godfather of surgery

Chapter 1272 Weren't you on a business trip?
The patient lay down on the examination bed, all eyes focused on his tongue that couldn't be pulled back, and several young graduate students and residents whispered among themselves.

"Could it be an acute anterior dislocation of the temporomandibular joint? Although the X-ray shows nothing wrong, could it be a special case?" A resident wearing black-rimmed glasses suggested, but then immediately dismissed the idea, "But the main problem with dislocation is that the mouth can't be closed and the tongue can't retract on its own... It doesn't seem typical."

"Isn't it more like a neurological problem? Like focal epileptic seizures, which only manifest as tonic spasms of the tongue muscles?" another graduate student with a lively mind chimed in.

"What about psychological factors? Hysteria? Abnormal bodily functions after being subjected to strong stimulation?" A doctor who seemed to focus more on psychosomatic medicine stroked his chin and analyzed, "Look, the patient's expression is very distressed and anxious, which may aggravate the symptoms."

Yang Ping bent down to examine the patient's protruding tongue closely. He didn't rush to touch or try to reposition it. He noticed that although the tongue was stiff, it wasn't completely immobile. With the patient's extreme effort, the base of the tongue seemed to tremble with an extremely slight backward retraction, but this was immediately fixed in place by a stronger force. The tongue was dry, dark red, and slightly cyanotic, indicating that there was indeed a problem with local blood circulation and nerve control.

Looking into the patient's eyes, which were almost filled with tears of pain and shame, Yang Ping calmly said, "I know you're feeling very uncomfortable right now, and it's not easy for you to speak. I'll ask you a few questions, and you can try to answer by nodding or shaking your head, okay?"

The patient nodded vigorously, a glimmer of hope flashing in his eyes.

"Was there any head injury before this happened this morning?"

The patient's wife immediately tried to answer for him, but Yang Ping waved her hand to stop her, saying that he needed the patient to answer himself.

The patient shook his head.

"Have you ever had a history of epilepsy? Or a similar situation where you suddenly couldn't move a certain part of your body?"

The patient shook his head again, his eyes resolute.

"Besides your tongue, do you feel stiffness, weakness, or numbness in your neck, arms, or legs?"

The patient carefully examined himself, but still shook his head.

Yang Ping nodded, gesturing for Li Min to hand him a new pair of sterile gloves. He put on the gloves and gently palpated both sides of the patient's neck, checking for carotid pulse and feeling for muscle tension.

"Relax, I'm just checking." His voice had a calming quality.

Next, he examined the patient's throat with a flashlight. The uvula was in the center, and there was no obvious redness or swelling in the throat. He then carefully examined the inside of the patient's mouth and the base of the tongue to rule out any foreign objects or abnormal structures causing pressure.

Everything looks “normal,” but this very normalcy is the biggest abnormality.

The hushed chatter around them gradually subsided, and everyone watched Yang Ping's every move with bated breath.

After the examination, Yang Ping straightened up, took off his gloves, and casually turned to the patient's wife, beginning a seemingly casual conversation.

Yang Ping's tone softened further, "How has Mr. Li been feeling lately? Has he caught a cold or fever? Or has he eaten anything unusual?"

This was a routine consultation, and the patient's wife immediately replied, "He's always been in good health, but... he probably ate something bad while on a business trip a few days ago. He kept vomiting, had no appetite, and was completely exhausted, right? He went to Shanghai on a business trip these past few days and only got back last night, so I'm not really sure."

While speaking, she would occasionally confirm information with her husband.

"Vomiting?" Yang Ping caught this information, his eyes narrowing slightly. "How many days has this been going on? Have you been to the hospital? Did the doctor prescribe any medication?"

“About a day, I didn’t go to the hospital or take any medicine,” the patient’s wife replied.

"You didn't take your medication? Are you sure?" Yang Ping emphasized again.

The patient's wife frowned, seemingly uncertain, as she didn't know much about her husband's two-day business trip.

Just then, the patient on the flat bed seemed to remember something, and made a more rapid "hoarse" sound in his throat. He struggled to raise his finger and pointed to his pocket.

"He has something in his pocket!" a sharp-eyed nurse shouted.

Li Min immediately stepped forward and carefully pulled a crumpled little paper packet from the patient's pocket. Upon opening it, he found several white pills wrapped in aluminum foil. The generic name of the drug—Metoclopramide Tablets—was clearly printed on the foil.

