Chapter 614: Starting from the course of the disease, come and sit with me more often when you have time
Sometimes he likes to use some black humor and tell some jokes.
And he is very sincere to others.
Of course, it is not the kind of sincerity without limits. With friends and people you trust, you can be extremely honest, but with patients and their families, it depends on the situation.
Any doctor who is a little older has experienced the pain of being bitten by a "poisonous snake" because of his kindness at work.
"If you weren't running away, then where were you doing? Did you go to the inpatient department to flirt with the nurse?"
Director Yin asked after hearing this.
"Hey, you can't say that. If my girlfriend hears it, she will punish me by making me sleep on the sofa. I just went to the ward to check on this female patient and did some tests and inquiries on her."
When Director Yin heard that Zhou Can went to the ward to check on the patients, a smile immediately appeared on his face.
"Wow! I underestimated you. Any diagnostic breakthrough?"
He cares most about the diagnosis and treatment of his patients.
I immediately asked whether there was any breakthrough in the diagnosis.
His eyes were full of anticipation, because Zhou Can was able to make a breakthrough every time he made a move and almost never let him down.
"I have made some small discoveries. Let me think about it carefully based on the patient's test results, and then provide some reference opinions."
After saying that, Zhou Can actually picked up the patient's information and began to study it carefully.
This is the second time I have studied this.
Sometimes doctors diagnose illnesses in this way. They need to repeatedly review the patient's examination report, cause of illness, and medical history, and only draw conclusions after confirming that they are correct.
Doctors are always treading on thin ice and being extremely cautious when diagnosing patients.
Director Yin did not disturb him. He smiled and silently poured him a cup of tea, then continued studying the case of high paraplegia.
They are both really interesting.
When encountering difficult cases, we diagnose each other's cases.
In clinical practice, this can be called a consultation.
Brainstorming is a common method used by doctors to deal with difficult cases. After all, a person's wisdom and strength are limited, and each doctor's diagnostic thinking is different, and the findings will also be different.
Just like a blind man touching an elephant, different diagnostic thinking will lead to different ways of discovering the cause of the disease.
For example, when diagnosing a cold patient, some people start with the patient's fever, some start with the patient's loss of appetite, and some start with the patient's headache or general fatigue. The diagnostic ideas are different, but the final correct answers are basically the same.
After nearly twenty minutes, Zhou Can seemed to have reached a conclusion.
He raised his head and looked at Director Yin.
"You talk, I listen!"
Director Yin had already finished diagnosing the paraplegic boy and was drinking tea leisurely. When he saw Zhou Can looking up at him, he immediately understood that Zhou Can's diagnosis had also come to an end.
"Although this female patient has had a long course of illness, after asking her, I think her illness started very quickly. It was because of an accidental cold that she started to have a headache, which has continued to this day. The characteristics of this disease are rapid onset, long course, and relatively slow progression. I just went into the ward to examine her and found that her optic disc was edematous, and she had pain in her head when she turned her right eye. She had an obvious pharyngeal reflex when she swallowed..."
"Her white blood cell count is high, ESR is increased, and the number of cerebrospinal fluid cells is increased, and the majority are mononuclear. The cerebrospinal fluid protein is also significantly elevated, the sugar is decreased, but the chloride is normal. No acid-fast bacilli, new cryptococcus, etc. were detected in the cerebrospinal fluid. The chest X-ray is normal, indicating that there are no obvious lesions in the chest and lungs. In addition, her blood count is also a bit high. Combined with the fact that the patient had a fever when she was admitted to the hospital, my diagnosis is that acute infection is more likely."
After Zhou Can described the patient's overall condition, he made a summary.
"I agree with this point. The patient does have the possibility of acute infection."
Director Yin nodded and agreed with Zhou Can's point of view.
"Let me first talk about the suspected diseases, and then we will discuss them one by one. The first one is cryptococcal meningitis. This disease often occurs in young and middle-aged people. The patient is in his thirties and is in his prime. This disease has two onsets: subacute and chronic, which is very consistent with the patient's acute onset. This disease is accompanied by moderate or mild fever, which is also consistent with the patient's condition. This disease also causes headaches, vomiting, blurred vision, double vision, stiff neck, and meningeal irritation signs, which are highly consistent with the patient's symptoms."
"Moreover, as the disease progresses, there will be impaired consciousness, and a few patients will experience convulsions, which is also consistent with the patient. The suspicion of this disease is extremely high."
Zhou Can first started with the patient’s symptoms and found a disease that was highly consistent with his condition.
