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Conan Doyle, the author of the world-famous detective masterpiece "The Sherlock Holmes", was actually a clinician at first
.
Why does a doctor have such careful thinking? In fact, in the process of exploring diseases, doctors often solve crimes like detectives, especially for complex neurological diseases
.
Therefore, Yimaitong will launch a series of columns-"The "God" Medical Detective" column, which will analyze the complex diseases of the nervous system in the form of detectives and uncover the mystery of the disease.
Then follow us to explore now.
Case it! For neurology doctors, cerebral infarction is an uncommon disease, but there are many types of causes
.
This article describes an ordinary case of cerebral infarction.
While thinking about its cause, it also discovered many unusual knowledge points
.
Let us find out what the situation is
.
01 witnesses an elderly male, 62 years old, admitted to the hospital for 1 day due to slurred speech and weakness of the right limb
.
After waking up 1 day ago, the patient developed slurred speech and weakness on the right side of the body, manifested as laborious lifting of the right upper limb, decreased grip strength of the right hand, and occasional coughing when eating water, and the symptoms continued without improvement
.
No fever or headache, unconsciousness
.
Past: Diagnosis of multiple myeloma and diabetes for 20 days, hypertension for 5-6 years
.
02 Physical evidence head CT showed multiple lacunar infarctions
.
Chest CT: old lesions of both lungs, interstitial changes, and left pleural hypertrophy
.
The aorta was dilated, the left ventricle was full, the coronary arteries and aorta were calcified, and multiple rib fractures occurred on the right side
.
Blood routine: white blood cell 4.
68×10^9/L, red blood cell count 2.
53×10^12/L, hemoglobin 74g/L, platelet count 155×10^9/L
.
Biochemical: Albumin 30.
34g/L (normal value 35-55g/L), globulin 64.
12g/L (normal value 20-33g/L), urea 11.
28mmol/L, creatinine 182.
00umol/L, uric acid 535.
00umol/ L
.
Cervical vascular color Doppler ultrasound: uneven intima-media thickening of the left and right common carotid and internal carotid arteries, plaque formation of the right common carotid artery, and no abnormalities in the left and right vertebral arteries
.
Echocardiography: Two small amount of tricuspid regurgitation, left ventricular diastolic function I level
.
Figure 1 Head MRI performance 03 case analysis and treatment process The patient was diagnosed with acute cerebral infarction (the cause is considered to be aortic atherosclerosis), multiple myeloma, diabetes, but frequent shortness of breath and blood oxygen saturation 99%
.
The re-examination of the electrocardiogram was normal, the monitoring heart rate was normal, and the re-examination of chest CT did not change significantly from the time of admission
.
Blood gas analysis: PH 7.
46, PCO2 41mmHg, PO2 91mmHg, Lac 0.
7mmol/L, D-dimer 2.
16ug/mL
.
When feeling strange, the tube bed doctor has solved the case.
It turns out that multiple myeloma itself is prone to chest tightness and shortness of breath, due to its anemia, kidney failure, rib fractures, combined with lung infections, etc.
, and the patient has a ball due to cerebral infarction.
Paralysis, nasal feeding, tongue immobility, multiple factors cause the patient to experience shortness of breath
.
Sure enough, the dissection and pulmonary embolism that I was worried about did not appear.
After symptomatic treatment, he was transferred to the hematology department to continue treatment.
.
Although the patient was discharged from the hospital, there are still many questions lingering in his mind.
Let us uncover the mysterious and unfamiliar veil of myeloma
.
04 Review of relevant knowledge points of the case Multiple myeloma (MM) is a human B-cell tumor characterized by malignant clonal expansion and abnormal proliferation of plasma cells in the bone marrow.
It is the second most common malignant tumor in the blood system
.
The median age of onset of MM patients in China is 59 years old.
The most important complications are rapid bone dissolution, acute or chronic renal insufficiency and infection-related hypercalcemia, as well as hyperviscosity, hyperuricemia and nerves.
