Chapter 293: Extremely Difficult Case Diagnosis, Du Leng Picking Peaches
"Okay, I'll be right there."
Zhou Can answered very straightforwardly, and he didn't move the phone away from his ear until Director Zhang hung up.
When talking on the phone with elders, teachers, or leaders, it is basic courtesy to wait for the other party to hang up first.
Some new employees in the workplace are used to being careless and don't pay attention to details when talking on the phone with their leaders. They rush to hang up the phone or rush to talk to their leaders. These are taboos.
If you don't pay attention to these details, it's easy to see other colleagues who entered the company with you, although their abilities are obviously not as good as yours, being promoted step by step every two years.
But I am still standing still.
Human factors are as important as work ability and professional level.
Doctor Pang, who was standing next to him, watched Zhou Can hang up the phone and secretly breathed a sigh of relief. She had just heard clearly that Director Zhang Bihua relied heavily on Zhou Can and treated him as an equal during the conversation.
She was particularly afraid that Zhou Can would report her.
Fortunately, Zhou Can is magnanimous like a man and acts in an upright manner.
He didn't punish her again.
"Doctor Pang, please take care of this place with the two nurses for a while. I'm going to the outpatient hall and should be back soon. If there is any emergency, please call me immediately."
After Zhou Can gave the three people instructions, he left quickly.
Doctor Pang watched Zhou Can leave and felt a chill on his back.
Only then did she realize that Director Zhang had just been talking to Zhou Can, which actually scared her into breaking out in a cold sweat.
When Zhou Can rushed to the outpatient hall, he found that the female patient who had polydipsia, diabetes insipidus, and impaired consciousness yesterday was sitting at Director Zhang Bihua's desk for diagnosis. She looked much better than yesterday.
He looked dazed, hunched over and sickly yesterday.
After a day of hospitalization, she now looks like a completely different person, much more conscious and with a hint of spirit in her eyes.
"Doctor Zhou, we're waiting for you to come over and help with the consultation!"
An associate chief physician in obstetrics and gynecology actually greeted Zhou Can with a smile for the first time.
"Ah... me? I'm just a junior trainee. You're flattering me too much! Director Luo, what you said is not just flattering me, it's simply putting a golden bucket on my head."
Zhou Can certainly wouldn't be so foolish as to accept other people's flattery.
Director Luo had never even looked at him before, but now he suddenly became so enthusiastic. In two words, he is snobbish.
"Doctor Zhou has experience rotating through multiple departments. He might be able to offer some constructive diagnostic advice on this case!" Zhang Bihua took over.
"After treatment with fluid replacement and intravenous insulin infusion, the patient's blood sugar and blood sodium have dropped significantly, and her consciousness is much clearer. However, she still has a poor appetite, poor mental state, and poor sleep. At the same time, symptoms such as polydipsia and polyuria still exist."
After Zhang Bihua said this, Zhou Can understood what she meant.
Even though the patient's condition has improved significantly after treatment, it is only a temporary solution.
Currently, only the patient's diabetes is alleviated.
Zhou Can looked at the patient.
“Are you having normal bowel movements now?”
"Once a day."
The patient has been able to communicate directly with Zhou Can.
This made Zhou Can very happy.
"Have you checked the patient's menstrual period and marital and reproductive history?" Zhou Can turned his head and asked Director Zhang.
"I asked her just now while she was still conscious. She had her first menstruation at the age of 14. Each menstrual cycle is about 50 days, with a period of about five days, and a heavy flow of blood. She got married at the age of 21 and gave birth to a child."
Director Zhang gave a brief introduction to the patient's condition.
The normal menstrual cycle of a woman is between 28 and 35 days. This patient's menstrual cycle is as long as 50 days, which is obviously abnormal.
But from another perspective, a menstrual cycle of 50 days may not necessarily be a bad thing.
Because women ovulate about 400-500 times in their lifetime. In fact, most women ovulate only about 400 times in total.
A menstrual cycle of 28 days means that all the eggs in the body are released in a shorter period of time.
At this time, women will stop menstruating and menopause will come.
Some women stop menstruating in their forties and enter menopause, which is not a good thing.
