Chapter 52
When Gain entered the hospital room with Eunjae, Lee Insook was half-reclining against the bed by the window, dozing.
The meal tray beside her was untouched.
She clearly had no appetite.
A common symptom of cancer.
"Aunt."
At Eunjae's voice, Insook opened her eyes.
She blinked and looked at Gain.
"Eunjae, you're here. Who's this?"
"Aunt, this is my director. The director of the clinic where I work."
Gain bowed politely.
"My name is Im Gain. I've heard a lot about you from Eunjae."
Lee Insook looked Gain up and down.
"My goodness. You're so young?"
"Aunt."
Eunjae lowered her voice in warning.
Gain smiled and changed the subject.
"May I examine your abdomen?"
"The professor already poked around this morning. Why does everyone keep touching it?"
Insook looked at Eunjae questioningly.
Eunjae gave a very slight nod.
At that moment, Gain felt a cool surge of divine power fill her chest.
It was the distinct feeling she got when a colleague acknowledged her.
Jo Eunjae was a colleague too.
"There's something I want to check."
Insook glanced at Eunjae again.
"...All right. Go ahead."
"Could you bend your knees for me?"
Insook bent them.
The tension in her abdomen relaxed.
Gain placed her hand on the lower right side first.
At first she pressed lightly.
Then slowly moved her hand.
Soon she slid her entire palm across the abdomen toward the left.
Then upward.
Her fingertips caught on something beneath the upper abdomen.
"Here. How does this feel?"
"It doesn't hurt. It just feels blocked."
Gain gently traced the area with her fingertips.
Then she moved along the edge of the mass.
Even when she followed it in a circle to the left and right, she could clearly feel a distinct boundary.
Hm?
A malignant mass usually did not feel like this.
She was being extremely careful because pressing a malignant tumor too hard could theoretically disturb surrounding tissue.
Yet this mass was clearly separated from what surrounded it.
The professor who rounded this morning said stage three or higher.
At stage three, there should not be only one clean mass in the abdomen.
On palpation, it should feel fixed and irregular, with poorly defined borders.
That was not what Gain felt.
She gently hooked her fingertips along the edge and nudged it sideways.
The mass moved.
Loose.
Mobile.
If cancer had spread and adhered to surrounding tissue, it should not have moved like that.
But she had more than two liters of ascites.
And her CA-125 was 840.
There were definitely signs pointing toward malignancy too.
Gain understood why the professor had called it stage three.
She thought for a moment.
Then decided to investigate several more things.
"Could you turn onto your left side for me?"
Insook groaned as she struggled.
Eunjae helped turn her.
When Gain palpated again with Insook lying on her side, she confirmed that the mass shifted slightly downward with gravity.
"You can lie on your back again."
After Insook returned to her original position, Gain stopped tracing the mass and moved her hand upward.
This time she did not press.
She swept lightly over the abdominal wall.
Across above the navel.
Then from side to side.
She was searching for the omentum, not the tumor.
Hmm. No omental thickening either.
Ovarian cancer often spread through the abdominal cavity like scattered seeds.
One of the first places those cells often settled was the omentum.
The omentum was a fatty apron hanging over the intestines.
When cancer infiltrated it, the soft thin tissue thickened and hardened.
It could often be felt under the palm.
And it did not move easily.
With two liters of ascites, I should be able to feel an omental cake if this were stage-three ovarian cancer.
Gain pulled the patient's gown down and removed her hands.
Then she opened the curtain.
"Aunt, how much are you eating these days?"
Insook glanced at the meal tray.
Gain and Eunjae looked there too.
Only a single spoonful of rice had been scooped.
The bowl itself was still nearly full.
Even that spoonful was still sitting on the spoon.
Nothing else appeared touched.
"I have no appetite at all."
Insook sighed.
"I feel full after just a few bites."
Eunjae's eyes filled with tears.
She looked ready to say something.
Gain asked first.
"This has been going on for several months?"
"Yeah. But my stomach feels full all day. Strange, isn't it?"
Gain nodded.
"May I ask you something else?"
"Have you ever had a sudden episode of severe abdominal pain?"
"Oh, yes. Once."
Insook pointed toward the upper abdomen.
"When I was leaving after signing that contract in Shanghai, this whole area suddenly clenched."
"I thought I was going to die walking down the stairs."
"How long did it last?"
"Maybe an hour?"
"I had been arguing with the factory manager all day, so I figured my stomach was upset."
"And after that?"
"Nothing."
Insook waved a hand.
"I've been fine ever since. Doesn't even hurt."
She looked at Eunjae.
"This girl is treating me like I'm on death's door, but I was working until yesterday."
Gain glanced at Eunjae.
Eunjae was also staring at her.
She understood exactly where Gain's questions were leading.
At that moment, the curtain opened.
A familiar face appeared.
Han Seongyeon stood there holding a chart, her expression stiff.
