The Surgeon's Studio

Decompensated cirrhosis, portal hypertension, hypoalbuminemia, electrolyte imbalance, ascites, hydrothorax…

The list of diagnoses was long and blurry.

It looked like this patient had a hepatitis B infection that had progressed to hepatic cirrhosis, splenomegaly, and portal hypertension. This had then led to refractory ascites.

The earlier diagnosis was similar to a disease progression of hepatitis.

Decompensated cirrhosis would lead to two fatal complications—hematemesis and ascites.

When the ascites developed into refractory ascites, the usual diuretic treatment would not work. The ascites would result in hypoalbuminemia, leading to the leakage of fluids, worsening the ascites, and further lowering the albumin levels.

It became a vicious cycle.

The clinical treatment of ascites and hypoalbuminemia were diuretics and an intravenous infusion of human albumin.

With the presence of refractory ascites, it did not matter how much human albumin was transfused as it would just leak out as ascites.

This complication was different from hematemesis. Even though hematemesis seemed more urgent than refractory ascites, hematemesis caused by portal hypertension was treatable with general surgery.

Before the emergence of TIPS surgery, patients with refractory ascites could only sit and wait to die. Even now, TIPS surgery was extremely difficult to execute, and only Class Three Grade A Hospitals in cities as big as provincial capitals were equipped enough to perform it.

Without TIPS surgery, patients diagnosed with this disease were pretty much getting sentenced to their deaths.

The patient would be in excruciating pain, suffering slowly while life ran its course.

Zheng Ren performed a simple checkup and questioned the patient about his condition when the labs were back.

The resident beside Chief Xia answered the questions in an orderly manner. The diagnosis by gastroenterology and the System’s monitor was similar.

There were no specific contraindications, so the patient was cleared for surgery.

Zheng Ren said, “Chief Xia, the patient did a liver DW-MRI. I’ve submitted the request for surgery tomorrow.”

“DW-MRI?” Chief Xia was stunned.

DW-MRI, diffusion-weighted magnetic resonance imaging in full.

DW-MRI differed from the usual MRI. DW-MRI utilized diffusion of water molecules to generate contrast by mapping the movements of water molecules in biological tissues, such as the brain, to provide clinical information.

It was mostly used for neurological treatment.

It could diagnose acute brain ischemia at a 94% sensitivity rate and 100% specificity. It could also reliably differentiate between an arachnoid cyst and epidermoid cyst, subdural empyema and subdural hygroma, and necrotic abscess and tumor.

Why did Zheng Ren order a DW-MRI for a TIPS surgery?

Chief Xia heard of how the experts from Imperial Capital and Sorcery Capital used DW-MRI to visualize the tumor. However, this patient was suffering from refractory ascites as a result of liver cirrhosis progression, not a tumor.

Little Zheng…

Chief Xia hummed softly.

Zheng Ren did not explain his decision further to Chief Xia. This was a preoperative assessment for TIPS surgery that he devised in the System’s operating room after countless practices. He had used it to locate the position of the portal vein and hepatic vein so that his catheterization had a higher rate of success.

If he were to explain from the very beginning, he would not be able to finish telling him the reasons why even after several days.

Zheng Ren was also too lazy to deal with other things.

After briefing Chief Xia about the patient, Zheng Ren took his leave and headed to the ICU.

He changed and entered the ICU ward. The ward had a strong, depressing atmosphere.

The chief of the medical administration division was sitting in the ward with deep, furrowed brows.

Su Yun was seated beside Yang Lili’s bed, his fringe swaying in front of his forehead while his head was buried in lab reports.

“What happened?” Zheng Ren approached Su Yun and asked softly.

“Boss, there’s something wrong,” Su Yun said. “We stopped the sedatives this morning but the patient started showing symptoms of mental disorders.”

Mental disorders?

Zheng Ren was stunned.

There was no mental disorder shown on the diagnosis on the System’s monitor.

“The routine blood work was mostly normal. The surgery’s aseptic environment was maintained well with no obvious signs of infection. Biochemistry analysis: 15.49 mmol/L of glucose, 134 mmol/L of sodium, and 4.15 mmol/L of potassium. Blood gas analysis: pH 7.46, 61 mmHg partial pressure of oxygen, 38 mmol/L of bicarbonate, 3 mmol/L base excess, and keto acids: +++.” Su Yun dictated the entire emergency lab report from this morning without even looking at the papers in his hand.

“How was Yang Lili’s mental state?” Zheng Ren asked with a frown.

“Extreme, intense fear, like phobia,” Su Yun said. “It was as if she had seen a ghost. She had an intense episode of emergency agitation and the hand straps couldn’t hold her down. Her heart rate shot up from 95 to 156 beats per min after we stopped administering sedatives.”

“That’s strange.” Zheng Ren recalled the lab results that Su Yun had just told him. The overall results seemed fine. It only had a slight increase in blood glucose, urine glucose, and keto acids. He considered that this was the body’s acute stress reaction in response to a traumatic injury.

Bloody h*ll…

This would not be easy to explain.

Could the intense shock from the incident have left her with psychological trauma?

It was possible. Nonetheless, psychological treatment was still a new branch of science in the country. Zheng Ren did not know any experts in the field.

More importantly, the psychiatrist would not be able to give Yang Lili counseling in her condition.

They were going to do a thoracotomy in a few days. If the complications of lung infection began to…

Zheng Ren had no choice.

No wonder the ICU’s atmosphere was so depressing. A patient with seemingly fine test results had manifested such strange complications.

Especially when this patient was someone highly regarded in the city. They had to report directly to the health bureau director and the deputy mayor who oversaw the cultural education and health of the patient’s condition every day.

What should they report today? Should they say that she saw ghosts after they stopped her sedatives?

Zheng Ren frowned deeply while he went through each and every diagnosis shown on the System’s monitor.

They had started her on sedatives again but Yang Lili’s heartbeat remained high.

Postoperative infection? The patient’s temperature was slightly elevated, most likely due to postoperative fever. The C-reactive protein had no apparent abnormality, which meant it was unlikely to be an infection.

Pulmonary embolism? Chest pains and respiratory distress that led to an increased heart rate?

Zheng Ren listened to Yang Lili’s breathing sounds on both sides with a stethoscope. It was not pulmonary embolism…

Zheng Ren was certain about it without the need to perform CT angiography on the pulmonary artery.

He should be able to derive a conclusion based on the combinatorial results from the body examination and the System’s diagnosis.

Could it be cardiac insufficiency due to the large volume of postoperative fluid replacement? Zheng Ren pondered. He then asked, “What was her input volume?”

Su Yun shook his head. Obviously, he had already thought of this.

“The postoperative fluid output was significantly lesser than the fluid input. On the first day post-surgery, the difference between fluid input-output had decreased. They reached the same volume as of yesterday.”

They administered a larger volume of fluid replacement because Yang Lili had lost a significant amount of blood.

Besides Yang Lili’s young and healthy body, she was able to recover just 2 days after surgery because of Su Yun and the ICU medical staff’s hard work.

Furthermore, Yang Lili had no family history of cardiovascular disease, so he eliminated the possibility of cardiac insufficiency.

Besides this… What else could it be?

The last possibility was diabetic ketoacidosis.

Since Yang Lili presented an increase of blood glucose, ketone in urine, acidosis, and normal levels of β-hydroxybutyrate, the ICU doctor administered a low dose of insulin.

It was not ketoacidosis either.

Could it really be a mental disorder… Zheng Ren was stuck.

After going through each diagnosis on the System’s monitor, Zheng Ren’s eyes suddenly lit up!

Could it be that?