The patient's bone marrow showed active proliferation, and erythroid hyperplasia was obviously active.
Accounting for about 0.64.
Among them, middle and late immature red blood cells are the main ones. Mature red blood cells vary in size and are helmet-shaped, and fragmented red blood cells account for 0.07.
Everyone knows that bone marrow has hematopoietic function.
Young red blood cells can be thought of as 'children'.
Judging from the combination of bone marrow imaging and blood routine, Li Jingsheng found that the female patient had obvious symptoms of hemolysis.
As for central neuropathy, he thinks the possibility is relatively small.
The initial diagnosis result given by Director Mu to the patient was a central nervous system infection? septicemia?
Does sepsis cause hemolysis?
Sepsis can cause functional abnormalities in multiple systems of the body, and severe infection can indeed cause abnormalities in coagulation function.
However, this patient's examination data and various aspects of performance do not seem to be consistent with sepsis.
"Dr. Li, I wonder if you have any diagnosis direction?"
Director Mu didn't dare to have too many extravagant expectations about him.
Anything that can provide a little bit of helpful diagnostic direction is great.
"I...dare not say it!"
Li Jingsheng looked like he was hesitant to speak.
"How dare you do this? I won't blame you if you say something wrong. Say it, feel free to say it."
Director Mu encouraged him.
Apparently, Director Mu thought Li Jingsheng had difficulty in diagnosis, had weak knowledge, and was worried about saying the wrong thing.
"Then I'm going to talk wildly. I think the possibility of infection of the patient's central nervous system exists, but it is very small. As for the possibility of sepsis, I think it can be almost completely ruled out."
Li Jingsheng was afraid that he would not be able to accept it when he was old, so he said it tactfully.
After Director Mu heard this, he didn't say anything for a long time.
After more than ten seconds, his face became a little stiff and he said, "You mean, both directions of initial diagnosis can be ruled out?"
This is the result of discussions between Director Mu and many doctors in the department.
A neurologist was even invited to participate in the discussion over the phone.
As a result, the doctor from this small clinic rejected both initial diagnosis opinions as soon as he came.
"It should be ruled out."
Li Jingsheng was very worried that this famous doctor from the Department of Internal Medicine would collapse directly.
Fortunately, Director Mu is more resistant to blows than he thought.
Director Mu picked up the stainless steel thermos cup, raised his neck and took two big gulps.
"Drink tea, you drink tea too. Then let's talk about the direction of your diagnosis. After ruling out the two initial diagnosis results we discussed, it's really yours."
Director Mu was obviously unconvinced.
But there is a trace of expectation.
He doesn't know yet whether this doctor from a small clinic is young and frivolous and talking nonsense here, or does he really have great abilities?
Li Jingsheng's current diagnostic capabilities are mainly concentrated in three directions: internal medicine, gastroenterology, and general surgery.
He is actually not good at neurological diseases.
But because of the clinic, we can often receive patients with skin diseases.
Patients who want to diagnose this often need to use knowledge of immunology. Therefore, he has learned a lot about immunology, especially skin immunology.
I often read books like this to recharge my batteries.
He picked up the tea cup and took a sip. It was slightly astringent in his mouth, and then his mouth became fragrant and his mind became clear.
“Good tea!”
Can't help but praise.
To put it bluntly, he has never had such good tea.
"Hey, this tea was given by one of my students. He is now in a compound in Shanghai. I heard that he has been promoted to team leader and his income is very good. He sent me a small box of tea a few days ago. I At that time, you said that this little tea would be enough for you to drink several times?”
The implication is that the student is a bit stingy.
But Director Mu's face clearly showed pride.
Sure enough, everyone is the same, sometimes they want to show off something that they are proud of or proud of.
"Later, a vice-dean came to see me for something, and I made some tea for him to drink. He could tell at a glance that it was a high-quality Dahongpao. He also said that in ancient times, it would have been at the royal level, and the output would be high. It is very rare. If you want to buy this tea, it is difficult to buy it with money, because the output is very small. Later I asked someone to ask about the price, and it was more than 70,000 yuan for just a small box. I am obsessed with this. Two months’ salary.”
Director Mu accidentally revealed his income level again.
He is the chief physician of the Department of Respiratory Medicine, and his salary is about thirty-five thousand, which is much lower than expected.
