4. The Purse


‘Jane! I can’t believe it! I missed you so much!’ I went in to hug my favorite nurse. After I became a PGY-2, I hadn’t seen her yet.

‘Lisa! Wow, you look tired.’ She said laughing.

‘Well, I can’t deny it.’ I rolled my eyes. ‘Are you staying on this floor now?’

‘Not really, but I’m covering for a friend this week.’

‘So who’s new?’ Jane always knew everything about the patients, usually even more than the doctors did.

‘We have two new patients.’ She said casually. ‘Oh, one of them is super interesting! No diagnosis yet, the kind you like.’ She winked. ‘Cecilia Gray.’ She handed me the chart.

I went straight to Cecilia’s room. I was curious, I couldn’t help it. Unfortunately for me, she was sleeping and there was no one by her bed. She was a young woman, mid-twenties maybe, and looked pretty weak.

I tried waking her up but she was very sleepy. Since she couldn’t talk to me, I told her I would examine her and she didn’t object. She was so thin I remember thinking I could break her with my hands.

Jane had already told me that she was a teacher and had passed out in the school where she worked that morning. When she got to the hospital they started IV fluids and electrolytes correction, because they were shockingly low. They had called her mother to come in but she lived far away and would take some time to get there.

I started with her head and what called out to me was that her tongue was very atrophic and she had a mouth ulcer. She was very thin and emaciated. She also had some scars on her elbows that looked like some kind of rash. When she opened her eyes I asked her to try and move her legs and it was clear she couldn’t really move them.

‘They feel heavy.’ She whispered.

‘Hi, Cecilia! My name is Lisa, I am your doctor now.’ I reintroduced myself to her. ‘What happened to you?’

‘I don’t remember.’ I could hardly hear her voice. ‘Feeling weak, passed out.’

I decided to let her rest and talk to the ED team to find out if they had any other info. As it turned out they didn’t know much more, they said her mother didn’t know of any previous health conditions.

‘Do you have any guesses on what she has?’ I decided to ask Jack, the ED resident. They usually have a different perspective, since they are always the first ones to see the patient.

‘I’m honestly clueless. She is excessively thin, maybe she has an eating disorder?’

‘True, it is a strong possibility.’ I wondered. ‘What about any medication use?’

‘The mother didn’t know. We asked Ms. Gray but we couldn’t understand her answer.’ He told me and we were both silent for a while.

‘What about any medication on her? Maybe she was using laxatives and had massive diarrhea and that’s why her electrolytes are depleted, I don’t know.’

‘That’s a good question. I guess the social department took care of her belongings, we could ask them if she had any pills on it.’

It seemed like a long shot but why not, right? We went there and they told us she had no laxatives, but she did have loperamide in her purse.

‘Really?’ He asked.

‘That can be used for Irritable Bowel Syndrome.’ I said. ‘So she was having diarrhea, but she was trying to control it, not cause it.’ Jack shrugged his shoulders like he was satisfied with that, but I was only getting more interested.

Even so, I needed to see my other patients first. For some reason I don’t remember my PGY-1 was not there that day so I was even more packed with work. When I finished I went to get a coffee and grab something to eat before rounds. My mind went back to Cecilia’s case.

Irritable bowel syndrome sucks, but it couldn’t explain her extreme thinness and weakness, it had to be something else. Besides, she also had signs of vitamin deficiency. Her atrophic glossitis could be B12 deficiency, which could also explain her leg weakness associated with her incredibly low potassium. She also had anemia and iron deficiency in her labs. And finally, her electrolytes showed her body was in complete chaos.

‘Chaos.’ I said out loud without noticing it. I suddenly remembered her elbow rash. ‘That’s it, her body is in crisis.’

I remembered a case I had once presented in medical school. Celiac crisis. A catastrophic presentation of celiac disease where patients have profuse watery diarrhea and severe metabolic disturbances. Celiac crisis is rare in adults, true, but they are also possible.

I presented this hypothesis to Dr. Rivers and he nodded.

‘I like it, Dr. Diaz.’ He had a funny way of saying things. ‘I really like it. Congratulations for thinking of it, and since you did, I’ll let you do what you want next.’ He smiled and so did I.

We ordered anti-tissue transglutaminase antibodies and suspended gluten from her diet when she was able to eat. We also tested and treated her vitamin deficiencies. The antibodies came back positive and an endoscopic biopsy showed villous atrophy confirming our diagnosis. She got better and better each day and left the hospital after a week.

I went home by subway that day thinking about how everything fit just right. Her thinness, her atrophic tongue, her mouth ulcer, her anemia, and even her elbow rash, which was dermatitis herpetiformis.

But I remember looking at my purse and thinking that in the end, it was her purse that completed the puzzle, even with all those signs right in front of me.

‘Chaos.’ I said out loud and laughed to myself.

Want to know more about Celiac Disease?


Want to read a real case of Celiac Disease?


Clinical Boards

SS: signs and symptoms; Abd: abdominal; Comp: complications; Def: deficiency; Tt: treatment.

No comments:

Powered by Blogger.