1. The Pilot

    ‘Get over it, Jax.’ 

    He was always so dramatic.

    ‘Nobody cares about what you wear today.’

    He shrugged upset. It was our first day at Brooklyn Hospital, but we knew each other way before that. We were both from Chicago, went to the same high school and college, but different medical schools. And now, we were roommates in New York. We had just got into residency, me in internal medicine, he in pediatrics.

    ‘Just let me be, Lisa.’

    The reception was actually pretty exciting. The staff seemed happy to welcome the new residents. Everybody had their white coats on, still, I told Jax he nailed his outfit.

    ‘You’re forgiven.’ He smiled and whispered. 

    ‘Good, ’cause we’re gonna need each other today.’ I sighed in relief and he suppressed a nervous laugh.

    As great as all the food and welcome smiles were, it was also overwhelming.  Each first-year resident would be assigned 10 patients as of that day, the on-call schedule was already on the whiteboard, and the classes’ calendar was set up.

    After the hospital tour and instructions, each of us was assigned to a certain ward. So Jax took off to the pediatrics ward after giving me a wink and mouthing ‘break a leg, nerd’. We were instructed to see our patients in the following two hours and meet at the conference room at 11 AM, where we would meet our attending.

    I had just arrived at my assigned ward when a nurse popped up in front of me. 

    ‘Dr. Diaz, welcome! You have an admission in room 4.’

    She said that and disappeared so fast I didn’t even get to thank her, she just dropped the chart on my hand and left. I was excited and a little anxious. It was not my first time at this, of course, I had seen hundreds of patients in my clinical years. But some patients always feel like the first time all over again.

    I quickly skimmed through the chart. Shea Lewis, 32 years old. Something about a seizure that was already under control. Apparently, low sodium was the cause and now she was getting NaCl replacement. Okay, I could handle that, it didn’t seem too complicated. At least the woman didn’t have 235 comorbidities.

    I went into the room and greeted the patient. She looked healthy and well, a good-looking caucasian woman in her thirties. I asked her the primary questions, name, age, profession, just for the sake of it. I have to admit I never understood the point of all this though, her name was on the chart for God’s sake, and who cared what she did for a living? Anyway, protocol.

    I asked her every pertinent thing that I could think of and examined her. I found nothing out of the ordinary, except that she was a little hypotensive, probably because of the low sodium. She denied any medical problems. No fever, no headache, no epilepsy, no nothing.

    ‘I’m fine, doctor. I don’t have any problems at all. Well, except that my hair is falling like crazy if that counts as a health problem.’ She smiled.

    Great, who doesn’t have hair shedding anyway, I thought. When I was almost exiting the room, she called me out.

    ‘You know, actually, I have been feeling tired these past months I guess.’

    ‘Okay, thank you, Mrs. Lewis.’

    I left the room. Dear God, I still had nine patients to check on. I wondered if Jax was doing fine in peds. He probably was, kids always loved him, almost just as much as they hated me. Maybe that’s why I went with adults, they didn’t love me, but they also didn’t have such a harsh opinion of me. More like a neutral, ‘she is okay.’ That was enough for me then, I guess.

    After checking on the other patients, I found a guy already in the conference room. He was tall, blond, probably my age, and seemed like the nice guy type. Too nice, I’d say. He only noticed my presence when I sat down at the table, then he looked at me and smiled.

    ‘Hi, are you with doctor Collins? I’m Peter, by the way.’ He shook my hand.

    ‘I’m Lisa Diaz. And yes, I’m with her too.’

    ‘Oh sure. Allen, I’m Peter Allen.’ He smiled.

    I checked my watch, 10:55 AM, just in time. We sat silently while I read my notes and he stared at his fidgeting hands. At exactly 11 AM, Dr. Collins walked in, I recognized her from the Hospital Staff’s photos. Brown hair in a loose bun, light skin, and a peaceful expression. I liked her already. 

    ‘You must be my new residents! Welcome, I hope we can learn a lot together. I am Lucy Collins, your attending.’ She extended her hand to greet us.

