Chapter 47: Making it Harder? (3)

'Patient Death'.

On the white background of the PPT, only these four characters were written.

After displaying the screen, Suhyuk slowly looked around the lecture room.

The faces of the students who had led the discussions in their groups, looking sharp and capable, were now crumpled as if it was to be expected.

Most of them had expressions of complete disbelief.

They probably thought Suhyuk was being unreasonable.

'What is it? What did I miss?'

Of course, there were students who didn't think so.

Uha Yoon, having heard about Suhyuk's skills through various channels, would naturally trust his opinion.

Even yesterday, he had solved a case where all the students had given the wrong answer, leading to the patient's death, with clear logic.

'I must have missed something.'

But a good attitude didn't make the answer visible.

After observing the confused lecture room for a moment, Suhyuk spoke.

"It seems you don't understand. Is that right?"

"Yes, that's correct."

In response to his words, a student sitting at the front, like Uha Yoon, immediately answered.

His bright eyes seemed to reveal his good grades.

'This is a good time.'

After a month of internship, that stiff white coat and attitude will be crumpled.

While thinking this, Suhyuk continued.

"Then I'll explain it step by step. First, you all concluded that this patient had pulmonary edema. Right?"

"Yes."

"Then, what do you think caused pulmonary edema in this patient?"

"Hmm."

There was a necessary process in diagnosing a disease.

The process of pondering, 'Why did this disease occur?'

But the students were not familiar with this process.

The problems they had been solving so far were about diseases, not about specific patients.

To improve this, Director Lee Hyun-jong introduced PBL, but it was still in its infancy.

Seeing the students at a loss for words, Suhyuk continued with a knowing look.

"First, the patient has diabetes. The treatment is vildagliptin. It's not a commonly used drug because it's less effective than others. From this, we can infer one fact: 'The patient must have had some kidney dysfunction.' If you look at the test results you provided earlier..."

Suhyuk flipped back the screen.

The results of the tests the students had provided were written out in one stroke.

Among them were BUN and Creatinine, which were 52 and 2.7, respectively, indicating an increase.

"We can consider kidney dysfunction."

"Then... Is the pulmonary edema due to that?"

"No. The patient's kidney dysfunction is not a recent issue. It has been years since the diabetes medication was changed. This is mentioned in the current medical history."

"Oh... Then... What is it?"

The student's eyes were now much dimmer.

He lacked confidence.

On the other hand, Professor Lee Hyun-jong's eyes were sparkling.

'He's weaving a good story. Could this be a real patient case? Where did he get it from? Originally... Originally, it must have been a case he knew.'

If so, it meant that Suhyuk studied an incredible amount.

Naturally, a pleased smile appeared on Lee Hyun-jong's face.

The thought of stepping in if things didn't go well had long disappeared.

"Think carefully. This patient has had diabetes for over 10 years. Of course, the treatment was received at another hospital, so there are no records. If you were an internal medicine doctor and saw this patient for the first time, what would be your first thought?"

Suhyuk deliberately asked, looking at Uha Yoon.

He believed that as the daughter of Professor Woo Chang-yoon, a professor of endocrinology, she should know this much.

Fortunately, Uha Yoon was a very diligent student, regardless of the reason.

She wasn't the type to miss such a straightforward question.

"Oh! Complications!"

Sadly,

The biggest risk factor for diabetes complications is the duration of diabetes.

While many people manage it well,

Diabetes is a disease that often shows no symptoms.

Often, people don't even realize they have diabetes.

"Yes. Complications. A problem that must be considered. Moreover, what medication is the patient currently taking?"

"Vildagliptin!"

"Yes. The kidneys are already damaged. What does this imply?"

"Oh..."

Diabetes complications are numerous.

But the two main areas of focus for testing are the kidneys and the eyes.

If the kidneys are damaged, it's reasonable to assume the eyes are also at risk.

The blood vessels involved in kidney function are generally larger than those in the eyes.

If the larger ones are damaged, it's logical to assume the smaller ones are already damaged.

"Vascular damage..."

"Yes. It means the patient's blood vessels, regardless of which ones, are damaged. You know why vascular damage occurs in diabetes patients, right? You're in your fourth year of medical school."

"Yes."

"Let's go back to the beginning. Why did the patient develop pulmonary edema?"

It was the exact same question as before.

