What is a good case writing technique? Just look at the record of the association in Sun Lien's hand. Unlike ordinary outpatient clinics, most emergency patients are acutely ill and critically ill. There is very little time left for doctors to write down medical records. In Central Hospital No. 4, cases in the emergency department are mostly done by interns and trainees. In the previous two months, Sun Lien's main job every day was to start writing cases after beating Zhou Jun. In the emergency room, Zhou Jun needs to take over, and there are four or five patients who need to be kept for observation every day - their cases are basically written by Sun Lien.

If you write the case according to the requirements of the association...... Sun Lien was frightened into a cold sweat by his own idea, and a patient's case description alone had to be densely packed with two pages, starting with two thousand words. That's 10,000 words for five patients. This is just a record of the case, and in the middle, you have to deal with the patient, participate in the rescue, go to various departments to invite doctors to consult, and by the way, seize the time to learn and enrich yourself - even an iron man can't resist it!

Although it is easy to use, it is difficult to implement. That's the biggest problem with the Concord model. Ordinary people always say that there are two major problems when seeing a doctor - it is difficult to see a doctor and expensive to see a doctor. In fact, if you think about it, if you look at the world, China's medical system is definitely among the top in the world. Like the British NHS system model, it is not expensive to see a doctor, but the price is that you need to wait in line for seven or eight hours in the emergency department, and wait a few days before you can be transferred to a specialist after the situation is stable. And in the United States. It's not hard to see a doctor. But even with million-dollar commercial insurance, a trip to the hospital for the middle class will inevitably hurt the bones. If surgery is required, the bill issued by the hospital is definitely not less than $20,000.

In China, as long as you come to the hospital to register, you can get timely treatment from emergency doctors and specialists. Moreover, the price of general surgery is covered by social insurance, and the part borne by an individual at a time will basically not exceed 2,000 yuan.

There used to be such a joke in the group of doctors about this difference. A person has appendicitis. In the UK, he suffered a perforated appendix because of a misreferral, the NHS. In the United States, he was prosecuted and imprisoned for failing to pay for his $50,000 surgery. In China, the patient beat up the doctor who operated on him because he didn't like the minimally invasive hole in his stomach for not looking good enough.

Different national conditions have different requirements. Sun Lien's thoughts turned around and returned to the case record book in front of him. It's not his job to think about what health care reform is going to do now. Participating in the diagnosis, treating the patient, this is what he should be doing now.

After thinking about it for a long time, Sun Lien suddenly looked at the treatment record and asked, "Have you given her antibiotics?"

"Because the initial suspicion is bacterial meningitis. Yuan Ping'an replied, "This patient's symptoms are actually quite obvious, and I don't quite understand why Boss Zhu would ask you to diagnose this case." ”

Sun Lien glanced at Lu Xuexin's status bar again, and suddenly asked, "Did you do a cerebrospinal fluid smear and culture for her?"

Cerebrospinal fluid (CSF) protein is so high that it is basically equivalent to directly claiming that the patient's nervous tissue has a serious infection or lesion. If the deputy director of the emergency department of Tongxie believes that Lu Xuexin has bacterial meningitis, then there is basically no need for further diagnosis of this patient. Adequate antibiotics are given and other symptoms are treated symptomatically.

"The patient was brought in this afternoon and the smear did not detect any pathogens. It will take about two days for the cultivation. Yuan Ping'an replied, "Is there any problem?"

"The results of the biochemical examination of the cerebrospinal fluid are a bit strange. Sun Lien found the cerebrospinal fluid biochemical examination report that the association had done for Lu Xuexin a few hours ago. Although the cerebrospinal fluid protein indicated above is still very high, it is only about 800mg/L. It is much lower than the current status bar of 1720mg/L. After a moment of silence, he asked, "The patient has a history of SLE (systemic lupus erythematosus) and has been taking immune suppressants for a long time. This situation should also be taken into account. ”

Yuan Ping'an furrowed his eyebrows, "What do you mean...... The bacteria that cause the infection may not be common?"

"If it was caused by common bacteria, her symptoms should have improved slightly after more than ten hours of antibiotic treatment. Sun Lien expressed cautious affirmation of Yuan Ping'an's inference. "She's still around 39 degrees and delirious, which doesn't look like she's getting better. ”

"Doctor Yuan, the results of the 9-bed MRI are out!" The little nurse who sent the MRI looked at Sun Lien with some curiosity, "This is the new doctor from our department?"

Yuan Ping'an took the imaging photo and said with a smile, "This is a doctor from a foreign unit who came to communicate." He was arrested by Director Zhu in the bathhouse and came for a consultation. ”

Sun Lien smiled a little embarrassedly, stood behind Yuan Ping'an, stretched his neck with him, and watched the film by the light of energy-saving lamps.