“Metoclopramide…” Li Min read aloud, then suddenly realized, “It’s metoclopramide!”

Some of the young doctors around looked puzzled. Metoclopramide, a very common anti-nausea drug, what does it have to do with the inability to retract the tongue?
However, the moment Yang Ping saw the name of the medicine, all the clues seemed to be connected by an invisible thread.

Instead of announcing the answer immediately, he turned to the crowd and began his "instructional" diagnostic reasoning.

“Okay, now we have a few key pieces of information.” Yang Ping’s gaze swept over each doctor present. “Patient’s chief complaint: tongue protruding from mouth and unable to retract on its own, lasting for about an hour. Past medical history: recent acute gastroenteritis with vomiting. Third, medication history: before the onset of the illness, the patient took an antiemetic—metoclopramide, also known as methiophora.”

He paused, allowing everyone to process the information.

“First, let’s think back to why we ruled out many common possibilities at the beginning.” He looked at the resident who initially suggested temporomandibular joint dislocation. “Joint dislocation, ruled out on X-ray, and the symptoms don’t match.”

He then looked at the graduate student who had guessed epilepsy, "Focal epilepsy is usually short-lived and may be accompanied by other abnormal movements or sensations, but the patient's history and presentation do not support this." Finally, he looked at the doctor who mentioned hysteria, "Hysteria, also called acute dissociation disorder, can indeed manifest as various functional neurological symptoms, but it usually has a psychological trigger, and the patient's symptoms may disappear or change when no one is paying attention or when the patient is asleep. As for this gentleman, from the onset of the illness until now, he has been conscious, has a strong sense of distress, has no history of mental stimulation, and his symptoms have persisted without relief. There is currently no evidence pointing to typical hysteria."

“Then we should continue to collect medical history. Medical history is very important. Many clues are sometimes hidden in the medical history. Now the patient’s medical history includes disease and medication history, so we should pay attention to the correlation between drugs and symptoms.” Yang Ping picked up the pack of metoclopramide. “Metoclopramide, a dopamine receptor antagonist, has a powerful antiemetic effect because it acts on dopamine receptors in the medullary chemoreceptor zone. However, its effects are not limited to this.”

Yang Ping's voice seemed to possess a magical quality, drawing everyone's thoughts to a deeper level—neurotransmitters and muscle tone regulation.

"Our bodies have a nervous system called the extrapyramidal system, which is responsible for coordinating muscle movement and maintaining muscle tone balance. The stable operation of this system depends on two key neurotransmitters—dopamine and acetylcholine. They act like the two ends of a balance scale, antagonizing and restricting each other to maintain a delicate balance."

He gestured with his hand to resemble a balance scale.

"Dopamine is mainly inhibitory, preventing muscles from becoming overly tense; acetylcholine is mainly excitatory, promoting muscle contraction. When this balance is disrupted, especially when the function of dopamine is relatively weakened and the function of acetylcholine is relatively overactive, a series of symptoms of cholinergic hyperactivity will occur, which we call extrapyramidal reactions."

At this point, some senior doctors began to show expressions of sudden realization, while the younger doctors became even more focused.

“The clinical manifestations of extrapyramidal reactions are diverse,” Yang Ping continued, his gaze returning to the patient’s stiff tongue. “One of them is acute dystonia. It can manifest as persistent, tonic contractions of certain muscle groups, leading to strange movements and postures. For example: oculomotor spasm, causing the eyes to roll upwards, which we call oculomotor crisis; cervical muscle spasm, causing the neck to tilt to one side, i.e., spasmodic torticollis; facial muscle spasm, causing facial asymmetry; and—”

He paused deliberately, then clearly uttered the last few words:

"Spasms of the tongue and jaw muscles can cause the tongue to involuntarily protrude or curl, or, like Mr. Li, be unable to retract after protrusion. The jaw may also be unable to open or close."

A collective gasp filled the consultation room. All eyes refocused on the small tablet of metoclopramide, their expressions now completely different. This common, seemingly harmless antiemetic had such a bizarre side effect.

"Professor Yang, do you mean... Mr. Li's strange illness is caused by an acute extrapyramidal reaction after taking metoclopramide?" Li Min's voice was filled with excitement, as if he had solved a difficult problem.

