11. The New Patient

‘Dr. Diaz, here are your charts for today.’

‘Thank you, Jane! I’ll take them in a minute’ I said as I swallowed the rest of my coffee.

I started looking at the charts. When I got to the last one, it read:

‘51-year-old man admitted to the emergency department with profuse gastrointestinal bleeding…’

My skin was suddenly cold. I couldn’t do this again, at least not yet. I had avoided that subject for so long, I didn’t want to go back to it. I had to switch patients with Peter.

I looked for him for what it seemed like an eternity, and every moment that passed my heart beat faster, my hands were sweatier, and my vision hazier. When I finally found him I must have been white, because he looked so worried.

‘Are you okay, Lisa? Take a seat, it looks like you’re going to pass out.’

He pushed a chair in my direction and I just let myself fall into it. I was trying to find the words, but I struggled. He filled a cup of water and gave it to me.

‘What’s the matter? Did you skip breakfast or something?’

‘No Peter, I’m fine.’

‘Okay, then what is it?’

I felt nervous for a moment, but I managed to ask him.

‘I just wanted to switch a patient with you.’ He looked troubled.

‘Well, I think we’re not supposed to do that.’ I knew that, but I was hoping he didn’t know it.

‘I know, but can you? Please?’ I must have sounded a little desperate because he reached out to get the chart of my hand.

He read a little bit, and I could see he remembered it.

‘Lisa, he’s not Jake Weiss. And I can’t switch with you, you know that. But I can go with you on this one if you’d like.’

I nodded.

We went to see Mr. Paul Reeter. That was his name. He was a very skinny middle aged man, and he looked very weak. I was supposed to conduct the interview, but Peter ended up asking most of the questions, to which I was very grateful for. And he knew it.

His medical records were unremarkable. He had hypertension (who doesn’t right?)  and was previously healthy apart from that, although he didn’t really seek medical care.

He reported a history of gastrointestinal bleeding for 1 month, along with malaise and severe abdominal pain. Besides that, he also had an annoying fever and rash in the past month. He thought it was gastroenteritis and was waiting it out, but then the bleeding got too intense.

At the physical exam, he was hypotensive and tachycardic. His lungs were clear, and he had mild edema in his lower extremities. We told him we would order some labs and come back later.

I don’t remember almost anything about that day. It just felt like I wasn’t there most of the time. Dr. Collins even made a comment about it, so I apologized and told her I would get myself together.

‘Lisa, now you have to present Paul Reeter. I can’t present it for you.’ Peter whispered to me.

I nodded and presented it. Despite being a little off that day, I knew everything about his case. It was like when you want so bad not to care that you care even more.

In the end, we all agreed to order a colonoscopy and some blood tests for him, like complete blood count, kidney and liver function, inflammatory markers, and coagulation panel.

Jax noticed I was weird when I got home and asked me what was going on. After I told him, he hugged me, because maybe I was trembling without even realizing it. Then he gave me some great advice I didn’t know I needed.

‘Lisa, I understand how you feel, really. But you can’t let this interfere with how you manage other patients. Every patient is a new patient, remember?’ 

We used to say that to each other sometimes to make us feel better. I smiled.

‘Besides, I think that this is a good opportunity for you to stop shutting this feeling out and start dealing with it.’

The next day, I was feeling a little bit better.

I got to the hospital and went straight to see his results. The colonoscopy showed blood but no source of active bleeding. On the other hand, his liver and kidney function tests were altered, and inflammatory markers were high.

Interesting. At first, we imagined he had a structural problem, like a bleeding polyp or even colon cancer, but the colonoscopy was clean. Besides, the coagulation panel was normal, so why was he bleeding? And what did that have to do with his liver, kidney and skin?

I remembered one of my teachers who used to say that we should follow anatomy and physiology when we can’t think of a diagnosis clearly. So when you have a problem with bleeding, there are mainly 3 possibilities: you have damage to the epithelial surface, you have a coagulation problem, or you have damaged blood vessels.

His colonoscopy was clean and his platelets and coagulation panel seemed normal, so it appeared Paul Reeter had a problem with his arteries, which uncomfortably reminded me of Jake Weiss. But I shook that feeling out of my head.

Anyway, he also had problems with his liver and kidneys. And all of that probably fit in a sole diagnosis, which was puzzling.

I hadn’t even noticed that I was already late for rounds. I had spent almost 2 hours reading about his case. I quickly got up and went to find Peter and Lucy.

We decided to order hepatitis serologies and redo the medical history to see if we missed anything, but we hadn’t. However, I did mention to Dr. Collins that I thought he could have a problem with his arteries.

‘Hum. Interesting. What are you thinking?’

‘Well, he is bleeding but has no ulcer, and his platelets and coagulation panel seem normal. So I was thinking maybe he either has an arteriovenous malformation, which I think is unlikely since he never bled like this before, or he has some type of vasculitis. Which would also explain his high inflammatory markers.’

She thought about it for a moment.

‘That makes a lot of sense. I’m glad to see you are more focused today, Lisa.’ She smiled. ’Search about the different types of vasculitis and see what fits better in his case.’

I nodded and left, back to the computer.

After a while, I had figured out what was the most likely vasculitis using his symptoms. Polyarteritis Nodosa is a medium vessel vasculitis that may present with fever, weight loss, malaise, and abdominal pain. Besides, it can affect almost any organ, but it usually spares the lungs, like in Paul Reeter’s case.

Another interesting feature was that most cases were related to hepatitis B infection. I went to get his serologies almost certain that he had it. And no surprises there.

In the end, he got better, we treated the vasculitis with steroids and scheduled a follow up to treat his hepatitis B infection.

But actually, I also got better after that. I realized Jax was right, and if Jake’s case should affect me in any way, it should be to take care of my patients each time a little better. As much as I struggled to admit it, I couldn’t do much to save Jake’s life; but I could still help a lot of people. Every patient is a new patient.


Want to read more about Polyarteritis Nodosa?


Want to read a real case of Polyarteritis Nodosa?


Clinical Board

Abd: abdominal; Tt: treatment.

No comments:

Powered by Blogger.