"Okay, I'll be right here."

Zhou Can replied very simply, and only when Director Zhang hung up the phone did he remove the phone from his ear.

It is the most basic courtesy to talk on the phone with elders, teachers, and leaders, and wait for the other party to hang up the phone first.

Some newcomers in the workplace are used to being very arrogant, and when talking to the leader, they are 'informal', rushing to hang up the phone, or rushing to talk to the leader, which are all taboos.

If you don't pay attention to these details, it is easy to see other colleagues who enter the company together are obviously not as capable as themselves, but they are rising step by step every two years.

And he is still standing still.

Human accidents are as important as work ability and business level.

Doctor Pang next to him watched Zhou Can hang up the phone and secretly breathed a sigh of relief. She could hear it clearly just now, Director Zhang Bihua relied on Zhou Can very much, and when she talked, she completely regarded Zhou Can as a level.

She was especially afraid of Zhou Can's complaint against her.

Fortunately, Zhou Can has a manly generosity and acts above board.

Didn't clean her up again.

"Doctor Pang, please take care of it with the two nurses for a while, I'll go to the outpatient hall, and I should be back soon." In case of any emergency, be sure to call me as soon as possible. ”

After Zhou Can told the three of them, he left quickly.

Doctor Pang watched Zhou Can's back as he left, only to feel a chill in his back.

Only then did I find out that Director Zhang was talking to Zhou Can just now, which scared her out of a cold sweat.

When Zhou Can rushed to the outpatient hall, he found that the female patient who had polydipsia, diabetes insipidus, and consciousness disorder yesterday was sitting at Director Zhang Bihua's desk for diagnosis. She looks much better than she did yesterday.

Yesterday I looked demented, leaning and sick.

After a day in the hospital, she now looks like two people. The consciousness is much clearer, and the eyes have a hint of brightness.

"Doctor Zhou, I'm just waiting for you to come over and help with the consultation!"

A deputy chief physician of the Department of Obstetrics and Gynecology greeted Zhou Can with an unprecedented smile.

"Ah...... I? I'm just a small pearson, you are too exalted of me! Director Luo's words are not to put gold on my face, but to put a gold bucket on my head. ”

Zhou Can naturally wouldn't be stupid and acquiesce to other people's flattery.

This Director Luo hadn't even looked at him before, but now he suddenly became so enthusiastic, just two words 'snobbery'.

"Dr. Zhou has experience in rotating through multiple departments, and this case may really be able to give some constructive diagnostic advice!" Zhang Bihua took the conversation.

"After the patient was treated with fluids and intravenous insulin infusion, his blood sugar and blood sodium have dropped a lot, and his consciousness is much clearer. However, she still has a poor appetite, a poor mental state, and poor sleep. At the same time, symptoms such as polydipsia and polyuria remain. ”

As soon as Zhang Bihua said this, Zhou Can understood what it meant.

Don't look at the patient's condition after treatment, it is only a temporary solution.

At present, it is only the patient's diabetes that is in remission.

Zhou Can's eyes looked at the patient.

"Are you having normal bowel movements now?"

"Once a day."

Patients have been able to communicate directly with Zhou Can.

This made Zhou Can very happy.

"Have you checked the patient's menstrual and marital history?" Zhou Can turned his head and asked Director Zhang.

"Just now, while she was conscious, I already asked. Menarche at the age of 14, each menstrual cycle is about 50 days, and the menstrual period is five days, and the menstrual blood is large. She married at the age of 21 and had a child. ”

Director Zhang gave a brief introduction to the patient's situation.

A normal woman's menstrual cycle is between 28 and 35 days, and this patient's menstrual cycle is as long as 50 days, which is obviously abnormal.

But on the other hand, a 50-day menstrual cycle is not necessarily a bad thing.

Because a woman ovulates about 400-500 times in her lifetime. In fact, most women only ovulate about 400 times in total.

A 28-day menstrual cycle means that the eggs in the body are exhausted in less time.

At this time, the woman will stop menstruating and menopause will come.

Some women stop menstruating in their forties, and menopause follows, which is not a good thing.

