qualifications are indeed a little bit weaker. When Ji Qing said he would hand over the diagnosis department to them for treatment, they were both surprised and happy.

Over the years, the diagnosis department was operating normally, and there were twenty or thirty people who had been clearly diagnosed. Both of them were trained and there was basically no pressure on them. Even if the medical school asked them to give reports in front of hundreds of people, Hu Dongsheng and Gao Jian were full of confidence and had nothing to be afraid of.

But now Qi Jing is back...

Only the two of them have experienced the oppression in their bodies, so they also clearly know that the "If you don't have a level, change people" was not empty talk. If Urte's diagnosis was stuck in their hands, it would be a matter of time before the replacement of people was replaced.

"Have you eaten?" Gao Jian asked, looking at the disposable lunch box in the stands.

"not yet."

"I just got a patient here, and I don't have one."

"I also......"

Hu Dongsheng sighed: "Put down everything in his hand, let's discuss it while eating. By the way, who will do the blackboard writing and repeat the medical records this time?"

"I'll do it. I know German and talk a lot with the patient." The female doctor got up and walked over, picked up the marker naturally, and then said as she wrote some key points on the recording board, "The patient's main complaint was repeated nausea and vomiting. 12     Day...

[...... There are frequent nausea and vomiting, more than 10 times a day, which has nothing to do with eating. The vomit is initially the contents of the stomach, and then it is foamy mucus. The symptoms worsen when opened and closed, and the degree of nausea is reduced. When it is relieved, the degree of nausea is reduced and the number of vomiting is reduced to 3-5 times a day.

I have asked about personal history, family history, and fertility history.

Admission examination: body temperature 36.    8℃, heart rate 75 beats/min, breathing 23 beats/min, blood pressure 120/63mmhg, stable vital signs, chronic disease condition, mild dehydration, nystagmus (), cardiopulmonary examination (-), abdomen (-), unpasteful mass, water sound (-).]

The female doctor said some basic content and then wrote down the second key point on the board: "In the blood biochemistry of auxiliary examination, the values ​​of several enzymes in liver function were significantly higher, and the review today did not drop."

【alt   458-466iu/l    ,as  314-333iu/l,hbv,hcv,hdv,hev(-)】

"There were two tests for hepatitis, and they were all negative." The female doctor turned a page and looked at the subsequent examination report and continued, "The blood is normal, the blood electrolytes are low in potassium, the urine is routine, yellow, clear, and the white blood cells are negative. Among them, the urine sugar and urine ketone abnormalities are obvious, and we monitor it every day..."

【Second Potassium 3.01-2.96-3.11, Urine Sugar (++++~), Urine Ketone Body (++++~)】

"The blood sugar has dropped, and urine sugar and ketone bodies have also dropped a lot."

The female doctor focused on urinary ketone bodies: "Taphthalemia is a key point. After one day of replenishment, we did not return to normal. At first, we thought it was ketoacidosis, but the blood sugar was not high. Now it seems that it was caused by less food and hunger. From the indicators, these are also transient and can be relieved with a little intervention. I personally think that it has nothing to do with the cause of nausea and vomiting.

Next is imaging examination..."

【Abdominal B-ultrasound (-), gastroscopy: esophageitis, skull ct (-), transcranial Doppler vertebra-basal artery spasm】

"It seems that there is nothing special," said a doctor in the audience. "The examination results are similar to yesterday. Can vertebrae spasm not tell the problem. Is there no plaque or embolism?"

"No, the rest is all (-), if there is one, I will definitely write it."

“Where is the last autoimmune hepatitis?”

"Looks pretty good."

"Let's take a look at all the symptoms. What are the problems with the patient's health now?" The female doctor circled the key point, "Diabetes, hypokalemia,"

Among diabetic ketopathy, Cushing's syndrome, primary aldosteronism, and hyperthyroidism, hyperthyroidism, hyperthyroidism, which can explain the overall picture of the disease more comprehensively, is the most likely. Because it is impossible to clearly diagnose, the thyroid function is reviewed, and the results show that:

Total triiodothyrogenine (tt3): 35.38   ng/ml; Total thyroxine (tt4): 579.95    μg/dl; Free triiodothyrogenine (ft3): 16.60    pmol/l; Free thyroxine (ft4): 113.84    pmol/l; thyrotropin (tsh); 0.01    μiu/ml.

It is clear that it is hyperthyroidism and hyperthyroidism liver damage.