The system is affected
.
Due to the onset of middle-aged and elderly patients with complex and diverse clinical manifestations, insidious onset, slow progress, and an incubation period of up to 10 years, many patients have low back pain, repeated fractures, anemia, proteinuria, abnormal kidney function, shortness of breath, and shortness of breath.
Chest tightness, fatigue, and fleshy jumps are treated in multiple disciplines in the outpatient clinic.
They think it is a common senile disease, but in fact it is a complicated and changeable blood disease
.
Literature, MM first symptom can be dizziness, vomiting, back pain, chest tightness, shortness of breath, palpitations, seizures, eye or lower extremity edema, abdominal pain, bloating, lungs or urinary tract infections, anemia, bleeding and so on
.
Patients often move around in various departments of the outpatient clinic
.
Therefore, when more than half of the patients went to the outpatient clinic, the receiving doctor did not consider the possibility of blood system diseases at all, let alone MM, so MM is also called the "variable devil"
.
It is reported that a female truck driver in her 60s who has worked for 30 years has suffered from long-term back and chest pains.
She prefers to lean on the cushions to make her comfortable.
She is often choked on her ribs by the buttons on her clothes, making her breathless.
The legs couldn't walk as if they were filled with lead
.
As the chest pain got worse, he went to the hospital for an examination and found that it was a compression fracture
.
At first I thought it was an occupational disease or senile disease, but I didn't take it seriously, until I had a nosebleed, I was diagnosed as multiple myeloma
.
Since MM is so cunning, how can he catch the "Devil"'s fox tail? When we are in the physical examination, we need to do all the blood biochemical items and check the globulin
.
If the value of globulin is higher than the normal value, it may indicate a problem, but this is not all liver disease.
At this time, it is recommended to go to the hematology department to check the identification of M protein to rule out diseases such as myeloma
.
Figure 2 MM clinical manifestations of neurological complications in 05 cases out of 3 MM thinking clinic, we often encounter shoulder pain, low back pain patients
.
In previous impressions, most of them were cervical spine, lumbar disc disease, joint hyperplasia, inflammation and so on
.
Speaking of extension, one would think of rheumatism, herpes zoster neuralgia, costochondritis, subclavian artery, lower limb arterial occlusion, etc.
, but never thought of MM
.
For patients with shortness of breath, in addition to cardiopulmonary diseases, MG crisis and Guillain Barre also need to be considered
.
The other is systemic diseases, including central nervous system diseases and multi-system diseases
.
Some time ago, the department admitted a patient with chest tightness, shortness of breath, gasping, and difficulty swallowing.
During the treatment, dizziness and skewed angle of the mouth appeared again.
After the cardiopulmonary disease was ruled out, he was finally diagnosed as acute bulbar infarction
.
Figure 4 Responsibility for clinical symptoms is attributed to 06.
The patient with myeloma was discharged from the hospital for less than a week.
When he went out of the clinic, he encountered such a patient: an elderly woman in her sixties.
Well, I'm going to put on the kang (Northeast dialect, meaning bedridden)
.
It turned out that a year ago, she was found to have a tumor in her nasal cavity and was suspected of malignant lesions locally.
She went to a higher-level hospital for surgery, but pathology and immunohistochemistry did not suggest malignant changes
.
The main complaint of the patient: nasal discomfort will cause weakness in the limbs, flesh beating, palpitation, chest tightness, shortness of breath, back pain and leg pain
.
The patient took out several films and took a lot of medicine, but it didn’t get better
.
Weak limbs to jump, is it "gradually freezing people"? But the patient did not have muscle atrophy
.
At this time, I was thinking whether it was a systemic disease? The patient was asked to take off the mask, and she turned pale, did not check the electromyogram, and did a blood test directly, and the third system reduced admission to hospital
.
