这哪是看病?简直就是一部悬疑推理小说!(强烈推荐)

2016-09-20 yf 医学界消化频道

导语:一步一步的推理,下诊断,推翻诊断,再推理,还有什么比这个过程更加的惊心动魄呢?一线医生有点支吾地说:“老师,这个病人有点奇怪呢?”我抽空瞄了一眼入院证,“27岁年轻男性,腹泻待诊”——这有什么复杂的?差不离就感染、非感染腹泻嘛,化验出来后安排一个肠镜也就ok啦。但是考虑到这医生基本功还是不错的,他困惑的病人,我得去看看。走到病床前,病人一般情况不错嘛,只是一直在干咳。抬手一摸——皮温高!一问

导语:一步一步的推理,下诊断,推翻诊断,再推理,还有什么比这个过程更加的惊心动魄呢?


一线医生有点支吾地说:“老师,这个病人有点奇怪呢?”我抽空瞄了一眼入院证,“27岁年轻男性,腹泻待诊”——这有什么复杂的?差不离就感染、非感染腹泻嘛,化验出来后安排一个肠镜也就ok啦。


但是考虑到这医生基本功还是不错的,他困惑的病人,我得去看看。走到病床前,病人一般情况不错嘛,只是一直在干咳。抬手一摸——皮温高!一问下来,每天午后发热39度已经3天了!诊断从腹泻待诊转变成发热待诊了。“发热待诊”——这就是一本书的鉴别诊断啊,我有种不祥的预感了。


唉,从头来吧!


病史:发热、腹痛伴粘液脓血便3天。发热多于午后出现,最高体温多为39-40°C,夜间无盗汗,晨起可以自行退热;粘液脓血便每次量少,约10-50ml,有里急后重;腹痛以上腹部为主,无放射,无呕吐及腹胀。期间间断干咳,无痰、无喘息。院外输液一天,输液后出现一过性荨麻疹样皮疹,未特殊处理后自行消退。既往体健,无特殊病史,无吸毒史及野游史,无热带地区居住史。查体:一般情况好,颈软,浅表淋巴结无肿大,咽部略充血,扁桃体不大。口腔内粘膜正常。双肺呼吸音居然是正常的(本来我预期可能会闻及少许干鸣的),上腹部轻微有点张力,压痛程度介于消化性溃疡和刚刚起病的胰腺炎患者之间,左上腹相对而言更明显一些(按理说粘液脓血便应该会有左下腹压痛,但是这个患者确实是左上腹压痛明显,下腹没有)。肝脾未扪及。叩诊无腹水。双下肢未见皮疹,无水肿。


目前唯一直观的感染灶就是肠道了,但是造成如此高热的肠道感染,常见的无非中毒性菌痢,IBD重型,但是哪里会有这么好的一般情况,那就算不是奄奄一息也是萎靡不振的,这患者可以说是平稳极了;外科的穿孔、梗阻、绞榨,也没有这么轻的体征啊!初起的胰腺炎,体征符合,但是哪里有胰腺炎发病还粘液血便呢?初期也不发热啊!午后发热+脓血便——肠结核?粟粒性结核也是常常肺部没有体征的,好像有点挂边……但是肠结核体征常常是右下腹,不是左上腹啊,如果是左上腹的疼痛会不会有胸膜炎了?胸膜炎也可以干咳无痰,但是没有吸气相关的腹痛也没有胸膜摩擦音呢!不吸毒、不野游,HIV肠病也不像,而且说实话HIV肠病常见的还是慢性腹泻,要是HIV肠病高热起来,多半合并播散性结核了,那时就是皮包骨了!


窘逼的二线我挠挠头发,心里说了一句超级不科学的话:“莫非要用二元论?”,但是,口里却故作淡定地说了一句非常科学的话:“先检查吧!”


初步检查下来一看:就是一句话,年轻人身体就是棒。除了血常规和大便常规异常外,生化都不错。血常规白细胞升高17.76x109,中性16.4%,淋巴9.1%,嗜酸71.2%,大便常规当然是白细胞、红细胞、隐血都阳性,没有吞噬细胞。腹部彩超没有问题,腹腔也没有腹水;胸腹片也就肺纹理多一点,没有胸膜炎表现。难道他真的就是一个肠道感染引起的高热?


