1. The Tan


4:40 am. I didn’t need to wake up that early. But I hate being late, especially on the first day. I know, technically it wasn’t my first day, I had been a resident at Brooklyn Hospital for a full year already. But still. I got into the shower and mentally went through my usual hospital routine to make sure I wouldn’t forget anything.

I got dressed and noticed my tanned skin while putting my makeup on. My vacation had been a true renewal. There was time to travel, to see my mom, and to not think about medicine at all for a few weeks. And it was also enough. I couldn’t wait to get back to work.

I checked my watch again. 5:40 am. Time to leave for the subway. I prayed silently for the new year I was about to start as a PGY-2 and felt butterflies on my belly while stepping out on the street. God, I had missed New York.

I got to the floor I was assigned to and went through my new patients’ charts. My colleague Dina had already sent me a dozen audios about the patients she was leaving for me, so I wasn’t completely in the dark. As a PGY-2 I would see twice as many patients as I used to. At least all the floor beds were full so there wouldn’t be any admissions on my first day. 

Henry Cohen was the last patient I saw. I had left him for last on purpose. He was a 45-year-old man admitted due to dyspnea and bilateral leg swelling. The weird part? Except for a diagnosis of diabetes in the past year, he was overall healthy. His initial exam and imaging suggested his heart was the problem. So far it looked like a first-time diagnosis of heart failure. He would get an echocardiogram that same morning for further investigation.

Odds were he probably had an ischemic cause, still undiagnosed, that caused his heart to fail. But he was so young and apparently healthy, it intrigued me.

‘Good morning, Mr. Cohen. I am Dr. Lisa Diaz, nice to meet you.’

‘Good morning, Dr. Diaz. Likewise.’ He smiled. Henry seemed like a nice guy, had a head full of black hair and tanned skin like my own.

‘I saw that you came here because you were feeling breathless, right? Can you tell me more about that?’

‘Yes! But I am so much better now, doc. Apparently, this Lasix works like magic.’

I laughed. He then started telling me that the dyspnea had worsened in the past week, along with his leg swelling.

‘But the truth is, I haven’t been feeling great for a longer time.’ He told me. ‘Every now and then my legs get swollen, my joints ache and I get tired more easily, but it had never happened like this before.’ 

‘I see. When was the last time you actually felt great, Mr. Cohen? Before these symptoms started.’

He thought for a moment. ‘I guess maybe a year ago.’

I mentally crossed viral myocarditis off my mind. This prolonged course was more compatible with other etiologies. I asked him thoroughly about everything I could think of as a cause. He completely denied any other symptoms like chest pain with exertion, he had never smoked, had a balanced food intake, and had a consistent exercise habit. He drank a couple of beers on weekends and had never been admitted to a hospital before in his life. His only medical problem was diabetes, which he had discovered on routine exams 8 months before.

I went to his physical exam and other than the expected signs from heart failure, like lung crackles and swollen legs, he had gynecomastia and a slightly distended abdomen. I got out of his room a little disappointed. I sat on a computer and started writing some preliminary notes until my new attending got there. I also typed in each patient’s lab results and took my time going through Henry Cohen’s exams. The only odd lab test was his liver enzymes, which were high, but that could be due to his heart dysfunction. His echocardiogram was scheduled for 10:00 am, so maybe we would have the results in time for rounds.

I had already done everything I could before rounds and it was still 9:00 am. Yeah, maybe I had exaggerated the whole arriving early thing. So I decided to get a coffee while I waited for Dr. Joe Rivers, my new attending. My mind was drifting when a girl walked in and startled me.

‘Sorry!’ She said, ‘I didn’t mean to alarm you.’ She seemed nervous.

‘That’s okay.’ I smiled to comfort her. ‘Don’t worry about it.’

She nodded thankfully. ‘I am Kate Anderson, the new PGY-1. I will be staying with you and Dr. Rivers this month.’ She reached out her hand to greet me.