When the patient walked out of the clinic, under such uncomfortable circumstances, he bowed to me and thanked me.
That scene made me unforgettable for a long time
.
Finally, the patient was diagnosed with acute myeloid leukemia
.
Confucius said that learning without thinking means nothing.
Only by combining learning with thinking can we discover the unusual in seemingly ordinary knowledge or things
.
Goethe said that thinking is more interesting than understanding, but not as good as observation
.
Things that seem ordinary, when you think with doubts and exploration, you can often find the unusual in the ordinary
.
Scientists have discovered the existence of bacteria by observing the spoilage process of food, and penicillin has been discovered by observing bacterial plaque.
It can be seen that careful and thoughtful observation can find many magical and unusual things in the ordinary
.
We are currently in an era of advanced information, and we can receive a wealth of knowledge every day
.
In fact, the more things we know, the more unknown things will be discovered.
There are too many unusual things hidden in the ordinary, waiting for us to learn, explore, think and comprehend
.
Only by finding out the real culprit in complex symptoms and sniping accurately can more patients take less detours and benefit better
.
References: 1.
Ye Shuo, Zhao Qian, Zhang Haoqiang.
Two cases of multiple myeloma combined with pathological fracture of limbs.
Chinese Journal of Bone and Joint Injury, 2021, 05.
2.
Du Wenjin, Zou Xu, Chen Jinwen.
Elderly patients with multiple myeloma Analysis of the mechanism of complicated nervous system damage.
Stroke and neurological diseases, 2008, 06.
3.
Zhou Jingyong, Wang Juan, Tang Hua.
Analysis of misdiagnosis data of multiple myeloma.
International Journal of Laboratory Medicine, 2016, 10.
4.
Liu Liping, Ren Cui’ai, Ran Xuehong.
Analysis of misdiagnosis of 16 cases of multiple myeloma.
Jilin Medicine, 2009, 23.
5.
Zhou Fenghua.
Analysis of misdiagnosis of 4 cases of multiple myeloma.
Frontiers of Chinese Medicine, 2009, 05.
.
Why does a doctor have such careful thinking? In fact, in the process of exploring diseases, doctors often solve crimes like detectives, especially for complex neurological diseases
.
Therefore, Yimaitong will launch a series of columns-"The "God" Medical Detective" column, which will analyze the complex diseases of the nervous system in the form of detectives and uncover the mystery of the disease.
Then follow us to explore now.
Case it! For neurology doctors, cerebral infarction is an uncommon disease, but there are many types of causes
.
This article describes an ordinary case of cerebral infarction.
While thinking about its cause, it also discovered many unusual knowledge points
.
Let us find out what the situation is
.
01 witnesses an elderly male, 62 years old, admitted to the hospital for 1 day due to slurred speech and weakness of the right limb
.
After waking up 1 day ago, the patient developed slurred speech and weakness on the right side of the body, manifested as laborious lifting of the right upper limb, decreased grip strength of the right hand, and occasional coughing when eating water, and the symptoms continued without improvement
.
No fever or headache, unconsciousness
.
Past: Diagnosis of multiple myeloma and diabetes for 20 days, hypertension for 5-6 years
.
02 Physical evidence head CT showed multiple lacunar infarctions
.
Chest CT: old lesions of both lungs, interstitial changes, and left pleural hypertrophy
.
The aorta was dilated, the left ventricle was full, the coronary arteries and aorta were calcified, and multiple rib fractures occurred on the right side
.
Blood routine: white blood cell 4.
68×10^9/L, red blood cell count 2.
53×10^12/L, hemoglobin 74g/L, platelet count 155×10^9/L
.
Biochemical: Albumin 30.
34g/L (normal value 35-55g/L), globulin 64.
12g/L (normal value 20-33g/L), urea 11.
28mmol/L, creatinine 182.
00umol/L, uric acid 535.
00umol/ L
.