Because according to scientific research, the later a woman's menopause age is, the slower she ages, and her body's immunity will remain at a high level.
This patient has her period only once every 50 days, which is almost twice as long as that of an average woman.
It also means that her menopause age is later than that of ordinary women, and her menopause comes later.
"What are her basic vital signs at present?"
"Body temperature is 37.7 degrees, heart rate is 83 beats/minute, respiration is 24 times/minute, and blood pressure is 116/75mmhg." Yang Chan answered beside him.
She is responsible for every physical examination of the patients.
It is equivalent to helping Director Zhang.
The body temperature is in a low fever state, and the blood pressure and heart rate are basically normal.
Zhou Can walked around to the patient and checked her neck.
"I have checked it. There is slight redness and swelling in the pharynx, and the tonsils are obviously enlarged. The thyroid gland is normal. There is no obvious edema in the lower limbs. The breathing is normal, and there is no murmur."
Yang Chan does her work very meticulously.
Zhou Can smiled and gave her a thumbs up.
"As expected, a good teacher produces excellent students. The squad leader's physical examination work is really great!" With just one sentence, both Director Zhang and Yang Chan were praised.
There was a smile on both of their faces.
There are very few women who don't like to be praised.
“Have you tested the patient’s urine?”
"Here, this is the latest urine test report." Yang Chan took the initiative to hand the urine routine test result sheet to Zhou Can.
After receiving it, Zhou Can took a look at it and checked the patient's other biochemical test data.
"The urine test is positive for ketones, and the blood gas indicates metabolic acidosis, so she should be suffering from ketoacidosis!"
After reading it, Zhou Can made a conclusion.
"Director Zhang and the other experts have just given us the diagnosis results."
Yang Chan replied.
"What we need to consider now is why patients develop impaired consciousness or even coma after stopping medication and taking Chinese medicine instead?" Director Zhang pointed out the problem that needed to be solved to Zhou Can.
The experts just discussed and there should be some conclusions.
It's just that there may be some differences of opinion.
"Based on the patient's symptoms and examination data, I think her illness should be treated separately. The cause of the disorder of consciousness and even coma is not necessarily related to taking Chinese medicine. She should be in a hyperosmotic coma."
Zhou Can found that during the diagnosis process, his mind was particularly clear and his ideas were specific.
"Hyperosmotic coma often occurs in elderly patients, but she is only in her thirties, still very young. I personally think that hyperosmotic is unlikely."
The somewhat snobbish Director Luo disagreed with Zhou Can's diagnosis.
"Nothing is absolute in this world. This patient's situation is rather special. My diagnostic thinking is this: the patient had been taking Mining before, and only when she stopped taking it did her diabetes insipidus worsen and her body become dehydrated. Then she also stopped taking her hypoglycemic drugs and took Chinese medicine instead. This led to an increase in blood sugar levels, which was bound to worsen dehydration and eventually lead to hyperosmolar coma. Ketoacidosis was also caused by discontinuation of hypoglycemic drugs."
Zhou Can made a detailed analysis of the patient's pathological mechanism and the pharmacological mechanism involved.
[Pathology diagnosis experience +1, pharmacology differentiation experience +1. You have successfully diagnosed a difficult case, and you will be awarded 100 pathology and pharmacology experience points each.]
The experience points have been credited, which means Zhou Can’s diagnosis is completely correct.
It is neither difficult nor easy to diagnose this disease in five dates.
The main reason is that it has multiple symptoms and the condition is complicated, like a tangled mess. If you want to correctly diagnose the pathology, you must first sort them out one by one.
Zhou Can separated amenorrhea, polydipsia, impaired consciousness and other symptoms for diagnosis and treatment, which greatly reduced the difficulty of diagnosis.
And it may not be interfered by other pathological mechanisms.
"Well said! I think the diagnosis of the patient's hyperosmotic coma is completely correct." After listening to Zhou Can's analysis, Director Zhang firmly supported his diagnostic conclusion.
"Okay, even if the patient's impaired consciousness is hyperosmolar coma, what about her polyuria?"
Director Luo compromised.
Forced to agree with Zhou Can's diagnosis, she raised a new question.
