Chapter 43: What kind of problem is this? (2)

‘A 78-year-old man came to the hospital due to breathing difficulties that started a day ago...’

[Since Lee Hyun-jong is a professor of cardiology, we should first consider causes related to the circulatory system.]

‘No, no...’

Suhyuk quietly shook his head at Baruda's words.

Then he recalled a time long ago, when he was a fourth-year medical student.

That was exactly when Woo Hae-yoon was in the same position.

‘Professor Lee Hyun-jong isn't called a genius for nothing. This is 100% a patient from another department.’

[Are you saying that the problem involves a case from another department and is made to be difficult?]

‘Yes, that's why he's a perverted genius.’

[Let's move on to the current medical history.]

Suhyuk clicked the mouse as Baruda suggested.

The screen, which had been paused at the chief complaint, moved to the current medical history.

As expected, the current medical history, set by Lee Hyun-jong, was bizarre.

"Look at this. What kind of current medical history is this...?"

Woo Hae-yoon, who had already tried and failed several times, had a pained expression.

"It's long... and complicated."

Suhyuk nodded in agreement, showing a face that fully empathized with her opinion.

Meanwhile, Baruda was digitizing the current medical history.

[Six weeks ago, the patient ate frozen salmon and developed fever, diarrhea, and hives a day later, receiving antibiotic treatment at a local clinic.]

‘He was probably diagnosed with food poisoning, right?’

[It's not written, but yes, that's the likely diagnosis.]

‘Immediately after discharge... he was admitted to a local clinic again due to non-itchy skin rashes on his left leg.’

A non-itchy skin lesion on one leg.

It might seem insignificant, but it was a sentence that contained significant hints.

It definitely felt like a case created for a problem rather than a real patient case.

[The possibility of an allergic reaction to medication is low.]

‘Right. It's not on both legs, and it's not itchy.’

[At the local hospital, he was diagnosed with cellulitis and treated with cefepime (a cephalosporin antibiotic), but later switched to vancomycin (an antibiotic for resistant bacteria).]

‘But it didn't improve.’

If it had been simple cellulitis, it should have been resolved with cefepime.

However, the symptoms progressed even after using vancomycin.

Fine wrinkles appeared on Suhyuk's face.

"The patient's infection... seems to be getting worse."

Woo Hae-yoon, looking back and forth between the pad and Suhyuk's side face, spoke cautiously.

It wasn't a wrong judgment.

It was actually written in the current medical history.

"That's right. Even with meropenem (an antibiotic for super bacteria), it progressed... and eventually, amphotericin B (a broad-spectrum antifungal) was used."

This meant that all possible medications had been used.

Despite this, the patient's skin lesions continued to spread, and a day before admission, he went into shock and was brought to the emergency room of Taehwa Medical Center.

[Even with 100% oxygen, his oxygen saturation was not adequately maintained, so he was intubated and admitted to the ICU.]

‘What is this?’

[We need to rule out infectious diseases that can cause a full-body rash, but I want to see what the rash looks like first.]

‘Of course, right?’

To an untrained eye, the rash might just look like a patchy redness.

However, it could provide significant clues to determine whether the patient was infected with a specific bacterium, virus, or toxin.

But when he turned the page, the screen displayed the patient's past medical history.

"The patient has hypertension and Graves' disease, but both are well-controlled with medication."

Woo Hae-yoon, who had already tried to treat the patient several times, knew the past medical history by heart.

[Both past medical histories do not seem to have a close relationship with the current illness.]

Unfortunately, Baruda's judgment was that they were not related.

So, Suhyuk continued to turn the pages.

"The patient was already in shock upon admission, so there are no direct complaints."

As Hae-yoon said, the patient's review of systems, or the systemic examination, was empty.

Instead, the physical examination section was densely filled.

[Upon admission, blood pressure was 119/51, heart rate was 129, respiratory rate was 33/min, and temperature was 37.9, indicating an overall infection.]

‘The patient was confused... Ah, there's a spot photo.’

It seemed that this problem was based on a real case.

Several actual photos appeared, showing spots on the patient's arms, legs, and torso.

[The spots are clearly distinguishable from the surrounding skin.]

‘The sizes are all over the place.’

[There doesn't seem to be any area that hasn't been affected.]

‘Hmm...’

This was a non-specific finding.

Suhyuk, who had hoped that the spots would provide clues through his extensive data, couldn't hide his disappointment.

Woo Hae-yoon, feeling guilty about his sigh, apologized again.

