tkworld Chapter 1385 is still missing one ring.
Chapter 1385 is still missing one ring.
Chapter 1385 is still missing a link
Having just finished participating in a case discussion, Yang Ping received a call from Director Lou Tian of the Overseas Chinese Building inviting him for a consultation.
"Professor Yang, could you please come for a consultation?"
"what's the situation?"
"The patient in the neurosurgery department has a brain hemorrhage. The family refuses surgery and requests conservative treatment. They have also asked you to take a look, so please help us."
Yang Ping frowned: "Come on, follow me to the Overseas Chinese Building."
Zaxi's heart skipped a beat; he had never been to the Overseas Chinese Building before. It was said that the building had its own elevator, security guards, and kitchen—a completely different world from the regular wards.
The two walked through the connecting corridor and swiped their access cards before entering the Overseas Chinese Building. The elevator was carpeted, and oil paintings hung on the walls; it was so quiet that they could hear their own breathing. Zaxi unconsciously softened his footsteps.
In the surgical ward, Director Tian and the attending physician were already waiting at the elevator entrance. When Director Tian saw Yang Ping, it was like seeing a savior: "Professor Yang, you've finally arrived."
"What's going on?" Yang Ping asked as he walked.
The attending physician was a young doctor in his early thirties, surnamed Meng. He wore glasses and looked tired. He handed over the medical record and spoke quickly: "The patient is a 54-year-old male entrepreneur. Three days ago, he suddenly experienced headaches and vomiting. An emergency CT scan revealed massive intracranial hemorrhage. Angiography showed a ruptured aneurysm located at a distal branch of the middle cerebral artery. Surgery is the proper procedure for this location, but the family strongly disagrees and only requests conservative treatment. We have tried to persuade them for a long time without success, so they are requesting your consultation."
Yang Ping took the medical record, his steps unwavering: "Why don't you agree?"
Dr. Meng smiled wryly: "The family said that the patient's health was already poor, and they were afraid that he wouldn't survive the operation. Moreover, they felt that since the bleeding had stopped, they should just let him recover slowly and didn't want to go through any more trouble."
"Has the bleeding stopped?"
“The angiography showed no signs of further bleeding from the aneurysm,” Dr. Meng said. “But you know, this thing is like a time bomb, it could explode at any moment.”
Yang Ping didn't say anything. He went to the ward door, and Director Tian knocked on the patient's door.
The ward was a suite; an outer meeting room led to the hospital bed. A middle-aged woman sat in the meeting room, her makeup impeccable, but her eyes were red and swollen, clearly indicating she hadn't slept well for several days. Seeing Yang Ping enter, she stood up, quite urgently: "Are you...Professor Yang?"
"I'm Yang Ping, I came to see you." Yang Ping's tone was calm. "Are you the patient's spouse?"
The woman nodded, glanced into the inner room, lowered her voice, and spoke with utmost respect: "Professor Yang, we've finally managed to get you to consult. Please, I beg you, help me think of a solution. My husband's health has been so poor this past year; he's lost over 20 kilograms. I'm afraid he won't be able to withstand the surgery."
Yang Ping nodded, not rushing to refute, but instead asked, "Can I see him?"
The woman immediately stepped aside.
In the inner room, on the hospital bed lay a thin man. He was fifty-four years old, but looked much older than his actual age, with a pale face, prominent cheekbones, and deep-set eyes. He had his eyes closed, but upon hearing footsteps, he opened them, his gaze somewhat unfocused.
Yang Ping walked to the bedside and asked softly, "Hello, I'm Dr. Yang Ping. I've come to see you. How are you feeling?"
The man opened his mouth, his voice hoarse: "Professor Yang!"
His eyes lit up, and he tried to sit up, but Yang Ping held him down: "Talk while lying down!"
"Thank you, my head... still hurts a little," the patient said.
“Headache is normal; it hurts after bleeding,” Yang Ping said, taking out a flashlight from his pocket, checking his pupil reflexes, and then briefly testing his muscle strength. “Squeeze me hard with your hand… okay, squeeze me again… lift your leg… okay, that’s enough.”
He straightened up and said to the woman, "Your nerve function is fine for now, there's no obvious damage. Your husband has been unwell for the past year?"
