Chapter 43: What Kind of Question is This? (2)

‘A 78-year-old male presented with difficulty breathing that started one day ago…’

[Baruda: As Professor Lee Hyunjong is a cardiology professor, it seems he should initially consider cardiac causes.]

‘No, no…’

Suhyuk gently shook his head at Baruda’s words. He recalled his fourth year of medical school, which was when Woo Hayoon had graduated.

‘There is a reason why Professor Lee Hyunjong is called a genius. This patient must belong to another department.’

[Is it possible for him to make a difficult question involving patients from different departments?]

‘Yes, hence why he is a twisted genius.’

[Baruda: First, I request moving on to the present illness section.]

Following Baruda’s advice, Suhyuk clicked with his mouse. The screen transitioned from the chief complaint, i.e., primary symptoms, to the present illness section.

As expected from a problem created by Lee Hyunjong, the current case was bizarrely strange.

“Look at this. Why is the current case so long…?”

Woo Hayoon seemed to have failed multiple attempts already, and she looked distraught.

“It is lengthy… Moreover, it is complicated.”

Suhyuk nodded, expressing his full agreement with her opinion.

Meanwhile, Baruda was digitizing the current case:

[Six weeks ago, after eating frozen salmon, symptoms such as fever, diarrhea, and hives occurred one day later. Treatment with antibiotics was received at a local clinic.]

‘Was he diagnosed with food poisoning?’

[It isn’t written, but yes. That seems likely.]

‘Shortly after discharge… He experienced non-itchy skin rash on his left leg and was readmitted to the local clinic.’

A non-itchy skin rash on one leg. It might seem insignificant, but it was quite a substantial hint. I felt this case wasn’t based on a real patient but rather created as a problem.

[The possibility of an allergic reaction to drugs is greatly reduced.]

‘Indeed. It isn’t both legs, and it isn’t itchy.’

[In reality, at the local hospital, they diagnosed it as cellulitis and used Cefepime (a cephalosporin antibiotic). Then they switched to Vancomycin (antibiotic for resistant strains).]

‘But it didn’t improve.’

If it were simply cellulitis, it should have been resolved with Cefepime. Yet, even after using Vancomycin, the symptoms worsened.

Fine wrinkles appeared on Suhyuk’s forehead.

“The infection of the patient… It seems to be worsening.” Woo Hayoon looked between Suhyuk’s profile and her notepad before cautiously speaking. Her judgment wasn’t incorrect. In fact, it was written in his current medical records.

“Yes, even after using Meropenem (an antibiotic used for super bacteria)…it progressed until we had to use Amphotericin B (broad-spectrum antifungal medication).”

This meant they had tried all available medications. Despite this, the skin lesions continued to spread, and one day prior, he went into shock, leading him to arrive at Taehwa Medical Center’s emergency room.

“[Despite providing 100 percent oxygen, saturation levels were inadequate, requiring intubation and admission to the intensive care unit.]”

‘What does that mean?’

“We need to rule out infectious diseases that can cause skin rashes across the body. First, I would like to confirm what these rashes look like.”

‘Indeed, as expected?’

To someone unfamiliar with them, the rashes might just appear as blotchy red patches. However, identifying the shape of the rashes could provide significant clues in determining whether it was due to bacterial infection, viral origin, or even toxin exposure.

As Suhyuk continued flipping through the pages, the patient’s medical history appeared on the screen.

“The patient has hypertension and Graves’ disease. However, both conditions have been well-controlled with medication.” Woo Hayoon, having attempted treatment multiple times before, was already well-versed in the patient’s past medical records.

“[Both previous conditions do not seem closely related to the current illness.]

Unfortunately, Baruda’s judgment was ‘not much relation’. Thus, Suhyuk continued to flip through the pages.

“When the patient arrived at the hospital, they were already in shock, so there is no direct account of their symptoms.”

As stated by Hayoon, the patient’s review of systems, which included questions about various body parts, was empty. Instead, the physical examination section was filled with details.

[Blood pressure: 119/51, pulse rate: 129, respiratory rate: 33/min, temperature: 37.9°C upon admission. These indicate overall signs of infection.]

‘Patient was unconscious… Wait, there are photos of spots.’

It seemed this case study was based on real-life medical records. Multiple actual photographs appeared, showing spots on the patient’s arms, legs, and torso.

[The red spots stand out clearly from the surrounding skin.]

‘The size of these spots varies.’

[It appears there is no specific area that isn’t affected.]

‘Hmmm…’

This was a non-specific diagnosis. Suhyuk had hoped to identify the cause by comparing it with his vast database, but he couldn’t hide his disappointment.

Woo Hayoon expressed her regret once again at his sigh.

“I’m sorry. I feel like I am bothering you on your day off.”

