Chapter 263: Diagnosis in the Specialist Clinic

Even though we live in a society ruled by law now, there are still too many people willing to risk it all for huge profits.

There have been cases in the past where famous actresses were kidnapped and hurt by criminals.

To Zhou Can, Su Qianqian was like a fragile mirror—he would never allow anyone to shatter her.

“Alright, alright! I’m not a three-year-old, you know. I promise I’ll be extra careful. Still, it really moves me to see how much you care. I’m so happy! (smiley face)”

After chatting with her, Zhou Can waited for Wei Fang to arrive.

It might sound hard to believe, but these days, money and kindness can truly buy deep loyalty from your people.

Back then, Wei Fang was in such a desperate state that she couldn’t even afford medical care.

If Zhou Can hadn’t spent a fortune to get her treated, her life would have turned out completely differently.

She came from the mountains, and compared to city women, she understood gratitude even more.

Now, Zhou Can had given her a high-paying, stable job, which let her support the grandmother who raised her. Both she and her grandmother could finally enjoy the vibrancy of city life.

She made sure to show her gratitude and loyalty to Zhou Can through her actions.

She watched over Su Qianqian for Zhou Can with unwavering dedication—and so far, she hadn’t slipped up once.

This time, Zhou Can needed Wei Fang to handle the shadowy part of the plan against Hu Wei.

…

After lunch, Zhou Can expected to spend his afternoon mostly moving between the Interventional Operating Room and the Inpatient Unit.

He kept busy until a little after four, when Director Shang hurried off for something urgent.

Zhou Can left the operating room too, heading back to the ward to check on his twelve assigned patients.

He’d thought that overseeing eleven patients was already his limit.

But Director Shang, seeing how effortlessly he managed so many beds, decided to give him one more.

Almost all of Zhou Can’s assigned patients were tough cases or high-risk ones within the department.

What could he say about having a mentor who thought so highly of him?

Even if it made him want to cry, he’d just have to grit his teeth and handle it.

Still, even juggling twelve inpatients, plus regular clinic and operating shifts, Zhou Can didn’t find it overwhelming.

Ironically, paperwork—writing up records, progress notes, and preparing discharges—actually ate up most of his time.

He was never told to run errands like picking up test results or taking documents to the Medical Department for signatures.

He’d just finished checking in on all twelve patients and had updated orders for some of them.

He sat down in the office for a quick breather when someone knocked on the door.

“Dr. Zhou, are you busy right now?”

Huang Liang, who used to look down on Zhou Can, now greeted him with a face full of smiles.

It’s amazing what strength can do: even your proud rivals will line up to win you over with their most flattering grins.

“What’s up, Dr. Huang?”

Zhou Can knew Huang never visited for nothing. If he’s here, he must want something.

“So, uh, here’s the thing. My mentor, Director Zheng, is consulting over in the clinic and just ran into a complicated case. With Director Shang out, he’d like your input—mind coming over to help us brainstorm?”

Director Zheng was also a recognized specialist in the Gastroenterology Department.

Still, he wasn’t as famous as Director Shang.

As for skills, opinions in the field vary.

For Director Zheng to set aside his pride and personally send someone to invite Zhou Can—it spoke volumes about Zhou Can’s growing reputation.

He’d only do that if he truly thought Zhou Can could solve the problem.

Zhou Can suspected that Director Zheng must have thought about this over and over before sending Huang.

“I’ll come with you right away.”

Zhou Can took a couple sips of water, then stood up and left.

When you get an invitation straight from Director Zheng, there’s no way you can refuse.

Following Huang Liang, he went straight to Clinic Room 2 in the Specialist Outpatient Department.

“Hello, Director Zheng!”

Zhou Can greeted him first, lowering his posture with respect.

There’s a saying—give a rose, and your hand will retain its fragrance.

Even though he’d been called in for help, Zhou Can still made sure to respect Director Zheng’s authority.

Taking the initiative to say hello was the best way to show that respect.

“Dr. Zhou, welcome! Please come sit over here!”

Director Zheng smiled, motioning for Zhou Can to take a seat.

In front of the family and patient, Zhou Can skipped any polite refusal and sat directly beside Director Zheng.

Two other young doctors stood watching, flashing Zhou Can friendly, admiring smiles.

Their eyes were filled with open respect and envy.

