Today's culprit, Dr.
Huang, knocked on the door tremblingly."
Dean Chen, I'm Huang Hong.""
Come in."
He took a few steps forward, stood in the position of Dr.
Zheng just now, and said very carefully, seriously and sincerely: "Dean Chen, I was wrong. ”"What's wrong?""
After I looked at the blood and urine routine and B-ultrasound examination brought by the patient, I first determined that she had ureteral stones.Then the subsequent physical examination and treatment, etc., I treated the ureteral stones. ”"Did you go for a physical exam?""
Go.I took the interns with me.After checking it out as an intern, I checked it again. ”Chen Wenqiang knew that it was impossible for Xiao Huang to lie here, but he decided to take Xiao Huang seriously.So he asked: "This patient with abdominal pain, if there is no B ultrasound, and there is no blood and urine routine, what diseases should you consider when receiving outpatient treatment?"
Typical or atypical should be answered in order of importance and the probability of occurrence. ”After Chen Wenqiang finished speaking, Xiao Huang's face was sweating.Abdominal pain, there are too many diseases involved......
"What, you can't answer?"
”Chen Wenqiang's face was covered with frost, and he stared at Xiao Huang with an unkind expression.For Xiao Huang, Dean Chen's demeanor seems to have a tendency to figure out where to start dissecting himself."
I, I, I may not be answering in the wrong order."
Xiao Huang had nowhere to hide in Chen Wenqiang's persecutive gaze.Seeing that Chen Wenqiang was getting more and more impatient, he had no choice but to say: "According to the physical examination symptoms, I will first suspect urinary stones, because in addition to the tenderness in her abdomen, she also has percussion pain in the kidney area. ”"Alright, you don't care about the order.You answer all the diseases that abdominal pain will involve. ”Little Yellow is like a woody chicken.Too many illnesses can cause symptoms of abdominal pain."
Lesions in the parenchymal and hollow organs of the abdomen can cause abdominal pain.Well, a heart attack can also present with symptoms of abdominal pain.There is also an acute abdomen in obstetrics and gynecology. ”Xiao Huang remembered the artificial blood vessel replacement a few days ago."
Well, there's also the vascular side, a ruptured abdominal aortic dissection.There is also mesenteric vascular embolism ......"......
Xiao Huang slowly regained his thinking, classified according to the discipline in which the disease occurred, and answered for ten minutes."
There are so many, there are more than a dozen common ones, why do you think it is urinary stones?
The possible percussion pain in a single kidney area, I remember that the medical record is (±), right?
”"Yes."
*"When encountering a patient with abdominal pain, the first thing to consider is whether there is a life-threatening situation.First of all, there is the rupture and perforation of the parenchymal or cavity organs, which you just talked about too much.Aortic dissection, typically atypical and atypical, has abdominal pain and back pain.Have you ever met it?
”"Nope."
Xiao Huang shook his head.I went from general surgery to study urology, and then came back to work in the original trauma surgery.Even if the provincial hospital receives aortic dissection, it is not my turn to get started for a physical examination.Then don't you have to worry that you will press the weight and cause the interlayer to rupture?"
The second is a heart attack.It may simulate any symptoms of abdominal pain and back pain, but is often accompanied by vomiting. ”Chen Wenqiang followed the important order of non-traumatic acute abdomen and patiently gave Xiao Huang a make-up lesson."
In addition to these two diseases that can be fatal immediately, you have to pay attention to the obstetrics and gynecology department is also fatal acute abdomen.Ectopic pregnancy, rupture of the corpus luteum, torsion of ovarian cyst pedicle.But for female patients in obstetrics and gynecology, you ask a few more questions about menstrual history, changes in menstrual flow, all of which can help in differential diagnosis. ”…… Chen Wenqiang spoke to Xiao Huang for a quarter of an hour."
Thank you, Dean Chen, I remember everything."
*"And then let's talk about this patient today, you can't rule out the possibility of a heart attack, have you done an electrocardiogram on her?"
Acute pancreatitis cannot be ruled out, did you give her a blood test for urine amylase?
Abdominal CT was also not done.If there is nothing, you dare to rely on a B-ultrasound conclusion, believe the diagnosis referred by the hospital, and believe the diagnosis of the outpatient clinic.Are you too bold?