"There is an obvious signal enhancement ...... in the meningeal part" Sun Lien's ability to read films is not very strong, but he can also see that something is wrong. "There is an abnormal signal at this location of the right basal ganglia. ”

Sun pointed to the part where he found the abnormality, which was near the basal ganglia of the human body, near the thalamus. On the MRI image, it is clear that several white circles are concentrated in this area.

As the two continued to read the film, more and more anomalies were recognized. Abnormal signals appeared in Lu Xuexin's brain, including the bilateral frontoprietal lobes, radial crown, left lateral ventricle, right basal ganglia, right parahippocampal gyrus and other parts.

These abnormal signals are different from the small white globules in Chen Wen's brain, they are more like small circles, and there are obvious white signals where the outer side meets the brain tissue, and the inner appearance of the circle is darker than the outer layer of brain tissue. This proves that the contents of the circle are at least a little more dense than normal brain tissue.

"What is this?" The well-informed Yuan Ping'an was also a little stunned, he subconsciously wanted to invite doctors from the neurosurgery and imaging departments to come for consultation, but suddenly saw Sun Lien, who was silent. "Dr. Sun, do you have any clue?"

"Look here. Sun Lien pointed to the anomalous signal area that he and Yuan Ping'an had discovered at the beginning, "Have you noticed that the abnormal signal here is not the same shape? It protrudes into the third ventricle. ”

Yuan Ping'an frowned and asked, "What does this mean?" He didn't see the significance of this sudden feature.

"The main components of the human brain are fats and proteins. Sun Lien used his knowledge to explain, "And its density should be relatively uniform in all regions." However, the ventricles are different, and the cerebrospinal fluid contained in the ventricles can be approximated as water. They are denser than brain tissue. ”

Yuan Ping'an was a little dizzy when he heard this, he shook his head and asked, "The density of cerebrospinal fluid is greater than the density of brain tissue, I know this, and then what?"

And the penetration here proves that the density of the material in these white signals should be greater than that of the cerebrospinal fluid, otherwise it will not burst into the ventricles, but should be squeezed down by the ventricles. Sun Lien clicked on the MRI films, "I think these may be abscesses." ”

"Abscess?" Yuan Ping'an was puzzled, "If it is a brain abscess, after antibiotic treatment, her condition should improve." ”

Sun Lien looked at the treatment plan, shook his head and said, "This is the main reason why Director Zhu used this case to test me." He pointed out the treatment plan in the case to Yuan Ping'an, "You have used meropenem and ceftriaxone, but your performance has not improved." ”

Meropenem is a β lactam antibiotic used in combination with ceftriaxone and is commonly used to treat bacterial meningitis and brain abscess.

"Therefore, what infected Lu Xuexin's brain should be a bacterium that is not sensitive to both meropenem and ceftriaxone, or is resistant to drugs. Sun continued his diagnosis, "At the same time, infections with this bacterium should be uncommon. It also exhibits symptoms of brain abscess as well as meningitis – at least I haven't heard of it. ”

"What does it mean to be uncommon?" Yuan Ping'an asked, "What do you mean...... Infections caused by rare bacteria?"

Sun Lien nodded and shook his head again, "There are two possibilities I can think of at present, one is that this bacterium itself is very rare, so there are relatively few corresponding case reports. But it's not that likely—if you've never seen it, then the possibility of the bacteria being there isn't much in itself. The second possibility is ......," Sun paused, "The second possibility is that it could be an infection caused by some relatively common and not virulent bacteria. ”

Yuan Ping'an's eyes widened, "Because...... SLE？”

"Strictly speaking, it's because of the medication that controls SLE. Sun Lien nodded, this was the part he was most worried about. "Because of SLE, the patient has been taking hydroxychloroquine sulfate and methylprednisolone for a long time, and her immune system will be much weaker than that of ordinary people. Some common bacteria have the potential to cause serious consequences. ”

Yuan Ping'an looked at Lu Xuexin who was in a coma with a headache, "Then it's troublesome." What bacteria are insensitive to two broad-spectrum antibiotics at the same time, undetectable on cerebrospinal fluid smears, and can infect the brain and cause both meningitis and brain abscess......"

"My advice is to increase observation and consult with a neurosurgeon and radiologist. The need for puncture decompression of a brain abscess is discussed first. Sun Lien sighed, despite all that, he didn't understand what bacteria were causing Lu Xuexin's symptoms. "At the same time, the laboratory should be asked if there are any tests other than cerebrospinal fluid culture that can detect the pathogen. Sun Lien paused, and he suddenly thought of the idea and initiative put forward by Xiao Lin Feng. "By the way, can Tongxie do mNGS testing?"

m.