Li Jingsheng thought that someone of his level could earn at least fifty thousand a month.
Some doctors cherish their reputation, abide by the law and do not like to earn gray income. This will certainly lead to differences in income levels as well.
Also, it’s the top surgeons who make the real money.
Although internal medicine is also very profitable, it cannot compare with top doctors in surgery.
The top surgical team leader in the country can have a stable annual income of more than 5 million. In internal medicine, even including lectures, academic exchanges held by manufacturers, etc., two million a year is considered to be the top dollar.
"Here, how much does this cup of tea cost? I have to drink it completely, otherwise it will be wasted."
Li Jingsheng also didn't expect that Director Mu would treat him with such expensive tea.
Although what he said was a bit exaggerated, it was still quite useful.
"Haha, if you like to drink, I will give you some later." Director Mu smiled proudly.
It's just that the patient's problem has not been solved, and the sadness in his brows has not dissipated after he finished laughing.
"Your student gave it to you. I drank all of it after one drink, and I was a little greedy after drinking and taking the cocoa. In addition to headache, fever, and aphasia, does the patient have any other symptoms now?"
Li Jingsheng took the initiative to bring the topic back to the patient.
We have to find a way to help Director Mu solve this difficult case.
"Cheng Qian is currently in a coma, experiencing urinary incontinence, convulsions, and soy sauce-colored urine. The bleeding under the skin has become more serious, and a very significant purpura phenomenon has appeared."
Director Mu gave a rough description of the patient's current situation.
Looking at this situation, if the cause of the disease cannot be found out as soon as possible, I'm afraid it won't last long.
"Is it okay to go to the ward and see the patient?"
"No problem, I'll take you there."
Director Mu personally led him to the ward to check.
Li Jingsheng went to the ward to check on the female patient. Although she was not admitted to the ICU for the time being, the bed card was marked with key points.
They are key patients monitored by nurses and doctors on duty.
In this case, medical staff usually go to the ward to check on you every fifteen minutes to half an hour.
Although there are family members accompanying the patient at the bedside, they do not understand medicine and cannot detect potential risks in time.
The patient is basically in a semi-coma state.
Seeing Li Jingsheng standing beside the hospital bed, her eyes changed slightly and her body twitched uncontrollably.
The middle-aged woman beside the bed was less than fifty years old, and her eyes were as red and swollen as peaches.
How can a parent not be anxious when he sees his daughter, who is a good person, suddenly becoming so ill?
The patient still has a high fever.
"Let me check her joints!"
Li Jingsheng said to his family members.
The family members just stood aside stupidly and did not speak.
Li Jingsheng lifted the quilt and touched the patient's arm ulna, radius, elbow joint, etc. Then her leg bones were examined.
Because the patient's high fever persisted and the cause could not be found, he thought of trying bone palpation.
When I felt her bones, I didn't feel anything unusual.
But strangely, he felt that the patient's bone temperature seemed to be much higher.
Because the patient is in a fever state and the bones are in the body, it is normal for the temperature to increase.
But the bone temperature that Li Jingsheng felt was not an increase in surface temperature.
Instead, it feels like the patient's bones seem to be slightly warmer than body temperature.
What disease can damage the patient's bones?
Then, he also discovered that several small blisters appeared in some places on the skin of the back of the patient's legs.
Uneven distribution.
This shouldn't be caused by a fever.
"Director Mu, I've finished checking."
After Li Jingsheng checked, he used to wash his hands with disinfectant.
In his mind, he was thinking about the cause of the patient's illness.
"Come on, let's go to the office to discuss it."
Director Mu guided Li Jingsheng back to the office.
"Tell me first, why can sepsis and neurological infection be ruled out?"
Director Mu has obviously recovered from the blow.
"The cerebrospinal fluid examination is normal, and the intracranial pressure is also normal. The head CT did not find any space-occupying lesions, internal bleeding, or cerebral infarction, so I think the possibility of nerve damage is very low. As for sepsis, I have seen some patients with many inconsistent symptoms. , the medical history and characteristics are not consistent, and the neutrophils alone are too distracting, so they can be ruled out. I now suspect that she may have an immune system disease."
Li Jingsheng already had doubts about this when he first read the patient's information.
After checking the ward just now, this suspicion has not been reduced, but has been further increased.
