Chapter 614: A Diagnosis Unraveled

He had a habit of dropping dark humor and telling the occasional cold joke.

But with people, he was always genuine.

Of course, that didn’t mean he was endlessly sincere. With friends and those he trusted, he could be brutally honest, but with patients and their families, well, that depended on the situation.

Any doctor with a few years under their belt had learned the hard way—not to be too soft-hearted at work, or they’d risk being bitten by a so-called ‘viper’.

“If you weren’t out making rounds, what were you doing? Did you run off to the inpatient unit to flirt with the nurses?”

Director Yin glanced over and asked.

“Hey now, let’s not toss those words around! If my girlfriend hears that, I’ll be banished to the couch. I just went to check on that female patient, did some examinations and asked a few questions.”

When Director Yin heard that Zhou Can had checked in on the patient, a smile crept onto his face.

“Well, looks like I underestimated you. Any breakthroughs in the diagnosis?”

What he cared about most was the patient’s diagnosis and treatment.

He immediately followed up, eager to know if there’d been any progress.

His eyes shone with expectation since Zhou Can rarely disappointed; every time Zhou Can took a case, fresh breakthroughs followed.

“I’ve found a few clues. Let me go over her test results one more time, dig deeper, then I’ll give you my suggestions.”

With that, Zhou Can genuinely picked up the patient’s records and pored over them.

This was already his second round of review.

Sometimes, diagnosing a patient meant repeatedly going over test reports, underlying causes, and medical history, only settling on a conclusion once everything lined up.

Walking on thin ice, careful with every step—that’s just a doctor’s daily routine.

Director Yin didn’t disturb him, just smiled and refilled his teacup before turning back to his own high-level paraplegia case.

The two of them made quite the pair.

When faced with tricky cases, they’d diagnose each other’s patients.

In clinical terms, this was a consultation.

Pooling collective wisdom is how doctors tackle complicated cases. One doctor’s insight is always limited; different minds mean different angles, and different discoveries.

It’s like the story of the blind men and the elephant—diagnostic perspectives vary, so do the methods for pinpointing the cause.

Take a simple cold, for example—one doctor might focus on fever, another on loss of appetite, and yet another on headaches or general fatigue. The approach differs, but the right answer is usually the same.

After nearly twenty minutes, Zhou Can seemed to have reached a conclusion.

He looked up at Director Yin.

“Go on, I’m listening!”

Director Yin had already finished diagnosing the paraplegic boy and was enjoying his tea. Seeing Zhou Can glance his way, he immediately knew Zhou Can was ready too.

“This female patient has been ill for a long time, but from my questioning, I think the onset was actually sudden. It started after she accidentally caught a chill. Then came the headaches, which have lingered ever since. It’s a disease that sets in fast, with a prolonged course, and slow progression. When I examined her earlier, I saw that her optic discs were swollen, her right eye hurt when she moved it, and swallowing triggered a pronounced gag reflex…”

“Her white blood cell count is up, ESR is speeding, cerebrospinal fluid cell count is increased, mainly monocytes. The CSF protein is also elevated, sugar is down, but chloride levels are normal. No acid-fast bacilli or cryptococcus found. Her chest X-ray is clear, so the lungs look fine. Bloodwork’s up too. She came in with a fever, so my assessment is that an acute infection is most likely.”

After laying out the patient’s situation, Zhou Can summed it up.

“I agree with you there—acute infection is definitely a strong possibility.”

Director Yin nodded in agreement.

“Let me lay out some illnesses I suspect and we can discuss them one by one. First, cryptococcal meningitis. It usually strikes healthy young adults—this patient is in her thirties, just the right age. It can develop acutely or chronically, which matches her history. This disease can also cause moderate or mild fevers, again, just like her case. Plus, it causes headaches, vomiting, blurred vision, double vision, stiff neck, and meningeal irritation—all symptoms she has.”

“As the disease advances, it can lead to impaired consciousness. Some patients even have seizures. That’s another close match. So, it’s highly suspicious.”

Zhou Can started with the set of symptoms, matching them to a likely disease.

“But though her CSF sugar is notably low, chloride levels haven’t changed, and the ink staining didn’t find any cryptococcus or cryptococcal organisms. So, we can’t confirm it yet. Repeated CSF draws and lab checks could help us track down the culprit.”

Every illness comes with its diagnostic gold standard.

Take cryptococcal meningitis—even if every symptom fits, if the lab can’t find the cryptococcus, the diagnosis can’t be settled.

Plenty of rare diseases can look almost identical to classic ones but aren’t the same thing.

That’s why doctors are so cautious about reaching a conclusion—without gold-standard proof, they won’t commit easily.

“I’ve suspected the same. We’ve drawn CSF for days, sent every sample for testing, and not a trace of cryptococcus has turned up.”

Director Yin sighed.

If it were that easy to diagnose, he wouldn’t have needed Zhou Can’s help.

“It really is odd—maybe we’ve got a disease that just mimics cryptococcal meningitis. My second suspect is tuberculous meningitis. This one usually sneaks in, lasts a long time, and symptoms vary in severity. Sometimes other parts of the body have a history of tuberculosis. In the early stage, you’ll see low fevers, night sweats, loss of appetite, mild headaches, general malaise, fatigue and so on.”

“As it progresses, headaches worsen with vomiting, stiff neck, Kernig sign, and Brudzinski sign both positive. Sometimes you get eyelid drooping, uneven pupils, paralyzed extraocular muscles, double vision, or facial paralysis. Usually, tendon reflexes become more active and pathological reflexes turn positive. If the spinal nerves are hit, tendon reflexes can even disappear.”

“Untreated or delayed, it keeps worsening and eventually threatens life in the late stage.”