Because according to scientific research, the later a woman stops menstruation, the slower the aging, and the body's immunity can always be maintained at a high level.

This patient only has one menstrual period in 50 days, which is almost twice as long as the average woman.

It also means that her menopause age is later than that of ordinary women, and menopause comes later.

"What about her basic signs at the moment?"

"Body temperature 37.7 degrees, heart rate 83 beats per minute, breaths 24 beats per minute, blood pressure 116/75 mmHg." Yang Chan replied beside her.

She is responsible for every physical examination of the patient.

It is equivalent to giving Director Zhang a hand.

The body temperature is in a low-grade fever, and the blood pressure and heart rate are basically normal.

Zhou Can walked around to the patient to check her neck.

"It has been checked, there is slight redness and swelling in the pharynx, the tonsils can be clearly enlarged, and the thyroid gland is normal. There is no significant edema in both lower extremities. Breathing is normal and there is no murmur. ”

Yang Chan's work is quite meticulous.

Zhou Can smiled and gave her a thumbs up.

"It is worthy of being a famous teacher and a high apprentice, and the squad leader's physical examination work is really good!" In a word, he praised both Director Zhang and Yang Chan.

There was a smile on both of their faces.

There are few women who don't like to be complimented on.

"Have you done a urine test on the patient?"

"Well, this is the latest urine test report." Yang Chan took the initiative to hand the result sheet of the urine routine to Zhou Can.

After taking it, Zhou Can took it and looked at it, and then checked the patient's other biochemical examination data.

"Urine ketone positive, blood gas suggests metabolic acidosis, then she should be ketoacidosis!"

After Zhou Can read it, he made a conclusion.

"This diagnosis has been given by Director Zhang and the experts just now."

Yang Chan replied.

"What we have to consider now is why do patients have impaired consciousness and even coma after stopping the drug and switching to traditional Chinese medicine?" Director Zhang pointed out the problems to be solved to Zhou Can.

The experts have just discussed that there should be some conclusions.

It's just that there may be some differences of opinion.

"From the analysis of the patient's symptoms and examination data, I think that her disease should be treated separately. The cause of consciousness impairment and even coma is not necessarily related to taking traditional Chinese medicine, and she should belong to a hyperosmolar coma. ”

Zhou Can found that during the diagnosis process, his mind was exceptionally clear and his thinking was clear.

"Hyperosmolar coma often occurs in older patients, but she is only in her thirties, which is still very young. Personally, I don't think it's likely to be hypertonic. ”

Director Luo, who was a little snobbish, did not agree with Zhou Can's diagnosis.

"There are no absolutes, and this patient's situation is quite special. My diagnosis was based on the fact that the patient had been taking diastonation for a long time, and it was only when she stopped taking the medication that it caused the diabetes insipidus to worsen and her body became dehydrated. Then she also stopped the hypoglycemic drugs and switched to traditional Chinese medicine. This leads to an increase in blood sugar levels, which inevitably worsens dehydration and eventually leads to a hyperosmolar coma. Ketoacidosis is also caused by discontinuation of hypoglycemic drugs. ”

Zhou Can made a detailed analysis of the pathological mechanism of the patient and the pharmacological mechanism in it.

[Pathological diagnosis experience value +1, pharmacological pattern differentiation experience value +1.] If you successfully diagnose a difficult case, you will be rewarded with 100 experience points for pathology and pharmacology. 】

The experience points have all arrived, indicating that Zhou Can's diagnosis is completely correct.

The diagnosis of this disease in five days is not difficult.

The main reason is that there are many of its symptoms, and the condition is complex, like a bundle of hemp, and if you want to correctly diagnose the pathologies in it, you must first straighten them out one by one.

Zhou Can separated the diagnosis and treatment of amenorrhea, polydipsia, consciousness disorders and other diseases, and the difficulty of diagnosis was greatly reduced.

Moreover, it can be undisturbed by other pathological mechanisms.

"Well said! I think the diagnosis of hyperosmolar coma in patients is completely correct. After listening to Zhou Can's analysis, Director Zhang firmly supported his diagnosis.

"Well, even if the patient's consciousness is hyperosmolar coma, what about her polyuria?"

