11. The Glasses
I was rotating in the ICU. I know what you’re thinking, I never talk about critical care patients. The truth is, it is not my favorite rotation. Most of the patients are sedated or confused and I missed talking to them. Still, I always learned a lot in my ICU days.
It was a holiday so we worked with a smaller staff. I was writing some notes alone in the room when the nurse in charge came to me.
‘Lisa, an admission for you arrived on box 12.’
‘Thanks, Marie!’ I started looking for the chart on the computer.
‘Oh, and you won’t find him on the system yet. Something is going on with the computers, IT called and said it will take a while.’
‘Oh, okay! No problem, I’ll see him. Just tell me his name, please.’
‘Victor Hill.’
I got up from my chair excited to see a patient I knew nothing of. It is so convenient for us to just get into the patient’s room after reading most of their chart. It was interesting to just go to a patient without any preconceptions whatsoever.
‘Victor Hill, 32 years old.’ I could see written on the sign of his footbed. He has a white man with dark hair. He looked young, muscular, and too healthy to be on that hospital gown. He looked like he didn’t belong at all.
‘Good afternoon, Mr. Hill. I am Dr. Lisa Diaz, I’m on call today.’ I said approaching his bed.
‘Hi, Dr. Diaz.’ He reached out his strong hand. ‘It’s nice to meet you.’
‘Likewise.’ I shook his hand. ‘So tell me, what’s going on with you?’
‘From the beginning?’
‘Yes, please!’ I said excitedly.
He straightened himself up in the bed. ‘Well, a few months ago I noticed I wasn’t seeing very well. Some things looked a bit blurry. So I tried some random over-the-counter glasses, but they didn’t help. Then I went to an ophthalmologist and he found out I had retinal hemangioblastomas.’ I was surprised by that, but I still couldn’t get why this man was in an ICU bed. So I nodded for him to continue.
‘So he scheduled a procedure for me today.’
‘Today?’ I asked frowning.
‘Yeah, go figure. A guy that likes to work on holidays.’ He smiled and so did I. ‘Anyway, when I got there they measured my blood pressure and it was something around 220 I guess. They got very worried and sent me here. In the Emergency Department, they asked me a million questions and I told them I was having a headache. Then they also looked worried and told me I needed to be started on a medication to lower my blood pressure. And now I’m here.’ He lifted his hand with the IV line hanging.
‘I see.’ Things were starting to make sense in my mind. Victor was considered to be having a hypertensive emergency so he was started on parenteral antihypertensive and sent to the ICU for close monitoring. ‘Do you have any other symptoms?’
‘No! Not at all. I feel fine. The headache is improving. I have no idea why my blood pressure is so high.’
I glanced at the monitor, 220/120 mmHg.
‘Did you ever have high blood pressure?’
‘Not that I know of.’
‘What about any other health conditions? Did you ever need any treatment or got admitted to a hospital?’
‘No, nothing. Besides this retinal problem, I have never been to a doctor before. And if the glasses had worked, I don’t even think I would have.’ He scratched his head.
‘Okay. Now I’m gonna go quickly from head to toe asking you some general health questions, alright?’
‘Yeah, go ahead.’
I thoroughly went through everything on the review of systems and some interesting things came up. Victor had occasional episodes of sweating and reported intermittent hematuria, which had never really worried him before. I left his bedside intrigued.
I went back to the computer to check his labs. Nothing of note. I tapped my fingers against the desk. What was going on with this guy? I pulled my notepad from my pocket and started writing it down.
Hypertension
Headache
Sweats
When I wrote those three words it occurred to me: Pheochromocytoma. It could explain the high BP and catecholamine excess symptoms. But then I wrote the next symptom on the bottom.
Hypertension
Headache
Sweats
Hematuria
I couldn’t think of how the hematuria could relate to the rest. I replayed my conversation with Mr. Hill in my mind until I realized I was missing something crucial.
Hypertension
Headache
Sweats
Hematuria
Retinal Hemangioblastomas
‘Oh my God!’ I said out loud even though no one was there. ‘Von-Hippel Lindau.’
I quickly opened my phone to look it up. An autosomal dominant disorder that results in multiple tumors in many organs, most commonly hemangioblastomas, pheochromocytomas, and clear cell renal carcinoma (hello, hematuria).
I ordered him a CT which showed both the pheo and the renal carcinoma. I called the consults he would need and discussed his case with the chief resident that was there. He agreed and came with me to break the news to Victor.
‘So what’s the next step?’ That was the only thing Mr. Hill answered to all the things we said to him. His face was dead serious.
‘We are going to take care of your blood pressure and program the treatment for these tumors with the specialists. Later on, we will also perform genetic testing to confirm this disease.’ I explained.
‘Speaking of, does anybody in your family have a history of cancer?’ My colleague asked beside me.
‘My dad.’ Victor answered. ‘He died of brain cancer when I was little.’
Damn, I thought to myself. I had completely forgotten to ask him that.
A year later I saw Victor again. I was a PGY-3 when I accidentally ran into him wandering in the hospital. He was walking funny, ataxic-like.
‘Hey, stranger!’ He greeted me.
‘Hi, Mr. Hill! What is up with those glasses?’ I noticed he was using them.
‘Well, I think they look good on me after all.’ He smirked. He looked good. So much better than the last time I had seen him.
I laughed. ‘And what are you doing here?’
‘Well, VHL gave me a tumor in the brain now.’ He smiled sadly. ‘But they told me it’s operable.’
I touched his arm. ‘I’m glad to hear it’s operable. When is your surgery?’
‘Tomorrow!’
‘Good. I will be praying for you.’ I smiled. ‘And keep the glasses. I like them.’
...
Want to know more about Von Hippel-Lindau Disease?
https://rarediseases.org/rare-diseases/von-hippel-lindau-disease/
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