The patient’s wife furrowed her brow, thinking hard. At that mont, the patient lying on the bed seed to rember sothing, emitted a more urgent "huh huh" sound from his throat, and struggled to lift his finger, pointing at his pocket.
"He has sothing in his pocket!" an observant nurse shouted.
Li Min imdiately stepped forward and carefully took out a crumpled little paper package from the patient’s trouser pocket. Upon opening it, he saw several white tablets wrapped in aluminum foil. The foil clearly bore the generic na of the dication—toclopramide Tablets.
"toclopramide..." Li Min read aloud and then suddenly realized, "It’s stomach relief!"
So of the young doctors around showed confusion; stomach relief is a common antietic—what does it have to do with the tongue not retracting?
However, the mont Yang Ping saw the na of the drug, a flash of understanding crossed his eyes. All the clues seed to be connected by an invisible thread at that mont.
He didn’t imdiately announce the answer, but instead turned to everyone and began his "teaching-style" diagnostic reasoning. His voice was clear and steady, carrying an undeniable logical force.
"Now, we have so key pieces of information," Yang Ping’s gaze swept over each doctor present. "First, the patient’s chief complaint: The tongue is extended outward and cannot retract on its own, lasting about an hour. Second, dical history: Recently experienced acute gastroenteritis accompanied by vomiting. Third, dication history: Before the onset, took an antietic orally—toclopramide, which is stomach relief."
He paused, allowing these details to settle in everyone’s minds.
"First, let’s recall why we ruled out many common possibilities initially." He looked at the resident who first suggested temporomandibular joint dislocation. "Dislocation is ruled out by X-ray, and the symptoms don’t match, well done."
He then looked at the graduate student who hypothesized epilepsy. "Focal epilepsy usually has a short duration and may be accompanied by other abnormal movents or sensations. The patient’s dical history and presentation don’t support this."
Lastly, he looked at the doctor who ntioned hysteria. "Conversion disorder can indeed manifest various functional neurological symptoms, but it usually has a psychological trigger, and symptoms may disappear or change when unnoticed or during sleep. As for Mr. Li, from onset until now, he remains conscious and acutely embarrassed, with persistent symptoms and no evidence pointing to typical hysteria."
Each ti he critiqued a hypothesis, he left the proposer convinced, while also narrowing down the diagnostic approach.
"Thus, our focus should shift to the relationship between dication and symptoms." Yang Ping picked up the foil-clad stomach relief. "toclopramide, a dopamine receptor antagonist, has a potent antietic effect derived from its action on dopamine receptors in the dullary chemoreceptor trigger zone. However, its effects are not limited to this."
Yang Ping’s voice seed to carry magic power, drawing everyone’s thoughts into a deeper dinsion—the microscopic world of neurotransmitter and muscle tone regulation.
"Deep within our brain, there’s a system responsible for coordinating muscle movent and maintaining muscle tone balance, called the ’extrapyramidal system.’ This system’s stable operation relies on two crucial neurotransmitters—dopamine and acetylcholine. They are like two ends of a balance, antagonizing and constraining each other, maintaining a delicate equilibrium."
He gestured with his hands to illustrate the balance.
"Dopamine is mainly inhibitory, preventing excessive muscle tension; acetylcholine is mainly excitatory, promoting muscle contraction. When this balance is disrupted, especially when the function of dopamine is relatively weakened and acetylcholine’s function is relatively heightened, a series of symptoms appear, which we call ’extrapyramidal reactions.’
At this point, so senior doctors began to show expressions of sudden realization, while younger doctors listened more intently.
"The clinical manifestations of extrapyramidal reactions are diverse," Yang Ping continued, his gaze again landing on the patient’s stiff tongue, "one of which is ’acute dystonia.’ It can manifest as sustained, tonic contractions of certain local muscle groups, leading to strange movents and postures. For example: eye muscle spasms causing the eyes to turn upwards, which we call ’ocular crisis’; neck muscle spasms leading to the neck tilting to one side, known as ’spasmodic torticollis’; facial muscle spasms causing skewed mouth and eyes; and also—"
He deliberately paused, clearly articulating the last few words:
"Spasms of the tongue and jaw muscles, causing the tongue to extend, curl involuntarily, or, like Mr. Li, extend without being able to retract, and the jaw may not open or close properly."
"Hiss—" A gasp filled the outpatient room. All eyes refocused on that small strip of stomach relief, now with a completely different awareness. This common, seemingly harmless antietic concealed such a "bizarre" side effect!
"Professor Yang, are you saying... Mr. Li’s strange illness is due to an acute extrapyramidal reaction induced by taking stomach relief?" Li Min’s voice held excitent, as if a puzzle had just been solved.
"Precisely," Yang Ping confird with a nod. "Mr. Li suffered from gastroenteritis, possibly making his body sensitive due to vomiting and poor intake. toclopramide, as a dopamine receptor antagonist, blocked the dopamine receptors of the extrapyramidal system, causing acetylcholine’s action to relatively intensify, disrupting the original balance, thus inducing acute dystonia of the tongue muscles. This is an adverse drug reaction. While not extrely common, it does occur clinically, particularly in younger patients or when the dosage is relatively high."
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