Director Luo compromised.

was forced to agree with Zhou Can's diagnosis, and she threw out a new question.

"Don't worry, let's separate them one by one. The patient's polyuria and polydipsia, from the analysis of the test data and her actual condition, can basically confirm the diagnosis of diabetes insipidus. And it is a central diabetes insipidus. ”

Zhou Can's split-and-hit style of play has also made many doctors refreshed.

This is because many doctors are accustomed to a fixed mindset that although a patient has many symptoms, there is usually only one cause. Finding the cause and treating the symptoms can cure the disease.

In fact, it is.

However, there is also the possibility of multiple diseases or multiple diseases.

The most common clinical situation is that a patient has multiple underlying diseases at the same time, such as hypertension, diabetes, and nephritis, which can be said to be extremely common in clinical practice.

However, this common underlying condition is very easy to diagnose.

High blood pressure, blood pressure measurement is detected.

Just check your blood sugar and urinalysis for diabetes. Even if it is a little more complicated diabetes, the liver and kidney function tests, blood lipids, and pancreatic islet function tests can be done to confirm the diagnosis.

Most of the above diseases have the gold standard for diagnosis, so they are easy to detect.

At present, the cause of this patient is confusing, type 2 diabetes is only one cause on the surface, but because the patient listened to the words of relatives and stopped taking Western medicine and Chinese medicine, the symptoms worsened, and it was obvious that there was more than one cause.

In this case, if the diagnosis and treatment of diabetes are still carried out, it will definitely not be able to cure the disease at all, just like the doctors in the previous hospitals.

"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 supports Zhou Can's diagnostic views.

So many experts at the scene jointly diagnosed the woman, which attracted many family members and patients to watch.

In addition to being surprised, they also wanted to take the opportunity to see which of these experts was more powerful.

At the same time, you can also see how the expert diagnoses the disease.

THE HYDRO-VASOPRESSIN TEST, WHICH SHOWED THAT DESMOPRESSIN, THE 2 STOP OF DESMOPRESSIN, THE 200 MOSM (I.E., THE REAGULANT DRUG THAT THE PATIENT OFTEN TAKES), SHOWED THAT THE BLOOD OSMOLALITY WAS 330 MOSM/L AND THE URINE OSMOLALITY WAS 103 MOSM/L AFTER EIGHT HOURS OF DEHYDRATION, AND THE URINE OSMOLALITY ROSE TO 590 MOSM/L AFTER THE INJECTION OF POSTERIOR PITUITARY LOBETIN.

MRI of the sellar region showed that the pituitary stalk was thickened, and the posterior pituitary hyperintensity disappeared.

It was on the basis of these key data that Zhou Can determined that the patient had central diabetes insipidus.

So what exactly causes central diabetes insipidus? Is type 2 diabetes caused? Yang Chan really didn't understand and asked, anyway, Zhou Can was her classmate.

"I think it's caused by a lesion of the pituitary stalk."

Zhou Can was very sure of this diagnosis.

There was no need for Yang Chan to take the initiative to ask, he went on to explain, "Pituitary stalk lesions, in the clinical process, germ cell tumors are easy to cause this disease. And it usually occurs in children. The patient was in his thirties, and the possibility of germ cell tumor could be ruled out. Judging from her examination data and symptoms, lymphocytic hypophysitis is more likely to be caused. ”

After listening to this, Yang Chan pondered for more than ten seconds, and nodded as if she didn't understand.

"Now I only suspect that lymphocytic hypophysitis has a high chance, but there is no way to diagnose it!"

She was able to put forward this opinion, which shows that she really thought about it, and she has a certain understanding of Zhou Can's diagnostic ideas and pathological analysis.

Zhang Bihua couldn't help but smile with satisfaction when she saw that her disciple's progress was obvious.

first looked at Yang Chan, and then at Zhou Can, there seemed to be a trace of expectation in his eyes, hoping that these two young people could communicate and cooperate more.

To be more precise, she hopes that Yang Chan can learn more from Zhou Can.

"The best way to diagnose the disease is to take a tissue sample for biopsy, but the operation is very difficult."

Zhou Can's current surgical ability is not bad.

It has even been able to match the level of many chief physicians of surgery.

Even he said that the operation was difficult, indicating 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 the ability to tolerate the surgery is enough to make any surgeon daunting.

"Is there any other way?" Yang Chan asked.

"There must be a way! For example, no pathological biopsy is done, and direct radiation therapy is done. Zhou Can's eyes looked at the family members and patients.

When many family members hear about radiotherapy, they can't help but associate it with cancer and strong side effects.

In fact, radiotherapy does cause some damage to the body.

For example, it can cause hair loss, sore throat, nausea and vomiting, headache, fatigue, etc.

"We don't do it, we don't do it!"

The family shook their heads and refused.

"In fact, radiation therapy is not as scary as imagined. I recommend that you try it once to see how effective the treatment is before deciding whether to continue radiotherapy. ”

Director Zhang Bihua spoke at this time.

She directly helped Zhou Can do the ideological work of his family and patients, which showed that she recognized Zhou Can's diagnosis very much.

"Thank you Director Zhang for your kindness, we don't do this treatment. Because one of our relatives died after radiotherapy, and there were people in our village who also died after radiotherapy, and their health deteriorated day by day, and finally died. ”

The family was extremely resistant to radiotherapy and was full of fear.

Doctors only have the right to make recommendations, and if the family and the patient do not agree, then there is no way to implement it.

Zhang Bihua couldn't be persuaded to move, her eyes rolled, and she thought of a new idea.

She looked at Zhou Can.

"What does Dr. Zhou think is causing the patient's amenorrhea?"

Zhou Can and Director Zhang glanced at each other and understood her deep meaning in seconds.

It seems that Director Zhang has already diagnosed the cause of the patient.

Maybe he can't be sure, or he wants to train his juniors, so he called him over to help with the consultation.

"I don't think the cause of secondary amenorrhea in patients is caused by dilation and curettage, but by pituitary lesions. It is not difficult to confirm the diagnosis, and it is enough to directly do a functional test of each axis of the thalamic-pituitary gland. ”

Zhou Can determined that the patient's central diabetes insipidus and amenorrhea were related to pituitary lesions.

"What about the opinions of the experts?"

Zhang Bihua also knew that Zhou Can was young and had little qualifications, and his family and patients might not be convinced by what he said.

This requires other experts to support Zhou Can's arguments.

"I think Dr. Zhou's diagnosis should be correct." Director Jiang was the first to support Zhou Can's view.

"It's a good idea to do a functional test of the thalamic-pituitary axis, and as long as the results are out, it can be determined whether the cause of amenorrhea is caused by pituitary lesions."

It was surprising that Du Leng actually stood up to support Zhou Can's inspection plan.

Facing Zhou Can's gaze, Du Leng immediately looked away.

He's a returnee doctor, he has to behave, right?

Can't watch Zhou Can make meritorious contributions and be in the limelight alone!

Shenwai happens to be his field of expertise, Zhou Can's analysis just now He has been listening carefully, and after analyzing it, although his face is not convinced, his heart is to recognize Zhou Can's diagnostic ideas and opinions.

Now jump out to support Zhou Can, which can not only show his generosity, but also show his face once.

It is equivalent to Zhou Can planting peach trees, and he picks peaches.

"Would you like to do this?"

Director Zhang looked at the family members and patients.

The patient belongs to the type of woman who has no opinions, and everything is based on her husband's opinion. She looked at her husband beside her.

"As long as we don't do that radiation, we're willing to do it."

The family agreed to the test.

Director Zhang gave them an application for inspection and asked them to hurry up and do it.

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 a patient's blood sugar should be a priority.

I have already taken the medicine yesterday and will definitely continue the treatment today.

Everyone knows that the treatment of diabetes only requires the use of insulin.

Director Zhang deliberately tested him, and naturally asked about specific medications.

"I think that regular administration of insulin glargine, followed by intensive treatment with insulin aspart before meals, should be able to control this patient's blood sugar very quickly."

Zhou Can gave the answer.

His mind was thinking about how to treat the patient's pituitary lesions.

(End of chapter)