Chapter 293: A Diagnostic Duel in the Outpatient Hall

“Alright, I’m on my way right now.”

Zhou Can replied without hesitation. Only after Director Zhang hung up did he move his phone away from his ear.

When talking to elders, teachers, or your boss on the phone, it’s basic etiquette to let them hang up first.

Some newcomers at work get careless and rush to end calls or interrupt the boss. That’s a big no-no.

If you ignore these little things, you’ll soon notice colleagues with less ability getting promoted every two years, always climbing higher.

Meanwhile, you stay stuck in the same place.

People skills are just as important as professional ability.

Dr. Pang watched Zhou Can finish the call and quietly let out a sigh of relief. She’d heard the whole conversation—Director Zhang clearly valued Zhou Can, treating him like an equal.

She was truly afraid Zhou Can would complain about her.

Thankfully, Zhou Can was mature and generous, handling things aboveboard.

He didn’t pursue the matter any further.

“Dr. Pang, could I trouble you and the two nurses to keep an eye on things here? I’ll head to the outpatient hall and should be back soon. If anything urgent comes up, call me right away.”

After leaving these instructions, Zhou Can hurried off.

Dr. Pang watched Zhou Can’s back as he left, feeling a chill creep down her spine.

Only now did she realize the conversation with Director Zhang had left her drenched in cold sweat.

When Zhou Can arrived at the outpatient hall, he saw yesterday’s female patient—the one with excessive thirst, diabetes insipidus, and impaired consciousness—sitting at Director Zhang Bihua’s desk for her exam. She looked much better than before.

Yesterday, she’d seemed muddled and dull, hunched over and listless.

After just one day in the hospital, she looked like a different person. Her mind was clear, and there was finally some life in her eyes.

“Dr. Zhou, we were waiting for you to join us for this consultation!”

To his surprise, an associate chief physician from the Obstetrics Department actually greeted Zhou Can with a smile.

“Me? I’m just a lowly trainee—you’re giving me too much credit! If you say that, Dr. Luo, you’re putting a gold crown on my head.”

Of course Zhou Can wasn’t silly enough to accept those compliments outright.

Dr. Luo had never even given him the time of day before. Her sudden friendliness? Just one word: ‘opportunistic.’

“Dr. Zhou has worked in several departments. Maybe he really will have some valuable insight into this case!” Director Zhang cut in.

“After treating her with fluids and intravenous insulin, the patient’s blood sugar and sodium have dropped significantly, and her consciousness is much clearer. But she still has poor appetite, low energy, trouble sleeping, and the excessive thirst and urination haven’t gone away.”

From what Director Zhang said, Zhou Can knew what she was getting at.

Even though the patient looked much better, this was just a temporary fix.

Right now they’d only relieved her diabetes.

Zhou Can turned his attention to the patient.

“Are your bowel movements normal now?”

“Once a day.”

She was able to respond directly now.

That made Zhou Can genuinely happy.

“Did anyone check her period and reproductive history?” Zhou Can asked Director Zhang.

“When she was lucid earlier, I asked. Her first period was at fourteen, each cycle is about fifty days, her period lasts five days, and the bleeding is heavy. She married at twenty-one and has one child.”

Director Zhang gave a quick rundown of the case.

A normal woman’s cycle should be between 28 and 35 days—her cycle was fifty. That’s obviously abnormal.

But then again, a fifty-day cycle isn’t all bad.

Women usually ovulate about 400-500 times in their life, with most averaging closer to 400.

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A cycle every 28 days means you run out of eggs faster.

Once that happens, periods stop, and menopause arrives.

Some women hit menopause in their forties, which is hardly good news.

Research shows that the later a woman enters menopause, the slower she ages, and her immunity stays higher for longer.

This patient’s fifty-day cycle was nearly twice as long as most women’s.

That means she’ll probably hit menopause later than normal, delaying its onset.

“What about her basic vitals?”

“Temperature is 37.7°C, heart rate 83, breathing 24 per minute, blood pressure 116/75 mmHg,” Yang Chan answered.

She always handled the patient’s physical exams.

That basically made her Director Zhang’s right hand.

Her temperature was slightly elevated, but her other vitals were mostly normal.

Zhou Can circled to check the patient’s neck.

“Already checked. Throat’s a bit red, tonsils visibly swollen, but thyroid is normal. No swelling in the lower legs, breathing clear, no extra sounds.”

Yang Chan’s work was impressively thorough.

Zhou Can smiled and gave her a thumbs up.

“No wonder you’re the class monitor—your exams really are top-notch!” In one sentence, he praised both Director Zhang and Yang Chan.

They both couldn’t help smiling at the compliment.

After all, very few women dislike being praised.

“Did you check her urine?”

