Chapter 113
Chapter 113
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Translator: crow
Chapter Title: It's Not Psychosis (1)
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“I need to check if it’s an ovarian teratoma.”
“What? Ovarian? Teratoma?”
Joo Jeong-hyun’s eyes went wide.
It was a perfectly natural reaction.
Telling a patient who was complaining of auditory and visual hallucinations and acting out that you were suddenly looking for a gynecological issue like an ovarian mass? You’d deserve to be called crazy.
“Yes.”
“But... I mean, it’s not technically impossible to scan all the way down while doing a brain CT with contrast... but radiology won’t approve it without a good reason. There’s the reimbursement issue too...”
Joo Jeong-hyun still looked unconvinced.
I glanced around and lowered my voice to a whisper, just loud enough for him to hear.
“I think it’s anti-NMDA receptor encephalitis.”
“What? NMDA encephalitis?”
Joo Jeong-hyun froze.
It used to be misdiagnosed as schizophrenia or demonic possession, locking countless patients away in psych wards or killing them.
But in reality, it’s an organic brain disease caused by autoimmune antibodies attacking receptors in the brain.
“The clinical symptoms match too perfectly. Like the lip-smacking you saw earlier, or the severe autonomic instability.”
I rattled off the points that the gallery’s anonymous user had pointed out.
“For a primary psychosis, the vitals are way too unstable. And you know one of the most common causes is antibodies from an ovarian teratoma, right?”
“Ah...”
Joo Jeong-hyun finally nodded.
His doubt hadn’t turned to certainty, but he’d at least reached the stage of reasonable suspicion—worth investigating.
“I see. We need to rule out paraneoplastic syndrome...”
“Yes, exactly.”
I checked my watch.
“NP doctor, this... the scans and results will take a while. You can head back up to the ward. No need to stick around here when you’re busy. It’s fine.”
“Oh, no. I’d have to come back down anyway if there’s a call... um...”
Joo Jeong-hyun hesitated.
He seemed worried about something going wrong during the tests.
“We’re suspecting a neurological cause right now, and even if the scans come back clean and it turns out to be psychiatric after all, admitting her will take time. I’ll take responsibility and handle the full workup.”
He let out a sigh of relief at my words.
Why would he say no to another department’s doctor digging this deep into an organic cause?
“Ah, okay... I’ll head up then. Call me if anything happens.”
“Yes, thank you.”
The moment Joo Jeong-hyun disappeared toward the elevators, I collapsed into the station chair.
“Phew... bought some time for now.”
First things first: order the CT.
Tap tap tap.
If anyone bitches about a pelvic CT on a psych patient, I’ll shove “r/o Anti-NMDA Encephalitis” right in the notes.
After hitting enter, another worry hit me.
“Should I start acyclovir... hmm...”
NMDA encephalitis was strongly suspected, but not confirmed.
The scariest thing in the ER is fixating on one diagnosis and missing the real culprit.
What if it’s not NMDA but herpes encephalitis?
HSV encephalitis worsens the longer treatment is delayed—the brain literally melts faster.
High mortality, severe sequelae.
“If encephalitis is possible, starting antivirals is standard...”
I was glaring at the monitor, tearing at my hair, when—
“Hey.”
Kim Ji-hoon had finished with another patient and sidled up next to me.
“What’s this? That psych patient from earlier? Why abdomen and pelvis?”
To Kim Ji-hoon, it probably looked like over-testing.
Imaging the belly for a headache patient.
Health insurance review board would foam at the mouth.
“Shut up. You’re breaking my concentration.”
“Come on, you lunatic. There’s gotta be an indication. Does the patient have belly pain?”
Kim Ji-hoon thumped his chest in frustration.
“Fine, what is it? Spill.”
He wouldn’t let go.
“You see The Exorcist?”
“What’s with the random movie talk?”
“You know the theory that the possessed girl wasn’t demon-possessed but sick?”
“You mean NMDA encephalitis?”
Oh, Kim Ji-hoon wasn’t a total meathead.
My internal rating of him went up a notch.
“Yeah, that. Know what causes over half of those cases?”
“What?”
“Ovaries teratoma. That’s why we scan the belly.”
Kim Ji-hoon’s jaw slowly dropped as he listened.
...
“Whoa... goosebumps. You a genius?”
“Yeah, genius.”
Thanks to the gallery anon bros.
“Anyway, that’s why. Or... whatever, eat some shit for over-testing.”
“Worth a shot.”
Kim Ji-hoon nodded.
Then he spotted the drug search window in the corner of the monitor.
“But acyclovir? Starting that too?”
“Yeah. That’s the dilemma. Looks like NMDA, but if it’s HSV, every minute without meds is brain cell damage.”