"Don't worry, let's treat them one by one. The patient's polyuria and polydipsia can basically be diagnosed as diabetes insipidus based on the test data and her actual condition. And it is central diabetes insipidus."
Zhou Can's divide-and-attack style of attack was refreshing to many doctors.
Because many doctors are used to a fixed mindset, they believe that although patients have many symptoms, there is usually only one cause. If the cause is found and treated accordingly, the disease can be cured.
In fact, this is indeed the case.
However, there is also the possibility of one disease causing multiple illnesses or multiple diseases causing multiple illnesses.
The most common clinical situation is that a patient suffers from multiple underlying diseases at the same time. For example, a patient suffers from hypertension, diabetes, and nephritis at the same time. This is extremely common in clinical practice.
However, this common underlying disease is very easy to diagnose.
High blood pressure can be detected by measuring blood pressure.
For diabetes, it is enough to check blood sugar and urine routine. Even for more complicated diabetes, liver and kidney function tests, blood lipids, and pancreatic islet function tests can also be done to make a clear diagnosis.
The above-mentioned diseases basically have gold standards for diagnosis, so they are easy to detect.
At present, the cause of this patient's illness is confusing. Type 2 diabetes is only one of the obvious causes, but because the patient listened to his relatives and stopped taking Western medicine and took Chinese medicine, his symptoms worsened. It is obvious that there is more than one cause.
In this case, if we still focus on the diagnosis and treatment of diabetes, we will definitely be like the doctors in the previous hospitals and will not be able to cure the disease at all.
"Judging from the results of the patient's water deprivation-vasopressin test, the diagnosis of central diabetes insipidus is valid." Director Jiang of the Department of Neurology supported Zhou Can's diagnostic opinion.
The presence of so many experts on the scene to jointly diagnose the woman attracted many family members and patients to watch.
In addition to feeling curious, they also wanted to take the opportunity to see which of these experts was more capable.
At the same time, you can also see how experts diagnose diseases.
The water deprivation-vasopressin test for this patient showed that after stopping desmopressin twice (the coagulant commonly taken by patients), the blood osmotic pressure was 330MOSM/L and the urine osmotic pressure was 103MOSM/L after eight hours of water deprivation. After the injection of posterior pituitary hormone, the urine osmotic pressure rose to 590MOSM/L.
MRI examination of the sellar region revealed that the pituitary stalk was thickened and the high signal of the posterior pituitary disappeared.
It was with the help of these key examination data that Zhou Can determined that the patient was suffering from central diabetes insipidus.
"Then what exactly causes central diabetes insipidus? Is it caused by type 2 diabetes?" Yang Chan asked because she really didn't understand. After all, Zhou Can was her classmate.
"I think it's caused by a lesion in the pituitary stalk."
Zhou Can seemed very confident about this diagnosis.
Without Yang Chan asking further questions, he went on to explain, "Pituitary stalk lesions, in clinical practice, germ cell tumors can easily cause this disease. And it usually occurs in children. This patient is in her thirties, so the possibility of germ cell tumors can basically be ruled out. Based on her examination data and symptoms, lymphocytic hypophysitis is more likely to be the cause."
After listening to this, Yang Chan pondered for more than ten seconds and nodded as if she understood.
"Now I just suspect that the chance of it being lymphocytic hypophysitis is high, but I can't confirm it!"
The fact that she could come up with this opinion shows that she had really thought about it and had a certain understanding of Zhou Can's diagnostic ideas and the pathological analysis involved.
Seeing her beloved disciple's obvious progress, Zhang Bihua couldn't help but smile with satisfaction.
He first looked at Yang Chan, then at Zhou Can. There seemed to be a hint of expectation in his eyes, hoping that the two young people could communicate and cooperate more .
To be more precise, she hopes Yang Chan can learn more from Zhou Can.
"The best way to diagnose this disease is to perform a biopsy of tissue samples, but the operation is very difficult."
Zhou Can’s current surgical skills are not bad.
His level is even comparable to that of many chief physicians in surgery.
Even he said that the operation was difficult, which meant that pathological biopsy sampling was basically impossible.