不可能吧。这病人干脆提请全科非正式讨论一下。一个人的思维总是会有局限性的,还是群策群力吧!大家七嘴八舌讨论开了——结合这个夏秋之交的季节,会不会有传染病?比如立克次体感染?——全身包括隐蔽部位没有焦痂,不像,但是可以给点四环素诊断性治疗看看;没有球结膜水肿,肾功能、尿常规正常,也不像出血热;追问下来患者爱在水里抓鱼,会不会有急性血吸虫?我们地区也是属于长江流域,虽然已经宣布消灭血吸虫很多年了,但是钉螺好像还没有灭完;结合嗜酸细胞那么高,不好说没有喔。立刻建议患者前往本地血吸虫防治站进一步检查。本地区没有疟疾,他无外地居住史,也就暂时不考虑了。目前能够确定的第一步方案,先按肠道感染给予抗生素治疗,再做个肺部及上腹部CT,算是再搜寻一下可能潜在的蛛丝马迹吧。


第二天,肺部CT做下来,我们傻了,和胸片差别太大了!从中下肺开始,那是大片的阴影啊!CT提示为间质性肺炎,找放射科主任读片,认为不符合肺结核、肺癌的表现(图1-3.)马上再回到病床前再次确认——没有吸烟史、没有慢性咳嗽史、没有咯血、没有盗汗史。再查体:浅表淋巴结确实不肿大,双肺呼吸音可以算略粗糙也可以算清晰。——这么这么静默的肺部体征,这么这么差的影像学结果,马上补查肿瘤标志物和自身免疫全套吧!


图1


图2


图3


——高热、粘液脓血便、肺部阴影……这是个什么鬼?


抗生素使用后的第三天,热型基本上没有变化,还是午后高热。只不过病人食欲好转了,咳嗽有点减轻,大便次数减少……四环素已经使用了4次,恙虫病可以不考虑了;目前结合患者超高的嗜酸细胞,血吸虫血清学反应阳性(大便孵化结果还没有拿到),开始按血吸虫病给予吡喹酮治疗。吡喹酮治疗后24小时,体温最高峰由39度降低到38度,咳嗽消失。从治疗反应来说,比较符合血吸虫感染了,但是患者的体温能够完全降至正常吗?肺部改变一定是血吸虫所致吗?


毕竟就已知的血吸虫相关知识而言,血吸虫主要还是寄生在门静脉系统,然后还是在肠系膜下静脉和直肠上静脉产卵……书本有提过血吸虫的肺部改变为间质性改变,因为相对少见而且缺乏具体的表述。毕竟大部分研究血吸虫的文献资料还是在90年代,肺部CT没有普及的时候。根据目前患者的情况,比较可行的确诊手段一个是等大便孵化出尾蚴,还有就是我们消化科先安排肠镜检查看看。结果肠镜做下来,确实有点意思。


不仅有我们常见的粘膜表面黄色点状颗粒(聚集成团的血吸虫虫卵)沉着,还有无数个丘疹样隆起(图4),活检了3块。看见这样的表现,我们心里已经基本有数了,回来立刻停了抗生素。在等待病理结果的过程中,患者体温慢慢的降至正常。吡喹酮治疗第六天,患者突然出现肌肉酸痛,一过性皮疹(可惜当时患者不在医院里边,我们没有看见患者也没有拍照),我们考虑为类赫氏反应,给予了激素,次日不适消失。最后肠镜病理回来:见图片5。同时血吸虫防治站的结果也回来了:大便孵化出较多尾蚴。急性血吸虫病得以确诊。


图4


图5


现在回过头来想:患者最初认为过敏的皮疹应该就是尾蚴性皮疹。后来他还回忆起4月前也是下水摸鱼后,出现过一次皮疹。


但是两次皮疹都是一过性的,故没有引起重视。患者摸鱼的地方平时是一条干的沟渠,平时都没有水的,今年气候异常,持续降雨,这条小河里边突然涨了水,所以应该是新出现的血吸虫疫情。


最后患者在治疗的过程中,联系了两位曾经和他在小河里摸鱼的朋友,居然都在高热。一个因为病情较重,已经转往省级医疗机构……治疗经过不详。还有一个因为肺部感染就住在我院呼吸科,我们后来接手了呼吸科的患者,也给 他完善了肠镜检查,获得了同样的结论。两人的肺部病灶及肠镜表现虽然轻重不同,但是基本上是类似的。(图片6-10)