Kim Ji-hoon crossed his arms, pondering seriously.
“Start it.”
Short and decisive.
“Why?”
“It’s a numbers game. If it’s NMDA and we give acyclovir, just stop it. Costs a bit, mild kidney strain, but no big deal. Pump fluids generously anyway.”
Crystal clear.
Our golden rule.
Cover the more dangerous possibility first.
When diagnosis is uncertain, treat toward the lethal diseases first.
“Okay.”
I nodded and hit enter.
“Cover shots till CSF results.”
“Good.”
And so ended our badass strategy session.
Dice are rolled.
Please, CT machine, find that teratoma in her gut.
***
“Hey.”
I opened my mouth, staring blankly at the monitor.
Ten minutes since the orders went in.
“What.”
Kim Ji-hoon gave a half-hearted reply while sorting charts next to me.
“No matter how I think about it, the acyclovir was the right call.”
“Right?”
Kim Ji-hoon agreed.
“PCR results take forever anyway. Even after LP to the lab, no instant results.”
“Yeah.”
We reaffirmed our decision was solid, trying to shake off the anxiety.
“Calling neurology first.”
I picked up the receiver.
We’d aligned with psych’s Joo Jeong-hyun, but neurology consult was mandatory for suspected organic brain disease.
If it’s encephalitis, they’d admit and take primary.
Riiiing.
Long signal tone.
Either dodging, swamped...
...
Or in the bathroom.
[Neurology on-call, Hwang Joo-hyuk.]
Irritable voice.
Already off to a bad start.
“Hello, doctor. This is Han Hyun-jae, second-year EM resident. Calling for a consult on a patient. 20s female with acute psychosis and autonomic instability...”
I briefed symptoms, treatments so far, and our suspicions: anti-NMDA receptor encephalitis and HSV encephalitis.
Cold response.
[...And? You do imaging?]
“Down for it now. Images coming soon.”
[LP?]
“Patient still sedated, no CT yet, couldn’t do it.”
[Haa... doctor.]
Deep sigh over the line.
[No objective data at all. No CT, no CSF, no MRI. Should’ve called psych first.]
“NP saw her already, prioritized organic causes...”
[Call back with data then. No images? What consultation is this? Wait for CSF and call again. Hanging up.]
Click.
Line dead.
“...”
I stood there blankly, receiver in hand.
From neurology’s view, scant evidence.
But that attitude and tone? Unacceptable.
What’s so hard about being civil?
“...Asshole.”
I slammed the receiver down.
“Got rekt?”
“Yeah. Call when all results are in. Acts like royalty.”
“Who’s neuro on-call?”
“Hwang Joo-hyuk.”
“What? Not Kim Na-jeong today?”
“That’s what the schedule said, but it’s Hwang, fuck.”
We turned back to the monitor.
Right then—
Ding-dong.
Cheerful alert.
“Ah, CT’s up. Brain first.”
Double-clicked Brain CT tab. Black-and-white slices filled the screen.
I scrolled through ventricles, parenchyma, vessels meticulously.
...
Clean.
Too clean.
Hemorrhage?
None.
Infarct?
Nope.
Tumor?
Nada.
Edema?
Sulci sharp, no swelling.
“Nothing... Hey, Ji-hoon!”
“What?”
“Come look. What do you see?”
Kim Ji-hoon shoved his face to the screen, scrolling up and down.
“...Nope. Looks totally normal to me. Healthy 20s brain.”
We sighed in unison.
Expected, really.
“CT often shows nothing anyway. Most cases normal on CT. Need MRI for details.”
Kim Ji-hoon crossed his arms.
“CT’s for bleed or big mass rule-out, not encephalitis confirmation...”
Ding-dong.
Second alert.
“Whoa, abdomen’s up!”
I cut him off, mouse flying.
“Damn, let a guy finish—huh?”
Kim Ji-hoon stopped mid-grumble.
I froze too.
Pelvis CT on screen.
Our eyes locked on the same spot.
As if by agreement.
Both sides of the uterus.
Where the ovaries should be.
Something that shouldn’t be there.
Massive lump at right ovary site.
White calcified lesion gleaming, mixed with dark fat components.
Grotesque, like another creature growing in her belly.
Tumor with teeth and fat.
Exclamation burst from me.
“Hey, this is...”
Kim Ji-hoon’s mouth gaped.
“Teratoma. Holy shit...”
That’s the bastard.
Spewing antibodies, attacking her brain.
Not possessed.
Demon was hiding in her lower abdomen, not her head.
“Found it.”
I clenched my fist.
Shivers ran up my spine.
We’d nailed the cause.