No doctor would dare to take such a risk.
In particular, the patient's current physical condition is extremely poor, and his tolerance for surgery is enough to scare any surgeon away.
"Is there any other way?" Yang Chan asked.
"There must be a way! For example, skip the pathological biopsy and go directly to radiotherapy." Zhou Can looked at the family members and the patient.
When many family members hear about radiotherapy, they can't help but associate it with cancer and severe side effects.
In fact, radiotherapy does cause some harm to the body.
For example, it may cause hair loss, sore throat, nausea and vomiting, headache, fatigue, etc.
"We won't do it, we won't do it!"
The family members simply shook their heads and refused.
"In fact, radiotherapy is not as scary as you might think. I suggest you try it once to see how effective it is before deciding whether to continue with radiotherapy."
Director Zhang Bihua spoke at this time.
She directly helped Zhou Can to do ideological work among the family members and patients, which showed that she agreed with Zhou Can's diagnosis results.
"Thank you for your kindness, Director Zhang. We will not do this treatment because one of our relatives died after radiotherapy. Someone in our village also got worse after radiotherapy and eventually died."
The family members are extremely resistant to radiotherapy and are full of fear.
Doctors only have the right to make recommendations. If family members and patients disagree, then the decision cannot be implemented.
Seeing that she couldn’t persuade him, Zhang Bihua rolled her eyes and came up with a new idea.
She looked at Zhou Can.
"Dr. Zhou, what do you think is the cause of the patient's amenorrhea?"
Zhou Can and Director Zhang looked at each other and immediately understood her meaning.
It seems that Director Zhang had already diagnosed the cause of the patient's illness.
Maybe they were not sure, or they wanted to train their younger generations, so they asked him to come and help with the consultation.
"I think the cause of the patient's secondary amenorrhea is not caused by curettage, but by pituitary lesions. It is not difficult to confirm this. You can just do a functional test of the thalamus-pituitary axis."
Zhou Can determined that the patient's central diabetes insipidus and amenorrhea were both related to pituitary lesions.
"What are the experts' opinions?"
Zhang Bihua also knew that Zhou Can was young and inexperienced, and that family members and patients might not believe what he said.
This requires other experts to support Zhou Can's argumentation.
"I think Dr. Zhou's diagnosis should be correct." Director Jiang was the first to support Zhou Can's point of view.
"It is a good idea to do a functional test of the thalamus-pituitary axis. Once the results come out, it will be clear whether the cause of amenorrhea is caused by pituitary disease."
Surprisingly, Du Leng actually stood up to support Zhou Can's inspection plan.
Facing Zhou Can's gaze, Du Leng immediately looked away.
As a returned overseas PhD, he should at least show something, right?
We can’t just watch Zhou Can gain fame and fortune alone!
Neurosurgery happened to be his area of expertise, and he had been listening carefully to Zhou Can's analysis just now. After analyzing it, although he looked unconvinced on the surface, he agreed with Zhou Can's diagnostic ideas and opinions in his heart.
Coming out to support Zhou Can now would not only make him appear magnanimous, but also give him a chance to show off his face.
It is equivalent to Zhou Can planting peach trees and picking peaches.
"Would you like to have this check?"
Director Zhang looked at the family members and patients.
The patient was the kind of woman who had no opinion of her own and always followed her husband’s advice. She looked at her husband beside her.
"As long as we don't have to do the radiotherapy, we are willing to do it."
The family agreed to do this examination.
Director Zhang gave them an application for inspection and asked them to do it as soon as possible.
After the family members and patients left, Zhang Bihua looked at Zhou Can.
"How does Dr. Zhou think this patient's blood sugar should be controlled?"
Finding ways to control patients’ blood sugar should be a top priority.
I took the medicine yesterday and will definitely continue the treatment today.
Everyone knows that the treatment for diabetes is just insulin.
Director Zhang tested him deliberately, and naturally the question he asked was about the specific use of the medicine.
"I think that regular use of insulin glargine, combined with intensive therapy with insulin aspart before meals, should quickly bring this patient's blood sugar under control."
Zhou Can gave the answer.
But his mind was thinking about how to treat the patient's pituitary disease.