“Here’s the latest report,” Yang Chan said, handing over the results.

Zhou Can took the report and looked over her other labs too.

“Positive for urine ketones and blood gas shows metabolic acidosis. That means she has ketoacidosis, doesn’t she?”

After reviewing, Zhou Can gave his diagnosis.

“Director Zhang and the other specialists already reached that conclusion.”

Yang Chan answered.

“Now we need to figure out why she had a change in consciousness—even coma—after stopping medications and switching to herbal medicine,” Director Zhang pointed out.

The experts just discussed this, but probably didn’t agree completely.

There were definitely some divided opinions.

“Based on her symptoms and test results, I think her problems should be treated separately. The impaired consciousness and coma aren’t necessarily caused by the herbal remedy. Most likely, she has hyperosmolar coma.”

While diagnosing, Zhou Can’s thoughts felt especially clear.

“But hyperosmolar coma usually shows up in elderly patients. She’s only in her thirties—still young. I don’t really think that’s likely.”

Dr. Luo, ever the opportunist, disagreed with Zhou Can’s assessment.

“There are always exceptions, and her situation’s unique. Here’s my thought process: She’d been taking Minirin, and when she stopped it, her diabetes insipidus got worse and she became dehydrated. Then she stopped her diabetes medication too and began herbal medicine. That sent her blood sugar up, worsened dehydration, and finally triggered hyperosmolar coma. The ketoacidosis came from quitting the diabetes meds as well.”

Zhou Can gave a detailed breakdown of her disease’s progression and the effects of her treatments.

[Pathology Diagnosis EXP +1, Pharmacological Reasoning EXP +1. You’ve successfully diagnosed a difficult case; +100 EXP each for pathology and pharmacology.]

Experience gained—it proved Zhou Can’s diagnosis was spot on.

Diagnosing this case across five different dates wasn’t so difficult after all.

It was just a tangle of symptoms—once you sort them out individually, the real diagnosis becomes much simpler.

Breaking down her amenorrhea, excessive drinking, and altered consciousness made things much more manageable.

Plus, you avoid getting sidetracked by unrelated conditions.

“Nicely explained! I fully support the hyperosmolar coma diagnosis,” Director Zhang said firmly after hearing Zhou Can’s analysis.

“Alright, say her consciousness issue is due to hyperosmolar coma. What about the excessive urination?”

Dr. Luo caved but quickly raised another question.

She’d been forced to accept Zhou Can’s diagnosis, but now threw him a new problem to solve.

“No need to rush. We’ll tackle each problem one at a time. The excessive urination and thirst—given her test results and symptoms—pretty much confirm diabetes insipidus. More specifically, central diabetes insipidus.”

This problem-by-problem strategy was quite an eye-opener for the doctors present.

Most doctors get stuck thinking one patient, one root cause—and just treat that. Cure the cause and the symptoms should vanish.

And that’s usually right.

But sometimes a patient can have several diseases or one disease with many symptoms.

It’s common to see patients with multiple underlying issues: like someone with hypertension, diabetes, and kidney inflammation all at once.

Thankfully, those are usually easy to diagnose.

Hypertension? Just take their blood pressure.

Diabetes? Do a blood sugar test and urine analysis. For more complicated cases, check liver and kidney function, blood lipids, and insulin levels.

All these illnesses have clear diagnostic criteria, which makes things straightforward.

But this patient’s case was still a mystery. Type 2 diabetes was only one problem. Because she ditched western meds for herbal remedies on a relative’s advice, everything snowballed, and now there’s more than one root cause.

Keep focusing on the diabetes and you’ll end up like the doctors from her previous hospitals—unable to fix the bigger problem.

“The water deprivation-vasopressin test results support central diabetes insipidus as well,” said Director Jiang from Neurology.

With so many experts gathered for this one patient, a crowd of families and patients gathered to watch.

They were curious and wanted to see which expert was most skilled.

And maybe catch a glimpse of how specialists actually diagnose real cases.

For this patient: during the water deprivation-vasopressin test, after skipping two doses of Desmopressin (that’s her usual Minirin), her blood osmolality was 330 mosm/l after eight hours without water, urine osmolality was 103 mosm/l. After a posterior pituitary injection, urine osmolality jumped to 590 mosm/l.

An MRI in the sellar region showed a thickened pituitary stalk and no visible high signal in the posterior pituitary.

Zhou Can based his diagnosis of central diabetes insipidus squarely on these crucial test results.

“So what’s actually causing the central diabetes insipidus? Is it her Type 2 diabetes?” Yang Chan asked, not pretending to understand—after all, Zhou Can was her classmate.

“I think it’s a pituitary stalk lesion.”

Zhou Can was utterly confident in this diagnosis.