The woman nodded: "Yes, it's an old problem. I always have diarrhea, sometimes better, sometimes worse. I've seen many doctors, and they all say it's irritable bowel syndrome, but the medicine they prescribed doesn't work. It started about six months ago, and I also have frequent fevers, in waves, but they can't find the cause. My weight keeps dropping, and our whole family is very worried."
Yang Ping listened, his brows twitching slightly: "Fever? Have you checked the cause?"
"We've had it checked—blood tests, liver and kidney function tests, tumor markers, everything—and they all came back normal." The woman sighed. "It's probably just from being overworked; he's under a lot of work pressure."
Yang Ping nodded and then asked, "Have the electrolytes been checked?"
The woman was taken aback: "What?"
"Sodium, potassium, and the like."
"They checked and said his potassium levels were a bit low, so they prescribed potassium supplements, but it hasn't helped." The woman said, then suddenly remembered something, "Oh right, during the days he was hospitalized, the nurses drew his blood every day and said his potassium levels were still low, so they've been giving him supplements."
Yang Ping's eyes flickered slightly.
He asked a few more questions, then turned and left the ward. Director Tian and Dr. Meng followed him out. Director Tian asked in a low voice, "Professor Yang, what do you think we should do? The family refuses to sign the consent form, so we can't perform the surgery."
Yang Ping didn't answer, but asked, "Let me see all his test results."
Director Tian led the man into the doctor's office. Dr. Meng brought out the patient's complete medical record, and Yang Ping sat down, turning the pages one by one. Zaxi stood behind him, barely daring to breathe.
The records from the past six months are quite thick. Blood routine, liver and kidney function, coagulation function, tumor markers, and thyroid function are indeed mostly normal. However, several indicators have been hovering outside the normal range: blood potassium has been consistently low, reaching as low as 3.0; blood sodium has also been low, reaching as low as 130; and C-reactive protein has fluctuated, sometimes reaching over 30 and sometimes approaching normal.
Yang Ping turned to the page on blood clotting function and suddenly stopped.
Zaxi followed his gaze and saw a D-dimer test report, which was taken on the day of admission. The value was five times higher than the normal value.
Yang Ping stared at the number, remained silent for a moment, and then continued flipping through the pages.
He flipped to the cerebral angiography report from the second day of his hospitalization and studied it for a long time. The report stated: "Saccular aneurysm at the distal branch of the right middle cerebral artery, approximately 8mm × 6mm in size, with an irregular shape."
He then turned to the CT report: "Hematoma in the right temporal lobe of the brain, about 40ml in volume, ruptured into the subarachnoid space."
Yang Ping put down the report, leaned back in his chair, and remained silent for a long time.
Director Tian asked cautiously, "Professor Yang, is there a problem?"
Yang Ping didn't answer directly, but said, "The location of this aneurysm is quite interesting."
"Location?" Dr. Meng leaned closer to look at the scan. "It's a bit far, not at the fork in the road. But we probably do run into each other occasionally, right?"
Yang Ping shook his head and didn't say anything more, as if he was thinking about a problem.
After a moment, Yang Ping asked, "Have the infection indicators been checked?"
"We've checked, done two blood cultures, both negative. We also did a cardiac ultrasound, but didn't see any vegetations," Dr. Meng said. "We've also considered the possibility of an infected aneurysm, but we couldn't find the source of infection."
Yang Ping nodded and didn't ask any further questions. He glanced at his watch and said, "That's enough for today. I'll come back tomorrow. Continue communicating with the family, but don't insist on surgery for now."
Dr. Meng was taken aback, clearly not expecting Yang Ping to leave so soon, but still nodded: "Okay, thank you, Professor Yang."
As they walked out of the Overseas Chinese Building, Zaxi couldn't help but ask, "Professor Yang, do you think there's a problem with that aneurysm?"
Yang Ping glanced at him, didn't answer, and instead asked, "What do you think?"
Zaxi thought for a moment and said, "The location is a bit strange, but Dr. Meng said the infection indicators are all normal..."
Yang Ping interrupted him: "Just because everything is normal doesn't mean there are no problems. Sometimes, the problem lies hidden in 'everything is normal.' Everything being normal is itself abnormal."