图6


图7


图8


图9


图10


患者朋友的病理


患者朋友的骨穿


通过查阅文献,了解到血吸虫的肺部表现应该属于异位损害的一种,异位损害包括皮肤、肺部、大脑、心肌和内分泌系统。目前血吸虫肺部损害的机理研究得远不如血吸虫肝硬化、血吸虫肠病透彻。一种观点认为是童虫移行至肺部,发育为成虫后产卵,形成嗜酸性肉芽肿和假结核结节,病变多位于肺间质。(童虫在体内游走的时候,体表会有宿主抗原,以逃避免疫攻击——披着人皮的虫!真够狡诈的!)另一种观点认为是接触的血吸虫太多,血吸虫成虫在门静脉大量产卵后,虫卵满溢出门静脉系统,流向肺及脑组织。治疗上除了吡喹酮外还可以和青蒿素制剂连用(伟大的中国青蒿素)。大部分的书籍上说类赫氏反应发生于首次给药后30分钟-4小时,但是我们这位患者却是治疗接近尾声才出现的。部分感染重的急性血吸虫患者在第一个6日疗程结束后,需要再次治疗。


我们这两位患者目前经吡喹酮治疗后体温正常了,但是嗜酸细胞没有下降至正常,血吸虫防治站要求他20天后还需要返回复查大便孵化情况,通过观察大便中虫卵计数,来评判是否需要再次治疗。关于肺部病灶的恢复,文献提示需要2-3月时间,所以我们和患者协商后,他选择3月后再返院复查。

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    2016-10-03 澹台本本

    这个医生真好。
    ps:我也想去摸鱼。

    0

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    2016-09-24 187清风

    继续关注

    0

  3. [GetPortalCommentsPageByObjectIdResponse(id=139708, encodeId=3b4f139e083e, content=这个医生真好。 <br> ps:我也想去摸鱼。, beContent=null, objectType=article, channel=null, level=null, likeNumber=69, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://thirdwx.qlogo.cn/mmopen/vi_32/Q0j4TwGTfTLDvXc47IcmibZQtPyb8ngMlIsAHgtjHDKqWOOiaFhwJPtZaumNKVXJsxiatE7kXqdL0ng4f4HH693xA/132, createdBy=49f61628387, createdName=澹台本本, createdTime=Mon Oct 03 23:40:32 CST 2016, time=2016-10-03, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=134139, encodeId=6da7134139c3, content=继续关注, beContent=null, objectType=article, channel=null, level=null, likeNumber=61, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=cb571956164, createdName=187清风, createdTime=Sat Sep 24 08:50:00 CST 2016, time=2016-09-24, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=134138, encodeId=e576134138b6, content=医学就是推理, beContent=null, objectType=article, channel=null, level=null, likeNumber=61, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=cb571956164, createdName=187清风, createdTime=Sat Sep 24 08:49:00 CST 2016, time=2016-09-24, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=132433, encodeId=f54d13243394, content=确实够悬疑的,西北地区基本见不到的案例,受教育了, beContent=null, objectType=article, channel=null, level=null, likeNumber=68, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=63d51718849, createdName=ly17291850, createdTime=Wed Sep 21 17:41:00 CST 2016, time=2016-09-21, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=131501, encodeId=a2f51315019d, content=学习了,又一次提示问病史很重要, beContent=null, objectType=article, channel=null, level=null, likeNumber=56, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/mONcle9pic3yVFeItvYLMR38WUsYtaRuSmqy9gDOnkr3D0usJ7SGXfFld6yx6ZXOfzic752zRyIoKaSmMyeZUel53m97J6WtlI/0, createdBy=e4191953752, createdName=花开冉末i, createdTime=Tue Sep 20 17:05:00 CST 2016, time=2016-09-20, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=131239, encodeId=60b21312398e, content=学习啦,,,,, beContent=null, objectType=article, channel=null, level=null, likeNumber=27, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/mStl88fu4NfdY7yem1P7bRvOP6z0jKsBoYR8ezfAricY7meQWcte7LRJsWHVn0CnPJg2JuQmevR0DoFmmEib5QLD2kNESBESQT/0, createdBy=59191706502, createdName=医路开来, createdTime=Tue Sep 20 10:02:00 CST 2016, time=2016-09-20, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=131240, encodeId=e3cd1312402f, content=谢谢分享,,,,, beContent=null, objectType=article, channel=null, level=null, likeNumber=27, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/mStl88fu4NfdY7yem1P7bRvOP6z0jKsBoYR8ezfAricY7meQWcte7LRJsWHVn0CnPJg2JuQmevR0DoFmmEib5QLD2kNESBESQT/0, createdBy=59191706502, createdName=医路开来, createdTime=Tue Sep 20 10:02:00 CST 2016, time=2016-09-20, status=1, ipAttribution=)]
    2016-09-24 187清风