Let's not talk about the correct rate of outpatient diagnosis in other hospitals, but only the correct rate of outpatient diagnosis in our hospital, and the misdiagnosis rate is more than 50%.Where do you have the confidence to use outpatient diagnosis directly?
”Xiao Huang had heard about the outpatient misdiagnosis rate for a long time, but he really didn't expect that this rate would pass through Chen Wenqiang's mouth, so he said it directly without disguise.He was a little dazed, but he still said what he thought at the time: "Because the person who admits patients to the outpatient clinic is the attending physician......"
Chen Wenqiang interrupted him: "It doesn't matter who admits the patient to the outpatient clinic.Today's patient, even if the person who admitted her to the hospital is the deputy chief physician, you can't believe that they will be 100% right.Otherwise, after the patient is admitted to the department, does it still need to ask for a detailed medical history, a detailed physical examination and related auxiliary examinations?
”Oh, yes!
Xiao Huang suddenly had a kind of enlightenment.He knew what he was wrong with, looked at the outpatient admission diagnosis, and went to the next step of diagnosis and treatment according to the outpatient diagnosis without suspicion.And Xiao Huang's expression did not miss it at all in Chen Wenqiang's eyes.He closed his eyes and couldn't bear to look at Xiao Huang's stupid appearance.But when he opened his eyes again, there was a hint of tenderness on his face and in his eyes."
Xiao Huang, we are surgeons, although we rely on scalpels to treat diseases, but clinical diagnosis and treatment decisions are in the brain, you have to establish correct clinical thinking first, like this patient, although the stones are admitted.You want to think that the diagnosis does not exist as an outpatient diagnosis.Determine whether the patient has a medical disease, a surgical disease, or an obstetrics and gynecology problem. ”"Yes.""
You are a resident doctor, and it is not ashamed to go to the general resident and attending physician of Corey to help you take a look and make sure that the diagnosis is correct.Moreover, Corey has set up a 24-hour hospitalization general to check and fill in the gaps. ”"Yes.""
Go back and carefully summarize all the diseases that can be involved in the symptom of abdominal pain, according to the classification of inflammation, obstruction, perforation, and dynamic, including vascular origin, and be complete, have a diagnostic basis and differential diagnosis, and do not omit auxiliary examinations.Give it to me on Monday morning. ”"Yes.""
You have to write a check when you go back.Seriously review why you are preconceived and do not have in-depth independent thinking.Turn it in together on Monday. ”"Yes.""
Remember to go to the ICU tomorrow morning and evening to see patients.""
Yes.""
You go back."
Xiao Huang didn't expect that he would pass the test so easily, he bowed slightly towards Chen Wenqiang, and then left briskly.* Chen Wenqiang looked at his young back and sighed: After graduation, I will go to the general hospital, without understanding the style of the director of surgery of the provincial hospital, it sounds like a good thing, and lay a good foundation for surgery first.But who would have thought of the "dark" psychology of Director General Surgery in controlling the operation, and leading the rest of the entire General Surgery Department to do things in one mold.Hum!
Layer by layer control of surgery, there is no conscious understanding of passing, helping, and bringing newcomers.As a result, the college students who have been divided in the past few years, except for Xie Xun, who stands out with outstanding talent, the others simply don't look at it.They were all delayed by Director Cheng!
Although the dead are rotten, the mess left by the dead has to be cleaned up by themselves.Chen Wenqiang rubbed his temples on both sides, and his head ached.The work habits of these young doctors have to be corrected little by little - more tiring than taking a college graduate with them.Chen Wenqiang thought of this and asked for the switchboard: "I am Chen Wenqiang."
I received calls from Director Puwai Liang, Director of Thoracic Extracalcular, Director Wang of the Department of Orthopedics, and Director Xiang of the Emergency Department. ”The call went through quickly."
Hey, I'm Chen Wenqiang, tell you about the medical records on the twelfth floor today."
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Chen Wenqiang crackled and told them a few things about his medical history and Xiao Huang's opinions on the ward.Then, Director Wang spoke first: "Lao Chen, this has nothing to do with orthopedics, right?"
”Director Xiang also asked at the same time: "Lao Chen, is the patient seen in the outpatient clinic or in the emergency department?"
