This case is indeed difficult to handle. So far, he hasn’t gained much experience. For the last case, he only solved it by consulting the literature. 𝑓𝑟𝑒𝘦𝓌𝑒𝑏𝑛𝑜𝘷𝑒𝘭.𝒸𝘰𝑚

Zhaxi furrowed his brows. Fever, joint pain, rash—these are signs of rheumatic immunological diseases. But the sudden onset of confusion suggests the central nervous system is involved. He continued to flip through. The Neurology Department’s examination records indicate that when the patient was admitted, he was in a confused state, with disorientation, reduced calculation ability, and significantly impaired recent memory. Physical examination did not reveal obvious neurological localization signs—no paralysis, sensory dysfunction, or ataxia. A head CT scan was normal. Lumbar puncture showed normal intracranial pressure; cerebrospinal fluid was routine, biochemical, and cytological tests were normal; pathogen tests were negative. EEG displayed diffuse slow-wave activity, suggesting diffuse brain dysfunction.

He turned to the section with the test results. Blood count, liver and kidney function, electrolytes, coagulation function—all normal. Rheumatism items—rheumatoid factor, anti-CCP antibody, antinuclear antibody—all normal. Inflammatory markers—ESR, C-reactive protein—slightly elevated. Tumor markers normal. HIV, syphilis, EB virus, cytomegalovirus, all negative.

Zhaxi closed the case file; another patient with all routine tests normal. Fever, joint pain, rash, combined with confusion. Rheumatic immunological diseases affecting the central nervous system? But all autoantibodies are negative. Infectious encephalitis? But cerebrospinal fluid is normal, and pathogen tests are negative. Tumor? But tumor markers and head CT are normal. What kind of disease is this?

He looked up at Director Liu, who said, "What do you think? Want to give it a try?"

"With Director Liu backing you, what are you afraid of? Be bold in your approach. If you need to order diagnostic tests, especially invasive ones, be sure to communicate with the Physician in Charge and report to Director Liu," Yang Ping advised Zhaxi, emphasizing that while training is important, safety comes first. This is called "letting go, but keeping an eye" in medical education.

"Director Liu, I’ll go see the patient," Zhaxi said.

Director Liu nodded, "Alright, the patient is in bed 15 of our Neurology Department. Off you go. I need to have a chat with Professor Yang. I’ve already informed Dr. Zeng, who is in charge there."

Zhaxi stood up, walked to the door, and suddenly glanced back at Yang Ping. Yang Ping waved, "Go ahead, don’t be afraid. Clinical physicians, the more you see and do, the more skilled you become naturally."

"Okay!" Zhaxi took a deep breath, and the stage fright that was evident the first time was no longer there.

Zhaxi arrived at the Neurology Department, and Dr. Zeng accompanied him to bed 15. The patient was a young-looking man, thin, with a pale face, lying in bed with his eyes open but looking a bit distant. His wife was sitting by the bedside and stood up when she saw Zhaxi come in.

Dr. Zeng introduced, "This is Dr. Zhaxi, invited for a consultation."

Seeing a young doctor, who didn’t look particularly impressive, the patient’s wife displayed displeasure, feeling that the Hospital did not take her husband’s illness seriously. She stood by the bed and did not make space for Dr. Zhaxi to conduct an examination.

Zhaxi didn’t care about her obvious unwelcome attitude, saying, "I am a student of Professor Yang, just here to have a look."

Upon hearing he was Professor Yang’s student, the patient’s wife’s attitude immediately changed, becoming respectful, forcing a flattering smile.

Zhaxi walked to the bedside and softly said, "Hello, I’m Dr. Zhaxi. Can I ask you a few questions?"

The patient turned his head, looking at him with a confused expression. After a while, he dully said, "Who are you?" His voice was light, like sleep-talking.

Zhaxi’s heart sank. The level of confusion was quite severe. He sat down and began taking a medical history. Most questions were answered by the patient’s wife. The patient had been ill for six months, initially with a fever thought to be a cold. After taking cold medicine, the fever subsided, but returned after a few days. Later, joint pain began—pain in the wrists, knees, and ankles, severe enough to impair typing. The rash appeared later—patches of red that didn’t itch, fading in a few days, then reappearing elsewhere. After visiting several hospitals and countless blood tests with nothing found, a week ago, he suddenly began talking nonsense. At work, colleagues noticed his incoherent speech and thought he was joking. But he returned home without recognizing his wife.

Zhaxi asked, "Before the onset, had he taken any special medication or received any vaccines?"

The wife thought for a moment and shook her head, "No, he’s always been healthy, rarely even catching a cold."

Zhaxi continued, "Any pets at home? Has he been to the wilderness?"

The wife replied, "No, he’s a programmer, sitting in front of a computer all day, going nowhere."

Zhaxi jotted down all the information and conducted a physical examination of the patient. His temperature was 37.8, indicating a mild fever. There was indeed a scattering of red rashes on his skin, mainly distributed on the trunk and proximal limbs. These were unclear-bordered red spots that would blanch under pressure. The joints showed no apparent redness, swelling, heat, or pain but resisted movement. Neurological examination: the patient was confused, disoriented. When asked for the date, he said he didn’t know. When asked where he was, he said the Hospital. When asked his name, he got it right only after three tries. His calculation ability was reduced, struggling with subtracting seven from a hundred, he eventually said ninety-three but couldn’t subtract further. Memory was impaired; he couldn’t recall any of three words told earlier, five minutes later. No paralysis, no sensory disturbances, no ataxia. Meningeal irritation signs were negative.