After the diagnosis is clear, propionuracil was given 3 times a day; propranolol 10    mg       3    mg                                                                                                                                                                                                                                 

After one week, the patient's heart rate dropped to 70 ~ 80 times per minute, nausea and vomiting were significantly reduced, and he could eat normally and move around. The thyroid function and liver function were significantly improved after the follow-up examination. After 3 months, the symptoms completely disappeared, the thyroid function was basically normal, and the weight gain was 8 kg.

Experience and lessons

Hyperthyroidism, which is prominent in the first diagnosis, is rare in clinical practice, and clinicians lack understanding of this and are prone to misdiagnosis and missed diagnosis.

The pathogenesis of hyperthyroidism, which has the first symptom of vomiting, may be related to the following factors:

Thyroid hormones cause gastrointestinal nerve dysfunction and vomiting caused by gastrointestinal peristalsis regulation dysfunction [1];

The synergistic effect of thyroid hormone and catecholamine enhances the effect on the hypothalamic vomiting center and the excitatory stimulation of the gastrointestinal tract, and may also be the enhanced response of the vomiting center to excessive thyroid hormone or catecholamine [2];

The direct effect of thyroid hormone on the trigger band of the chemosensory zone of the vomiting chemical receptive zone. Excessive thyroid hormone stimulates the chemically sensitive zone at the bottom of the fourth ventricle and causes a decrease in the vomiting threshold [3];

Hypokalemia, hypomagnesemia: Thyroid hormone increases the sensitivity of adrenergic β-receptors to catecholamines, and at the same time increases the activity of na-k-atp, and causes potassium ions to transfer into cells or abnormal sugar metabolism, resulting in low potassium. Low potassium can lead to weakening of gastrointestinal movement, weakening of smooth muscle contraction, causing nausea, vomiting, and vomiting and aggravation of low potassium. Magnesium can reduce the release of acetylcholine at the junction of neuromuscles and sympathetic ganglia, thyroid hormone promotes the excretion of magnesium in urine, low magnesium causes the enhancement of neuron inflammatory properties and the enhanced conduction through neuromuscular junctions, causing weakening of peristalsis in the upper digestive tract, increasing the autonomic nerves of smooth muscle in the upper digestive tract, thereby causing vomiting [4].

Hyperthyroidism causes secondary gastroesophageal motor dysfunction.

Clinical characteristics of hyperthyroidism liver damage:

Most of them have no obvious characteristics, and liver function can be restored in the short term after hyperthyroidism is controlled;

The clinical symptoms are mild, mostly mild digestive disorders, such as annoyance, loss of appetite, diarrhea, fatigue, liver discomfort or dull pain, liver enlargement, and there may be no symptoms of liver damage;

In severe cases, flaccidosis, liver and spleen enlargement, obvious abnormal liver function, and high enzymatic elevation;

It is closely related to the patient's age, course of the disease and condition. It is more common in patients with long courses of hyperthyroidism, older age, severe condition and not reasonably treated for a long time, but there are also reports on the contrary.

Diagnosis of hyperthyroidism liver damage:

Hyperthyroid liver damage is a person who diagnoses hyperthyroidism and has the following 6 items [6]:

No previous history of viral hepatitis or other hepatobiliary diseases;

No recent history of drug damage to the liver;

If any of the 2 items or 2 items or above in the liver function detection index are abnormal, alt, aspartate aminotransferase (ast), alp, γ-gt, tb (total bilirubin) and db (direct bilirubin) are increased, while total protein and albumin are decreased;

There may be or without hepatic or jaundice;

Hepatitis classification test was negative;

The liver function index returns to normal after hyperthyroidism control.

treat:

Controlling hyperthyroidism is the fundamental treatment of hyperthyroid liver damage; therefore, antithyroid therapy is the key to avoiding liver damage, and it is also necessary to supplement liver protection treatment. Although oral antithyroid drugs also cause liver damage, controlling hyperthyroidism is the fundamental treatment of hyperthyroid liver damage.

Therefore, patients should be given oral small doses of antithyroid drugs to protect their liver and as a long-term treatment for hyperthyroidism, but the trend of changes in relevant indicators should be dynamically monitored. If the corresponding indicators are stable or have a trend of improvement, treatment can be continued.

The author believes that for those who have poor treatment of gastric or liver disease, even if there is no typical manifestation of hyperthyroidism, and if the digestive system symptoms are prominent, and the digestive system related examination cannot reasonably explain the condition, the diagnosis basis for digestive system diseases is insufficient or the treatment effect is not ideal, even if there is no typical manifestation of hyperthyroidism, there is no goiter. Hyperthyroidism should be considered, and thyroid function examination should be performed in time, and the diagnosis should be correct as soon as possible.
Chapter completed!