Chapter 112
Chapter 112
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Translator: crow
Chapter Title: Psychosis or Not? (2)
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The automatic doors slid open with a hiss.
I strode into Zone B, where Kim Ji-hoon was standing.
"Ji-hoon!"
Kim Ji-hoon had just set down the handset and turned his head.
"Yeah, what's up? I just called the on-call psychiatrist. They said they'd give Ativan first, wait for her to calm down a bit, then come check her out."
"Cancel the call. Or at least hold off."
"What?"
Kim Ji-hoon looked utterly baffled.
"This might not be psychiatry. Could it be HSV encephalitis?"
"HSV? Herpes encephalitis?"
Kim Ji-hoon's eyes widened.
"Encephalitis out of nowhere? Her fever's not even that high. 37.8°C could just be from her agitation."
"No, check the EMR. She was in our ER three days ago with flu-like symptoms. Fever, sore throat."
I quickly reviewed the textbook knowledge in my mind.
Herpes encephalitis.
It starts like a cold with fever, headache, sore throat, then a few days later suddenly personality changes, hallucinations, seizures—a deadly disease.
High mortality rate, and delayed treatment leaves permanent brain damage. It's an emergency.
"Flu three days ago. Acute delirium today. Textbook viral encephalitis prodrome."
Kim Ji-hoon's expression turned serious at my words.
"Hmm... Yeah, when you put it like that. If it's encephalitis and we send her to psych, we're screwed."
"Yeah. So let's run the full workup. Brain CT first to rule out bleed or mass, then LP right away. MRI too, but... wait times..."
I glanced at the station monitor's MRI queue.
[7 waiting]
Even as an emergency push, it'd take a while.
"CT first, add labs for viral markers and inflammation. Maybe start empiric acyclovir..."
With that, we pulled back the curtain around the patient's bed.
For additional neuro exam.
Swish.
But...
"...Huh?"
Kim Ji-hoon froze.
"She's awfully quiet now?"
The bed was silent.
Just moments ago, she'd been screaming about ghosts, thrashing like a maniac trying to chew through the restraints. Now she was limp, snoring softly in sleep.
Ativan 4mg.
Enough to knock out a grown man.
"Yeah... she is..."
I muttered while checking her pupils.
Breathing steady, pulse down from 120s to 90s and stable.
The meds had kicked in.
"Benzos working..."
Kim Ji-hoon let out a sigh of relief.
"If it's encephalitis, her brain's swelling like crazy. Does Ativan just mellow that out? Don't temperament issues usually not respond to sedatives?"
"Acute seizures do respond to benzos."
I was starting to second-guess myself.
Encephalitis patients sleep from sedatives too.
Acute or recurrent...
Screw it.
"Just acute psychosis? Transient?"
Kim Ji-hoon eyed me.
Over-treatment?
But that flu note from three days ago nagged at me.
I looked down at the sleeping patient's face.
Hair matted with cold sweat.
Pale skin.
Eyelids trembling faintly.
Just crazy? Or brain under attack?
"Still."
I made the call.
"CT it is. When she wakes, consent for LP."
"Yeah, gotta do it."
Kim Ji-hoon grumbled but pulled up the order screen.
I tucked the blanket over the sleeping patient, thinking.
*Please let me be overreacting.*
***
I watched the monitor, then scrutinized the patient's face.
Her lips were moving on their own.
Chewing gum-like smacking, tongue flicking—too rhythmic, too mechanical for a sleep habit.
*...Orofacial dyskinesia.*
A ominous term surfaced in my mind.
Usually a side effect in schizophrenics on long-term antipsychotics.
But the family said no meds ever.
Acute abnormal movements without drugs?
Doesn't add up.
Vitals were all over the place too.
Temp dropped from 37.8°C to 36.5°C, then spiked to 38.2°C.
Fever up, down.
BP shooting to the moon, then crashing near shock. Eerie.
Like autonomic nervous system gone haywire.
"Damn... ugh..."
Sketchy.
Too complex for plain HSV encephalitis.
But too organic for psychosis.
My head was a tangle when the ER doors opened. A white-coated guy walked in.
"Psych on-call. You paged?"
Joo Jeong-hyun, second-year psychiatry resident.