The exact same question about the same patient.

But now the students could finally recall that the patient had had diabetes for a long time and might have complications.

With this in mind, different answers started pouring in.

"Worsening of kidney failure?"

"No, no, heart failure?"

"Right ventricle?"

Suhyuk nodded at the answers coming in from all directions.

"Good. What tests would you need to confirm this? Tell me what additional tests you want to add to the ones you've already done."

He pointed to the test items the students had provided.

If an intern had done this, they would have been eager to add more tests.

Something was missing from the routine.

They had learned routines in the university hospital to reduce errors.

There would have been prescriptions they had been giving without knowing why.

But the students had only just thought of these tests.

"Electrocardiogram!"

Uha Yoon was the fastest.

Suhyuk nodded with a satisfied smile.

"Good. Electrocardiogram. Anything else?"

"Since we suspect heart failure, we also want to add an echocardiogram."

"Good."

This was followed by blood tests to identify myocardial infarction, such as cardiac muscle enzymes.

Suhyuk wrote all these tests on the PPT and even wrote down the results.

'Is he really a genius?'

Watching this, Lee Hyun-jong couldn't help but tilt his head.

He realized that Suhyuk hadn't looked at anything since the lecture began.

This meant he was reciting everything from memory.

It was hard to understand logically.

[CK-MB is 49.1.]

[Troponin-I is 34.]

Of course, Suhyuk didn't memorize all of this.

Baruda had recorded everything.

'Good. CK?'

[635.]

'Good job.'

In this way, Suhyuk laid out the test results.

The cardiac muscle enzymes, which can rise during a myocardial infarction, were significantly elevated.

The T-wave on the electrocardiogram was inverted, another important indicator of myocardial infarction.

Only then did the students face the most critical issue causing the patient's pulmonary edema and leading to death.

"It was a myocardial infarction..."

"The echocardiogram also shows abnormal wall movement..."

Suhyuk looked at the murmuring students with a faint smile.

"Yes. The patient has a myocardial infarction. What treatment should be done?"

While looking at Professor Lee Hyun-jong, who was standing in the corner smiling.

This was a huge hint for the students.

"Coronary angiography and stent insertion!"

"Correct. Let's see how it goes."

Suhyuk immediately displayed the angiography image.

To an untrained eye, it might look like all three coronary arteries were fine.

But someone with a little knowledge would see that the left anterior descending artery, the most important coronary artery, was blocked.

"By opening this with a stent... the patient will survive."

After showing the stent procedure, Suhyuk turned to the front again.

The students who had followed Suhyuk's lead were sitting there.

At first, some of them had wondered who he was.

Now, they were all overwhelmed.

It was such an engaging lecture, and it was also very realistic.

No one spoke until Suhyuk opened his mouth again.

"Then, what can we learn from this case?"

Even after asking the question, no one spoke.

After about five minutes, someone slowly raised their hand.

It was Lee Hyun-jong, not a student.

"In long-term diabetes patients, chest pain, a symptom of myocardial infarction, can be absent. Right?"

Who could argue with the director?

Especially when he was a world-class expert in coronary angiography.

Suhyuk nodded quickly.

"Yes, that's right."

"Hmm. It's a very important point. In fact, many cases have missed the golden hour this way. Even your seniors have done this."

As he said this, Lee Hyun-jong turned to the students.

Naturally, the focus of the lecture shifted from Suhyuk to Lee Hyun-jong.

"Long-term diabetes doesn't just damage blood vessels. Well, ultimately, it's about blood vessels. The blood vessels that supply the nerves are also damaged. This makes the patient less sensitive to pain. Especially for internal organs, which are already less sensitive, the pain can almost disappear. Do you understand?"

The students could only swallow hard.

Lee Hyun-jong continued, addressing the slightly frightened students.

"Like you did earlier, thinking, 'Oh, no chest pain! It can't be a myocardial infarction.' and missing the patient. This happens often. Here, Teacher Suhyuk has taught you something very important for your medical career. The symptoms the patient describes are important, but relying on them absolutely can lead to big mistakes. Basic tests are called basic for a reason. Understand?"

"Yes."

"But what are you doing? Not clapping? Did I give this lecture? It was Teacher Suhyuk."

"Oh, yes!"

"You deserve applause. I didn't know you could do this well, really."