“Huh? No, not at all. Anyway…this is quite interesting. I got too absorbed.”

“Ah…thank you very much for saying so. Also, please speak casually now. You’re older than me.”

“I’ll let go once you feel comfortable.”

After saying this, Suhyuk turned towards the black screen.

[H-Her breathing is rough.]

There was a description of her ribs sinking with each breath. Her rapid breathing meant she was using all the muscles between her ribs.

‘Both lungs sound bad.’

[Pneumonia may not be the cause of infection, but it could still lead to the patient’s death.]

‘True.’

In many cases, especially for elderly patients, pneumonia was often the direct cause of death regardless if they had cancer or another illness. It ultimately meant that pneumonia occurred before their demise.

Woo Hayoon shook her head as if she hit a roadblock in this case.

“They continue to die from pneumonia…”

“Ah… Still showing ‘You have died’ like that Flash game?”

“The director outsourced it to a game company. My father’s hospital is also planning to introduce this starting this year.”

“Aha… So it was made by a game company… No wonder…”

Currently, I was viewing the results of already implemented tests. After everything finished, some choices would be presented.

What test should be conducted? What treatment should be administered?

Then based on these actions, the patient’s condition changed. If wrong, it often led to the death of the patient.

[The blood test shows an increase in white blood cells, with neutrophils being predominant. It suggests a bacterial infection.]

‘Why is creatinine so high? Is there kidney failure?’

[Sodium levels are also low. Considering they said shock…it appears to be due to symptoms of renal failure.]

‘They gave this case to save students?’

[Director Lee Hyunjong is literally insane.]

What would happen if such a patient arrived at the emergency room? Among the current Internal Medicine residents, many would kill the patient if told to handle it alone. Yet, this was given to medical students? Lee Hyunjong was crazy.

‘I’m supposed to become the primary physician for such a person.’

[I will do my best to assist you.]

‘It isn’t that comforting.’

[Let’s start with this first. Consider it as practice.]

‘Yes…’

Suhyuk decided to focus on solving the assignment before him and once again examined the test results. The patient had attached chest x-rays taken at a local hospital, which were marked by date.

[The progression has been rapid over the last four days.]

‘Too fast. Considering they were using antibiotics… It is unbelievable.’

In just four days, the patient’s lungs changed from normal black to pure white.

“The patient also underwent a CT scan, upperclassman.”

“Really? Where?”

“Here. Both thorax and abdomen.”

“Ah, it was sandwiched between them. I almost missed it.” Suhyuk muttered while examining the CT images.

Suhyuk murmured while examining the CT images.

“The chest X-ray and CT scans show almost identical results. The CT seems to have been taken at Taehwa Medical Center.”

‘In the abdomen… these… could they all be lymph nodes?’

“They appear irregularly enlarged. They don’t seem malignant.”

‘So many instances of reactive lymph node enlargement? Indeed…’

“It suggests a systemic inflammatory response.”

In truth, Suhyuk didn’t need the CT scan for this conclusion. Upon admission, the patient had a fever above 38 degrees Celsius, rapid breathing with 33 breaths per minute, accelerated heart rate, and significantly elevated white blood cell count—all indicative of a systemic inflammatory reaction.

“What could have caused this?”

Now, it was important to find the cause of these symptoms.

On the screen, various tests that could be added were listed. It ranged from simple blood and urine tests to a PET-CT scan. All possible tests available at the hospital appeared on the list.

‘Did they actually implement all these test results…?’

Suhyuk looked towards Hayoon with this thought.

Hayoon quietly nodded her head.

“Yes. The result will pop up for any test you select… However, if we take too much time, the patient might die.”

“I see. Then we need to carefully choose which test to perform? By any chance, is there a limit on money or something?”

“Oh no, not at all.”

“That’s good.”

Suhyuk became absorbed in the case, forgetting his earlier formality.

[Firstly, I suspect a severe infection, so we need to determine the cause. Request blood culture tests, sputum culture tests along with staining, and PCR for bacterial strains.]

‘Hmm.’

It was a reasonable opinion. Based on these tests, it should be possible to identify the cause.

However, there was a problem: time.

‘It will take at least two weeks to get the results.’

[Hmm.]

‘During that period, the patient might die.’

For a moment, Suhyuk forgot this was merely a test question. The case felt incredibly real.

‘We must start treatment simultaneously. Since meropenem hasn’t worked yet, let’s add teicoplanin. How about that?’

[A valid choice.]

‘And regarding kidney issues, initiate dialysis.’

[That seems like a necessary decision.]

‘However…’

Suhyuk raised his eyebrows and flipped forward through the pages again. He stopped on a page containing photos of the patient’s rash.

‘Doesn’t it seem like there is more to discover here?’