    医学就是推理

    0

  4. [GetPortalCommentsPageByObjectIdResponse(id=139708, encodeId=3b4f139e083e, content=这个医生真好。 <br> ps:我也想去摸鱼。, beContent=null, objectType=article, channel=null, level=null, likeNumber=69, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://thirdwx.qlogo.cn/mmopen/vi_32/Q0j4TwGTfTLDvXc47IcmibZQtPyb8ngMlIsAHgtjHDKqWOOiaFhwJPtZaumNKVXJsxiatE7kXqdL0ng4f4HH693xA/132, createdBy=49f61628387, createdName=澹台本本, createdTime=Mon Oct 03 23:40:32 CST 2016, time=2016-10-03, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=134139, encodeId=6da7134139c3, content=继续关注, beContent=null, objectType=article, channel=null, level=null, likeNumber=61, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=cb571956164, createdName=187清风, createdTime=Sat Sep 24 08:50:00 CST 2016, time=2016-09-24, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=134138, encodeId=e576134138b6, content=医学就是推理, beContent=null, objectType=article, channel=null, level=null, likeNumber=61, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=cb571956164, createdName=187清风, createdTime=Sat Sep 24 08:49:00 CST 2016, time=2016-09-24, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=132433, encodeId=f54d13243394, content=确实够悬疑的,西北地区基本见不到的案例,受教育了, beContent=null, objectType=article, channel=null, level=null, likeNumber=68, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=63d51718849, createdName=ly17291850, createdTime=Wed Sep 21 17:41:00 CST 2016, time=2016-09-21, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=131501, encodeId=a2f51315019d, content=学习了,又一次提示问病史很重要, beContent=null, objectType=article, channel=null, level=null, likeNumber=56, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/mONcle9pic3yVFeItvYLMR38WUsYtaRuSmqy9gDOnkr3D0usJ7SGXfFld6yx6ZXOfzic752zRyIoKaSmMyeZUel53m97J6WtlI/0, createdBy=e4191953752, createdName=花开冉末i, createdTime=Tue Sep 20 17:05:00 CST 2016, time=2016-09-20, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=131239, encodeId=60b21312398e, content=学习啦,,,,, beContent=null, objectType=article, channel=null, level=null, likeNumber=27, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/mStl88fu4NfdY7yem1P7bRvOP6z0jKsBoYR8ezfAricY7meQWcte7LRJsWHVn0CnPJg2JuQmevR0DoFmmEib5QLD2kNESBESQT/0, createdBy=59191706502, createdName=医路开来, createdTime=Tue Sep 20 10:02:00 CST 2016, time=2016-09-20, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=131240, encodeId=e3cd1312402f, content=谢谢分享,,,,, beContent=null, objectType=article, channel=null, level=null, likeNumber=27, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/mStl88fu4NfdY7yem1P7bRvOP6z0jKsBoYR8ezfAricY7meQWcte7LRJsWHVn0CnPJg2JuQmevR0DoFmmEib5QLD2kNESBESQT/0, createdBy=59191706502, createdName=医路开来, createdTime=Tue Sep 20 10:02:00 CST 2016, time=2016-09-20, status=1, ipAttribution=)]
    2016-09-21 ly17291850

