Chapter 2332: 2253 Strict Medical Record Writing (Alliance Leader IvanLIN Bonus Chapter 3)

All routine clinical tests on the patient were normal, including imaging data. Actually performing a full battery of tests would be utterly impractical.

"What about bipolar disorder caused by thyroid dysfunction?" Su Yun asked.

"In your terms, we still can't explain Wang Canlan's existence." Zheng Ren kept slowly scrolling the mouse wheel, carefully examining the extensive medical record.

Bipolar disorder is just a possibility, and Zheng Ren thinks the likelihood is low.

"Boss, why are you examining the medical record so closely?" Su Yun asked.

"The medical record was written by Zhong Min; she's more meticulous." Zheng Ren said simply.

When writing a major medical record, clinicians used to handwrite it, and a standard record took at least one hour.

Now with electronic medical records, many fields are just options, making it far more convenient than handwritten records.

But precisely because of that, many doctors don't carefully review or fill in the default options. After all, time is limited each day, there's too much to do, clinical staff are insufficient, so they just gloss over the unimportant parts.

Zhong Min is a typical internal medicine doctor; previously, internists didn't do surgery, so they spent much more time writing records and seeing patients than surgeons, making their records relatively more detailed.

Plus, her own personality is meticulous; after being frightened once by the Magic Pen Signature Disappearance Event, she became conscientious to the point of being strict.

Speaking only of medical record writing, Zheng Ren believes he could never catch up to Zhong Min, let alone Chang Yue.

"Pupillary light reflex is normal, the conjunctiva is slightly yellow—does that mean anything, boss?" Su Yun asked.

I've already looked at the lab sheet; bilirubin and similar tests are normal, basically ruling out jaundice-related diseases.

Moreover, hepatic encephalopathy can also present with psychiatric symptoms, but the patient's condition is worlds away from hepatic encephalopathy.

"A single finding is meaningless, but there's a 1 mm red swelling at the eye corner with peeling." Zheng Ren then saw another patient sign described by Zhong Min.

Su Yun didn't retort to Zheng Ren; instead, she sat down seriously beside him to jointly examine the medical record written by Zhong Min.

Lin Yuan was puzzled; generally, primary hospitals deal with common diseases' diagnosis and treatment. Although she's never been to Hai Cheng, she imagined they only performed minor surgeries.

The medical record is described in such detail, like a realist literary giant using concise language to depict a passerby—completely meaningless!

Yet Zheng Lao Ban and Yun Ge'er silently examined the record, leaving Lin Yuan with the feeling that she had missed something.

At that moment, she seemed to sense a solemn atmosphere.

Conjunctiva and sclera are yellow, the eye corner has a small red swelling—what's the problem?

She also began to focus and follow along reading the record; occasionally Zheng Lao Ban's hand would pause slightly, but the relevant spots were just very common minor issues not worth attention.

For example, pale lips, occasional gum bleeding, etc.

This medical record is…… Suddenly, Lin Yuan felt a bad premonition.

She had seen Chang Yue's medical record before; compared to the current one, it's even more meticulous, to the point of describing every trivial detail.

Surely I won't have to write medical records like this in the future!

She vaguely saw a dark future ahead; she didn't want to sit in the office every day writing records, she wanted to perform surgeries and become a world-renowned surgeon.

Nausea, no vomiting, progressive weight loss, body weight dropped 2.3 kg within one year.

This description is overly detailed; Lin Yuan's head began to throb on and off.

Even Lin Yuan recalled seeing earlier that this Hai Cheng doctor had written in the record that the patient had oral ulcers, several ulcer surfaces, and how they were treated.

The patient suspected a psychiatric illness; why write about oral ulcers—what does that mean?! Lin Yuan felt a surge of indignation.

Are all of Zheng Lao Ban's subordinates perverts, writing a major medical record with such strictness?

No, it's not strict; it can already be described as severe.

Immediately, Lin Yuan saw in the medical record summary the line 'dietary change history for three months.' She was already speechless about it; if every record required such description, she'd probably rather go home after a few days.

"Su Yun, ask Zhong Min what she means by dietary change." Zheng Ren suddenly said.

"Well, it's already quite clear; I guess Wang Zong hasn't encountered similar patients." Su Yun said softly, picking up her phone, not looking up a number in the contacts, and directly dialed a mobile number.

Clear? What exactly is clear!

The hairs on Lin Yuan's neck stood up all at once.

How did it become clear? Exactly what did they see that made Wang Canlan's existence clear?

The red swelling at the eye corner? Oral ulcers? Or the dietary change?

In an instant, a sense of helplessness welled up deep within Lin Yuan. Something she once took pride in collapsed before the two monsters, Zheng Lao Ban and Yun Ge'er, so quickly it was unbearable.

"Zhong Min, the medical record Wang Zong just sent over—was that written by you?"

"The record for the patient named Han Cuijuan."

"You wrote a line about dietary change—what does that mean?"

"Alright, tell Wang Zong that we already have a clue. After I discuss it with the boss, I'll immediately inform you of the diagnosis."

Having said that, Su Yun hung up the phone.

"Zhong Min said the patient started having a salty taste three months ago, eating food too salty." Su Yun said.

"Well, then the diagnosis is quite clear. Don't stop carbamazepine; give olanzapine 10 mg orally once daily. Vitamin B12: 1 mg/day intramuscular for the first six days, then 1 mg weekly for six weeks, then 1 mg monthly intramuscular." Zheng Ren directly stated the treatment.

"Boss, that's not rigorous enough."

"We still need to do the tests, do we even need to say that?"

"Or should we check vitamin B12 and homocysteine?" Su Yun asked.

"Well, the positive rate for serum vitamin B12 testing isn't high, so we must check homocysteine." Zheng Ren said, "Let's do it now; tell Wang Zong we'll wait for the results."

Lin Yuan wordlessly watched Su Yun make another call, recalling the diagnostic criteria for vitamin B12 deficiency in her mind.

"Zheng Lao Ban, vitamin B12 deficiency generally presents as megaloblastic anemia, glossitis, and neuropsychiatric symptoms." Lin Yuan whispered doubtfully.

"Hmm, there are also some minor details; not every vitamin B12 deficiency patient will have glossitis and megaloblastic anemia." Zheng Ren said.

"……"

"For example, glossitis is the most common, but diagnostic literature states inflammation of the mucosa of the tongue, oral cavity, and digestive tract. If conditions allow, giving the patient a gastroscopy would be ideal."

"Huh?" Lin Yuan stared blankly for a moment.

"A gastroscopy would most likely show gastric mucosal atrophy, chronic inflammation, with 50-60% of biopsied epithelium exhibiting intestinal metaplasia."