27. The Wife
‘Everything good? You haven’t touched your waffles.’ I smiled at Kate, she was a little too quiet that day. We were on night float that week so we had just arrived from the hospital and we were having our pre-nap breakfast.
‘Yeah, just worried about my dad.’ She scratched her head and took a bite of her cold waffle. ‘He’s losing some weight and having some weird bowel movements. I’m trying to convince him to get a colonoscopy but that seems harder than making you late for sign out.’ She laughed.
‘Ha-ha, funny.’ I tossed a napkin at her face. ‘I hear you though, some people have a hard timing seeking healthcare.’
‘Tell me about it.’ She got up from her chair. ‘Night, Lisa.’
It was wintertime, and cold was creeping into the hospital no matter how many jackets I put on. Even so, I always found winter nights to be particularly interesting because patients who came in at night were more likely to be sick since they had to leave their warm beds to get there.
And that chilly night was no different. Mr. Garfield came to the ER that night because he couldn’t walk after falling a few days before. He was in his forties and came into the hospital in a wheelchair. The ER doctor on call was concerned about a structural problem because of the fall and ordered an MRI, which Mr. Garfield was waiting for. Oh, and his wife was with him - which was crucial to getting to the correct diagnosis.
‘Hi, Mr. Garfield! My name is Lisa Diaz and I’ll be taking care of your admission today. The doctor in the ER already told me a little bit about you but can you tell me what is going on that you came here today?’
‘Sure, doctor.’ He smiled. His voice was soft like he was not really alarmed that he was in a wheelchair. ‘A few days ago I was fixing the roof and I don’t know what happened except that I fell and hit my back. Ever since that day, I’ve been having a backache and now my legs feel weak.’
‘That ain’t what happened.’ His wife interrupted him and gave him a nasty look. ‘He’s been feeling weak for weeks!’ She turned to me. ‘And he complains of pain too, especially in his right leg.’
‘Oh, is that so?’ I said wanting more information but also trying not to stir the fight. But if his weakness was old, that could change everything.
‘Yeah, I was. But I was good though, I could still do everything I needed for work and such. But now it’s getting worse. Yesterday I couldn’t walk by the end of the day.’
‘Yesterday? And why didn’t you come yesterday?’ I asked.
‘Ain’t that a great question?’ That was on me, I should have seen that coming. ‘I’ve been telling him to come for a long time.’ Mrs. Garfield crossed her arms.
‘I thought I was just tired and would sleep it off.’ He continued to ignore his wife's comments. ‘But today I am worse again. I just wish you could give me some medicine so I can go home today.’ A classic never-seek-medical-care kind of guy.
‘Go home in a wheelchair? Let’s try to fix you up first.’ I smiled at him and he smiled back. I knew I would have to play my A game to convince him to stay.
‘Exactly, I ain’t taking you home like that.’ Mrs. Garfield jokingly teased him and I couldn’t hold my smirk.
‘Okay, is there any other symptom you want to tell me about?’
While he was nodding no Mrs. Garfield stole the scene again.
‘Oh, he dropped a ton of weight. He lost about 10 pounds in the past two months.’
Red. Flag.
The fall wasn’t everything.
I went to grab a coffee and met Kate there. I filled her in and she was also intrigued.
‘So ED wants to check MRI, but what do you internist want to check for?’ She teased.
‘I think we can start with his basic labs.’
As we sat on the computer nothing seemed to stand out too much as a possible cause for his weird symptoms. As we drank our coffee we tried to come up with differentials for asymmetric weakness, myalgia, and weight loss. Hard not to think of something dramatic as metastatic cancer with spinal infiltration. If that was the case though, we would have to end up looking at his MRI to figure it out.
‘Can’t believe the answer is going to be in the MRI.’ I joked as we walked to the radiology room to check the results.
It turns out no sign of metastasis, spinal compression or any trauma-related lesion on the back, which was the first hypothesis. Puzzling.
‘Okay, so what now? His labs are fine except for high glucose but he’s probably diabetic and just doesn’t know it.’
‘Wait.’ I interrupted Kate.
‘Wait what?’ She was confused.
‘That could be it!’ I smirked. ‘I blew past his glucose because we’re so used to seeing high values in diabetic patients, but you’re right. He could have undiagnosed diabetes.’ Her facial expression remained confused. ‘Have you heard of diabetic amyotrophy? Acute asymmetric proximal painful neuropathy. It can also cause autonomic dysfunction and weight loss.’
‘Wow. That one came straight out of the book.’ Kate shrugged. ‘But hey, if you’re right, the answer was in the CBC after all.’ She winked.
We discussed our hypothesis with our attending and he thought it was worth the shot. The patient’s glycated hemoglobin came back 11% and we went to tell Mr. and Mrs. Garfield the news. We started him on insulin and he showed steady improvement in the following couple of weeks. Mrs. Garfield was happy she found out what was going on and that it wasn’t as serious as cancer. On the other hand, Mr. Garfield was happy he could go home.
‘Bye, Dr. Diaz! Thank you for everything and I hope I don’t see you tomorrow.’ He told me when I was finishing my night shift.
‘I guess your dad is not alone in this not seeking medical care.’ I whispered to Kate as we left his room. ‘Maybe he only needs a stubborn wife.’
She smirked. ‘Oh, my mom is definitely playing her part.’
‘So he’ll come around. Don’t worry.’
‘I know he will.’ She sighed. ‘ I’ll turn him around if I have to.’
…
Want to know more about Diabetic Amyotrophy?
https://www.ncbi.nlm.nih.gov/books/NBK560491/
Want to read a real case of Diabetic Amyotrophy?
https://bjgpopen.org/content/4/1/bjgpopen20X101026
Clinical Board
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