Cervical vascular color Doppler ultrasound: uneven intima-media thickening of the left and right common carotid and internal carotid arteries, plaque formation of the right common carotid artery, and no abnormalities in the left and right vertebral arteries
.
Echocardiography: Two small amount of tricuspid regurgitation, left ventricular diastolic function I level
.
Figure 1 Head MRI performance 03 case analysis and treatment process The patient was diagnosed with acute cerebral infarction (the cause is considered to be aortic atherosclerosis), multiple myeloma, diabetes, but frequent shortness of breath and blood oxygen saturation 99%
.
The re-examination of the electrocardiogram was normal, the monitoring heart rate was normal, and the re-examination of chest CT did not change significantly from the time of admission
.
Blood gas analysis: PH 7.
46, PCO2 41mmHg, PO2 91mmHg, Lac 0.
7mmol/L, D-dimer 2.
16ug/mL
.
When feeling strange, the tube bed doctor has solved the case.
It turns out that multiple myeloma itself is prone to chest tightness and shortness of breath, due to its anemia, kidney failure, rib fractures, combined with lung infections, etc.
, and the patient has a ball due to cerebral infarction.
Paralysis, nasal feeding, tongue immobility, multiple factors cause the patient to experience shortness of breath
.
Sure enough, the dissection and pulmonary embolism that I was worried about did not appear.
After symptomatic treatment, he was transferred to the hematology department to continue treatment.
.
Although the patient was discharged from the hospital, there are still many questions lingering in his mind.
Let us uncover the mysterious and unfamiliar veil of myeloma
.
04 Review of relevant knowledge points of the case Multiple myeloma (MM) is a human B-cell tumor characterized by malignant clonal expansion and abnormal proliferation of plasma cells in the bone marrow.
It is the second most common malignant tumor in the blood system
.
The median age of onset of MM patients in China is 59 years old.
The most important complications are rapid bone dissolution, acute or chronic renal insufficiency and infection-related hypercalcemia, as well as hyperviscosity, hyperuricemia and nerves.
The system is affected
.
Due to the onset of middle-aged and elderly patients with complex and diverse clinical manifestations, insidious onset, slow progress, and an incubation period of up to 10 years, many patients have low back pain, repeated fractures, anemia, proteinuria, abnormal kidney function, shortness of breath, and shortness of breath.
Chest tightness, fatigue, and fleshy jumps are treated in multiple disciplines in the outpatient clinic.
They think it is a common senile disease, but in fact it is a complicated and changeable blood disease
.
Literature, MM first symptom can be dizziness, vomiting, back pain, chest tightness, shortness of breath, palpitations, seizures, eye or lower extremity edema, abdominal pain, bloating, lungs or urinary tract infections, anemia, bleeding and so on
.
Patients often move around in various departments of the outpatient clinic
.
Therefore, when more than half of the patients went to the outpatient clinic, the receiving doctor did not consider the possibility of blood system diseases at all, let alone MM, so MM is also called the "variable devil"
.
It is reported that a female truck driver in her 60s who has worked for 30 years has suffered from long-term back and chest pains.
She prefers to lean on the cushions to make her comfortable.
She is often choked on her ribs by the buttons on her clothes, making her breathless.
The legs couldn't walk as if they were filled with lead
.
As the chest pain got worse, he went to the hospital for an examination and found that it was a compression fracture
.
At first I thought it was an occupational disease or senile disease, but I didn't take it seriously, until I had a nosebleed, I was diagnosed as multiple myeloma
.
Since MM is so cunning, how can he catch the "Devil"'s fox tail? When we are in the physical examination, we need to do all the blood biochemical items and check the globulin
.
If the value of globulin is higher than the normal value, it may indicate a problem, but this is not all liver disease.
At this time, it is recommended to go to the hematology department to check the identification of M protein to rule out diseases such as myeloma
.
Figure 2 MM clinical manifestations of neurological complications in 05 cases out of 3 MM thinking clinic, we often encounter shoulder pain, low back pain patients
.
