PDLP Chapter 31 Preliminary Rounds in Progress
Chapter 31 Preliminary Rounds in Progress
June 27, Sunday, 6 PM.
Lecture Hall 3 on the third floor of the Graduate School of Xiangya Hospital.
Chen Zhuoan sat in the middle, looking around curiously.
Having not sat in the exam seat for many years, he truly found this feeling quite mysterious.
This is a clinical reasoning skills competition for graduate students.
Three examiners were organizing the answer sheets, exam papers, and draft paper into brown paper bags, checking the seals and labels.
The broadcast is mechanically repeating the exam rules and corresponding legal responsibilities.
Su Xiheng was not in the same examination room as him.
The only familiar face in the examination room was Hou Zexin, a second-year doctoral student of Professor Liu Zhenbang in orthopedics.
Xiangya Hospital has many master's and doctoral students, but this clinical thinking competition is only open to graduate students, so both master's and doctoral students can apply.
I heard that nearly ten exam rooms were set up in total, but Xiangya Hospital will only select two teams to participate in the provincial competition. After the provincial competition, only three teams will remain...
These three teams must stand out from the master's and doctoral teams of the three Xiangya hospitals, as well as other master's and doctoral teams such as those of the Provincial People's Hospital.
……
Soon, the answer sheets and scratch paper were handed out.
Chen Zhuoan also filled in his name and student ID number in a standard manner.
04821...
After the examiner announced the examination rules again, the test papers were distributed.
There don't seem to be many questions, only six major questions!
The six major questions filled thirteen pages, each with a very long question stem, and were accompanied by printed images of the radiology photographs.
That was not a simple report.
The sound of pages turning and gasps of surprise filled the examination room.
Although there are only six questions, the actual number of questions is not small.
Chen Zhuoan first checked the test paper for any missing or incorrect printing, and then began reading the first question.
[18 points.]
[A 25-year-old female, a gymnastics teacher. She has sought medical attention multiple times for "episodic loss of consciousness accompanied by limb convulsions for 3 years."]
The patient reported that each episode of loss of consciousness and limb convulsions occurred while running, training, or during intense arguments with family members. It manifested as a sudden fall, upward rolling of the eyes, and tonic-clonic contractions of the limbs, which would spontaneously resolve within 1-2 minutes, followed by extreme fatigue.
[The patient was diagnosed with "epilepsy" at another hospital and has been taking sodium valproate continuously, but seizures still occur 1-2 times per month. Routine electrocardiograms, 24-hour Holter monitoring, and cranial MRI at our outpatient clinic all showed no abnormalities. The electroencephalogram report showed a small number of sharp waves in the frontal lobe.]
I was previously in good health.
[Family history: The elder brother suffered from epilepsy since childhood and died suddenly while jogging at the age of 30.]
problem:
1. What is the most likely diagnosis? Please list the diagnostic criteria.
2. What is the most important examination for making a definitive diagnosis?
3. Briefly describe the treatment principles.
After reading it, Chen Zhuoan immediately frowned.
This first question is so cunning! There are so many traps, at least five!
Convulsions are directly equated with epilepsy.
Medical history of being diagnosed with epilepsy at another hospital.
My brother's sudden death from epilepsy is a family history.
A small number of sharp waves on an electroencephalogram (EEG) are being over-interpreted.
Normal resting electrocardiogram (ECG) and routine Holter monitoring results are used as evidence to rule out heart disease...
However, Chen Zhuoan had been a question setter before, so he naturally knew that the testing approach for this type of question was to make you bold and careful.
Actually, the answer to the first question is relatively simple.
[Diagnosis: Catecholamine-sensitive polymorphic ventricular tachycardia (CPVT).]
[Diagnostic criteria: 1. Specific triggers: exercise, emotional excitement; the massive release of catecholamines after sympathetic nerve excitation is the only trigger for CPVT malignant arrhythmias.]
2. The seizure pattern is cardiogenic syncope: sudden onset and cessation, accompanied by convulsions, and extreme fatigue after the seizure. It is a hypoxic convulsion, caused by insufficient systemic perfusion following cardiac arrhythmia.
[3. Ineffective antiepileptic treatment, normal resting electrocardiogram and 24-hour Holter monitoring, and normal cranial MRI, ruling out specific organic lesions.]
4. A peculiar family history: The older brother died suddenly while jogging in the morning.
[The most important examination: ECG during exercise stress test]
[Treatment principles: 1. Strict lifestyle management: Strictly avoid triggers, prohibit competitive sports and strenuous activities, and avoid emotional excitement and fright.]
2. Long-acting β-receptor blockers without sympathomimetic activity: naldolol, with flecainide added if necessary.
[3. If the above treatments are still unsatisfactory, an implantable cardioverter-defibrillator (ICD) or left-sided cardiac sympathetic denervation may be considered, and oral medications will still be required...]
After writing down these answers, Chen Zhuoan checked the time.
Goodness, six minutes have already passed.
The exam lasts two hours in total. The first question is a simple one, and you need six minutes for that.
For most people, they wouldn't even be able to finish answering these six major questions.
I wonder if Su Baobao will fall into a trap.
Chen Zhuoan continued to look at the second question—
A 28-year-old female was admitted to the hospital due to "recurrent abdominal colic, nausea, and vomiting for 2 years, with a recurrence of the previous episode for 2 days." The patient reported severe, colicky abdominal pain, accompanied by constipation. She had previously undergone exploratory laparotomy at another hospital for "intestinal obstruction," but no mechanical obstruction was found. Physical examination on admission revealed: heart rate 130 bpm, blood pressure 160/100 mmHg, indwelling urinary catheter, dark yellow urine that gradually turned wine-red under sunlight. The abdomen was soft, with no significant tenderness or rebound tenderness…no other abnormalities were noted.
Laboratory tests showed hyponatremia (128 mmol/L) and slightly elevated transaminases. An enhanced abdominal CT scan revealed no obvious organic lesions.
problem:
What is the most likely diagnosis? Please list the diagnostic criteria.
What key tests are needed for a confirmed diagnosis?
Why does urine change color in sunlight, and what does this indicate?
This question has many pitfalls.
Those with deeper knowledge, considering the severity of symptoms and mild physical signs, might consider mesenteric artery embolism...
But in reality, this is a truly difficult problem, requiring a thorough understanding of the book and its fundamental principles to find the answer.
Preliminary diagnosis: Acute intermittent porphyria.
[Diagnostic Criteria]
When Chen Zhuoan wrote this, he suddenly paused and wondered to himself: Is this the teacher who set the questions deliberately messing with me to get revenge on me for "setting the questions" last time?
However, Chen Zhuoan quickly put that idea aside.
This exam is open to all master's and doctoral students at Central South University. If the examiners try to target themselves by creating problems, the scores will inevitably be poor.
However, the conditions given in these questions are relatively objective and detailed. As long as you have a deep understanding of the basic principles of the disease, it is not difficult to answer them.
Getting a perfect score isn't easy.
Chen Zhuoan continued writing down the diagnostic basis.
The exam proceeded slowly, and by the 102nd minute, Chen Zhuoan had finished answering all the questions.
After reviewing his answers and checking that there were no errors or omissions, Chen Zhuoan chose to submit his paper early.
He has set exam questions before, so he has a knack for it. He knows exactly what aspects each question is testing.
I handed in my paper 105 minutes early, which was only 15 minutes early.
This falls within the scope of the normal early submission regulations.
But others also saw Chen Zhuoan hand in his paper, and they were still nervous.
Can you hand in your paper early for this kind of question?
elder brother?
But the only sound in the examination room was Chen Zhuoan's light footsteps.