The case was from the Department of Neurology of the Second Central Hospital, and the patient's surname was Shen, male, and he was only 18 years old.

"This is my cousin. Shen Xi introduced, "He has always been in good health before, and he has never heard of any problems." ”

"And then I had a sudden seizure of epilepsy?" Sun Lien quickly browsed the cases brought by Shen Xi, "The MRI noncontrast scan showed that there was an abnormal signal in the right nominal junction area, and the symptoms were also like epilepsy. He put the case down, "That's fine." ”

"The problem is that there is nothing wrong with this. Shen Xi sighed and said, "The diagnosis of the second hospital is symptomatic epilepsy, and my medical records also look like epilepsy, but the second hospital gave phenobarbital, levetiracetam and mannitol for treatment. But the situation did not improve, but began to get worse. ”

"What does it mean that it's serious? The frequency of epilepsy has increased?" Xu Yourong became a little interested when he heard this, "Or does it take longer to have seizures each time?"

"During the treatment, there were three episodes of numbness and weakness in the left upper limb, then convulsions in the limbs, and loss of consciousness. The symptoms were exactly the same as before the seizure, and the left upper limb was still numb and weak after waking up, and the area of weakness has now extended from the left finger to the proximal forearm. Shen Xi said solemnly, "I don't think there is any serious problem with multiple seizures, but the numbness of his upper limbs spreads, which makes me feel very wrong." ”

The persistence of the disease indicates that standard treatment has not had an effect on his epilepsy. This could mean that Shen Xi's cousin's epilepsy is more stubborn, and phenobarbital and levetiracetam are not effective enough — perhaps the medication regimen needs to be adjusted. But the taste of the progression of the disease is very wrong, which shows that the problem encountered by Shen Xi's cousin is likely to be deeper than epilepsy, something caused his epilepsy, and the cause of this epilepsy is not affected by phenobarbital and levetiracetam or even mannitol. It is still deteriorating further.

Xu Yourong leaned over and looked down at the case in Sun Lien's hand. Sun Lien shifted his focus to the follow-up diagnosis plan of the second hospital.

"Are they suspecting poisoning?" Sun Lien looked thoughtfully at the latest series of examination reports in the case. The suspicion of the second hospital is indeed in the direction of the numbness and weakness that extends from the ends of the limbs upwards, which is indeed similar to some cranial nerve damage caused by certain poisoning symptoms. Coupled with the case of Zhan Hao, the elder brother of Zhan Jun, who was previously regarded as a simple demyelination and did not conduct follow-up examinations, Sun Lien has enough reason to believe that the neurophysicians of the Second Hospital were hung up by the director and whipped over.

Otherwise, how could he suspect poisoning in the first place? This symptom is obviously wrong! Sun Lien muttered in his heart that after getting out of the poisoning environment, the poisoning symptoms should be improved. At that time, Zhan Hao's illness recurred, which was caused by the second ingestion of bacon containing lead. Any symptoms of poisoning should at least resolve or stop progression after removal from the toxic environment. Where is there a deterioration after leaving the poisoned environment?

If not poisoning, then what disease causes epilepsy, and phenobarbital and levetiracetam are ineffective against it?

The reasoning came to an abrupt end at this point. Sun was frustrated to find that he didn't have the ability to continue reasoning—as an emergency physician, he was not familiar with either drug. This is especially true when it comes to the mechanism of action. In fact, this is inevitable, there are only hundreds or thousands of drugs used in the hospital, except for the old things, Sun Lien suspects that the entire Song'an Province and even the whole country will not be able to find a doctor who can memorize the mechanism of action of all drugs.

"I think there might be something wrong with the direction of the poisoning. Sun Lien and Xu Yourong exchanged a few words, and then said to Shen Xi, who was a little anxious, "The second hospital may be a little too concerned about the previous mistakes...... In fact, Sun Lien himself didn't believe it, the second hospital is so big and a tertiary hospital, it is rare for a single case to deliberately emphasize the diagnosis plan. It is more likely that the attending doctor who received Shen Xi was the one who received Zhan Hao before - Zhan Hao's severe lead poisoning could actually pass under the nose of Dr. Shennai, and even almost caused a medical accident. This is bound to cause serious psychological consequences for the doctor.

