I recently saw a 63-year-old male patient in Beijing. 20 years ago, there was no discomfort in the body, and a physical examination of coronary CT found that the distal stenosis of the gyroste branch was 90%. A clinician in 301 Hospital believes that there is no discomfort in the patient's climbing and running, there is no need for angiography and stents, and patients also have concerns about stents. Several times in 20 years, the CT was repeated, and the lesions remained basically unchanged.
He has smoked and has been abstinent for more than ten years. Alcohol consumption is also limited. Have high blood pressure and control it well. Total cholesterol and LDL cholesterol tests were in the normal range, but statins were not adhered to. No diabetes. Intermittently consulted the doctor at 301 Hospital and insisted on recommending no contrast, no stent. But patients don't know why stents are not needed. Is there a risk that coronary artery disease with a stenosis of 90% is not treated? From various information, I learned that coronary angiography is the gold standard, and it is unreliable to do only CT.
On November 25 last year, he went to Beijing's most famous cardiology hospital to register as a specialist, was admitted to the hospital, and the next day he had a coronary angiogram. The surgeon communicates with the patient on the stage that the first is that the blood vessels with narrow lesions are smaller than other branches, the lesions are distal to the blood vessels, and it is okay not to do stents, but it is easy to do it, and it is recommended to do it once. So a stent was placed on the lesion.
After discharge, the first three months, there are not many cases of self-conscious physical discomfort, not obvious. However, after three months, a variety of inexplicable symptoms in many parts of the body began to appear gradually, and even some symptoms were difficult to accurately describe in words, including: 1, the back neck was hard; 2, the two jaws twitched; 3, the heart had a foreign body feeling; 4, the teeth were numb; 5, under the sword protrusion, the upper abdomen was swollen and painful, and the appetite was significantly reduced; 6, the front chest was cold; 7, after breakfast and afternoon, I felt food to the top of the abdomen; 8, the muscles of the lower limbs were crisp and numb; 9, the anus fell; 10, the sleep was obviously worse, it was difficult to fall asleep, and it was early to wake up; 11. Physically and mentally exhausted during the day; 12, the mood is extremely low, there is no mood, it is easy to be irritable.
To the China-Japan Friendship Hospital and Wangjing Hospital many times to see the outpatient clinic, check back and forth, the doctor said that there is nothing abnormal. A doctor in Wangjing told patients that the most sensitive test for myocardial infarction is to take blood to check for troponin. Patients keep in mind, as long as there is discomfort, go to the nearest Wangjing Hospital to check troponin, more than 20 times a year, troponin is not high.
The patient was worried about the side effects of the drug, and he was stopped with tantine, aspirin, and tigrelor. Switching to Tibetan medicine, the symptoms have decreased, but there are still recurrences.
Trying chinese medicine also has some effect, but the residual general discomfort still lingers.
In the process of communicating with me, the patient proposed that the stent could not be taken out, not at home, and it was also possible to go abroad to pick it up.
The patient also mentioned that a doctor, considering that his symptoms may be related to depression, prescribed one of the most expensive but not suitable drugs at the moment, plus lorazepam and eszolam. The most expensive medicine was prescribed 20 boxes at a time, and after using it for a while, the symptoms still did not alleviate.
From the diagnosis and treatment process of this patient, what lessons should we learn?
1, 20 years has been stable coronary artery disease, even if there is angina, as long as it is stable, that is, the latest month and the previous ratio is not aggravated, stent does not resolve the risk, it is impossible to prevent myocardial infarction, can only alleviate and alleviate the symptoms of angina. The patient had no symptoms at all for 20 years before stent surgery. There is no discomfort when running and climbing the mountain, so why take the sheep and place the patient with a stent that is not needed at all?
2. Tell the patient that the information and medical records only have the degree of vascular stenosis, and there is no mention of the collateral circulation from the anterior descending branch that I saw on the patient's copy disc.
3. The patient had no symptoms of angina in the 20 years before surgery, but the discharge diagnosis was written as "coronary heart disease, unstable angina". Angina is the patient's own discomfort, i.e., the symptom, and the gold standard for diagnosing angina is the patient's complaint of symptoms, not the degree of narrowing of the blood vessels seen on CT or contrast. The patient does not even have angina, what else to talk about instability?
The purpose of fabricating the diagnosis is also very clear, and it is not all to blame the doctor, in order to obtain medical insurance payment, saying that the insurance fraud is somewhat unpleasant, but this is the case. This diagnosis of fabricated instability angina is fairly common. Nowadays, few doctors spend time to seriously communicate symptoms with patients, symptom science is the basis of diagnosis, and what is ignored today is precisely the consultation link.
4. The lack of follow-up and rehabilitation after surgery led to the patient stopping all drugs such as statin and aspirin that could not be stopped. This is a risk for patients after stenting.
5. The multi-part and diverse symptoms of the whole body caused by postoperative depression cannot be recognized in time. "Double Heart Medicine" does not land in most hospitals, and the training of doctors is a simple biomedical technology, and they do not understand or learn spiritual and psychological common sense. This is the root cause of the patient's pain being misdiagnosed and mistreated for a long time.
Even if a doctor ends up thinking about depression, why not discuss treatment options with an experienced psychiatrist and prescribe the most expensive but symptomatic medication for the patient? Is it necessary for patients to take more than one of these medications? After the prescription, the patient's condition did not improve, and the doctor did not follow up and communicated with the patient in time.
6, 301 Hospital that doctor insisted on not recommending patients with contrast and stents, which is obviously a correct and standardized medical behavior. However, if the reason for not doing contrast and not doing stents can be clearly stated, patients may not end up being over-stented. Large hospitals are overcrowded, a doctor has to see 30-50 patients in the morning, and indeed there is no time to explain these problems, which requires fundamentally changing the high monopoly of medical resources in large hospitals, so that a large number of common diseases, multiple diseases, and common patients flock to large hospitals, specialized hospitals and expert outpatient clinics. Not only townships and communities, but also non-mainstream tertiary hospitals and secondary hospitals are left out in the cold.
I asked Dr. Qu Shan, a psychiatrist who came to the clinic together, to analyze the ins and outs of the disease for the patient, spent an hour of communication and answering questions, and formulated a comprehensive "double heart" treatment plan for the patient. And let the patients add our WeChat, easy to communicate at any time, follow-up.
After the diagnosis is in the right direction, the key is to do the details. For the same disease, no patient is the same, and the type, dosage, and course of treatment of the drug are crucial. Follow-up and doctor-patient interaction can individually explore the optimal treatment plan, ensure the safety, efficacy and compliance of drugs, and guide patients to make five prescriptions for rehabilitation.