20. The Vomiting

September 26, 2020

It was 10am and I had already seen all of my patients in the ward. Or so I thought. Thank God for Jane. I was waiting for time to pass until the rounds when I saw Jane walking towards me. ‘Did you take a look at Ms. Davis from bed 8, Lisa? She doesn’t seem so well.’

‘Wait, who?’

Somehow I completely missed this admission. I thanked Jane and ran to find the patient’s chart so I could see her in time. Adeline Davis, 27 years old, admitted for intense and unremitting vomiting. She was found to be hypotensive and hypoglycemic in the ED, for which she received fluids and apparently improved her general state.

I had just entered the room when Ms. Davis threw up on the floor beside her bed. Yep, she really looked sick. I quickly got her a tissue while I called for a nurse so we could help her get cleaned.

‘Are you okay?’ I asked while helping her sit up straight.

‘Yeah, it sucks but I’m almost used to it.’ She said with a hoarse voice.

Jane got there with a cup of water in her hands which Ms. Davis promptly accepted.

‘Thank you, Jane.’ Ms. Davis said.

‘Don’t mention it.’ Jane winked and left.

‘Ms. Davis, we haven’t met yet. I am sorry it took long for me to get here. I am Lisa Diaz, your doctor from now on.’

‘Oh, nice to meet you.’ She smiled. ‘I am Adeline.’

‘Okay then, Adeline. Do you think we can talk a little bit right now?’

‘Yes, no problem.’

Adeline told me how she was struggling with repeated episodes of vomiting in the last 2 months.

‘Sometimes it happens 10 times a day. Other days are a little better. But it got even worse this week, that’s why I came and they decided to admit me.’

She told me she had no fever. She had lost a lot of weight, but she didn’t know if it was because of the vomiting or not. Other than the nausea and vomiting she didn’t have any other symptoms. 

‘When the vomiting started I went to a gastroenterologist. I started taking medication to stop the nausea but they didn’t work. Then they ordered an endoscopy for me that showed some inflammation but nothing major. I can’t take it anymore, it is taking over my life.’

‘I am sorry to hear that. We’ll do everything we can to find out what is going on.’

I thoroughly asked her about her past medical history. I thought about Cannabinoid hyperemesis syndrome, but she denied ever using marijuana, and hot showers didn’t help her either. It turned out she had a history of atrophic gastritis. Since this discovery, she had been prescribed B12 shots as management. No other conditions in her past. In her family history, her mother had hypothyroidism.

In her physical exam she was still hypotensive. She also seemed a little too thin with some muscle wasting. She looked weak, not like a 27 year old woman. The rest of her exam was unremarkable.

I told Adeline I would be back later that day. It was already 10:56am so I had to run to get to the rounds in time. On my way there I tried to check on her exams from the ED with the work phone because I knew it would be needed in the discussion.

I managed to skim through almost all of them before getting into the room and noticed she had hyponatremia. On my turn, I presented my other patients first and left Ms. Davis for last.

‘Adeline Davis, 27 years old, came in for unremitting vomiting. She has had these episodes for the past two months, accompanied by weight loss. Antiemetics don’t help. At admission, she was hypotensive and hypoglycemic. Blood workup showed hyponatremia. She had partial improvement of her general state after fluid administration.’

‘Poor girl. Hyperemesis is so disabling.’ Lucy said. ‘Is the vomiting related to eating?’

‘No. She says it just happens, up to 10 times a day.’

‘I see… What else?’ Collins continued.

‘She had an endoscopy in this mean time. It showed a little inflammation, but nothing in her workup suggested an intestinal obstruction. It doesn’t look like a structural problem. ’

‘Tell me about her history.’

‘She has atrophic gastritis, which kind of explains the inflammation. She follows treatment with B12 shots and denies use of alcohol or drugs. Her mother has a history of hypothyroidism.’

‘Interesting.’ Lucy looked puzzled. ‘An autoimmune kind of family. Something on her skin?’

‘Well, no. She was only tanned really.’ I was surprised by the question. ‘Her oral mucosa was a bit darker though.’

‘Maybe is not just a tan.’ Peter spoke up. ‘Addison’s disease?’

‘Yes, Peter! I think that is our main hypothesis, her adrenal might be failing.’ She smiled broadly. ‘That means we can probably treat her. She will get better.’

I left the rounds happy to have something so concrete to look for, that doesn’t happen everyday. Her ACTH was high as expected, and the cortisol was low. I delivered Adeline the news as soon as I got her results.

‘It’s called Addison’s disease. Your adrenal gland is not working right, which disrupts a lot of functions in your body, causing, among other things, this persistent vomiting and weight loss.’

She listened carefully in silence.

‘And the good news is we have a treatment for it.’ I smiled. ‘We can replace the hormones missing from your body and hopefully you will get better.’

Ms. Davis smiled back. ‘I can’t wait.’

We started her on hydrocortisone, fludrocortisone and more fluids. She had an amazing improvement over the next few days and I discharged her with the appropriate medications and a follow-up with her new endocrinologist.

'Thank you, Dr. Lisa. I will take them forever.’

I laughed. ‘You better.’

Leaving her room I saw Dr. Collins in the hallway humming an upbeat tone.

‘How great is to find something we can treat?’ She said when she saw me.

I smiled. 

‘Pretty great.’



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Clinical Board
SS: signs and symptoms; BP: blood pressure; 1°: only in primary insufficiency; Tt: treatment. 


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