Chapter 531: A Difficult Diagnosis

“I heard that even the top hospitals in the Imperial Capital couldn’t treat this illness, but you managed to cure it. That’s why we came here especially to see you.” The retired official’s son chimed in from the side.

These people were well-informed and had heard about Zhou Can’s legendary accomplishments through various channels.

Especially families with some influence—those trying to curry favor would go out of their way to find them the most renowned doctors.

“Thank you for your trust and kindness, but I’m really not that amazing. I’m just an ordinary doctor. Let me examine you first.”

Zhou Can wasn’t used to being put on a pedestal like this.

He was a down-to-earth guy, happiest when burying himself in medical research or treating patients.

The patient’s bloodwork, urinalysis and stool test all came back normal.

Because of the patient’s leg pain and blackened toes, with signs of gangrene, Zhou Can was worried about kidney failure, like uremia, and ordered renal function tests just to be safe.

The results showed the patient’s kidneys were functioning normally.

He then considered diabetes and checked fasting blood glucose, but that too was normal.

He even suspected liver problems.

But after checking liver function, everything still came back normal.

Diabetes, uremia, hepatitis—typical causes of lower limb gangrene—had basically been ruled out.

At this point, the diagnosis process had hit a wall.

That was exactly why Zhou Can wanted to see the patient in person. Physical examination might seem routine, but skilled doctors can discover vital clues that are easy to miss, providing huge help for diagnosis.

At the very least, it can point you in the right direction.

Both the patient and his family cooperated fully, eager for Zhou Can’s help.

He first lifted the blanket to check the patient’s right foot.

Some disinfecting and care had been done already, mainly to prevent further necrosis, rot and infection after the flesh started dying.

Gangrene refers to local tissue death and blackening—a distinct physical change.

It’s usually caused by problems with blood flow due to disease or trauma.

It leads to large areas of tissue losing blood supply, dying, and then getting infected by certain bacteria.

There are two kinds: dry and wet gangrene. Dry gangrene makes your limbs black, dried out, and dead-looking. Wet gangrene is worse and not worth describing—it oozes pus, breaks open, and stinks.

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All in all, dry gangrene is a little less severe.

But nothing in medicine is absolute.

Some patients have scary-looking wet gangrene, but it’s actually easier to treat at times.

The key is always to find the root cause and restore local blood flow, while preventing infection.

From what he could see, Zhou Can noticed the fourth toe on the right foot was badly blackened—a clear case of gangrene.

There wasn’t even a clear line between the dead and healthy tissue.

Meaning the gangrene could keep spreading upward.

No wonder all the doctors at the previous hospitals insisted on amputation to save his life.

After checking the foot, Zhou Can examined the patient’s neck.

With those symptoms—leg pain and gangrene—most common causes already ruled out, only two real possibilities remained: either an infection, or a vascular problem.

The patient had received anti-infection treatment at two other hospitals, but it hadn’t helped much.

The disease had continued to get worse.

That made infection with viruses or bacteria less likely.

Plus, the patient’s lab tests and organ functions—including liver and kidneys—were normal. That left blood vessel problems as the likeliest culprit.

Leg veins are the most common trouble spot.

If this was an accident, like a car crash, you’d worry about damage to the femoral artery. Especially with crushing injuries, the artery can rupture and cause massive bleeding.

But this retired official was more in line with venous disease.

So if Zhou Can wasn’t checking the right foot, but instead the neck, what was that about?

Well, the deep veins in the legs can’t actually be seen or felt. Zhou Can had already checked the surface veins on the right foot while examining it.

He hadn’t found anything obviously wrong.

That’s why he went straight for the largest vein you can touch on the surface—the jugular vein in the neck.

All blood in the body is pumped from the heart, whether it’s arteries or veins.

But when examining a patient, you obviously can’t cut open their chest to check the veins. The usual approach is to feel their jugular veins.

Of course, this takes a lot of clinical experience.

Through palpation, Zhou Can discovered the jugular veins weren’t swollen, the carotid arteries were pulsing normally, and the windpipe was centered—everything seemed fine.

