32. The Fall
It was the middle of the week and I was as tired as I could be. God, I love my job. But sometimes, for half a second, I wonder why I chose it. I could’ve gone for something else, with less hours.
I got to my floor with a coffee in my hand to find Jane waiting for me.
‘Good morning, Lisa. You look tired.’
I laughed. ‘Thanks, Jane. How are we today?’
‘Everybody’s doing ok, thankfully. And you have only one admission.’ She smiled and handed me the chart she was holding. ‘Joanna Campbell, but she prefers to be called Jo.’
‘Noted. Better get to that.’
While putting my backpack in the locker I started reading her chart. Jo was only 19 years old, a previously healthy college student. She came in for a fall from own height, which was strange. I wouldn’t expect that at her age.
On her initial work-up she had a hemoglobin of 5. Ouch. So her fall was attributed to a symptomatic anemia. She was admitted, transfused and sent to the ward. Apparently, it was an iron deficiency anemia. But to be this low, good chances it wasn’t her nutrition. Jo had to be losing blood.
I got to her bed and she was still sleeping. I have that problem. Ever since I was a medical student, I tend to arrive at the hospital too early, so I end up having to wake patients every day.
‘Good morning, Jo!’ I said with a louder voice hoping she would open her eyes. Nothing happened. ‘Good morning!’ I said again while moving her arm a bit. That did the trick.
‘Hi.’ She yawned. ‘I’m Jo.’
‘So I’ve heard.’ I smiled. ‘I’m Lisa Diaz, your doctor as of today.’
‘Okay. Can you help me with my leg then?’
I frowned. ‘What is going on with your leg?’
‘It’s been hurting a lot.’ Of course, I thought, she fell. ‘Especially here.’ She pointed to the upper portion of her right thigh, near her crotch. Looking more carefully I noticed that her thigh was externally rotated and her leg slightly flexed.
‘We’re gonna take care of it, okay?’ I requested some pain medication so Jo would be more comfortable. ‘Now, can you tell me everything from the start?’
Then Jo told me about how she had been feeling weak for some weeks before the fall.
‘When I fell it was like a faint you know? I just couldn’t hold myself steady.’
‘I see. And beside the weakness, did you have any other symptoms? Fever? Weight changes?’
‘I’ve lost a lot of weight lately. And I sometimes had that feeling of fever, but I didn’t check my temperature, I just took a tylenol.’
‘How much weight are we talking here?’
‘About 14 pounds over the last year.’
A lot of red lights popped on my mind. So I started asking thorough questions on her review of systems. She denied almost everything, the only positive finding was when I asked about bowel habits.
‘It’s normal.’ She answered me at first. But I thought of the anemia and all her other worrisome symptoms and couldn’t leave it at that.
‘What is normal for you?’
‘I go to the bathroom every day, usually once a day. Every now and then I have had diarrhea, like last week, but it stops eventually.’ Jo said.
‘Have you ever saw blood on the stool?’ I asked thinking she could be losing blood all along.
‘Well, only on the paper when I clean myself.’
‘How often does that happen?’
‘I don’t know… not too often.’
That wasn’t working too well, Jo wasn’t much of a talker. Still, I gathered some important info there. Until proven otherwise, her anemia seemed to be coming from this GI blood loss. She said it was rare, but you would be surprised to learn how often people underestimate blood on stool.
At rounds, I discussed the case with Dr. Lucy Collins and she agreed with me we should take a look at her GI tract.
‘So young.’ Lucy said. ‘Her options aren’t great… what are you thinking, Lisa?’
‘Well. Cancer, of course.’
‘Yes, that is quite possible. What else?’
‘Something autoimmune?’ I tried.
‘Hum… Immune mediated, yes, but be more specific.’
Then it came to me. ‘Crohn's? Colitis?’
‘Precisely. I believe those are her top 2 options: cancer or inflammatory bowel disease.’ Lucy completed. ‘Any family history to clue us in?’
‘None.’
It wasn’t until I got home that I noticed I had completely forgotten about Jo’s thigh pain. Damn it. She probably wasn’t in pain anymore because the on-call doctor would prescribe her painkillers, but I made a mental note to not forget it the next morning.
Jo’s physical exam was difficult because she had very limited range of motion and moderate-severe pain, which made walking difficult for her. I was worried. Did she break something in the fall? Strained a muscle? I ordered a hip x-ray and discussed it with Lucy.
‘I think she deserves a consult from Ortho.’ Dr. Collins said.
‘I do too.’
It was a Friday and I wouldn’t work that weekend. Jo’s colonoscopy was scheduled for Saturday and the Ortho consult would probably happen later that day.
So Monday I got to Brooklyn’s Hospital early as usual and went to check the weekend notes. Jo’s colonoscopy description was a vegetating bleeding mass near the cecal valve, with surrounding areas of inflammation. An incisional biopsy was sent for analysis and it would probably take two weeks for its result. The location made me think of Crohn, but this mass led me closer to cancer. Interesting.
As for her limb pain, the orthopedist requested an MRI after the x-ray, which showed femoral head osteonecrosis. My jaw dropped. I never thought of it. I mean, it made sense thinking of her exam, she had her limb rotated in a suggestive way. But she was so young! How did that happen?
At the morning rounds, we started with Jo. I started by explaining the colonoscopy findings and what I thought of it.
‘I agree, Lisa.’ Collins said. ‘It could be either. This drastic presentation with weight loss and severe anemia can’t exclude cancer. But the location, her age… it could very well be Crohn.’
‘Which of them would you rather?’ Peter that had been quiet for some time spoke up.
Me and Lucy paused.
‘I honestly don’t know.’ I answered. ‘Maybe if it’s early cancer, she can be cured and healthy afterwards. If it’s Crohn’s…’
‘It’s a battle for life.’ Peter completed.
I moved on to tell them about Jo’s femoral head avascular necrosis.
‘Well, there you go!’ Lucy said happily. ‘It’s settled.’
‘What?’ I asked cluelessly.
‘Think: it’s highly unlikely that she has more than one problem. Occam’s razor.’
‘It’s not super common,’ Peter thought out loud, ‘But Crohn’s Disease can have many extra-intestinal manifestations, and I think avascular necrosis might be one of them.’
‘Yes.’ Collins smiled sadly. ‘I guess Jo Campbell has a new battle to fight.’
...
Want to meet someone who fights Crohn’s Disease?
https://badgut.org/about-us/newsroom/badgut-stories/sonia-b-glover-my-life-with-crohns/
Want to read more about Crohn’s Disease?
https://www.crohnscolitisfoundation.org/what-is-crohns-disease
IBD: inflammatory bowel disease; GI: gastrointestinal;
SS: signs and symptoms; Abd: abdominal
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