"I'm sorry. I don't know if I'm bothering you on your day off."

"Huh? No, no. Anyway... This is quite interesting. I'm just really into it."

"Ah... Thank you for saying that. And you can speak informally now. You're older, after all."

"I'll do that when I feel comfortable."

Suhyuk said this and turned his eyes back to the examination findings.

[The breathing is rough.]

There was a description that the ribs were caving in when the patient breathed.

This meant that the breathing was so labored that all the muscles between the ribs were being used.

‘Both lung sounds are poor.’

[While pneumonia is not the cause of this infection, it could certainly lead to the patient's death.]

‘Right.’

The direct cause of death, especially in the elderly, is often pneumonia.

Whether the patient had cancer or another condition, pneumonia was the final event leading to death.

Woo Hae-yoon, who seemed to be stuck on this case, shook her head.

"Patients keep dying from pneumonia..."

"Ah, is it still showing 'Patient died' like in a flash game?"

"This was made by outsourcing to a game company at the director's request. My dad's hospital is also adopting it from this year."

"Ah... So it was made by a game company... No wonder..."

Now, they were looking at the results of already performed tests.

After finishing, they would be given choices.

What tests to perform, what treatments to administer.

The patient's condition would change based on these actions, and if they made a mistake, the patient would die.

[The blood test shows an increased white blood cell count, with neutrophils being the main component, indicating a bacterial infection.]

‘Why is the creatinine so high? Is the kidney failing?’

[The sodium level is also low. Given the shock, it seems that acute kidney injury has occurred.]

‘Is this meant to be a challenge for the students?’

[Director Lee Hyun-jong is truly a pervert.]

If a patient in this condition were brought to the emergency room, even among the current internal medicine residents, many would likely fail to save the patient.

And he gave this to a student?

Lee Hyun-jong was crazy.

‘That means I'll be the attending physician for such a person.’

[I will do my best to assist.]

‘That's not much of a comfort.’

[Let's solve this first. Consider it a practice run.]

‘Sure...’

Suhyuk, determined to tackle the task at hand, examined the test results again.

The patient had brought chest X-ray images from the local hospital, dated.

[It has progressed rapidly over the past four days.]

‘That's too fast. Considering the use of antibiotics... It's almost unbelievable.’

The patient's chest X-ray, which was normal just four days ago, had turned completely white.

"CT scans were also taken, senior."

"Really? Where?"

"Here. Chest and abdomen."

"Ah, they're in between. I almost missed them."

Suhyuk muttered this and examined the CT images.

[The chest CT matches the X-ray almost exactly. It seems to have been taken after the patient came to Taehwa Medical Center.]

‘In the abdomen... Could these all be lymph nodes?’

[They are irregularly enlarged, but do not appear to be malignant.]

‘Reactive lymph node enlargement appearing so extensively? Indeed...’

[It suggests a systemic inflammatory response.]

Actually, this could have been deduced without the CT.

The patient had a fever of over 38 degrees upon admission, a respiratory rate of 33 per minute, rapid heartbeat, and a high white blood cell count.

All of these were signs of a systemic inflammatory response.

"What could have caused this?"

Now, the important thing was to find the cause.

On the screen, a list of additional tests to be performed appeared.

From simple blood and urine tests to PET CT.

All possible tests that could be done at the hospital were listed.

‘Could they have implemented all these results...?’

Suhyuk looked at Hae-yoon with this thought.

Hae-yoon nodded quietly.

"Yes. Any test you select will show results... but if you spend too much time, the patient will die."

"Man. That means we have to be very careful with each test. Is there a budget limit or something?"

"No, there isn't."

"That's a relief."

Suhyuk, now fully immersed in the case, had forgotten that he was speaking informally.

[Given the suspicion of a severe infection, we need to identify the cause. I request blood cultures, sputum cultures and stains, and PCR for specific pathogens.]

‘Hmm.’

It was a reasonable suggestion.

If the tests listed above were done, the cause would be clear.

However, there was a problem.

Time.

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

‘Hmm.’

‘The patient will die in the meantime.’

Suhyuk had momentarily forgotten that this was just a test problem.

The case was that realistic.

‘We need to start treatment. Since meropenem didn't work, let's add teicoplanin. What do you think?’

[It's a reasonable choice.]

‘For the kidneys, we should start dialysis.’

[It seems to be a necessary choice.]

‘But...’

Suhyuk, tilting his head, turned the page forward again.

He stopped at the page with photos of the patient's rash.

‘There must be something more to discover here, right?’