Zhou Can shared his second major suspicion.

“Honestly, this woman looks to be in stage two of that. But there are contradictions too. For example, some symptoms don’t match up, and her chest X-ray is clean. Lab results show protein elevation and some sugar decrease in CSF, but again, chloride levels look normal.”

He raised the possibility, then listed the points that argued against it.

Diagnosis can be self-contradictory at times.

You have to sift through all the evidence before the picture becomes clear.

“We’ve basically ruled out tuberculous meningitis in our department, though your note about positive Kernig and Brudzinski signs is a fresh observation.”

Director Yin seemed thoughtful as he listened.

“Well! Even though this seems least likely, I happen to think the opposite—it could very well be this. Her symptoms fit multiple diseases. That’s why we can’t only look at symptoms. You have to look at the clinical course and medical history for deeper reasoning.”

Zhou Can never just skims the surface—he’d rather dissect each clue and target the true cause.

Maybe it was just diagnostic talent.

When it came to tough cases, he’d always find the subtlest detail—the one other doctors missed—and dig in until he unraveled the mystery.

“Interesting.”

Director Yin’s eyes lit up.

“Diagnosing by combining symptom evolution with the course of the disease—that’s something we really hadn’t considered.”

“I even thought of a few more possible diseases but ended up ruling them out, like suppurative meningitis and viral meningitis.”

What Zhou Can really meant was, he strongly suspected tuberculous meningitis.

Clinically, doctors dread any illness involving tuberculosis.

Tuberculosis is highly contagious, stubborn, very slow to heal, and the treatment course is painfully long.

Plenty of patients and families know nothing about medicine. After a while on meds with no improvement, they start doubting the doctors and lose faith in the treatment.

That just wipes out all previous progress.

In the end, all the doctor can do is watch the patient spiral—and then suffer the blame, accused of being a useless quack.

“So tell me, what makes you so sure she has tuberculous meningitis?”

There was a sly gleam in Director Yin’s eyes; he wanted to dig deeper into Zhou Can’s diagnostic skills.

“There’s more—she’s had fevers, vomiting, double vision, seizures, all matching the second stage. Plus, her optic discs are swollen, right extraocular muscles are paralyzed, meningeal irritation is positive, so are pathological signs. Her ESR is up, neutrophils are increased. All those make tuberculous meningitis highly suspect.”

Zhou Can didn’t just rely on the timeline—there were loads of symptoms that matched.

Plenty of indicators supported his suspicion.

“Yeah, after hearing all that, I’m convinced too. Still, medicine demands strict evidence; you need solid test results before confirming and prescribing.”

Director Yin was thoroughly impressed by Zhou Can’s talents.

He was blown away by how quickly Zhou Can improved—every time he checked in, the kid’s skills had skyrocketed.

“Want evidence? Easy—just do a PPD test! Have her get a head CT or MRI too. TB loves to attack the organs in the chest and abdomen, but just because her chest X-ray is clean doesn’t mean there’s no brain infection, right?”

Zhou Can grinned as he spoke.

“Makes sense. I’ll order a tuberculin pure protein derivative test right away. Once we have her head CT and other results, we can follow up as needed.”

Director Yin agreed happily.

Older doctors liked to use full names or official abbreviations, while younger ones cut corners and threw around English acronyms.

The PPD test is pretty much the gold standard for diagnosing tuberculous meningitis.

Director Yin held off on a head CT—for the patient’s financial sake. Ethical doctors only order what’s really justified.

It’s only the greedy types, obsessed with money or department quotas, who pile on unnecessary tests.

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They’d run every test possible, given the chance.

On one hand, it racks up bonuses and, on the other, it supplies diagnosis evidence and reduces the chances of missed diagnoses. It sounds good for the doctor, but the patient ends up suffering and paying for tests they didn’t need.

Only thing you can say is, doctors like that lack even basic empathy—they’re way too selfish.

Being sick is hardship enough on its own.

Getting treated like a cash cow and gouged in the hospital only makes things worse.

With healthcare regulations improving, there ought to be a system for rating doctors’ ethics. A failing grade or black mark should mean a lifetime ban.

Once Director Yin finished filling out the test orders, still in high spirits—

Zhou Can took a sip of water and said, “Director Yin, since I helped crack your department’s tough case, isn’t it time you returned the favor and gave me some insights on the high-level paraplegia case?”

Only someone who got along as well with Director Yin as Zhou Can could joke like that.

Around older folks and superiors, he was always sincere and respectful.

There’s a saying—the closer you are, the less formal you need to be.

“Ha! You really don’t miss a trick. I checked on that little boy with paraplegia just now. No major discoveries, but with my years in neurology, I’m guessing his trouble’s in the head, or maybe it’s something more complicated.”

Director Yin was in great spirits—thanks to Zhou Can, he’d finally made progress with the female patient, so he shared his thoughts about the paraplegic boy.

Laughing out loud, he got into the root of the high-level paraplegia case.

“Wait, there are composite causes for high-level paraplegia? That’s new to me!”

Zhou Can had heard of mixed hemorrhoids, but never mixed causes for paralysis.

A mix of internal and external hemorrhoids is called a mixed hemorrhoid in medicine.

So does high-level paraplegia mean multiple nerve systems are in trouble?

“Never heard of it, huh? There’s plenty more you haven’t seen. Make sure you come by my office whenever you have a chance, all right?”

Director Yin beamed at him.

He loved having sharp young minds like Zhou Can stop by to chat.

Whether it was trading stories over drinks or talking medicine over tea, that’s what real legends do.

“You got it, I’ll come by often for some real learning!”

Zhou Can agreed wholeheartedly.