He didn't explain further and quickened his pace toward the operating room: "I have surgery this afternoon, let's go."
That afternoon, Zaxi assisted Yang Ping in performing two spinal surgeries.
After finishing his work, Zaxi pondered the case in the Overseas Chinese Building. The location was strange, but the infection indicators were normal. So why did Yang Ping still ask about it?
He couldn't understand it. The next morning, Zaxi appeared in the department at six o'clock as usual, browsed through the new test results of the cases in the department, reviewed all the medical records, and Yang Ping asked him to go to the neurology ward to participate in ward rounds.
Morning rounds begin at eight o'clock. A dozen or so doctors form a circle. The head doctor is a professor in his early forties, surnamed Zhou, who speaks slowly and deliberately. When they checked on a patient, Zaxi suddenly perked up his ears.
The patient was a woman in her fifties who was admitted to the hospital due to recurring headaches. After various tests, it was finally discovered that she had an intracranial infection. Professor Zhou asked the attending physician, "Have you found the source of the infection?"
The attending physician said, "No, the blood culture was negative, and the cerebrospinal fluid culture was also negative."
Professor Zhou nodded, paused for a few seconds, and then said, "Sometimes, not finding the source of infection doesn't mean there isn't one. You need to think about it differently; the infection might not be in the brain, but somewhere else. The intestines, teeth, sinuses—all are possibilities."
Zaxi's heart skipped a beat.
After finishing his rounds, he caught up with the old professor and mustered up his courage to ask, "Professor Zhou, I'd like to ask, can intestinal infections cause intracranial problems?"
The old professor glanced at him and recognized him as a trainee from the training course. Professor Yang had specifically called him yesterday to ask him to bring this student along for ward rounds. Professor Zhou nodded: "Yes! Gut microbiota imbalance, with bacteria entering the bloodstream, can cause brain abscesses, meningitis, and even infectious aneurysms." He paused, "What, have you encountered a difficult case?"
Zaxi nodded and briefly recounted the case from the Overseas Chinese Building.
After listening, Professor Zhou seemed thoughtful: "An aneurysm in an unusual location, chronic diarrhea, antibiotic use, low-grade fever, electrolyte imbalance..." He paused for a few seconds, "Interesting. What does Professor Yang think?"
Zaxi said, "Professor Yang went for a consultation yesterday. He didn't say much, just that 'the location is interesting,' and then asked me to come and do rounds with you."
Professor Zhou smiled: "He knows what's going on, he just doesn't say it." He patted Zaxi on the shoulder, "You should learn from him. You can learn a lot from these kinds of cases."
Zaxi was startled.
In the afternoon, Zaxi found two of his roommates and told them about the cases in the Overseas Chinese Building.
"An infectious aneurysm?" a classmate frowned. "But the blood culture is negative."
“I know,” Zaxi said, “but that location is really strange, and the patient had so many problems: diarrhea, low fever, low potassium, low sodium, and had been on antibiotics. All of these together, I don’t think it’s a coincidence.”
Another student asked, "What did Professor Yang say?"
Zaxi shook his head: "He didn't say anything, just that we'd go tomorrow."
After thinking for a moment, Ali said, "How about we look up some literature ourselves?"
Zaxi's eyes lit up: "Great idea!"
That night, the three of them stayed up until the early hours of the morning in their dormitory, browsing through research papers on their computers. Zaxi had seven or eight web pages open on his computer, all of them papers about infectious aneurysms.
“Look at this,” Zaxi pointed to the screen. “A review article says that the most common pathogens of infectious aneurysms are streptococci and staphylococci, but they can also be caused by intestinal bacteria, such as Salmonella and Clostridium difficile…”
"Clostridium difficile?" a classmate leaned closer. "What's that?"
"It's an opportunistic pathogen in the gut, and people who use antibiotics long-term are prone to infection," Zaxi read from the literature. "Symptoms include diarrhea, low-grade fever, weight loss, electrolyte imbalance..."
The three people exchanged a glance.
Another classmate said, "Isn't that the patient?"
Zaxi's heart raced: "But how can Clostridium difficile infection cause an aneurysm?"
