19. The Birthday
I don’t know why but I was studying that day. Of course, I liked studying, but I don’t know why exactly that day.
It was my birthday. Not that it made any difference in the adult world. I remember that when I was a kid I thought adults skipped work on their birthday just like I skipped school as a child. I didn’t mind working anyway though.
I was studying that night because I didn’t know what my patient had. And I just couldn’t let it go.
Park Swan, a 58-year-old caucasian male, who woke up the day before with sudden ptosis of the right eye. He came straight to the emergency department fearing a stroke, but the CT scan at the admission showed a normal brain. He had no other symptoms and no known medical problems.
He was going to be discharged after that, but then they noticed a pleural effusion at the physical exam along with a hyperdynamic precordium, and that’s why he was admitted.
The next day he was the first patient I saw. He still had ptosis and he was a little confused about what he was doing there. I asked him some questions trying to figure out other symptoms to help the diagnosis, and the only thing I got was that he had some hearing loss, but I don’t know if he said that just to stop denying all of my questions.
In the afternoon I stayed in the hospital to study his case. I was already done for the day and could have gone home, but something was keeping me there. The curiosity was killing me. And I had arranged to go out with Jax only at night, so I still had time.
Trying to figure it out, I thought about his symptoms again. He had a third-nerve palsy and what looked like heart failure. Well, and a hearing loss maybe. All of which seemed entirely unrelated.
I decided to start at what seemed to be the most specific symptom, which was nerve palsy.
It was tempting to think of a stroke, but it was very unlikely after the normal imaging. The other options were that something was impinging his nerve, or the nerve was degenerating because of something like an undiagnosed diabetes.
But in the morning we had ordered some workup, and his blood glucose was normal. Everything was normal actually, pretty disappointing. Well, not entirely, since it helped us exclude some conditions.
Okay, so nerve impingement. A tumor was a possibility too, but it didn’t appear at the imaging. I was starting to think I needed to take a look at that image again. But either way, a tumor was hard to miss.
I decided to go for a coffee and get a break from all that reading. My eyes were hurting from the computer light and I was also a little tired. On my way there, I saw Jane and she wished me a happy birthday.
‘How did you know it was my birthday?’
She smirked.
‘What don’t I know, Lisa?’ She finally started calling me by my first name.
‘Well, you have a point there.’ Jane in fact always knew everything, it was pretty impressive.
‘Why are you still here, Lisa? Go celebrate.’
‘Park Sway.’ I handed his chart to her.
‘What’s wrong with him?’
‘I don’t know. That’s the problem.’
She laughed.
‘You can figure this out tomorrow.’
‘I know. But I can also figure it out today, don’t you think?’
‘Yeah, I bet you can.’ She smiled and touched my forehead with her finger. She probably noticed a sudden change in my mood. ‘What happened?’
‘You just gave me a great idea, Jane. Thank you!’ I hugged her and rushed out of there.
‘Well, it was your birthday gift then.’
We both laughed.
When she touched my forehead I just thought of something we might miss on a CT scan when we are looking for a stroke. A bone problem. Which by the way could cause nerve impingement. And hearing problems. I smiled slightly as I thought about it.
I was heading to get his CT to see it again when Jax called me.
‘Lisa, where are you?’
‘What do you mean? I’m at the hospital.’
‘You’re kidding me, right? You said 6 PM.’
I looked at the clock and was shocked to see that it was already 7:15 PM.
‘Damn. I’m sorry Jax, I swear I thought it was earlier.’
‘Dear God, Lisa, it’s your birthday.’
‘I know, but I was studying a case and lost track of time. I’ll be on my way there in 10 minutes, I swear. Bye.’
I hung up before he could say anything. I had arranged to go out with him and Meg to celebrate and he always got mad when I was late - which in his defense happened a little too often. Well, he was mad at that and at the fact that I didn’t answer any of his texts.
Anyway, I went to see his CT scan and I was right. Everyone was looking at his brain but no one looked at his skull. His bone had mixed lytic and sclerotic lesions consistent with Paget’s disease. That even explained the high-output heart failure.
I ordered Swan’s alkaline phosphatase levels just before rushing to the subway.
When I got there, Jax and Meg were waiting for me at our usual table, but I noticed there was someone with them, which I couldn’t recognize from his back.
Just when I reached to greet Jax I saw that it was Peter. It had been weird between us since he sort of asked me out. Well, for me at least. He seemed totally fine but I was still uncomfortable.
I probably didn’t hide my shock face very well, because he stood up and smiled at me.
‘I told your friend you probably wouldn’t want to see me here, but he insisted. Happy birthday, Lisa. Jax told me you love sports.’
He handed me a little box with a ticket for an amazing seat at the Nets game and I smiled.
Actually, it was a fun night.
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Want to know more about Paget’s disease?
Want to read a real case of Paget’s disease?
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3757888/
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