    确实够悬疑的,西北地区基本见不到的案例,受教育了

    0

  5. [GetPortalCommentsPageByObjectIdResponse(id=139708, encodeId=3b4f139e083e, content=这个医生真好。 <br> ps:我也想去摸鱼。, beContent=null, objectType=article, channel=null, level=null, likeNumber=69, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://thirdwx.qlogo.cn/mmopen/vi_32/Q0j4TwGTfTLDvXc47IcmibZQtPyb8ngMlIsAHgtjHDKqWOOiaFhwJPtZaumNKVXJsxiatE7kXqdL0ng4f4HH693xA/132, createdBy=49f61628387, createdName=澹台本本, createdTime=Mon Oct 03 23:40:32 CST 2016, time=2016-10-03, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=134139, encodeId=6da7134139c3, content=继续关注, beContent=null, objectType=article, channel=null, level=null, likeNumber=61, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=cb571956164, createdName=187清风, createdTime=Sat Sep 24 08:50:00 CST 2016, time=2016-09-24, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=134138, encodeId=e576134138b6, content=医学就是推理, beContent=null, objectType=article, channel=null, level=null, likeNumber=61, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=cb571956164, createdName=187清风, createdTime=Sat Sep 24 08:49:00 CST 2016, time=2016-09-24, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=132433, encodeId=f54d13243394, content=确实够悬疑的,西北地区基本见不到的案例,受教育了, beContent=null, objectType=article, channel=null, level=null, likeNumber=68, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=63d51718849, createdName=ly17291850, createdTime=Wed Sep 21 17:41:00 CST 2016, time=2016-09-21, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=131501, encodeId=a2f51315019d, content=学习了,又一次提示问病史很重要, beContent=null, objectType=article, channel=null, level=null, likeNumber=56, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/mONcle9pic3yVFeItvYLMR38WUsYtaRuSmqy9gDOnkr3D0usJ7SGXfFld6yx6ZXOfzic752zRyIoKaSmMyeZUel53m97J6WtlI/0, createdBy=e4191953752, createdName=花开冉末i, createdTime=Tue Sep 20 17:05:00 CST 2016, time=2016-09-20, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=131239, encodeId=60b21312398e, content=学习啦,,,,, beContent=null, objectType=article, channel=null, level=null, likeNumber=27, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/mStl88fu4NfdY7yem1P7bRvOP6z0jKsBoYR8ezfAricY7meQWcte7LRJsWHVn0CnPJg2JuQmevR0DoFmmEib5QLD2kNESBESQT/0, createdBy=59191706502, createdName=医路开来, createdTime=Tue Sep 20 10:02:00 CST 2016, time=2016-09-20, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=131240, encodeId=e3cd1312402f, content=谢谢分享,,,,, beContent=null, objectType=article, channel=null, level=null, likeNumber=27, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/mStl88fu4NfdY7yem1P7bRvOP6z0jKsBoYR8ezfAricY7meQWcte7LRJsWHVn0CnPJg2JuQmevR0DoFmmEib5QLD2kNESBESQT/0, createdBy=59191706502, createdName=医路开来, createdTime=Tue Sep 20 10:02:00 CST 2016, time=2016-09-20, status=1, ipAttribution=)]
    2016-09-20 花开冉末i

    学习了,又一次提示问病史很重要

    0

  6. [GetPortalCommentsPageByObjectIdResponse(id=139708, encodeId=3b4f139e083e, content=这个医生真好。 <br> ps:我也想去摸鱼。, beContent=null, objectType=article, channel=null, level=null, likeNumber=69, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://thirdwx.qlogo.cn/mmopen/vi_32/Q0j4TwGTfTLDvXc47IcmibZQtPyb8ngMlIsAHgtjHDKqWOOiaFhwJPtZaumNKVXJsxiatE7kXqdL0ng4f4HH693xA/132, createdBy=49f61628387, createdName=澹台本本, createdTime=Mon Oct 03 23:40:32 CST 2016, time=2016-10-03, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=134139, encodeId=6da7134139c3, content=继续关注, beContent=null, objectType=article, channel=null, level=null, likeNumber=61, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=cb571956164, createdName=187清风, createdTime=Sat Sep 24 08:50:00 CST 2016, time=2016-09-24, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=134138, encodeId=e576134138b6, content=医学就是推理, beContent=null, objectType=article, channel=null, level=null, likeNumber=61, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=cb571956164, createdName=187清风, createdTime=Sat Sep 24 08:49:00 CST 2016, time=2016-09-24, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=132433, encodeId=f54d13243394, content=确实够悬疑的,西北地区基本见不到的案例,受教育了, beContent=null, objectType=article, channel=null, level=null, likeNumber=68, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=63d51718849, createdName=ly17291850, createdTime=Wed Sep 21 17:41:00 CST 2016, time=2016-09-21, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=131501, encodeId=a2f51315019d, content=学习了,又一次提示问病史很重要, beContent=null, objectType=article, channel=null, level=null, likeNumber=56, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/mONcle9pic3yVFeItvYLMR38WUsYtaRuSmqy9gDOnkr3D0usJ7SGXfFld6yx6ZXOfzic752zRyIoKaSmMyeZUel53m97J6WtlI/0, createdBy=e4191953752, createdName=花开冉末i, createdTime=Tue Sep 20 17:05:00 CST 2016, time=2016-09-20, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=131239, encodeId=60b21312398e, content=学习啦,,,,, beContent=null, objectType=article, channel=null, level=null, likeNumber=27, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/mStl88fu4NfdY7yem1P7bRvOP6z0jKsBoYR8ezfAricY7meQWcte7LRJsWHVn0CnPJg2JuQmevR0DoFmmEib5QLD2kNESBESQT/0, createdBy=59191706502, createdName=医路开来, createdTime=Tue Sep 20 10:02:00 CST 2016, time=2016-09-20, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=131240, encodeId=e3cd1312402f, content=谢谢分享,,,,, beContent=null, objectType=article, channel=null, level=null, likeNumber=27, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/mStl88fu4NfdY7yem1P7bRvOP6z0jKsBoYR8ezfAricY7meQWcte7LRJsWHVn0CnPJg2JuQmevR0DoFmmEib5QLD2kNESBESQT/0, createdBy=59191706502, createdName=医路开来, createdTime=Tue Sep 20 10:02:00 CST 2016, time=2016-09-20, status=1, ipAttribution=)]
    2016-09-20 医路开来