No swelling in the neck lymph nodes or thyroid either.

No signs of neck stiffness, either.

After finishing up with the neck, he put on his stethoscope to check the patient’s chest and abdomen.

A glance showed the patient’s chest was symmetrical, breathing even. Vocal tremors were even on both sides, though breath sounds in both lungs were a bit rough—possibly just nerves during the exam but nothing too out of the ordinary.

He did catch faint rales in the lower right lung.

Sometimes it was there, sometimes not.

That was a new finding. Zhou Can’s eyes flickered with interest and he continued the check-up.

When he listened to the heart, there were no pathological murmurs or pericardial friction rubs.

The heart seemed normal.

By this stage, most doctors would just refer the patient to another department.

But Zhou Can didn’t do that.

They’d come here just for him—even if it was all polite formality, he felt he owed them his best effort.

Cases like this were how Cardiothoracic Surgery built its reputation—one difficult case after another.

Zhou Can was fascinated by tough diseases like this.

He moved on to the abdomen but found nothing unusual—no odd bowel sounds, the belly was soft, no tenderness or masses. No pain when tapping on the liver or kidney area.

Chest and abdomen gave him nothing new, so he checked the patient’s spine—no deformities.

No obvious lumbar disc problems, either.

He remembered the patient had symptoms as a young man—walking too much left his legs numb and cold. That made Zhou Can consider whether spinal disease might be pressing on nerves and causing everything else.

With his pathology diagnosis skill now at level six, Zhou Can had gained a deeper understanding of the body’s nine major systems and three major circulatory pathways.

He used to think blood flow issues only had to do with the blood vessels.

Now, as his skills improved, he realized that was way too simplistic. Nerves can affect blood supply, and many other factors can too.

For instance, heart failure or premature contractions.

Done with the upper body, Zhou Can focused again on the patient’s right leg.

The fourth toe on the right foot had turned black—classic gangrene. When he compared the skin temperature between the right and left lower legs, the right was much colder.

That pointed to serious problems with blood flow in the right leg.

“I need to check the nerve reflexes in both your feet to figure out the cause. Just stay relaxed—it won’t cause any harm.”

Zhou Can spoke gently to the patient.

“Good, finally a physical exam different from all the other doctors!”

The patient was clearly pleased.

After being poked and prodded by so many doctors with no results, the stress must have been immense.

Just when he’d nearly lost hope, suddenly a doctor tried something new. That sparked a glimmer of hope—no wonder he was happy.

“Alright, please sit up. Let your legs hang down naturally.”

After seating the patient, Zhou Can signaled the family to steady him, just in case.

He brought down the reflex hammer on the patient’s left knee.

Thunk.

The left leg gave a clear knee jerk, and so did the right—though the right was a little weaker.

That made sense, given the right leg’s condition.

He then tested physiological nerve reflexes in both feet—even the affected right foot still had reflexes.

So nerve problems causing poor circulation could basically be ruled out.

Zhou Can turned his attention back to the blood vessels in the right leg.

He could feel the femoral pulses on both thighs; the strength was pretty normal.

Next was the popliteal artery behind the knee—the left one was present and normal, but he couldn’t feel a pulse in the right one.

That made things much clearer—an important finding.

Going further down, he felt the left dorsalis pedis artery on the top of the foot, but didn’t find a pulse on the right.

That was textbook chronic arterial ischemia.

Based on what he’d found, the right foot had at least stage two chronic arterial ischemia, maybe even progressing to stage three.

Chronic arterial ischemia, stage one, usually means numbness, chilliness, cold intolerance, soreness, and fatigue in the limb. If it’s the foot, patients sometimes limp.

It’s especially obvious after a long walk.

Calves or feet might ache or cramp.

Pressing on like that often makes the pain worse.

But if you stop and rest, the pain goes away almost instantly.

Looking back, the retired official’s early symptoms fit stage one perfectly.

Zhou Can felt more certain now—this was the disease.

Once you uncover the real problem, you can start thinking of solutions.

