Chapter 47: Raising the Difficulty Level, III

‘Death of Patient’.

These four words were written on a white PowerPoint slide. After displaying it, Suhyuk slowly scanned the lecture hall. The faces of the students, who had led their group discussions with confidence, now looked crestfallen. Most of them wore expressions of disbelief, clearly thinking that Suhyuk was being unreasonable.

‘What is it? What have I missed?’

Of course, not all students felt this way. Woo Hayoon, having heard about Lee Suhyuk’s expertise through various channels, fully trusted his opinions. In fact, yesterday, when every other student’s incorrect choice led to the patient’s death, she had provided clear reasoning for her answer.

‘What am I missing?’

However, being polite didn’t mean he had found the answer.

Suhyuk observed the flustered lecture hall for a moment before opening his mouth again.

“It seems like you don’t understand this well. Am I correct?”

“Yes, that is right.”

One of the students sitting at the front immediately responded to him, similar to Woo Hayoon’s behavior earlier. His bright eyes made it clear how good his grades were likely to be.

He’ll learn soon enough.

After one month as an intern, both his crisp lab coat and attitude would become wrinkled.

With these thoughts, Suhyuk continued speaking.

“I will explain each point then. First, all of you diagnosed this patient with pulmonary edema. Correct?”

“Yes.”

“What do you think caused the pulmonary edema in this patient?”

“Hmm.”

There was a mandatory process required when diagnosing any disease.

This was the process of pondering ‘Why did this disease occur?’. However, students were not accustomed to this approach. The problems they had been solving until now focused on diseases, not specific patients.

To improve this situation, Director Lee Hyunjong introduced Problem-Based Learning (PBL), but it was still at its infancy stage.

Suhyuk continued speaking as if he anticipated their silence, observing the puzzled students.

“Firstly, the patient has diabetes and is being treated with vildagliptin. This medication isn’t commonly used due to its lower efficacy compared to others. From this, we can infer one crucial fact: ‘There must be some issue with the patient’s kidney function.’ Indeed, if you look at the lab results you provided earlier…”

Suhyuk flipped through the presentation slides.

Suhyuk had written down his results based on the students’ tests. Among them were the items ‘BUN’ and ‘Creatinine’, which increased to 52 and 2.7 respectively.

“We can consider it as abnormal kidney function.”

“Then…is pulmonary edema caused by this?”

“No. The patient’s kidney problem has been ongoing for more than a day or two. It has already been several years since switching to this diabetes medication. This was mentioned earlier in the current medical history.”

“Ah…then…then what is it?” The student’s eyes became hazy, reflecting their lack of confidence.

In contrast, Professor Lee Hyunjong’s eyes sparkled with interest.

‘A well-crafted story. Is this actually a real patient case? Where did he find it? Perhaps…perhaps it’s a case he knew beforehand?’

It meant Suhyuk must have been studying extensively all this time. Naturally, Lee Hyunjong wore a pleased smile on his face. The thought of having to step in if things went awry had vanished from his mind.

“Please think carefully. This patient has suffered from diabetes for over ten years. Of course, there are no records as they were treated at another hospital. As internal medicine doctors seeing this patient for the first time, what should be your initial thoughts?”

Suhyuk intentionally directed the question towards Woo Hayoon. He believed that as the daughter of Professor Woo Changyun and an endocrinologist, she should know the answer. Fortunately, Woo Hayoon was quite diligent, regardless of her background.

She wasn’t someone who would fail to answer Suhyuk’s probing question.

“Ah. Ah! Complications!”

Sadly, the biggest risk factor for diabetic complications was the duration of having diabetes. Even if some people properly managed their condition, diabetes often showed no symptoms. Many individuals were unaware they had diabetes until it was too late.

“Yes. Complications. It is an issue we must consider. Moreover, what medication is this patient currently taking?”

“Bildegliptin!”

“Yes. Her kidneys have already failed. What does that imply?”

“Ah…”

Diabetes could lead to various complications. However, there were two significant areas primarily monitored: kidney function and eyesight.

If one of them, such as the kidneys, was damaged, it would be correct to assume that the eyes were also at risk. The blood vessels involved with kidney function tended to be thicker than those in the eyes. Therefore, if the larger vessels were compromised, it was reasonable to infer that the thinner ones might already be affected.

“Vascular damage…”

“Yes, it means there is damage to the patient’s blood vessels, regardless of their location. You should know why vascular damage occurs in diabetic patients without further explanation since you are fourth-year medical students.”

“Yes.”

“Now let’s go back to the beginning. Why did the patient develop pulmonary edema?”

It was precisely the same question asked earlier about the exact same patient. However, now the students could consider the possibility of complications arising from the patient’s long-standing diabetes.

