检验医师与临床沟通的重要性--附2例病例分析

Importance of communication between clinical laboratory physicians and clinic:2 cases of medical records

目的探讨检验医师与临床进行沟通的重要性。方法回顾分析横州市中医医院检验科医师对2例患者异常凝血结果的处理过程,检验科医师及时与临床进行沟通,并对异常检验结果进行分析和解释,帮助临床医生快速找到患者凝血功能异常的原因。结果病例1为50岁女性,无明显诱因出现面色苍白、全身多处瘀斑,至该院就诊,经凝血五项检查,凝血酶原时间(PT)结果检测不出。通过与临床医生进行沟通,对检验结果进行解释,最终确定杀鼠药是导致患者凝血功能异常的原因,给予注射维生素K1拮抗杀鼠药抗凝作用,输注冰冻血浆补充凝血因子,快速纠正凝血功能紊乱。病例2为73岁女性,无明显诱因出现言语欠清,就诊后诊断为脑梗死。血常规及生化检验中血样标本不凝固,且凝血功能检测显示PT、活化部分凝血活酶时间(APTT)明显延长。发现异常后,检验科及时与临床进行沟通,通过详细了解患者病程及药物使用情况,分析入院时与入院后凝血功能指标变化,协助临床医生推断出患者使用头孢哌酮钠-舒巴坦钠抗感染是导致凝血功能异常的原因。建议停用头孢哌酮钠-舒巴坦钠,注射维生素K1纠正凝血功能异常。经以上处理,2例患者的凝血功能异常得到及时纠正,避免患者因严重的凝血功能异常而发生颅内出血、上消化道出血、失血性休克等严重后果,甚至危及生命。结论检验医师发现异常检验结果时应及时与临床医生进行沟通并对检验结果进行解释,从而协助临床医生分析患者结果异常的原因,从而保证实验室检验结果的准确性、及时性,并使医疗过程更加合理有效、安全规范。

Objective To explore the importance of communication between clinical laboratory physicians and clinic.Methods The treatment process of the clinical laboratory physicians of Hengzhou Hospital of Traditional Chinese Medicine on the abnormal coagulation results of two patients were reviewed and analyzed.The clinical laboratory physicians communicated with the clinic in time,analyzed and explained the abnormal test results,so as to help clinicians quickly find the causes of the abnormal coagulation function of the patients.Results Case 1 was a 50-year-old female with pale complexion and multiple ecchymosis.After coagulation tests of five indicators,the results of prothrombin time(PT)could not be detected.Through communication with clinicians,the test results were explained,and finally it was determined that rodenticide was the cause of abnormal coagulation function.Vitamin K1 was injected to antagonize the anticoagulant effect of rodenticide,frozen plasma was injected to supplement coagulation factors,and the disorder of coagulation function was quickly corrected.Case 2,a 73-year-old female,was diagnosed as cerebral infarction due to unclear speech without obvious inducement.In blood routine and biochemical tests,blood samples did not coagulate,and coagulation function test showed that PT and activated partial thromboplastin time(APTT)were significantly prolonged.After finding the abnormality,the department of clinical laboratory communicated with the clinic in time,understood the patient's course of disease and drug use in detail,analyzed the changes of coagulation function indexes in admission and after admission,and assisted the clinician to infer that the patient's anti infection with cefoperazone sodium sulbactam sodium was the cause of abnormal coagulation function.It is suggested to stop cefoperazone sodium sulbactam sodium and inject vitamin K1 to correct abnormal coagulation function.After the above treatment,the abnormal coagulation function of the two patients was corrected in time to avoid serious consequences such as intracranial hemorrhage,upper gastrointestinal bleeding,hemorrhagic shock and even life-threatening.Conclusion When the clinical laboratory physicians find abnormal test results,timely communication with clinicians,analysis and interpretation of test results,and assisting clinicians to analyze the cause of abnormal test results,are the key links to ensure the accuracy and timeliness of clinical laboratory results,and could make the medical process more reasonable,effective,safe and standardized.