In previous impressions, most of them were cervical spine, lumbar disc disease, joint hyperplasia, inflammation and so on
.
Speaking of extension, one would think of rheumatism, herpes zoster neuralgia, costochondritis, subclavian artery, lower limb arterial occlusion, etc.
, but never thought of MM
.
For patients with shortness of breath, in addition to cardiopulmonary diseases, MG crisis and Guillain Barre also need to be considered
.
The other is systemic diseases, including central nervous system diseases and multi-system diseases
.
Some time ago, the department admitted a patient with chest tightness, shortness of breath, gasping, and difficulty swallowing.
During the treatment, dizziness and skewed angle of the mouth appeared again.
After the cardiopulmonary disease was ruled out, he was finally diagnosed as acute bulbar infarction
.
Figure 4 Responsibility for clinical symptoms is attributed to 06.
The patient with myeloma was discharged from the hospital for less than a week.
When he went out of the clinic, he encountered such a patient: an elderly woman in her sixties.
Well, I'm going to put on the kang (Northeast dialect, meaning bedridden)
.
It turned out that a year ago, she was found to have a tumor in her nasal cavity and was suspected of malignant lesions locally.
She went to a higher-level hospital for surgery, but pathology and immunohistochemistry did not suggest malignant changes
.
The main complaint of the patient: nasal discomfort will cause weakness in the limbs, flesh beating, palpitation, chest tightness, shortness of breath, back pain and leg pain
.
The patient took out several films and took a lot of medicine, but it didn’t get better
.
Weak limbs to jump, is it "gradually freezing people"? But the patient did not have muscle atrophy
.
At this time, I was thinking whether it was a systemic disease? The patient was asked to take off the mask, and she turned pale, did not check the electromyogram, and did a blood test directly, and the third system reduced admission to hospital
.
When the patient walked out of the clinic, under such uncomfortable circumstances, he bowed to me and thanked me.
That scene made me unforgettable for a long time
.
Finally, the patient was diagnosed with acute myeloid leukemia
.
Confucius said that learning without thinking means nothing.
Only by combining learning with thinking can we discover the unusual in seemingly ordinary knowledge or things
.
Goethe said that thinking is more interesting than understanding, but not as good as observation
.
Things that seem ordinary, when you think with doubts and exploration, you can often find the unusual in the ordinary
.
Scientists have discovered the existence of bacteria by observing the spoilage process of food, and penicillin has been discovered by observing bacterial plaque.
It can be seen that careful and thoughtful observation can find many magical and unusual things in the ordinary
.
We are currently in an era of advanced information, and we can receive a wealth of knowledge every day
.
In fact, the more things we know, the more unknown things will be discovered.
There are too many unusual things hidden in the ordinary, waiting for us to learn, explore, think and comprehend
.
Only by finding out the real culprit in complex symptoms and sniping accurately can more patients take less detours and benefit better
.
References: 1.
Ye Shuo, Zhao Qian, Zhang Haoqiang.
Two cases of multiple myeloma combined with pathological fracture of limbs.
Chinese Journal of Bone and Joint Injury, 2021, 05.
2.
Du Wenjin, Zou Xu, Chen Jinwen.
Elderly patients with multiple myeloma Analysis of the mechanism of complicated nervous system damage.
Stroke and neurological diseases, 2008, 06.
3.
Zhou Jingyong, Wang Juan, Tang Hua.
Analysis of misdiagnosis data of multiple myeloma.
International Journal of Laboratory Medicine, 2016, 10.
4.
Liu Liping, Ren Cui’ai, Ran Xuehong.
Analysis of misdiagnosis of 16 cases of multiple myeloma.
Jilin Medicine, 2009, 23.
5.
Zhou Fenghua.
Analysis of misdiagnosis of 4 cases of multiple myeloma.
Frontiers of Chinese Medicine, 2009, 05.