"Director Luo from Shenai mentioned that the patient might have tuberculous meningitis. What do you think?"
Director Mu didn't agree when he heard that Li Jingsheng suspected that the patient had an immune system disease.
"Isn't the cerebrospinal fluid examination normal? This disease can be ruled out directly."
Li Jingsheng didn't understand why Director Mu asked like this?
"I think so too. This case is really complicated. If you say it's a lung or respiratory disease, I'm good at it. This patient's headache and fever are very similar to an upper respiratory tract infection. After checking, it's actually not a respiratory disease at all. Well!"
Director Mu complained like a child.
He was also unlucky when this happened.
The symptoms are similar to respiratory illnesses, but they are actually illnesses from other areas.
It directly confused him, a famous doctor in the field of respiratory tract.
"Why do you think it's an immune system disease? Tell me what you think."
Director Mu decided to listen to the young people's opinions first.
"My idea is actually very simple. Common diseases cannot explain all the patient's symptoms. The patient must have a rare disease. Based on the patient's hemolysis, I thought of a terrible skin disease, which is caused by immune system lesions. of."
Li Jingsheng's medical knowledge can only be said to be relatively solid, but he cannot be considered a scholar.
At least he himself never considered himself knowledgeable.
It’s true that I love reading books.
It is true that learning is relatively complex.
One is that when you are a doctor in a large hospital, you have to rotate and change departments more frequently. Every time you go to a new department, you must strengthen the study of medical knowledge in that field.
Later, I opened my own clinic, not to mention.
Even though all the illnesses you encounter are minor illnesses, there are so many kinds of diseases that you may encounter any kind of illness.
This also requires extensive medical knowledge.
Director Mu was right.
Is this okay for diagnosis?
I originally thought that Li Jingsheng would give a eloquent explanation of medical syndrome differentiation.
Unexpectedly, if common diseases cannot be explained in one sentence, then think in the direction of rare diseases.
The words are rough and the reasoning is not rough.
In fact, diagnosis does not have to be formulaic or rigid and textbook-style.
The thinking in clinical diagnosis is more flexible. Sometimes the sword may go astray and hit the lesion just right.
"I suspect that the patient may have SLE. Although the patient did not have obvious joint and muscle symptoms, nor serious damage to the liver or kidneys, the patient did have thrombocytopenia, systemic hemolysis, and some preliminary damage to the skin. So I It is suspected that lupus erythematosus may be more likely. At least it is worthy of further examination."
Think of the patient's bone temperature rising, blisters appearing on the back of the calf, hemolysis, persistent high fever, severe headache, and low platelets with no known cause.
The only thing that comes to mind is the notorious disease lupus erythematosus.
It is an immune system disease.
The symptoms are diverse and often make it easy for doctors to misdiagnose or be confused during the diagnosis.
If tuberculosis is easy to be misdiagnosed and missed, then this disease is easy for doctors to be confused about.
"Listening to what you said, it seems to make some sense. I will immediately order a skin biopsy for the patient."
Director Mu is also a veteran who has been on the clinical battlefield for many years.
It's one thing to save face, but in the face of the truth, he is by no means the kind of indestructible lump.
"Skin biopsy may take a little longer. It's safer for me to check her for anti-nuclear antibodies first."
Director Mu prescribes these examinations without consulting the patient at all.
This is the benefit of doctors in big hospitals.
There is no need to exhaust your words to explain, and your efficiency can be greatly improved.
"Well, you've discussed it after seeing the case, and I've had some of your good tea, so I'll go back first."
Li Jingsheng was also very happy to be able to help Director Mu find this important diagnostic direction.
It seems that it would be good to have time to learn more medical skills in the future.
If you had not learned medical knowledge about skin diseases and skin immunology, you would have been blinded today.
"Don't be anxious, don't be anxious. Director Hua from the Department of Orthopedic Surgery wants to ask you, how do you think about what I discussed with you that day?"
This matter is relatively secretive.
Only Li Jingsheng and Director Hua talked.
Now that Director Mu knows, it means that Director Mu and Director Hua should have a good relationship.
Also, when Director Hua recruits people, he must discuss it with the hospital leaders.
He alone can decide this matter, but it is not appropriate.
After all, Li Jingsheng's employment conditions have many special features. For example, you only work three days a week.