‘Oh!’ I stood up and shook her hand. ‘Nice to meet you. I am Lisa.’ Somehow I had completely forgotten I would rotate with an intern. How crazy it was that I was already a second-year resident.

Kate had an easy smile and her white cheeks turned pink as we talked. I liked her already.

‘So, did you see Mr. Cohen?’

She nodded.

‘What did you think of him?’ I asked while sitting and pointing her to the chair next to me.

‘Well.’ She shuffled the loose papers she had on her hands. ’Here it is. I think he seems well today, his symptoms are improving, maybe we can consider switching his Lasix to PO.’

‘Yes, maybe. But what about his heart failure? We need to start thinking about what is causing it.’

‘Oh.’ She paused thinking. ‘I was thinking ischemic since it’s more common. Or maybe an undiagnosed long-standing hypertension.’

‘Yeah, but he's so young and his history seems unremarkable on that matter. He had yearly consultations with his primary care doctor and he never had an increased BP.’

‘I hadn't thought of that.’ She said frowning.

‘Did you find anything different? On your history or physical?’

She nodded no with a concentrated look trying to recall any details. ‘Well,’ she started, ‘I thought he was a bit tanned.’

I smiled remembering my own tan. ‘Yeah, I thought so too.’

Dr. Rivers walked in just then. He was a tall black man, wore glasses and a buttoned-up white shirt. He carried a relatively large briefcase which made him look like a lawyer. He introduced himself with a broad smile and asked some questions about ourselves. We then started rounds and Kate presented the cases pretty well. She choked every now and then but still I was impressed.

After she presented Mr. Cohen’s case, I added some of my thoughts on how we should look into his heart failure etiology.

‘I agree, Dr. Diaz.’ Joe said. ‘Do you have his lab results?’

I gave him a paper with the fishbones.

‘The only thing abnormal is his liver enzymes.’ I added.

‘True, but that could be from his heart.’ He thought out loud.

‘I thought so too. But I checked some other tests from his admission, and it looks like it is not just his enzymes. His liver function is altered.’ I handed him another piece of paper.

‘Interesting. This could also be due to heart failure, but is much less common and it usually happens in more severe chronic cases.’ He scratched his chin. ‘So what are you thinking?’

‘I don’t know.’ This time I was the one who blushed.

‘Let’s think. Mr. Cohen is a 45-year-old diabetic. His heart and liver aren’t working properly. What can cause that?’

‘Alcohol.’ Kate answered. 

‘Excellent, Dr. Anderson. But, assuming Mr. Cohen is telling us the truth about his alcohol consumption, it would be very unlikely that a beer a week would cause that. So what else?’

We were silent for a moment when it came to me.

‘Iron!’ I finally answered. ‘Hemochromatosis can explain everything.’ Dr. Rivers nodded satisfied and I continued. ‘His heart and liver are loaded with iron. It explains his lack of other risk factors, his young age, his recent diagnosis of diabetes, and even his tan.’ I finished with a laugh.

Damn, I had missed this.

We finished in time to check Mr. Cohen’s echo, which showed diastolic dysfunction. We ordered him ferritin and transferrin saturation which later that day came back absurdly high. I got stuck on paperwork and got home at 7pm, tired and happy.

It was only when I opened the door of my apartment that it hit me. Jax was gone. He and Meg decided to elope after his proposal. I was so happy for them. After that, it all happened so fast, I was busy traveling while he moved out, so it was only that day, my first day as a PGY-2, that I truly felt his absence, in that heavy silence. 


Want to know more about Hemochromatosis?


Want to read a real case of Hemochromatosis?


Clinical Board

DM: diabetes mellitus; hyperpig: hyperpigmentation; AR: autosomal recessive; SS: signs and symptoms; HF: heart failure; Transf. Sat.: transferring saturation; Bx: biopsy.

No comments:

Powered by Blogger.