”Director Liang didn't expect that the call was a multi-party call, and he waited for Director Wang and Director Xiang to finish before he wanted to speak, so he heard Chen Wenqiang say: "It's not about whether it has anything to do with you, but the work habits of young doctors."
Belief in senior physicians should be there, but blindly believing in senior physicians, specifically today's patient, because of the habit of believing in outpatient diagnosis, has led to today's incident. ”Speaking of believing in the diagnosis of the senior doctor, the three of them immediately felt that they understood the meaning of Chen Wenqiang's call.It was Director Wang who spoke first."
Lao Chen, I believe that the senior physician should be.But," Director Wang wanted to believe in himself, but when the words came to his lips, he changed it to: "But this blindness shouldn't be." ”"Isn't this nonsense, when is it right to believe, and when is it blind obedience?
Lao Wang, you tell me a way. ”When Director Xiang went to the emergency department, he was so angry whenever he thought that Director Wang had picked up a big bargain and sent it with his own hands.But in several meetings, Director Wang avoided his edge, and he couldn't find an excuse to get angry at Director Wang.Now that he's caught on the phone, how can he just let it go?
Director Liang interjected at the right time: "Why don't we go to the twelfth floor."
Idle at home is idle anyway.It's good to talk to your face. ”Chen Wenqiang also realized that he might make a mistake if he had to talk to the director on the phone, and immediately said, "Then I will give you fifteen minutes to come over." ”Then he put the phone down.The busy sound reached Director Xiang's ears, and Director Xiang suddenly felt that the stick he was holding high fell short, and he almost flashed to his waist.He snorted angrily and turned off the telephone, and decided to have a good fight with Lao Wang for a while.Did that guy be the director for more than two months and forget to follow his own pace?
*Director Shi put down the phone and changed his clothes.His wife saw that he came back to eat with a calm face, put down his chopsticks and listened to the phone, and his face became more depressed, and now he put down the phone and wanted to go out, so he chased him and asked: "Lao Shi, what's the matter with the hospital?"
”"Hmm.There was a little doctor in Corey who misdiagnosed, but the patient was fine.You don't have to worry.I went over and met with Dean Chen. ”"Who are you?
Xiao Huang or Xiao Zheng?
”These young doctors from the Department of Cardiothoracic Surgery have all been to Director Shi's house, and they are all graduates of the Medical University, and Director Shi's wife has a good feeling for these young people.is more familiar with Li Min and Pan Zhi because they are neighbors.Director Shi smiled and teased his wife: "Why don't you guess that it's Xiao Li and Xiao Pan?"
”"If only the two of them—" Director Shi's wife said with a smile, "It wouldn't be a trivial matter if something happened to them."
There's no way you're going to come back for dinner. ”It makes sense."
It's Xiao Huang.He treated ectopic pregnancy as a ureteral stone. ”"Oh, is the patient alright?"
Director Shi's wife was surprised."
It's okay, I just had surgery before I got off work.""
It's fine.Then you have to tell Dean Chen well, Xiao Huang's child is young and inevitably inexperienced, so don't beat him to death with a stick.Our little stone graduated this year, don't you say?
”"Mmmm, don't worry, I know the severity."
The two chatted at the door of their house for a while, and when Director Shi went downstairs, they happened to see Director Liang and others coming over one after another.So he stood still and waited for them to go together."
Old Shi, what's going on?"
Although Chen Wenqiang said some, it will certainly not be very detailed.The patient on the twelfth floor, of course, has to ask him."
The patient was admitted to the hospital at noon......
Found during rounds before leaving work in the evening. ”Director Shi confessed the cause of the accident.At the same time, he also sighed: "If there is no late ward round, maybe I will let people look at each other, maybe Xiao Huang will give the patient another 654-2." ”Director Liang looked at Director Shi and said, "Old Shi, you are so blessed." ”Director Shi nodded.Director Xiang and Director Wang also understood that if they were given another 654-2, the symptoms of the patient's abdominal pain would be masked, and they might not know that they were in shock.Director Wang's expression froze, and then when he looked at the director, he said, "Lao Shi, I have to learn from you next week, and I can't let them see themselves." ”Director Xiang immediately said: "Lao Wang, see what you can, can you still do it?"