"Director Hua, do you want me to answer him now?"
Li Jingsheng asked back.
I originally wanted to discuss this matter with Director Hua yesterday.
It turned out that Li Jingsheng was too busy.
In addition, Dr. Xu gave him advice, saying that he would cooperate well with Li Jingsheng and let him increase his worth.
Nothing unauthentic.
Everyone is for profit.
Now Director Hua couldn't hold his temper and took the initiative to ask Li Jingsheng about his thoughts, which was a good thing.
It means the time is ripe.
"I didn't say that I have to give an answer now. I just said that if you come to the Second Hospital, I will ask you to go to his office."
"Then let me go there now!"
Li Jingsheng just decided on this matter.
"Originally, I really wanted to compete with the Orthopedic Surgery Department for your talent. But I can't give you such generous treatment as the Orthopedic Surgery Department. You can go ahead. If you have time in the future, you can often visit our Department of Respiratory Medicine. I'm very optimistic about it. you."
Director Mu is a kind person.
Clearly state your interests.
Li Jingsheng has the ability to manipulate bones and is a special talent in orthopedic surgery, so his net worth has naturally doubled.
But in the Department of Respiratory Medicine, no matter how good he is, he is very replaceable. If he wants to impose some excessive conditions, it will be a fool's errand.
He arrived at the Orthopedic Surgery Department with ease.
Director Mu should have informed Director Hua.
As soon as Li Jingsheng arrived, Director Hua was already waiting there waving to him.
"Li Jingsheng, here!"
After seeing Director Hua, Li Jingsheng walked over quickly.
"Because my clinic has been very busy these past two days, I'm really sorry that I couldn't come to see you in time."
Li Jingsheng took the initiative to apologize to Director Hua.
"It's okay, it's okay. I understand all of this. Your clinic was on the TV news. It must have been overcrowded with patients in the past two days, right?"
Director Hua asked with a smile.
"It's not overcrowded. It's true that the number of outpatient clinics has increased several times compared to usual. But no matter what, I'm just a clinic. I basically treat minor illnesses such as headaches, brain fever."
Li Jingsheng is very humble.
Director Zhao, Doctor Xu and others all sent a signal to Li Jingsheng.
The Second Hospital is the real overlord in the south area of the city.
It seems not to allow any medical establishment that might threaten its status.
Therefore, it is necessary to be miserable and self-deprecating appropriately.
"The clinic does have some restrictions, so coming to our hospital is a very good choice for you. How have you considered the things we talked about two days ago?"
Director Hua brought him into the department director's office.
"I work here three days a week, and I am only in the outpatient clinic. Although it will have some impact on my clinic, the advantages outweigh the disadvantages. So I am very happy to join the Second Hospital. In addition, I have such a wise and kind person like you. Department Director, I would be even more happy."
Li Jingsheng is not pretentious. Now that he has made a decision, he will be straightforward.
"Haha, you kid, don't put a high hat on me."
Director Hua couldn't help but throw his head back and laugh when he praised him.
"Since we agree, let's discuss the details directly, and then we can call the personnel to come over and sign the contract."
Director Hua was very anxious about Li Jingsheng's appointment.
Can you not be in a hurry?
Dr. Xu is ill and cannot work.
There was a large loss of patients in the manual reduction clinic. He, the department director, saw this and was worried.
If Li Jingsheng could come over to replace Dr. Xu, even if he only worked three days a week, the situation could be greatly improved.
"I basically have no requirements in other aspects and can obey all your work arrangements for me. However, in terms of freedom, some conditions may be a bit excessive. Please be more understanding and tolerant."
Li Jingsheng basically holds the initiative now.
That's how negotiations are, the party that loses its temper will suffer a little loss.
But in general, everyone must cooperate and win-win.
At most, you can win in some small interests.
"You tell me first. As long as it's within my scope of authority, I will try my best to take care of you."
Director Hua's expression became much more serious.
"Working three days a week can't be done at the same time. Try to work one day on and one day off."
"no problem."
"Working hours are from 8 a.m. to 5 p.m., so I can't be forced to work overtime. You can't even call me during non-working hours to force me to go back to the hospital to work overtime." Li Jingsheng put forward a more critical additional condition.
Thank you book friend 20200102144655894 for your support. Thank you very much.
(End of chapter)