Tashi continued scrolling down: "The literature says that Clostridium difficile infects the intestines and damages the intestinal mucosal barrier, allowing the bacteria to enter the bloodstream. Once in the bloodstream, if there is damage to the heart valves, it can cause endocarditis; if there is damage to the blood vessel wall, it can cause an infectious aneurysm."
He paused, then pointed to the screen: "Look at this picture, it shows the formation process of an infectious aneurysm. Bacteria attach to the blood vessel wall, causing local inflammation, which damages the vessel wall, causing it to bulge slowly and form an aneurysm. This process can take several months, and it is only discovered when it ruptures."
A thought suddenly flashed through Zaxi's mind.
The patient started experiencing fever, diarrhea, and weight loss six months ago. Six months is enough time for an infectious aneurysm to form.
He took out his notebook and wrote down the idea.
On Wednesday morning, Yang Ping went to the Overseas Chinese Building again, with Zaxi following behind him. He was preoccupied with the documents he had read the night before, and he wanted to speak several times, but he swallowed his words back.
In the ward, the patient's complexion was slightly better than the day before, but she was still weak. The woman was sitting by the bed. When she saw Yang Ping come in, she stood up, her expression filled with anticipation.
Yang Ping asked a few questions about the patient's condition, examined the nervous system again, and then said, "The recovery is going well; the bleeding is slowly being absorbed."
The woman breathed a sigh of relief, but then frowned again: "Professor Yang, what about the aneurysm? It's still there, and we're always uneasy about it, but we don't want to have surgery, so we're really conflicted. Please help us make a decision, we'll listen to you."
Yang Ping nodded and said, "I understand, but given the current situation, the surgery is indeed high-risk. I'd like to review his medical records again and see if there are any other options."
The woman paused for a moment: "Another way?"
Yang Ping said, "Some aneurysms don't necessarily require surgery. If the cause is found, there may be other ways to treat them." He paused, "Let me ask about his medical history. In the past six months, besides diarrhea and fever, has he had any other discomfort?"
The woman thought for a moment and said, "My joints hurt. For a while, my knees and wrists hurt. I thought it was an autoimmune rheumatic disease, but after getting checked, it wasn't."
Yang Ping's eyes flickered slightly: "Have you used any medications? Antibiotics, anti-inflammatory drugs, etc."
The woman said, "Yes, we used it. When he had a fever, the community hospital prescribed cephalosporin, and he took it for seven or eight days. He took other things after that, but I can't remember exactly. We definitely used it several times."
Yang Ping nodded and then asked, "When was the worst time for your diarrhea?"
The woman recalled, "During the time I was taking the medication, I thought it was because the medicine was causing the problem, but the doctor said no, that it was irritable bowel syndrome, and told him not to be nervous."
After asking the question, Yang Ping said, "Don't worry, let me go back and think about it and see if there are any other good ideas."
Stepping out of the ward, Zaxi finally couldn't hold back any longer: "Professor Yang, do you suspect Clostridium difficile?"
Yang Ping paused, turned around to look at him, a hint of surprise in his eyes, and smiled, "You know about Clostridium difficile?"
Zaxi nodded and recounted the literature he had read the previous night. After finishing, he looked at Yang Ping nervously, like a primary school student waiting for the teacher to grade his homework.
Yang Ping laughed after hearing what he said.
“Good, you know to check the literature,” he said, “but you missed a crucial point.”
Zaxi was stunned: "What?"
Yang Ping asked, "What's the diagnostic method for Clostridium difficile infection?"
Zaxi thought for a moment: "Really...fecal culture?"
"Oh, right!" Yang Ping said, "But has this patient had diarrhea during his hospital stay?"
Zaxi was stunned. He remembered that his family had said that he hadn't had much diarrhea during his hospital stay because he hadn't eaten anything.
"If he doesn't defecate now, we can't get a stool sample, so how can we conduct the examination?" Yang Ping asked.
Tashi opened his mouth, but couldn't answer.
Yang Ping patted him on the shoulder: "The idea is right, but clinical work is not a guessing game. You need evidence to make a diagnosis. Right now, the chain of evidence is missing a link."
After he finished speaking, he walked towards the elevator.
Zaxi stood there, stunned for several seconds. The chain of evidence was missing a link. Which link was missing?
He chased after him, wanting to ask, but Yang Ping had already entered the elevator.