Same year as me, but we rarely crossed paths. Calm vibe.
"Yeah. This patient's a 20s female. Acute delirium, visual/auditory hallucinations, paranoia. Ativan 4mg, settled now."
Joo Jeong-hyun gravely checked her lip movements and the monitor.
His brow furrowed.
"History clean except flu three days ago?"
"Yes. PMH, FH, meds—all negative."
"Hmm..."
He pulled a penlight, checked pupils.
Stared at her lips for a long beat.
"Lip movements? No meds, right?"
"Family and our records say no."
Joo Jeong-hyun scratched his head awkwardly.
"Could be first-episode schizophrenia or brief psychotic disorder... but the vitals swings and dyskinesia bug me. Plus the flu history."
I glanced at him cautiously.
"Neuro consult?"
"Hmm..."
He rubbed his chin.
I laid out the plan.
"Brain CT first. When she wakes, consent for CSF. We'll do that in ER before sending up. Gotta rule out encephalitis/meningitis."
"Sounds good. If imaging and CSF clean, we admit for psych. Keep organic psychosis on the table for now—appreciate it."
Solid reasoning.
Image the brain, tap the spine.
*Encephalitis, encephalitis...*
HSV?
Usually hits temporal lobes—memory loss, seizures. Not weird mouth moves or BP rollercoaster. Atypical?
Frustrating.
Missing puzzle piece.
What the hell turned this young woman mad?
While Joo Jeong-hyun interviewed the family, I fired up my one escape.
[Burnt-Out Doctors Gallery]
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20s F, encephalitis suspicion but symptoms weird
Posted by: HellJoseonSlave1
20s F. Flu 3 days ago. Acute delirium + hallucinations today.
Ativan sleeping, but lips smacking nonstop.
Fever up/down, BP all over.
HSV workup but feels off.
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Comments poured in from the bored ghosts.
[Comments]
Anonymous (210.94): Possessed. Needs an exorcism lol.
ㄴ HellJoseonSlave1: You're the ghosts, you ghost doctors. Get serious.
ㄴ Anonymous (210.94): Chill, it's a joke.
HippocratesHeir: Hmm. Curious. Drug side effect?
ㄴ HellJoseonSlave1: No drugs.
LatteIsHorrible: HSV hit autonomic that hard? Usually seizures/LOC main. Lip smacking unique.
NRNRNR: Limbic encephalitis? Autoimmune. Young F—rule out lupus encephalitis. ANA, dsDNA sent?
ㄴ HellJoseonSlave1: Not yet. Adding.
Speculation flew: viral, autoimmune, metabolic...
No clear "aha" answer.
Then one comment grabbed me.
Anonymous (118.235): Abdomen CT go.
"...Abdomen?"
I frowned.
Head's nuts, scan the belly?
BS.
ㄴ HellJoseonSlave1: Head's messed up, dude. Don't wanna get dinged by insurance review.
Immediate reply.
ㄴ Anonymous (118.235): Ovarian teratoma ring a bell?
"......"
Ovarian teratoma?
ㄴ HellJoseonSlave1: Know it. So what? Not OB/GYN.
ㄴ Anonymous (118.235): Anti-NMDA receptor encephalitis. Know it?
ㄴ Anonymous (118.235): Usually from antibodies in young F ovarian teratoma. Symptoms match perfect. Flu prodrome, psych, dyskinesia, autonomic instability.
"Ah...!"
Hammer to the back of the head.
Anti-NMDA receptor encephalitis.
Autoimmune encephalitis.
Immune system attacks brain's NMDA receptors.
Culprit often ovarian tumor—teratoma—producing the antibodies.
Normal person suddenly rages mad, bizarre movements, gasping death.
The one mistaken for demon possession, leading to failed exorcisms and deaths.
Every puzzle piece clicked chillingly perfect.
I shot up.
Joo Jeong-hyun was back from family talk.
"Psych doc!"
"Yeah. Family consents to proceed..."
"Brain CT, and add pelvic CT too."
His eyes bugged out.
"Pelvic? Why abdomen all sudden...?"
Psych patient—or neuro—sudden abdomen CT?
Sounded insane.
But I met his gaze with conviction.
"Checking for teratoma."