“Exactly,” Yang Ping nodded affirmatively. “Mr. Li suffers from gastroenteritis, and his body may be in a sensitive state due to vomiting and poor appetite. Metoclopramide, as a dopamine receptor antagonist, blocks dopamine receptors in the extrapyramidal system, causing a relatively increased effect of acetylcholine, disrupting the original balance, and thus triggering acute dystonia of the tongue muscles. This is an adverse drug reaction, although not very common, but it does occur clinically in patients with drug sensitivity, impaired liver and kidney function, elderly patients, or when the dosage is too high.”

"So that's it!"

"How could I not have thought about the side effects of the medication!"

The young doctor experienced firsthand the charm of reasoning in clinical diagnosis.

Although the patient's wife was confused by terms like "dopamine" and "acetylcholine," she clearly understood two things: first, her husband's illness had a cause, it wasn't due to evil spirits or a terminal illness; second, the young Professor Yang in front of her was a true miracle doctor.

"Professor Yang, can this be cured? How?" she asked anxiously, her voice full of expectation.

“It can be treated, and the effect is usually very quick.” Yang Ping gave an affirmative answer, his tone full of reassuring power. “Since it is a relative hyperactivity of acetylcholine, then we will use drugs that can antagonize the effects of acetylcholine to restore the balance.”

He turned to Li Min and clearly gave the medical order: "Immediately administer an intramuscular injection of 0.3 mg of scopolamine to the patient. Observe the patient's reaction carefully."

Scopolamine, an anticholinergic drug, is an effective treatment for this acute dystonia.

"Yes, Professor!" Li Min immediately wrote out a doctor's order and instructed the nurse to prepare the medication for injection.

The nurses helped keep the patient in a side-lying position to prevent the tongue from falling back or vomit from causing choking. Under everyone's watchful eyes, the nurses skillfully administered the intramuscular injection.

The medication was administered. A brief silence fell over the clinic as everyone stared intently at the patient's tongue, awaiting a miracle.

Time passed slowly, minute by minute. About three or four minutes had passed, but to the waiting people, it felt like an eternity.

Suddenly, the patient made a soft swallowing sound. Then, the tongue, which had been frozen on the lower lip for over an hour, visibly twitched slightly, and then began to retract backward at a slow but undeniable pace!
"It moved! The tongue moved!" a nurse couldn't help but exclaim in a low voice.

Like rusty gears being re-lubricated, the tonic spasm of the tongue muscles quickly subsided. To everyone's surprise, the patient's tongue smoothly and completely retracted into the mouth.

The moment his tongue retracted, the patient instinctively and eagerly closed his mouth, finally bringing his jaw together. He tried moving his tongue, licking his dry lips, and then swallowing the pent-up saliva. Although the movements were still somewhat stiff, they were completely effortless.

"It's...it's all better? It's really all better?" The patient touched his mouth in disbelief, trying to make a sound. Although it was a little hoarse, the words were clear: "I...I can speak...my tongue is back..."

Overwhelmed with joy and relief, his eyes instantly welled up with tears. He looked excitedly at his wife, then at Yang Ping, stammering, "Thank you! Thank you so much, Professor! Thank you so much!"

His wife was overjoyed and wept, covering her mouth and bowing repeatedly.

A burst of heartfelt applause and admiration erupted in the consultation room. The young doctors looked at Yang Ping with eyes filled with near-reverence. Such a bizarre and intractable case, which had baffled both the emergency department and the dental department, was cured by Professor Yang in less than twenty minutes, from consultation to diagnosis to treatment. How could one not be impressed by such precise, detective-like reasoning and profound knowledge?
Yang Ping smiled gently and gestured for the nurse to pour the patient a glass of warm water. He then instructed the patient and his family, "Mr. Li, your gastroenteritis still requires treatment, but you have a sensitive constitution to metoclopramide, so please remember not to use it again. Whenever a doctor prescribes medication, you must proactively inform them of any history of adverse drug reactions. There are many options for antiemetics, such as domperidone or ondansetron, which are more selective and less likely to cause extrapyramidal reactions."

"I'll remember, I'll remember, I'll never take this medicine again, even if you kill me!" the patient repeatedly assured him, still shaken.

"After you get back, make sure to rest and replenish your fluids and electrolytes. Scopolamine may cause dry mouth and blurred vision, which are normal reactions and will subside on their own after a while," Yang Ping explained the precautions in detail.

The patient's wife examined the bag of medicine closely: "Weren't you away on a business trip these past few days? Why is the label on this medicine bag..."