Are the staff composition and number of patients the same for thoracic and orthopedic departments?
120 beds, you take care of all the patients yourself. ”Director Liang said to Yuanchang: "Don't worry about people above the attending physician.The bed taken by the inpatient doctor should still be visited.Especially if you haven't been working for a long time. ”Although Director Wang has a soft temperament, her position as the director of the Department of Orthopedics is firm, and she has long since listened to the performance of the years, he added faintly: "In the incident of the trauma surgery on November last year, the doctor in charge was the attending physician. ”Director Liang was so angry that he curled his beard and said angrily: "You are a good one, so I owe Lao Xiang to clean you up." ”Xiang nodded with a smug smile."
That's different, that's mental arithmetic or unintentional."
Director Shi defended Dr.
Yang."
That's also because the director isn't serious."
Xiang to the director to the blood.This remark not only involved Zhang Zhengjie's ward rounds, but also involved Director Li and Xie Xun on duty.Then, and then several people stopped talking.When the elevator arrived, Director Liang was the first to enter.When the elevator went up, he saw Director Wang's frowning pitiful look and said, "It's impossible to inspect 120 beds every day."
I didn't have a medical team here, but the patients of Lao Bian, Lao Xu and Xie Xun were in charge of themselves. ”Director Wang's face was full of envy: "The strength of your general surgery department is the strongest in the whole hospital.With the four deputy chief physicians of one department, plus the two senior attending physicians, the ......
"General Surgery also has the most patients and is the most complicated." ”It's true.Even Director Xiang, who likes to raise the bar, did not object.When the elevator arrived, Director Shi pressed the button to open the door, letting the three directors who were older than him go first.Director Xiang got out of the elevator, turned back to Director Shi and said, "Old Shi, there are not so many deputy chief physicians in your department, and it is not realistic to let an attending doctor like Pan Zhi lead the medical team, you might as well let Yang Weiguo help you take part of it."
Count on Dean Chen, you can't count on it. ”Several people entered the director's office while talking.Chen Wenqiang happened to hear the last words of Director Xiang from the open office door.As soon as he opened his mouth, he asked, "Old Xiang, what do you mean you can't count on me?"
”"Speaking of old stones.The patient on the twelfth floor can't count on you to help him. ”That's really not to be counted on.Chen Wenqiang still has to count on Director Shi to help him manage the eleventh floor.Director Xiang regarded Chen Wenqiang's silence as a softness, and he made persistent efforts and said: "Old Chen, the provincial hospital has undergone earth-shaking changes from your management of surgery and medical treatment.If you want me to say that your progress in the past year or so is too fast, your steps are too big, and you are careful to pull the egg.Look at our hospital, except for general surgery, which is better, the rest of your brain, Lao Shi's chest, and orthopedics are not optimistic now. ”Chen Wenqiang told the truth about Director Xiang's stabbing like this, although he was very uncomfortable, he did not deny it.He kneaded his ten fingers and said, "This is a problem left over from history, what can I do?"
I can't let the provincial hospital miss the opportunity to develop because of this.However, I have to ask you directors to work harder and take care of the patients in your respective departments. ”Director Wang said, "Lao Chen, why don't you transfer Lao Xu to the orthopedic department for me?"
Although there are still a few orthopedic attending physicians, I still can't rest assured. ”Chen Wenqiang immediately shook his head: "You don't have to think about it, it's impossible."
There are many patients outside the general area, and the condition is more complicated than orthopedics, so I won't transfer Lao Xu to you.I am not calling you here to discuss who to transfer, but to study the clinical thinking, their work habits, and how to reverse their existing clinical thinking, correct their work habits, and how to let them embark on the path of growth as a qualified clinical doctor as soon as possible.Well, I can't help but mention how to make them obey the senior physician without blindly obeying them. ”*At the home of Director Wu of Pediatrics, Director Wu is flipping through a book with a frown."
What's wrong?"
Director Fan, who was sitting across from him reading a book, asked."
A 7-year-old child in Xiaofeng has been suffering from chronic abdominal pain for three months, and all the tests that should be done have been done, but the cause cannot be found."
Director Fan put down the "Latest Clinical Medication Guidelines" that he was looking at again, and waited for his wife to talk about it."