    学习啦,,,,

    0

  7. [GetPortalCommentsPageByObjectIdResponse(id=139708, encodeId=3b4f139e083e, content=这个医生真好。 <br> ps:我也想去摸鱼。, beContent=null, objectType=article, channel=null, level=null, likeNumber=69, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://thirdwx.qlogo.cn/mmopen/vi_32/Q0j4TwGTfTLDvXc47IcmibZQtPyb8ngMlIsAHgtjHDKqWOOiaFhwJPtZaumNKVXJsxiatE7kXqdL0ng4f4HH693xA/132, createdBy=49f61628387, createdName=澹台本本, createdTime=Mon Oct 03 23:40:32 CST 2016, time=2016-10-03, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=134139, encodeId=6da7134139c3, content=继续关注, beContent=null, objectType=article, channel=null, level=null, likeNumber=61, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=cb571956164, createdName=187清风, createdTime=Sat Sep 24 08:50:00 CST 2016, time=2016-09-24, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=134138, encodeId=e576134138b6, content=医学就是推理, beContent=null, objectType=article, channel=null, level=null, likeNumber=61, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=cb571956164, createdName=187清风, createdTime=Sat Sep 24 08:49:00 CST 2016, time=2016-09-24, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=132433, encodeId=f54d13243394, content=确实够悬疑的,西北地区基本见不到的案例,受教育了, beContent=null, objectType=article, channel=null, level=null, likeNumber=68, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=63d51718849, createdName=ly17291850, createdTime=Wed Sep 21 17:41:00 CST 2016, time=2016-09-21, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=131501, encodeId=a2f51315019d, content=学习了,又一次提示问病史很重要, beContent=null, objectType=article, channel=null, level=null, likeNumber=56, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/mONcle9pic3yVFeItvYLMR38WUsYtaRuSmqy9gDOnkr3D0usJ7SGXfFld6yx6ZXOfzic752zRyIoKaSmMyeZUel53m97J6WtlI/0, createdBy=e4191953752, createdName=花开冉末i, createdTime=Tue Sep 20 17:05:00 CST 2016, time=2016-09-20, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=131239, encodeId=60b21312398e, content=学习啦,,,,, beContent=null, objectType=article, channel=null, level=null, likeNumber=27, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/mStl88fu4NfdY7yem1P7bRvOP6z0jKsBoYR8ezfAricY7meQWcte7LRJsWHVn0CnPJg2JuQmevR0DoFmmEib5QLD2kNESBESQT/0, createdBy=59191706502, createdName=医路开来, createdTime=Tue Sep 20 10:02:00 CST 2016, time=2016-09-20, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=131240, encodeId=e3cd1312402f, content=谢谢分享,,,,, beContent=null, objectType=article, channel=null, level=null, likeNumber=27, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/mStl88fu4NfdY7yem1P7bRvOP6z0jKsBoYR8ezfAricY7meQWcte7LRJsWHVn0CnPJg2JuQmevR0DoFmmEib5QLD2kNESBESQT/0, createdBy=59191706502, createdName=医路开来, createdTime=Tue Sep 20 10:02:00 CST 2016, time=2016-09-20, status=1, ipAttribution=)]
    2016-09-20 医路开来

    谢谢分享,,,,

    0

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