"Then what should I do, Brother Sun, can you accept it?" Shen Xi revealed his true intention, the main purpose of his coming here with the case was actually to let his cousin come to the diagnostic center for treatment. "The water over there in the second courtyard ...... To be honest, I'm not too reassured. ”

The level of the second hospital is actually quite good. Although Sun Lien wanted to say this, he really couldn't say it when he saw that two cases in the second hospital had been planted in his hands.

"I think I can take this case. Xu Yourong, who was in charge of the preliminary review, simply took the case from Sun Lien's hand and began to read it in detail, and after a few minutes, she gave her opinion, "This kind of progressive disease of unknown cause has the value of intervention. The second hospital is a little less able to deal with this type of disease. ”

The translation is "this disease may be very dangerous, and I can't believe the level of the second hospital." Sun Lien nodded, Xu Yourong said so, it seems that there is indeed value in the future.

"Yes, you can contact the other side to transfer to the hospital. Sun Lien nodded, he was also very curious about this patient. Of course, more importantly, he also wanted to know what the epilepsy of phenobarbital and levetiracetam did not work for. "Can you turn around today?"

"No problem. Shen Xi was overjoyed, he had already heard other seniors and teachers in the department complain that the high standard of patient acceptance in the diagnostic center was not ordinary. He didn't have much expectation of transferring to the hospital to see a doctor at the diagnostic center, and he just wanted to hear if Sun Lien had any other views on his cousin's condition. I didn't expect it to be transferred. "I'll get in touch now, and I'll have someone come over before noon today!"

"Then you go through the formalities first. Sun Lien nodded and pointed to the case in Xu Yourong's hand, "We will make a copy of this case, and when the patient comes, bring the latest examination report and the like from the second hospital." "The level of the second hospital may not be very high, but the level of the laboratory department is still quite good. With the ready-made test report, even if nothing abnormal was found, at least it could help Sun Lien eliminate some problems as soon as possible in the subsequent diagnosis.

After Shen Xi left, Brune also came over. He didn't understand Chinese very well, but it was not a big problem to listen to Xu Yourong's retelling. After listening to the general content, he rubbed his chin thoughtfully, "This symptom description sounds like glove-like numbness." ”

"You suspect acute demyelination? That's going a little slowly. Xu Yourong is not very optimistic about this opinion, "The glove-like numbness is generally symmetrical on both sides, and when the disease occurs, the whole hand is numb together, and his progress is not very similar." ”

Sun Lien also joined in the excitement, "Many patients with glove-like numbness come to the hospital when the symptoms are obvious, and the main reason why this patient is admitted to the hospital is because of epilepsy - the onset symptoms of epilepsy are more obvious, could it be because of this, first admitted to the hospital and then found that the glove-like numbness is in progress?"

"It's a bit far-fetched, but it's barely in the past. Xu Yourong nodded, "Do you think the cause of his glove-like numbness is directly related to epilepsy?"

"That's not what you think?" Sun Lien's eyes widened, "I thought you recognized this point and let people transfer to the hospital." ”

Xu Yourong shook his head, "You think that the epilepsy happened because of the numbness of the left limb, I suspect that there is a more fundamental cause that causes both the epilepsy and the numbness of the limbs." This explanation is a bit awkward, but Sun Lien still understands what Xu Yourong means - epilepsy is a manifestation of abnormal discharge in some areas of the brain, and Xu Yourong feels that there is some kind of disease that causes abnormal discharge, and it progresses to numbness of one of the patient's limbs. Sun Lien's judgment is that the numbness of the limbs and the abnormal electrical discharge in the brain are actually abnormalities in the same area. Both inferences can be established under the available evidence, but the diagnostic directions and ideas led by the two inferences are very different.