As such, completely different answers started pouring out:

“Worsening kidney failure?”

“No, no, heart function failure?”

“Right ventricle?”

Suhyuk nodded as he listened to their scattered responses.

“Good. Then what tests should we perform to confirm this? Please mention any additional tests you would like compared to the ones suggested earlier.” He pointed at the list of tests previously mentioned by the students.

Even an intern with proper training would have been eager to request more tests upon seeing that list. Something was missing from their routine, which they had learned to minimize errors in university hospitals. They might not fully understand why certain medications were continuously prescribed, but now the students finally recalled one crucial test.

“E…ECG!”

Woo Hayoon was quickest to respond. Suhyuk nodded with a satisfied smile.

“Good. An ECG. Anything else?”

“As we suspect heart failure, I would like to add an echocardiogram.”

“Great.”

This was followed by blood tests for cardiac enzymes that could identify myocardial infarction. Suhyuk wrote all these tests on his PowerPoint presentation and immediately added their results as well.

‘Is he really a monster?’

Lee Hyunjong observed quietly, and without realizing it, he raised an eyebrow. He noticed Suhyuk hadn’t looked at any notes since starting the lecture. This meant Suhyuk had memorized everything beforehand, which seemed implausible.

“[The CK-MB level is 49.1.]

[Troponin-I is 34.]

Of course, Suhyuk didn’t memorize everything. Baruda had recorded all the details for him.

‘Good. What about CK?’

[It is 635.]

‘Okay. Well done.’

Using this cheating-like method, Suhyuk presented the test results. The cardiac muscle enzymes, which could rise during a heart attack, were significantly elevated. In addition, the ECG showed inverted T waves, another crucial indicator of myocardial infarction.

Finally, the students confronted the primary issue causing the patient’s death - pulmonary edema.

“It was a heart attack…”

“The echocardiogram also shows abnormal wall movements…”

Suhyuk smiled faintly as he observed the murmuring students.

“Yes, the patient has had a heart attack. Then what treatment should be done?”

At this moment, Suhyuk glanced at Professor Lee Hyunjong standing and smiling in one corner of the room. This was already too big of a hint for the students.

“Cardiovascular angiography with stent insertion!”

“That’s correct. Let’s see how it goes.”

Suhyuk promptly displayed the angiogram image. An untrained eye might think, ‘All three coronary arteries seem fine?’ However, someone with some knowledge could identify that the left anterior descending artery, the most crucial coronary artery, was blocked.

“If we open this using a stent…the patient will survive.”

After showing the stent procedure, Suhyuk turned to face forward again.

The students, who had been following Suhyuk’s lecture, were now sitting quietly. Initially, some of them questioned his authority, but now they were completely captivated. His lecture was both engaging and grounded in reality.

No one dared to speak until Suhyuk opened his mouth again.

“Alright, what can we learn from this case?”

Even after posing the question, there was silence for about five minutes before someone slowly raised their hand. Turning to look, it wasn’t a student but Lee Hyunjong himself.

“In patients with long-standing diabetes, chest pain may not be present during a myocardial infarction, correct?”

Who could dare contradict the director, especially when he is considered among the best in cardiac angiography? Suhyuk nodded swiftly in agreement.

Moreover, Lee Hyunjong could be considered one of the best in the world for cardiac angiography procedures. Suhyuk nodded quickly as if he was afraid to disagree with him.

“Yes. That’s correct.”

“Hmm. It is very important information. In reality, there have been numerous cases where the golden hour was wasted due to this misunderstanding. Even some of your seniors fell prey to it.” As Lee Hyunjong spoke, he turned towards the students, naturally taking over the lecture from Suhyuk.

“Diabetes doesn’t just damage blood vessels over time. Well, ultimately, it does affect blood vessels, but specifically, the blood vessels supplying nerves can also be damaged. This leads to decreased sensitivity to pain. Particularly in internal organs, which already have less sensation, the pain might almost disappear entirely. Do you understand what I’m saying?”

The students just swallowed nervously. Lee Hyunjong continued speaking to the slightly frightened students, “If you think one-dimensionally like ‘Ah, there is no chest pain! Then it can’t be myocardial infarction,’ then you will lose patients. This actually happens often. Today, Teacher Lee Suhyuk has taught you something very important for your medical career. The symptoms described by the patient are naturally important. However, if you absolutely rely on them, you will make big mistakes. There is a reason why basic tests exist. Understood?”

“Yes.”

“What are you doing? Why aren’t you clapping? Did I give this lecture alone? It was done with Lee Suhyuk’s help.”

“Oh, yes!”

“You deserve applause as well. I didn’t expect you to do this well.”