9. The Garden
Kate had just moved in. After living about 3 months by myself, I had finally decided it was time to have a roommate again. It turns out that Kate, my intern, was looking for a place closer to the hospital when she found out I was looking for someone.
That week we would both work at the Primary Care Clinic so I got up at 5 am and made coffee for us. Kate sat at the table with me at 5:30 am for breakfast.
‘So, where are you from?’ I started. Although we had spent quite some time working together, we had never really got to know each other.
‘Philly.’ She stated. ‘I moved to New York for residency. You?’
‘Chicago. Do you miss your hometown?’
‘I miss my family.’
‘Yeah, I get that.’
She had some eggs and I remember being horrified at how much sugar she put on her coffee, but decided it was too soon to tell her that.
Kate looked at her watch just before we walked out of the subway.
‘So, why again are we getting there so early?’ She asked me, raising an eyebrow.
‘You know, just to be safe. It’s not that early anyway.’ I shrugged.
We got to the office after a 5-minute walk from the train station to find the clinic still closed. Kate didn’t say anything but I could almost hear her thoughts.
‘Okay, maybe we're too early.’ I said uncomfortably.
‘Yep.’ She said smiling. ‘Don’t worry though, I was expecting it. Jax had given me a heads up.’
I rolled my eyes. ‘That sounds like something he would do.’
‘Morning, Dr. Diaz.’ Paula, the clinic’s secretary, said as she got there ten minutes later and opened the clinic for us. ‘You’re late.’ She said laughing loudly as we got in.
My first 2 patients didn’t show so I was at my office playing crosswords on the computer when someone knocked on the door.
‘Come in.’
‘Hi Lisa.’ Kate said as she walked in. ‘Can I discuss a case with you?’
‘Of course. Shoot, Dr. Anderson.’ I smiled.
She took a seat across from me and started. ‘The patient is a 25-year-old female, Ms. Garrett. She is previously healthy and came in for a first visit today with a weird complaint. She noticed some round swellings in her jaw a couple of months ago.’
‘Interesting.’ I thought out loud.
‘Yeah. And then she brought a dental x-ray.’
‘Oh.’
‘So I was wondering if you have any idea of how to look at it.’
I laughed. ’I don’t. But let’s see it anyway.’
She handed me the CD and we opened Ms. Garret’s dental panoramic tomogram. I started by counting her teeth because, well, why not?
‘Huh.’ I started counting it again. ‘I think she has supernumerary teeth.’
‘Oh yeah, she does! Sorry, I forgot to mention that. That’s why her dentist ordered this x-ray apparently.’
‘Ok. Let’s see if we can find anything else.’
‘This looks wrong.’ Kate pointed to some white spots near the jawline.
‘You’re right.’ I said zooming in. She had these small round opacities. ‘Did you see these swellings she complained about?’
‘I couldn’t see it. But I could feel them as I palpated her jaw.’
I nodded. ‘Anything else?’
‘Not really.’
I scratched my head. ‘I am not sure if there is anything we can help her with. She needs to go back to her dentist.’
‘Exactly, I thought so too. But then it occurred to me, what if these are some kind of, I don’t know, bone tumors?''
‘You have a point.’ I tapped my fingers at the table. ‘Osteomas maybe? Wait! How is her bowel habit?’
Kate frowned. ‘Normal I guess. She denied any changes.’
‘Damn. What about family history?’
‘Colon cancer on her mother.’
‘That’s it. Colon cancer and jaw osteomas. What does that tell you?’
Kate stared blankly at me. ‘Sorry, I don’t think I know.’
‘Garden Syndrome!’ I helped her out.
‘Oh, I see! You mean Gardner Syndrome?’ She looked confused.
‘Yes.’ I said laughing. ‘I always mix them up. I meant Gardner.’
‘It’s a type of familial adenomatous polyposis, right?’ Kate followed my lead.
‘U-hum. I had a trick for remembering that in med school. I used to think of a garden full of intestinal polyps and a big skull full of osteomas eating them.’
‘That’s very creepy.’ Kate said. ‘But probably helpful.’
‘It is.’ I nodded. ‘Although it makes me misspeak the name sometimes. So what now?’
‘Well, I think we could start with a colonoscopy. Either way, she should also go back to her dentist, so he can look at her x-ray and tell us his input.’
‘Agreed.’
Ms. Garrett was a little alarmed when Kate explained she would need to undergo a colonoscopy.
‘What does that have to do with my swellings, Dr. Anderson?’ She had asked.
Kate told me she struggled to explain that she wanted to rule out a condition that could be related to Ms. Garrett’s jaw findings without freaking her out.
‘It’s crazy.’ Kate told me later that day. ‘You go to the doctor because you are bothered by some esthetic thing and then you find out you may have a very cancerous condition and will probably need a colectomy.’
‘Yeah. Tough news to break to someone.’ I answered.
‘Tell me about it.’
A month later Ms. Garrett came back to the clinic for a follow-up and coincidently I was the one who got to see her. Her colonoscopy made it crystal clear that she had familial adenomatous polyposis, so I referred her for a GI and a geneticist. She had also seen her dentist again, who agreed with our hypothesis and recommended urgent colonoscopy which luckily we had already ordered.
I got home and found Kate sitting on the couch with a box of Grimaldi’s Pizza she had got for us. Her eyes were fixed on the TV that was showing the Nets warmup. I smiled before she saw me. It was nice having a roommate again.
‘Finally!’ She said as she realized I was there. ‘Come on the game is almost starting.’ She tapped the cushion next to her.
‘I saw Ms. Garrett today.’ I said as I took a seat.
‘Oh, I remember her!’ She snapped her fingers. ‘And? Was her garden full of polyps?’
‘Yep.’ I laughed. ‘Packed.’
...
Want to know more about Gardner Syndrome?
https://rarediseases.info.nih.gov/diseases/6482/gardner-syndrome
Want to read a real case of Gardner Syndrome?
https://www.sciencedirect.com/science/article/pii/S1741940905000105
No comments: