Edema is a symptomatic manifestation that can be large or small. Some girls often complain that their faces are swollen when they wake up, and call it "edema".

Actually, it's just plain fat......

There are two types of edema, local and generalized, and mild edema is only seen in the soft tissues of the eyelids, infraorbitals, and the subcutaneous tissues of the anterior tibia and ankles. There will be a slight sag when the fingers are pressed.

There are generally four causes of this type of edema: decreased plasma colloidal osmotic pressure, increased hydrostatic pressure in capillaries, increased capillary wall permeability, and obstruction of lymphatic fluid reflux. Protein malabsorption, malnutrition, or renal disease with proteinuria, respectively. Venous obstruction or impaired venous return. Infection or inflammation. Disruption of regional lymphatic circulation, or blockage of parasites and cancer cells.

Judging from the prompts in the status bar, Wang Lin should belong to the first condition, kidney disease with proteinuria.

Tuberculosis, on the other hand, generally does not cause kidney lesions, let alone proteinuria. Therefore, Sun Lien affirmed Xu Yourong's diagnosis as soon as he saw the patient's state, which is indeed not like tuberculosis. Instead, it seems to be some kind of infection that develops and manifests very similar to tuberculosis.

The preliminary diagnosis under the leadership of Zhou Jun also eliminated some suspicions for Sun Lien. A negative sputum smear indicates that the patient's sputum does not have a pathogen that can be directly visualized under the microscope. However, the "Staphylococcus aureus infection" indicated in the status bar does not explain why the patient has a long-term low-grade fever, fatigue and cough. Pneumonia caused by Staphylococcus aureus infection usually presents as acute purulent pneumonia. The onset is rapid, the progression is rapid, and patients generally present with high fever and chills, chest pain, and purulent sputum.

In general, it is reasonable to suspect Staphylococcus aureus pneumonia without looking at the patient's condition in the past month, just by looking at the recent symptoms. However, this state of affairs still does not explain the sudden massive coughing up of blood in the last two days.

Although it is uncertain what disease the patient has, it is certainly not tuberculosis. This is Sun Lien's current diagnosis.

For a middle-aged man in his fifties, lung and kidney problems that the status bar now suggests could be life-threatening. But what gave Sun Lien a headache was that he couldn't judge which of the two problems was more deadly.

"This patient's problem is not simple. Sun Lien and Zhou Jun roughly shared their analysis process, of course, he omitted the prompt in the status column, and simply analyzed the cause of tuberculosis from the patient's disease manifestation. Then he proposed, "I suggest that he be transferred to our treatment group." ”

There have been no new patients in the treatment group for so long that Sun Lien's hands are a little itchy.

"Yes. After a moment of silence, Zhou Jun agreed to Sun Lien's suggestion. Then he pulled the phone out of his pants pocket. "Dean Liu, there is a new patient who wants to be transferred to Sun Lien's treatment team. ”

Sun Lien blinked, he almost forgot that his treatment team now has a vice president as a supervisor.

"Dean Liu said that you can accept the patient, but you have to explain to him why you want to accept the patient after the patient's condition is stable. Zhou Jun nodded at Sun Lien, "He's under your control now." ”

·

·

·

"There's definitely something wrong with the kidneys. As for whether it is glomerular or tubular or mixed spillover histological, it needs to be judged in combination with other examination results. Zhou Ce was called to a meeting in a small conference room by a phone call, and the doctors present were the oldest except for Dr. Pascal - Zhou Ce was a year older than Xu Yourong.

Dr. Pascal was called back from the hotel for a consultation, not only not dissatisfied, but in high spirits. This is the main reason why he came to Ningyuan from the United States! Who would have thought that after coming to Ningyuan, he would work as a cow and a horse in the outpatient clinic, and he was almost so tired that he died suddenly. But now I finally have a job to do. Comrade Lao Pa rubbed his hands and looked at the inspection report in his hand carefully.

Yuan Ping'an is working on reorganizing the patient's condition. Before coming to the conference room, he first went to the patient's family to re-inquire about the condition. And he re-questioned the patient himself. After comparing the private complaints on both sides, Yuan Ping'an summed up a relatively accurate case record. And he is also prepared to re-screen for the cause based on case records and progress—the patient has already undergone a lung lavage sample, but the laboratory says that the culture will take at least three days. If the suspicion can be narrowed as soon as possible, it may be confirmed by PCR testing – which can save a lot of time for the patient's treatment.

Xu Yourong was very quiet, except for occasionally translating the content of the case to Dr. Pascal, she was more often observing Sun Lien's movements. Sun Lien affirmed her diagnosis, which made Deputy Chief Physician Xu feel a little proud. But more often than not, there is confusion. She compared the course and progression of the patient several times before making the judgment that "it may not be tuberculosis". And Sun Lien just glanced at the patient, and knew that the patient's legs were swollen under the quilt. Although Sun Lien explained it with "the patient has slight edema at the eyelids". But Xu Yourong still couldn't figure it out - he didn't see the edema that the patient didn't notice, how did Sun Lien see it at a glance, and based on this, he supported his diagnosis?

Sun Lien is recording the patient's symptoms on a whiteboard. He wrote in black pen "cough, low-grade fever, fatigue for one month, cough worsening, coughing up 200 ml of blood for two days, dyspnea for one day, slight edema of undetermined duration, proteinuria, undetermined duration." ”

"You're really a bit like House now. Dr. Pascal looked at the handwriting on the whiteboard and smiled, "It's just that you don't make fun of us ducklings, and you're not as magical as he is." ”

Sun Lien covered the lid of the pen and said, "And I am the chief physician, and I am just a small regulation." He smiled and pointed to the record on the whiteboard behind him, "From this record, the patient's condition is mainly divided into two stages. He pointed to the first line of words, "First the respiratory symptoms lasted for more than a month, and then the condition suddenly worsened within two days." ”

"The duration of proteinuria and slight edema is uncertain, and it is possible that it will continue to occur for a month or more, right?" Zhou Ce put forward a different opinion, "What if his kidney symptoms are not secondary to lung disease, but are primary in the kidneys, and then affect the lungs?"

"Then the diseases we need to consider need to include lupus erythematosus, renal arteriosclerosis, gout kidney, congestive heart failure, heavy metal poisoning, multiple myeloma...... Dr. Pascal casually lists the names of the diseases. "If you want to check them one by one, it will take about a month. ”

Sun Lien was not too impressed by Zhou Ce's suggestion, after all, there was already a hint of lung infection on the status bar. That proves that Wang Lin's current condition must be related to a lung infection. Whether the infection is transmitted through the blood or the lymphatic ducts, they will only appear in multiple places at the same time, and will not first infect the kidneys, and then abandon the base camp and all of them will move to the lungs – if Staphylococcus aureus causes the kidney lesions and then the lungs, then the kidneys should still have Staphylococcus aureus infection.

"Combined with the results of blood routine and urine tests, it is more like glomerulonephritis. And it should be acute. Zhou Ce made his own diagnosis. "Acute glomerulonephritis usually occurs after a streptococcal infection, and pneumoniac infection can explain both pulmonary symptoms and proteinuria. ”

"I agree. Xu Yourong and Dr. Pascal both nodded.

Sun Lien pondered for a while. Although Streptococcus pneumoniae and Staphylococcus aureus are not the same thing at all, they are both positive Gram stain representative bacteria, and there is a considerable degree of commonality in treatment. The only caveat is that Staphylococcus aureus is highly resistant to penicillin antibiotics, while Streptococcus does not.

"Give him cefuroxime sodium, add oral roxithromycin, give him protamine, and monitor his clotting time. Sun Lien gave his own initial treatment plan. "Maintain oxygen and 24-hour cardiopulmonary monitoring. If treatment is effective, refer the patient to a respiratory medicine specialist. ”

The diagnosis team disbanded, and Dr. Xu Yourong and Dr. Pascal went to the emergency room to give a prescription. Sun Lien sat in the empty conference room and began his contemplation.

Zhou Ce's diagnosis had a fatal problem - Wang Lin was not infected with streptococcus, but with Staphylococcus aureus.

In other words, the treatment plan given by Sun Lien could only suppress the problem of his double lung infection and coughing up blood, but did not help the patient's proteinuria.

He had to figure out as soon as possible what was causing Wang Lin's kidney problems.

·

·

·

Sun Lien thought about it for a long time, but he still didn't have a clue. Zhou Ce of the Department of Nephrology gave a judgment that acute glomerulonephritis, but there was no streptococcal infection, and this judgment was not tenable at all.

Suddenly, Sun Lien had a flash of inspiration. What if Zhou Ce's initial assumption was correct? Kidney problems may last longer, but because the symptoms are not obvious, they are ignored by the family and the patient himself?

He took the patient's medical history that Yuan Ping'an had sorted out and re-read it. Soon, he found some suspicious traces in his medical history.

The patient himself was at the critical value of hypertension for a long time, and was officially diagnosed with stage 1 hypertension at the physical examination organized by the unit three months ago.

Chronic glomerulonephritis may be triggered by kidney damage due to high blood pressure, which may in turn worsen the increase in blood pressure. Symptoms of proteinuria are also present. In this case, in occult glomerulonephritis, the amount of protein in the urine may be less than one gram a day, and there are no signs of edema, hypertension, and renal decline.

After the lung infection, the burden on the body increases, and the persistent low-grade fever and fatigue cause the patient to exercise less. In addition, due to the weather, the amount of water in the body is greater than the amount of water out, which increases the burden on the kidneys.

Could this be the real cause of Wang Lin's symptoms?