    ‘I am Lisa Diaz. It’s a pleasure to meet you, Dr. Collins.’

    ‘Peter Allen. Nice to meet you.’ He shook her hand after me.

    ‘Well, the first day is always a bit more crowded, so let’s get started. One of you presents a case and we all discuss it, okay? I don’t do monologues.’ She smirked. ‘I really do want to know what you’re thinking about the cases. It’s the only way we can help each other. Who wants to start?’

    ‘I’ll go first.’ I said. I could feel the butterflies on my belly, so I decided to just get it over with. 

    ‘Okay. Start by telling me who the patient is and why he is here. Then tell me your findings in history, physical exam, and initial assessment.’ 

    ‘Shea Lewis, 32 years old female, previously healthy, came to the emergency department today because of a prolonged seizure. On her initial workup, it was found that she had significant hyponatremia, which probably caused the seizure. Then the appropriate NaCl replacement was started to increase her Na+ levels by 10 mEq/day. The patient denies any previous medical conditions or seizures but admits to fatigue and constipation in the past 4 months.’

    ‘Hum, I see.’ Dr. Collins said, ‘Anything else?’

    I thought about what was missing in my presentation and couldn’t find anything. So I decided to tell her whatever extra info came to mind. ‘Mrs. Lewis has a child and denies any family history. Oh, and she is also experiencing hair loss. Her physical exam showed low blood pressure, and the lab workup showed mild hypoglycemia. Her tox screen is clean and right now she is waiting for the EEG and CT scan.’

    ‘Okay. Now, what do you think is happening with Mrs. Lewis?’

    ‘Well, I believe she may have adrenal insufficiency.’

    ‘Good thinking. That does explain some of her symptoms and findings. In fact, her whole case points toward hormonal problems. Do you agree, Dr. Diaz?’

    ‘I do.’

    ‘Then what other information can we gather from the patient to assess her hormonal balance?’

    I started to go through my endocrinology notes on my mind when Peter cleared his throat and said ‘We could ask her about her menstrual cycles.’ Ouch, rookie mistake. How could I have possibly missed that? I had done these interviews a million times. 

    ‘That’s right, Dr. Allen. Can you tell us that, Dr. Diaz?’

    I sighed. ‘I am sorry. I forgot to ask.’ I could feel myself blushing.

    ‘It’s fine, Dr. Diaz. That happens, it’s not supposed to, but it does. Let’s go! We can ask her now.’

    The three of us walked together towards Mrs. Lewis’ room while I tried to maintain a neutral expression to hide the shame inside. 

    ‘Good morning, Mrs. Lewis! I am Dr. Lucy Collins, the attending doctor of this ward. How are you?’

    ‘I am good now, thank you.’ She sat up.

    ‘Do you mind if I ask you a few questions?’

    ‘No, doc. You may ask.’ She smiled and seemed comfortable.

    ‘We were wondering, how are your menstrual cycles?

    ‘Well, ever since I gave birth I haven’t had them.’

    ‘Oh, and when was that Mrs. Lewis?’

    ‘My baby Amy is already 4 months old. A cutie!’

    ‘I can imagine! And how was the delivery, do you remember?’

    ‘It was a natural delivery. I ended up losing a lot of blood but the doctors were great, they stabilized me and I got home pretty soon.’

    I shut my eyes. I wanted to ask the next question.

    ‘Did you try to breastfeed, Mrs. Lewis?’ I asked eagerly.

    ‘I tried, honey. But my milk dried out when Amy was only a month old.’

    Dr. Collins smiled at me as we walked out of the room. ‘You know what she has, don’t you, Dr. Diaz?’

    ‘Postpartum pituitary necrosis. Sheehan’s Syndrome. Hyponatremia, hypotension, fatigue, constipation. Everything fits, even the hair loss. Her pituitary is not working. How did you know?’

    ‘I didn’t. Mrs. Lewis just told us. Don’t forget: the patient is the one with the answers that can lead to the diagnosis. You can only use your textbook knowledge if you have the information you need.’


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HypoG: hypoglycemia; HypoNa: hyponatremia; BP: blood pressure.

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