"However, although the sugar content in the patient's cerebrospinal fluid was significantly reduced, the chloride content did not change, and the ink stain did not find cryptococci or new cryptococci, so the disease cannot be diagnosed. The cerebrospinal fluid can be drawn multiple times and sent to the laboratory to repeatedly search for cryptococci."
Every disease has a gold standard for diagnosis.
For example, in the case of new cryptococcal meningitis, even if the patient's symptoms are consistent with the disease, if cryptococci are not found in the cerebrospinal fluid test, the disease cannot be diagnosed.
In clinical practice, there are many strange diseases whose symptoms are basically similar to those of a certain disease, but they are not that disease.
Therefore, doctors are extremely cautious when diagnosing the cause of the disease and will not easily make a conclusion unless they find the gold standard.
"I also suspected this disease and had taken cerebrospinal fluid samples for testing for several consecutive days, but no cryptococcus was found."
Director Yin sighed.
If this disease was so easy to diagnose, there would be no need to ask Zhou Can for help.
"This is indeed very strange. It may just be a disease with symptoms similar to those of new cryptococcal meningitis. The second disease I suspect is tuberculous meningitis. This disease has an insidious onset and a long course, and the symptoms can be mild or severe. The patient may have a history of tuberculosis infection in other parts of the body. The prodromal stage includes low-grade fever, night sweats, loss of appetite, mild headache, malaise, fatigue, etc."
"As the disease progresses, the headache worsens and is accompanied by vomiting, the neck becomes stiff, and both the Kernig sign and the Brudzinski sign are positive. There may also be ptosis, pupil size differences, extraocular muscle paralysis, diplopia, facial paralysis and other symptoms due to meningeal adhesion. Under normal circumstances, after suffering from this disease, the tendon reflexes may be hyperactive and the pathological reflexes are positive, but damage to the spinal nerves may lead to the disappearance of tendon reflexes."
"If the disease is not treated promptly and correctly, it will continue to worsen and eventually enter the advanced stage, directly endangering life."
Zhou Can mentioned the second disease he suspected.
"This female patient seems to have progressed to the second stage of the disease. However, there are some arguments that do not support this disease. For example, some of the patient's symptoms are inconsistent with this disease, and the patient's chest X-ray showed no abnormalities. Cerebrospinal fluid test showed elevated protein and decreased sugar, but no significant change in chloride."
First he doubted the disease, and then he gave some arguments that did not support the disease.
Diagnoses are sometimes contradictory.
It is necessary to see the light through repeated inferences.
"Tuberculous meningitis. After consultation within our department, we have basically ruled it out. But you just mentioned that Kernig's sign and Brudzinski's sign were positive. These are some new findings."
After listening to this, Director Yin was slightly thoughtful.
"How should I put it? Although this disease is the least likely, I think it is very likely. The symptoms of this female patient are relatively classic, and there are many diseases that can be associated with her. Therefore, I think we should start with the symptoms, but we cannot rely solely on the symptoms. At the same time, we should also combine the progression and the patient's medical history for comprehensive dialectical analysis."
Zhou Can never looks at the symptoms when diagnosing a disease. He prefers to unravel the problem and get to the root of the problem.
Maybe it’s a diagnostic gift.
This allows him to identify the most hidden or least likely to be taken seriously by other doctors among many doubts when diagnosing various difficult cases, and then pursue the case in depth, eliminate interference, and ultimately find out the cause of the disease.
“Interesting.”
After hearing this, Director Yin Hua's eyes lit up slightly.
"The diagnosis can be made in conjunction with the progression of the disease. This is something that neither I nor other doctors have thought of."
"In fact, I just thought of some other suspected diseases, but they were all ruled out in the end. For example, purulent meningitis, viral meningitis, etc."
What Zhou Can meant was very straightforward, which was that he highly suspected the patient had tuberculous meningitis.
In clinical practice, what doctors dislike most is diseases related to tuberculosis.
Tuberculosis is easily contagious, it is particularly stubborn, has an extremely long course of illness, and takes an extremely long time to cure.
Many patients and their families do not understand medicine. After taking medicine and injections for a period of time, they find that their condition does not seem to improve, so they begin to doubt the doctor's diagnosis and treatment plan and are unwilling to cooperate with the treatment.
This will result in all previous efforts being wasted.
In the end, the doctor could only watch the patient fall into the abyss. Afterwards, the family members and the patient collectively scolded the doctor for being a quack who couldn't even cure an illness.
"Tell me the basis for your conclusion that the patient has tuberculous meningitis."