“This patient started having frequent abdominal bloating and pain a year ago, which would ease a bit after bowel movements. Then, about a month ago, he suddenly had watery diarrhea—sometimes more than ten times a day, and averaging at least five daily. For over a week now, even after taking anti-diarrheal medicine, the symptoms haven’t improved. In fact, they’ve gotten worse. Besides diarrhea, he’s also gotten very thirsty, drinking a lot, urinating frequently, with high urine output.”

Diarrhea is one of the fastest ways to get dehydrated.

Long-term diarrhea is tough for anyone to bear.

No wonder he felt so thirsty and needed to drink lots of water—it was totally normal.

“His weight dropped by more than ten pounds almost overnight. Sometimes his upper chest goes red for about ten minutes, then it fades.”

From Zhou Can’s experience, losing that much weight that quickly was a huge red flag.

Usually a sign that something serious is going on.

“Is this the patient?”

Zhou Can glanced at the man sitting there. His mother must be the other woman—a woman in her fifties, skin darkened by sun, big hands with rough, calloused skin on the backs.

She looked like a woman who’d endured a hard life.

“Yes, that’s right. My son’s the one who’s sick. Please, doctor, do your best.” The patient’s mother spoke simply but respectfully, making no fuss about Zhou Can’s young age.

It was the patient himself who seemed unimpressed by Zhou Can.

That made sense.

After all, Zhou Can looked even younger than the patient.

“Has a physical exam been done?”

Zhou Can turned to Director Zheng.

Admission exams cover a lot—whether the patient walked in or was carried, overall appearance, and basic vital signs.

From a quick look, this patient appeared thin, but not dangerously so.

Zhou Can had seen ICU cases so skeletal you’d think they’d wasted away—that was truly alarming.

“All checked. Physical findings, main complaints, medical history—everything’s right here.”

Director Zheng handed Zhou Can the medical record book.

Exam notes: mild weight loss, alert, blood pressure, breathing, and pulse all normal. Heart and lungs fine. Abdomen soft when pressed, no obvious lumps. No shifting dullness or swelling in the legs.

Some patients with severe diarrhea develop tight abdominal muscles or bloating with fluid accumulation.

For those, the belly is usually hard when pressed.

But with this patient’s abdomen soft on palpation, you could rule out a lot right away.

Zhou Can kept looking over the tests.

Outside hospital labs had done a lot: bloodwork, urine test, stool test, chemistry panel.

They’d run plenty, but nothing obvious jumped out.

Urinalysis showed normal sugars, proteins, microscopic results. The only oddity was a low specific gravity, around 1.0004.

Stool test, bacterial culture, and Sudan III staining were all negative.

Ultimately, that big hospital had labeled it ‘functional diarrhea.’

But because of the symptoms—excessive drinking, lots of urination, low specific gravity urine—they also suspected diabetes insipidus.

There are three main types of diabetes insipidus: central, nephrogenic, and psychogenic polydipsia.

This patient also had low potassium levels—serum potassium between 2.2 and 2.8. So that hospital figured it might be nephrogenic diabetes insipidus due to hypokalemia.

With a question mark, meaning the attending wasn’t willing to be 100% certain in case it turned out wrong.

So in medical notes, the question mark signaled the need for more evidence.

That same hospital measured his 24-hour urine output—sky high.

Just to picture it: a standard bottle of mineral water holds 550ml, and this guy peed out enough in a day to fill 20 of them.

To get to the root of the low potassium, the hospital did a potassium balance test, had him fast for three days, and gave him 3g of IV potassium chloride daily.

On Day 3, rechecked blood potassium: 3.3 mmol/L. Urinary potassium: 14 mmol/day, stool potassium: 32 mmol/day.

One day is 24 hours.

Normally, people take in about 100 mmol of potassium a day, nearly all absorbed in the gut.

The kidneys regulate most potassium balance; about 90% is excreted through the kidneys.

Stool only accounts for less than 10% of potassium excretion.

This patient’s stool potassium was more than triple the normal range—that pointed to kidney dysfunction.

There aren’t many causes for low potassium: poor intake, excessive loss from vomiting, or potassium shifting from outside to inside the cells.

But this patient only had diarrhea, no vomiting—so cross that cause off.

His diet was basically normal, so potassium deficiency from eating too little was also unlikely.

That only left potassium moving into cells from the outside.

There are four common causes for this shift.

One: acid-base imbalance. Two: insulin. Three: aldosterone. Four: sympathetic nervous system activation.

Cases like this are a true test of internal medicine—it was no wonder Director Zheng wanted Zhou Can’s help.

What he didn’t know was that Zhou Can’s medical reasoning was strong, but his foundation wasn’t especially deep.

