醫學偵探

這幾天收了一個年輕的I型糖尿病病人，被家人發現昏迷在房間裏，EMS到達的時候發現學糖非常低。這個病人的門診紀錄發現病人最近頻繁的發作低血糖，雖然把他的胰島素用量一再降低，仍然數次因為發作低血糖被送到急診。

低血糖有很多鑒別診斷，病人收進來以後，自然是一步步work up。在診斷過程中，發現病人在入院時血中胰島素濃度偏高，入院以後，胰島素濃度逐步降低。同時測試的c-peptide濃度卻一直很低。這時候我們對病人就產生了懷疑。

I型糖尿病的原理，是胰島細胞自身免疫破壞，導致體內沒有或者很少胰島素，所以絕對需要胰島素治療。這類病人的血胰島素水平應該是很低的。因為病人接受胰島素注射，所以病人較高的胰島素水平會導致診斷的混淆。聰明的科學家於是又研究出對C-peptide的測試。

C-pepetide是人類胰島素在激活之前需要被切割掉的一段蛋白質結構，自己的胰島分泌多少胰島素，就會有多少C-peptide被釋放出來。所以C-peptide能夠準確地告訴我們病人自生胰島素的能力。

回到這個病人。他的C-peptide水平很低，胰島素水平卻偏高，這中間的差異就是他人為注射了過量的胰島素。他現在的胰島素治療劑量非常低，是絕對不可能導致這樣的嚴重低血糖，入院以後我們給他固定劑量的胰島素，他的血胰島素水平逐漸降低，血糖也穩定下來。

我開誠布公地把我的想法和懷疑告訴他，把我們的數據給他看，然後耐心地開導他，終於慢慢地撥開了蒙在事實外麵的疑霧。因為自幼糖尿病，他對糖尿病的並發症恐懼至極，所以每天都要反複檢查自己的血糖，如果稍為高一點，他就給自己注射胰島素，然後馬上再檢查，如此循環，一直到血糖低到危險的閾值，或者到昏迷為止。這是一種類似OCD的表現，隻是更加極端和危險。我們請了心理治療師，但是這種心理疾病往往非常棘手，網上文獻顯示治療效果很不如意。

記得申請住院醫生的時候，我在自己的PS上說，喜歡醫學，是因為從小喜歡看偵探小說，醫學如神探，追溯蛛絲馬跡，發現匿藏的隱情。有意思，有意義。

[punny]

很想看那本推理偵探小說，嗬嗬

[落花飄零]

小米粥好久不見！醫學和偵探許多時候都是緊密相連的，在推理步驟上也很相似。我的一個主治醫生就最近寫了一本推理偵探小說，嗬嗬。
縱然平行，無獨有偶，我去年也收過一個病人，懷孕自己注射insulin的，等一下我貼上來。
aaalbert,你笑話我呢，不過那位大叔真的是很牛的，我當初想來美國做醫生就是看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. :-)

[縱然平行]

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，有意義。

這兩天很迷House，就是這種把醫生當偵探來演的節目，在這個old school偵探片稀缺的時代，是一個很好的替代品。

繼續繼續。

[落花飄零]

謝謝ruby。：）
點滴同學好，andrea是意大利人，在我貼的video裏，主持人介紹andrea出場時念他的名字的，你再聽聽。：）
大皇好！我覺得病例討論的時候就是這種場麵啊，就是我們沒有戴帽子抽煙，不過神似神似，嗬嗬。

[黃大皇]

你們成立個偵探科吧，然後大家帶著帽子，叼著煙鬥坐在裏麵，旁邊留個叫華生的專門寫醫囑。有意思！

[點點滴滴在心頭]

對了， Andrea Bocelli 中的 Bocelli 應怎念？ 這是法文發音對嗎？謝謝指教！

[點點滴滴在心頭]

拜讀了您的作品，喜歡你的文字。 也看了那篇 Andrea Bocelli & Vivo Per Lei 的合唱（歌名是？）動聽極了！！！很喜歡，去YouTube 搜索 了，點擊率很高嗬。 非常謝謝您，在這裏很高興自在，以後會常來欣賞！

[Ruby@Cuisine]

有道理，有道理，你很心細呀。