医学侦探

这几天收了一个年轻的I型糖尿病病人，被家人发现昏迷在房间里，EMS到达的时候发现学糖非常低。这个病人的门诊纪录发现病人最近频繁的发作低血糖，虽然把他的胰岛素用量一再降低，仍然数次因为发作低血糖被送到急诊。

低血糖有很多鉴别诊断，病人收进来以后，自然是一步步work up。在诊断过程中，发现病人在入院时血中胰岛素浓度偏高，入院以后，胰岛素浓度逐步降低。同时测试的c-peptide浓度却一直很低。这时候我们对病人就产生了怀疑。

I型糖尿病的原理，是胰岛细胞自身免疫破坏，导致体内没有或者很少胰岛素，所以绝对需要胰岛素治疗。这类病人的血胰岛素水平应该是很低的。因为病人接受胰岛素注射，所以病人较高的胰岛素水平会导致诊断的混淆。聪明的科学家于是又研究出对C-peptide的测试。

C-pepetide是人类胰岛素在激活之前需要被切割掉的一段蛋白质结构，自己的胰岛分泌多少胰岛素，就会有多少C-peptide被释放出来。所以C-peptide能够准确地告诉我们病人自生胰岛素的能力。

回到这个病人。他的C-peptide水平很低，胰岛素水平却偏高，这中间的差异就是他人为注射了过量的胰岛素。他现在的胰岛素治疗剂量非常低，是绝对不可能导致这样的严重低血糖，入院以后我们给他固定剂量的胰岛素，他的血胰岛素水平逐渐降低，血糖也稳定下来。

我开诚布公地把我的想法和怀疑告诉他，把我们的数据给他看，然后耐心地开导他，终于慢慢地拨开了蒙在事实外面的疑雾。因为自幼糖尿病，他对糖尿病的并发症恐惧至极，所以每天都要反复检查自己的血糖，如果稍为高一点，他就给自己注射胰岛素，然后马上再检查，如此循环，一直到血糖低到危险的阈值，或者到昏迷为止。这是一种类似OCD的表现，只是更加极端和危险。我们请了心理治疗师，但是这种心理疾病往往非常棘手，网上文献显示治疗效果很不如意。

记得申请住院医生的时候，我在自己的PS上说，喜欢医学，是因为从小喜欢看侦探小说，医学如神探，追溯蛛丝马迹，发现匿藏的隐情。有意思，有意义。

[punny]

很想看那本推理侦探小说，呵呵

[落花飘零]

小米粥好久不见！医学和侦探许多时候都是紧密相连的，在推理步骤上也很相似。我的一个主治医生就最近写了一本推理侦探小说，呵呵。
纵然平行，无独有偶，我去年也收过一个病人，怀孕自己注射insulin的，等一下我贴上来。
aaalbert,你笑话我呢，不过那位大叔真的是很牛的，我当初想来美国做医生就是看ER看的。

[AAAlbert]

Interesting story and well told.

In my opinion, things are similar in every truth-searching activities. Many have achieved professional status with the passion to search for the truth, yet few are able to tell a story in a vivid and enticing way. Michael Crichton is an exemplar.

You are probably just a few steps away from him. :-)

[纵然平行]

Last night, I called home, and it was just a routine call. At the end of conversations, out of curiosity, I mentioned your diabetic pt's case to my mother who is an OB/GYN doctor working at a teaching hospital affricated with a medical school in a major city of China. To my surprise, she enlightened me with an eye-opening story that really shocked me.

Not very long ago one of my mother’s pts developed diabetes during her first trimester of the pregnancy, and she was prescribed insulin to lower her blood sugar level in order to safeguard the health of mother-to-be and the fetus. Unfortunately, one day this young woman found out , by a chance, that her husband was having an affair with a girl secretly behind her back. As the traumatic event unraveled this young women made a suicidal attempt by injecting herself with a large quantity of insulin. Shortly after she did that, her body was starting shivering , and she was on the verge to lose her consciousness, luckily her husband, a young orthodontist, with suffice medical knowledge discovered her in the bathroom and immediately fed her drink with very high contents of sugar in it while calling for the medical help. In the end, my mother’s pt turn out to be ok , and she didn’t die from the tragic event. In fact, six months later she gave birth to a healthy baby girl. Interesting enough, her marriage was apparently saved, and her husband stopped seeing the other girl. According to my mother it was true happy ending after all of the exhilarations. She pointed out that there also has a twist in this true story that the young mother who committed suicide with insulin has pharmaceutical background.

In the other end of my phone call my mother “seized” a rare opportunity to lecture me about the evil source of that had happened and usual jazz about responsibility so on so forth, etc. That was kind of boring -:).

Anyhow, my take-away was that on the one hand knowledge is powerful and lifesaving, on the other hand it could be fetal and sinister when used by a wrong person.

[小米粥]

有意思，有意义。

这两天很迷House，就是这种把医生当侦探来演的节目，在这个old school侦探片稀缺的时代，是一个很好的替代品。

继续继续。

[落花飘零]

谢谢ruby。：）
点滴同学好，andrea是意大利人，在我贴的video里，主持人介绍andrea出场时念他的名字的，你再听听。：）
大皇好！我觉得病例讨论的时候就是这种场面啊，就是我们没有戴帽子抽烟，不过神似神似，呵呵。

[黄大皇]

你们成立个侦探科吧，然后大家带着帽子，叼着烟斗坐在里面，旁边留个叫华生的专门写医嘱。有意思！

[点点滴滴在心头]

对了， Andrea Bocelli 中的 Bocelli 应怎念？ 这是法文发音对吗？谢谢指教！

[点点滴滴在心头]

拜读了您的作品，喜欢你的文字。 也看了那篇 Andrea Bocelli & Vivo Per Lei 的合唱（歌名是？）动听极了！！！很喜欢，去YouTube 搜索 了，点击率很高呵。 非常谢谢您，在这里很高兴自在，以后会常来欣赏！

[Ruby@Cuisine]

有道理，有道理，你很心细呀。