Cormier R E, Chase B A, Peterson G S, Pauker S G
Med Decis Making. 1982;2(3):323-39. doi: 10.1177/0272989X8200200309.
DT, a 63-year-old white male with insulin-dependent diabetes mellitus and severe peripheral vascular disease, was admitted with a five-day history of vague abdominal pain and diarrhea. On the day of admission he vomited three times, was noted to have a bloody stool, and came to the emergency room. DT denied hematemesis, fever, or chills. He had bilateral leg amputations and had sustained three myocardial infarctions, the last one 15 months before this admission. He had never experienced symptoms of abdominal angina. Of significance was his history of congestive heart failure, mitral regurgitation, and atrial fibrillation. His medications on admission included digoxin 0.25mg per day, furosemide 40mg per day, and NPH insulin 15 units per day. On admission to the hospital his oral temperature was 38 degrees C, pulse was 90/min, respiratory rate was 24/min, and blood pressure was 134/80mmHg. Abdominal examination revealed a distended abdomen with hypoactive bowel sounds and mild tenderness. Chest x ray revealed cardiomegaly. The electrocardiogram demonstrated atrial fibrillation. A plain film of the abdomen was positive for gallstones and edema of the bowel wall (thumb-printing). Laboratory results included blood urea nitrogen 48mg%, creatinine 1.2mg%, hemoglobin 18g/dl, and hematocrit 52.9%. White blood cell count was 11,900 cells/cc with 33% polymorphonuclear leukocytes, 47% bands, 8% lymphocytes, 11% monocytes, and 1% atypical lymphocytes. The prime considerations for differential diagnosis were mesenteric ischemia and infectious gastroenteritis. While it was appreciated that mesenteric ischemia, if present, might warrant surgical intervention, the risk of anesthesia itself in this patient was felt by his attending physicians to exceed 30%. Furthermore, the clinical findings were only "suggestive" of mesenteric eschemia. They were certainly not "diagnostic." In view of this dilemma, a consultation with the Division of Clinical Decision Making was requested.
DT是一名63岁的白人男性，患有胰岛素依赖型糖尿病和严重的外周血管疾病，因持续五天的模糊腹痛和腹泻入院。入院当天，他呕吐了三次，出现便血，随后前往急诊室。DT否认呕血、发热或寒战。他双腿截肢，曾发生过三次心肌梗死，最后一次是在此次入院前15个月。他从未经历过腹部绞痛症状。值得注意的是，他有充血性心力衰竭、二尖瓣反流和心房颤动病史。他入院时的用药包括每天0.25毫克地高辛、每天40毫克呋塞米和每天15单位中效胰岛素。入院时，他的口腔温度为38摄氏度，脉搏为90次/分钟，呼吸频率为24次/分钟，血压为134/80毫米汞柱。腹部检查发现腹部膨隆，肠鸣音减弱，有轻度压痛。胸部X光显示心脏扩大。心电图显示心房颤动。腹部平片显示有胆结石和肠壁水肿（指压痕）。实验室检查结果包括血尿素氮48毫克%、肌酐1.2毫克%、血红蛋白18克/分升和血细胞比容52.9%。白细胞计数为11,900个/立方厘米，其中多形核白细胞占33%，杆状核占47%，淋巴细胞占8%，单核细胞占11%，非典型淋巴细胞占1%。鉴别诊断的主要考虑因素是肠系膜缺血和感染性肠胃炎。虽然认识到如果存在肠系膜缺血可能需要手术干预，但主治医生认为该患者麻醉本身的风险超过30%。此外，临床发现仅“提示”肠系膜缺血，肯定不具有“诊断性”。鉴于这一困境，请求临床决策部门进行会诊。