There was a hint of cunning in Director Yin Hua's eyes, as if he wanted to take the opportunity to further explore Zhou Can's diagnostic ability.
"There are some other evidences. For example, the patient has low fever, vomiting, double vision, and convulsions, which are similar to the symptoms of the second stage of tuberculous meningitis. In addition, the patient has optic disc edema, right extraocular muscle paralysis, meningeal irritation sign +, and positive pathological signs. ESH is increased and the neutrophil count is high. These evidences are enough to highly suspect tuberculous meningitis."
Zhou Can strongly suspected that the patient had this disease, but he did not just determine it based on the fact that the course of the disease was similar to this disease.
There are many other symptoms that match this.
"Well, now that you've mentioned it, I think it's this disease. But medicine is a rigorous discipline, and we need some solid examination evidence to confirm the diagnosis and use medication."
Director Yin was amazed at Zhou Can's strength.
He found that Zhou Can's progress was extremely fast, and every once in a while, his strength in all aspects would improve significantly.
"Isn't it easy to find evidence? Take a sample and do a PPD test! Then you can have the patient do a head CT or MRI! The most common targets of tuberculosis are the organs in the chest and abdominal cavity, but that doesn't mean that if the chest X-ray doesn't show any problems, we can assume that there is no infection in the head, right?"
Zhou Can said with a smile.
"That makes sense. I'll apply for a test now and have the patient undergo a tuberculin purified protein derivative test. It won't be too late to order more after the results of biological tests such as the head CT scan come out."
Director Yin readily accepted Zhou Can's suggestion.
Older doctors usually like to say the full name of a certain examination or the shortened Chinese name, while younger doctors would rather be lazy and prefer to say some English abbreviations.
The PPD test is considered the gold standard for detecting tuberculous meningitis.
Director Yin did not prescribe a head CT scan for the patient because he considered the patient's financial situation. Doctors with medical ethics would carefully consider every test they prescribe for their patients and would only prescribe it if they felt it was necessary.
Only some doctors who have no medical ethics and are only concerned with making money and completing their department's tasks will deliberately prescribe more tests for their patients.
As long as they can get the above examinations, they would like to examine the patients.
On the one hand, they can earn performance commissions, and on the other hand, more tests can provide more diagnostic evidence and reduce the probability of misdiagnosis and missed diagnosis. All the benefits go to the doctors, while the patients suffer more and have to pay a lot of unnecessary test fees.
All I can say is that such doctors lack the most basic human compassion and are too selfish.
It is already very unfortunate for the patient to be sick.
When you go to the hospital, the doctors treat you as a tool to make money and rip you off.
As the medical supervision system becomes more and more sound, a medical ethics scoring system should be established in the future. Doctors who fail to pass the score or have a bad history will be banned from practicing medicine for life.
Wait until Director Yin excitedly finishes writing the inspection application.
Zhou Can took a sip of water, looked at the other party and said, "Director Yin, I helped you solve the difficult cases in your department. Can you also help me and provide some reference opinions on the case of high paraplegia?"
Zhou Can dared to say this only because he was very familiar with Director Yin and had a good relationship with him.
He is always respectful when speaking to elders and seniors.
There is a saying that goes, the closer the relationship, the more casual you are when you are together.
"Haha, you are not at a disadvantage. I just went to the ward to check on the little boy. I didn't find anything significant. But based on my many years of clinical experience in neurology, I think the cause of the child's illness is likely in the head. Or it may be a combination of causes."
With the help of Zhou Can, Director Yin made a major breakthrough in the diagnosis of the cause of the disease for this female patient who had been troubled for many days, and was in a good mood.
He laughed heartily and talked about the cause of the little boy's high-level paraplegia.
"Is there a complex cause of this type of high-level paraplegia? I've learned a lot today."
Zhou Can had only heard of mixed hemorrhoids, but had never heard of paralysis having complex causes.
The simultaneous occurrence of internal hemorrhoids and external hemorrhoids is clinically called mixed hemorrhoids.
High level paraplegia, could it be that there are problems with multiple parts of the nervous system?
"You haven't heard of it, have you? There are many things you haven't heard of. In the future, whether you are free or not, come and sit with me more often, okay?"
Director Yin invited with a smile.
He likes good talents like Zhou Can and asks him to come to his office more often to chat.
Drinking wine and discussing swords, drinking tea and discussing philosophy, these are things that many heroes like to do.
"Okay, okay, I will definitely come to you more often to ask for your advice in the future."
Zhou Can agreed readily.