Before the Spring Festival, parents brought their children to the clinic, and at that time they suspected that their children did not like and did not adapt to school.But as the Chinese New Year grew, the child still had abdominal pain to the point that his appetite began to be affected, and the parents took the matter seriously. ”"Don't have a clue?""
Pretty much.I'm going to have a bone marrow aspiration on my child. ”"What is the suspicion?""
CT saw suspicious lymph nodes on the mesentery.After Director Hu gave the enhancement, he suspected lymphoma.However, there was no comparison of normal abdominal CT radiographs from three months ago, but it could not be defined as enlargement.However, there is no splenomegaly, nor are there any other features of swollen lymph nodes throughout the body. ”Director Wu was embarrassed: "You can't open your stomach to take lymph nodes for pathology."
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I had to do a bone marrow aspirate first. ”Director Fan thought for a while and said, "The laparoscope that Xie Xun asked for arrived yesterday, why don't you see if you can support the laparoscope to remove this lymph node?"
”Director Wu's furrowed eyebrows immediately relaxed.He said happily, "I'll ask him."
If the lymph node can be taken out for a biopsy, it will be clear whether it is lymphoma or not. ”Director Wu went to the hall to call Xie Xun."
Xiao Xie, I'm a pediatric old Wu.""
Ah, Director Wu.What do you command?
”Xie Xun's posture was very low, and his son Xie Baobao did not trouble Director Wu less."
That's right, I have a 7-year-old child here......"
Director Wu detailed his medical history, and then said: "Our old fan said that laparoscopy has arrived.I want to ask if you can take this lymph node out for pathology?
”"I'll have to look at the CT film before I can answer you.""
Okay, then I'll go back to Corey now and get you a film.""
No, I don't.I'm on the day shift tomorrow, and I'll go to your pediatrics to watch a movie.Half past eight, is that okay?
I'm going to do my rounds first. ”"Yes, then I'll wait for you in Corey at half past eight tomorrow morning
.
"* In the director's office on the twelfth floor, after Chen Wenqiang finished his intentions, everyone including Director Liang was silent.Some people can teach, and some people have formed habits of thought that are really hard to change.Director Shi thought for a while and said, "Lao Chen, let me tell you my opinion first.If you don't get it, all of you will give your opinions. ”"Okay, you say.You have worked in the affiliated hospital for more than 20 years, and your teaching experience is second to none in our provincial hospital. ”Director Shi was humble for a moment before he continued: "I think the blind obedience of young doctors is related to the fact that their basic knowledge is not strong enough.The solution is exams.The textbooks of medical schools are divided according to the organ system of the human body and according to the division of diseases.Let's take the exam, let's take the exam in a different way, take the test horizontally, and take the test according to the symptoms.A symptom sometimes involves multiple organs and systems. ”Director Xiang immediately said, "Lao Chen, I think what Lao Shi said makes sense.If you take more exams, your knowledge of books will naturally be solid.For example, today's abdominal pain is very good to be used as a hospitalized doctor.The usual thinking of diagnosis and treatment is to consider common diseases and frequent diseases first, but when dealing with emergencies in the emergency department, we must first exclude the fatal ones.The rest can be examined slowly. ”Director Liang also agreed: "It's easy to pick out one symptom test, and you can pass the test if you endorse it well."
We can also combine symptoms to test.For example, painless progressive obstructive jaundice with gallbladder enlargement suggests pancreatic head cancer.There are many such combinations, so that young people can form a network in their minds, and they can think of the most likely diagnosis at the first time with different combinations, which also helps young doctors to quickly improve their diagnosis level. ”"The test questions should combine symptoms and signs, plus differential diagnosis and auxiliary examinations.I don't think it's better to take the previous difficult cases from the case room, especially those that are consulted by the whole hospital. ”"That's a test for you.You used it to test those resident doctors, and you still think they are wrong?
Too many mistakes can affect their self-confidence. ”"Only when you are wrong will you remember it for a long time.Why don't you ask that Xiao Huang today, if he encounters an acute abdomen again, will he be wrong?
”"He'll probably get it right verbally.But actually doing it is another matter.We have been working for 30 years, and who dares to say that they have not fallen into the trap of acute abdomen over the years?
”Look, let's talk about work, and as soon as I came out, I started to talk about it.() The distance is a bit far