He’d just worked hard the last couple years to catch up on basic knowledge so he could handle cases like these.

To get to the real reason for the potassium balance issue, Zhou Can reviewed all the test results again.

After painstaking elimination, he finally diagnosed this as a potassium shortage caused by acid-base imbalance.

To be more precise, it was alkalosis.

[Pathology Diagnosis +1.]

[You’ve identified an especially tricky pathological mechanism for the first time. Reward: Pathology Diagnosis +100.]

It was the first time he gained experience points for pathology diagnosis without having nailed down the final cause.

Solving this case was a massive learning boost for Zhou Can.

All that foundational science he’d studied finally clicked into place in practice.

“Dr. Zhou, any findings so far?”

Director Zheng wasn’t trying to rush him. He was just worried the family would get impatient if they waited too long.

You have to make it clear that the doctors are working hard to diagnose.

Otherwise, it just seems like you’re wasting their time.

“So far, it looks like alkalosis is causing the patient’s hypokalemia. As for what’s leading to both the diabetes insipidus and diarrhea, we’ll need further discussion and investigation.”

Zhou Can delivered his first clue.

“No wonder you’re the youngest and brightest in our GI Department—your diagnostic skills are rare indeed. You figured out the link to alkalosis so quickly. It took me ages to reach this step. You younger docs really do have sharp minds!”

Director Zheng Hongtao couldn’t help but praise him.

“You’re too kind! Since we both agree that the hypokalemia comes from alkalosis, it shows our earlier analysis was on track. If we can discover the reason for the alkalosis, maybe we’ll break through and get to the bottom of this.”

Zhou Can felt fired up tackling such a tough case.

It felt like slowly conquering a formidable city.

He’d already taken one part of the stronghold. Now, if he could find the cause of the alkalosis, it would be like breaching the city’s main defenses.

Then they’d finally have a breakthrough to treat this illness.

Even though Huang Liang was about to be promoted to attending, he couldn’t contribute at all to a case of this level.

All he could do was quietly listen in.

“With alkalosis, hydrogen ions shift outside the cell, changing the electric charge and causing potassium to move inside—thus, hypokalemia. Is there any way to fix the alkalosis itself?”

Zhou Can’s first thought was treatment.

Sometimes you can’t chase down the true cause right away; treating the symptoms first is common in clinical practice.

You could call it symptomatic treatment.

Basically, if you spot a problem, try to help the body correct it, then watch for a reaction.

Often, it’s just one tiny part of the body’s system that’s malfunctioning. Fix it with meds or another method, and everything can run smoothly again.

A lot of chronic illnesses get managed like that.

Some patients need lifelong medication.

Doctors might know which system has a minor glitch but can’t find the exact problem—so they use medication to force the body into balance, and don’t worry about the underlying cause.

The human body really is mysterious.

With drugs, even if the cause is never found or cured, patients can still be treated.

Like with diabetes—as long as you keep taking insulin, you’re fine.

Doctors know there’s an insulin problem, but the exact reason can be a mystery. Medical technology just isn’t there yet.

In the end, almost all chronic illnesses like diabetes and hypertension need lifelong treatment.

“He already had regular IV potassium replacement elsewhere, but still couldn’t shake the low potassium.”

So to fix the alkalosis, you’d need to start with the diarrhea.

Zhou Can shifted his focus back to what triggered it all—the diarrhea.

The patient started out with bloating and only after a month did it become severe diarrhea.

“Director Zheng, could we do a small intestine perfusion test? It might help us figure out both the type and the deeper cause of the diarrhea.”

After thinking for a moment, Zhou Can offered his suggestion.

“Your reasoning’s still rooted in the diarrhea then?”

Director Zheng Hongtao’s eyes lit up.

If you can’t solve the alkalosis riddle, tackling the symptom itself is still a solid move.

“You have to untie a knot where it was first tied. By retracing the diarrhea’s sources, we might crack this impossible case,” Zhou Can replied with a smile.

“That makes sense!”

Director Zheng immediately explained to the patient and his mom that this was a very tough case and recommended a hospital stay for more observation and investigation.

A small intestine perfusion test needed to be arranged and required a longer period to monitor how the gut was working.

The patient already knew how stubborn his illness was after failed treatments elsewhere.

After seeing these two doctors reach some progress, the family finally saw hope and agreed to hospitalize him.

As always, gastroenterology beds were in short supply.

They started with observation and the new test, waiting for a bed to open up for inpatient treatment.