Without waiting for Yang Chan to ask, he went on, “Pituitary stalk lesions—germ cell tumors are a common cause, especially in children. But since she’s in her thirties, that’s unlikely. Based on her labs and symptoms, lymphocytic hypophysitis is more likely.”

Yang Chan mulled that over for several seconds, then nodded slowly—as if she partly understood.

“But at this point, lymphocytic hypophysitis is just a suspicion. We can’t prove it yet!”

Just asking proved she’d really thought things through—and understood the gist of Zhou Can’s reasoning.

Director Zhang Bihua noticed her protégé’s growth and couldn’t help but smile in satisfaction.

She looked at Yang Chan, then at Zhou Can, her eyes full of hope that these two young doctors would work together more.

Really, she was hoping Yang Chan could learn from Zhou Can.

“To confirm this, the best way is surgery for a tissue biopsy, but that’s extremely challenging.”

Zhou Can’s surgical skills weren’t bad these days.

He could even keep up with some chief surgeons from the Surgical Department.

But if even he said the surgery was tough, getting a biopsy was pretty much out of the question.

No doctor would risk it.

Especially given how poor this patient’s current condition was—even the bravest surgeon would hesitate.

“Isn’t there any other way?” Yang Chan pressed.

“There are options. For example, we could skip the biopsy and go straight to radiation therapy.” Zhou Can looked at the patient and her family.

Many families hear “radiation” and instantly think of cancer and terrible side effects.

And truthfully, radiation does have its side effects.

Things like hair loss, sore throat, nausea, vomiting, headaches, fatigue, and so on.

“We don’t want radiation. No way!”

The family flatly refused.

“Actually, radiation isn’t as scary as people imagine. I suggest you give it a try and see how it works before making a final decision.”

Director Zhang Bihua spoke up at this point.

Stepping in to help Zhou Can persuade the family showed her faith in his diagnosis.

“Thanks for your concern, but we’re not going through with that. We had a relative who died after radiation therapy, and in our village, someone else kept getting worse after radiation until they died too.”

The family had a deep-rooted fear of radiation and outright refused.

Doctors can suggest treatments, but if the patient and family refuse, there’s nothing to be done.

Seeing persuasion wasn’t working, Director Zhang’s mind quickly turned to another idea.

She glanced at Zhou Can.

“Dr. Zhou, what do you think is behind her amenorrhea?”

Zhou Can met Director Zhang’s gaze and understood right away.

It was clear she already had a diagnosis in mind, but either wasn’t sure or wanted to test her juniors—so she’d brought him in for the consult.

She’d probably guessed the problem but wanted to give them a chance to work it out.

“I don’t think the amenorrhea is due to curettage, but to a pituitary disorder. That’s easy to confirm; just test the hypothalamic-pituitary axes.”

Zhou Can connected the central diabetes insipidus and amenorrhea to a pituitary problem.

“Do the rest of the experts agree?”

Director Zhang knew Zhou Can was young and less experienced, so families might not believe him easily.

He’d need other experts to back him up.

“I think Dr. Zhou’s diagnosis is correct,” Director Jiang again was the first to speak in support.

“Testing the hypothalamic-pituitary axes is a great idea. Once the results are in, we’ll know for sure if her amenorrhea comes from a pituitary problem.”

Surprisingly, even Du Leng stepped forward to back Zhou Can’s plan.

When Zhou Can glanced at Du Leng, he quickly averted his eyes.

As a returnee PhD, he had to show off a little sometimes.

He couldn’t just stand by and let Zhou Can take all the credit.

Neurosurgery happened to be his area of expertise, and he’d been paying close attention to Zhou Can’s analysis. Even if he scowled on the outside, inside he agreed with Zhou Can’s approach.

Jumping in now let him look magnanimous—and still get a bit of the limelight.

It was like Zhou Can planted the peach tree, and he picked the fruit.

“Are you willing to do the test?”

Director Zhang turned to the patient and her family.

The patient was a woman who always deferred to her husband, so she looked at him for his opinion.

“As long as it’s not radiation therapy, we’ll do it.”

The family agreed.

Director Zhang filled out the paperwork and told them to hurry to the lab.

Once the family and patient had left, Director Zhang looked to Zhou Can.

“Dr. Zhou, how should we control this patient’s blood sugar?”

Controlling her blood sugar was an urgent priority.

She’d already had medication yesterday, and the treatment would definitely continue today.

Everyone knows insulin is the go-to therapy for diabetes.

Director Zhang’s question was a test—she wanted specifics.

“I’d recommend routine Glargine, combined with pre-meal Novorapid for intensive control. It should stabilize her blood sugar quickly.”

That was Zhou Can’s answer.

But in his mind, he was still considering how best to treat her pituitary disorder.