“If you’d gotten treatment when you were younger, maybe it never would’ve gotten this bad,” Zhou Can said with a soft sigh.

So many illnesses start small and are left to fester into something serious.

“When I was young, medical care was lousy—doctors couldn’t diagnose anything. And I had no time for a hospital stay, so I just took whatever meds they gave me. You know, young man, in life you might have only one great opportunity. If you miss it, it’s gone forever. Back when I joined the authorities, there were six of us—only I seized the chance to rise.”

Talking about his life brought a bit of pride to the old official.

He couldn’t resist sharing some secrets of his success with Zhou Can.

The other five missed their chance—most of them only ever made it to entry-level posts. At best, they’d maybe get to be section chiefs.

Compared to them, the old official had done amazingly well.

“Thank you for sharing your hard-earned wisdom.”

Zhou Can was genuinely grateful for the life lessons.

Sometimes, conversations between doctor and patient can be truly enjoyable—you even learn a lot of useful things from them.

“Seeing a hardworking young man like you, I can’t help but offer a few words. When I was your age, I wanted success too—I worked hard every day. During your exam, I could tell how careful and thorough you were. That kind of attitude matters a lot.”

Years of leadership had given the old official a habit of mentoring others even in casual conversation.

Zhou Can smiled humbly and got back to his examination.

Stage two of this illness is called the nutrition disorder stage.

The limb grows more numb, cold, sore and weak—walking distance starts to shrink dramatically, and only long rest brings any relief. Sometimes, the pain keeps going even while they rest.

This so-called rest pain is truly torturous, especially at night.

It can leave the patient sleepless and in agony.

Skin on the affected limb gets pale, sometimes turns purple or red, becomes dry and hair falls out.

Some people even have thickened, misshapen nails and muscle wasting.

If it happens to the hand, the nail changes and muscle atrophy get extreme—almost like ALS.

It’s not easy to distinguish between this and ALS, so misdiagnosis is possible.

The old official had already entered stage two, but still hadn’t gotten proper treatment.

By the time his illness hit stage two, he’d had it for more than a decade—long enough that he was used to it. Even with his status and access to good care, he still only got anti-infection meds at the local hospital.

Only when his toe turned black and started dying did he realize it was serious, and rush to the big city for help.

He first tried the Provincial People’s Hospital, but it’s unclear if it was his idea or the doctors’ to keep up with just anti-infection medicines.

Even at the Provincial People’s Hospital, they merely continued with antibiotics.

No further treatment was pursued.

Honestly, Zhou Can found that a bit odd for someone in his field.

It put him on guard—is this old official, or one of his family, the type to cause trouble?

A lot of patients seem friendly enough at first—smiling, kind, easygoing.

But let the treatment fall short or the effects disappoint, and some immediately turn furious—throwing accusations, complaints, even demanding answers from management.

Most doctors just keep their distance from patients like that.

If there’s no way to avoid them, all you can do is practice defensive medicine.

In these situations, if you don’t protect yourself, do you really think doctors and nurses are fools?

Stage three chronic arterial ischemia is called the tissue necrosis stage.

Sadly, the old official had now reached this phase—though it was early. If things went further, the whole right leg could die, and that would be terrifying.

The main sign of the tissue death stage is increasing pain, a cold limb, and the toes turning black with dead tissue.

Even the skin on the foot loses its gloss, turning dull and corpse-like.

That’s a clear sign of life and vitality draining out.

“Dr. Zhou, have you figured out what’s wrong with my father-in-law?”

The patient’s daughter-in-law, who had been silent all along, finally spoke when she caught Zhou Can frowning with a grave look.

“It looks a lot like chronic arterial ischemia of the leg, and the disease is already advanced. We’ll need more tests to figure out what’s causing the poor blood flow. Clinically, the usual solution is to create collateral circulation and improve local blood supply. That usually relieves symptoms and improves the illness dramatically.”

Zhou Can was almost completely sure by now, which is why he spoke with such confidence.

As for exactly what kind of surgery might help, he’d need an in-depth exam of the leg’s arteries first.