Behind her were a fellow, residents, an intern, medical students, and nurses.
They appeared to be making afternoon rounds.
Han Seongyeon spoke sharply.
"If you want another hospital's doctor to examine you, why don't you just discharge and transfer there? That would be cleaner."
Gain answered calmly.
"I'm here visiting someone I know."
"Han Seongyeon! Why aren't you making rounds?"
A familiar voice came from behind.
Then,
"Oh, Gain?"
Professor Kim Dohyeon appeared.
He had supervised Gain's OB-GYN rotation when she attended the Second Campus.
"Professor, it's good to see you."
"I heard you opened your own clinic and it's doing well. Congratulations."
"Thank you."
"You know this patient?"
"The patient's guardian is one of the nurses at my clinic."
Kim Dohyeon looked at Jo Eunjae, then back at Gain.
"I was on duty when this patient came into the emergency department yesterday."
"I was planning to transfer her to the main hospital's gynecologic oncology department tomorrow."
Gain looked at him.
"Professor, I have a different opinion."
Kim Dohyeon crossed his arms.
"There are no peritoneal nodules on CT, and no omental thickening."
"I couldn't palpate an omental cake just now either."
"The mass moves when pushed sideways, and it shifts downward when her position changes."
"She has two liters of ascites and a CA-125 of 840."
Kim Dohyeon frowned.
"There's even a pleural effusion."
"You think the oncology team called it stage three for no reason?"
"I saw the pleural effusion."
Gain nodded.
"There's a small amount on the right."
Kim Dohyeon narrowed his eyes.
"And you're still saying that?"
"The omentum and peritoneum are too clean."
"If we can check the cytology result, I think we'll know more."
Gain continued with her reasoning.
"She said she becomes short of breath when lying flat."
"Not long ago, she had severe epigastric pain that lasted about an hour and then disappeared on its own."
"I think she may have had partial torsion that resolved spontaneously."
Ovarian torsion occurred when the ovary twisted around its supporting pedicle.
The blood vessels inside the pedicle twisted as well.
The pain could begin suddenly and disappear just as suddenly if the ovary untwisted itself.
A cancer mass firmly rooted into surrounding organs could not easily torsion.
It was too fixed.
Kim Dohyeon looked at Han Seongyeon instead of answering.
"A fibroma?"
"Meigs syndrome is also possible."
Gain explained,
"That would also explain the elevated CA-125."
Meigs syndrome involved a benign ovarian tumor, usually a fibroma.
Fluid leaked from the tumor and collected inside the abdomen.
Sometimes that fluid passed through small openings in the diaphragm and entered the chest.
When pleural fluid occurred, it was often on the right side.
Kim Dohyeon held out his hand.
Han Seongyeon immediately gave him the chart.
He stared at the CT report.
"When does the cytology from the ascites tap come back?"
"This afternoon."
"Go to pathology and confirm it right now."
Han Seongyeon's expression changed subtly before she left.
That was clearly an intern's job.
But Kim Dohyeon had ordered Han Seongyeon herself to go.
The intern stood behind them looking awkward.
Kim Dohyeon turned back to Gain.
"You thought this through well."
Then he added,
"The differential diagnosis on that other patient you sent us was good too."
Gain felt the cool rise of divine power again.
"So you're saying I don't have cancer?"
Lee Insook asked.
Kim Dohyeon softened his voice.
"We're checking that possibility."
"The result we're waiting for should help us know for sure."
"I've got too many orders coming in. I need to get back to the factory."
"Work matters, but you need to be healthy enough to do it."
Han Seongyeon came back panting.
She looked out of breath.
"No malignant cells were found in the ascitic fluid."
The corner of Kim Dohyeon's mouth lifted.
"Director Im."
He looked at Gain.
"Become an adjunct clinical professor."
"What?"
Gain stared at him.
It was completely unexpected.
"I heard you put up a banner saying you're starting deliveries."
"Yes. Starting next week."
"We currently have five deliveries scheduled."
"We don't have enough deliveries here anymore."
Kim Dohyeon sighed.
"Our students don't have enough places to train."
"One hospital stopped doing deliveries, so we lost a training site."
"Starting next semester, I'll send groups of third-year medical students to your clinic."
"You can supervise them."
Gain's clinic had only been open for a short time.
The delivery-unit construction was not even finished yet.
It still felt too early to take students.
But by next semester, she could prepare.
"Sending students to a private clinic that's only been open for half a year..."
Han Seongyeon muttered from behind them.
Kim Dohyeon turned his head.
"If she were like you, I wouldn't send them."
Then he said flatly,
"But Gain is good with patients."
Han Seongyeon's ears turned bright red.
The residents, interns, nurses, and students gathered for rounds all pretended they had not heard anything.
Kim Dohyeon looked back at Gain.
"So, Director Im."
"What do you think?"
