She Never Looked Sick

Sometimes we can diagnose an illness but not treat it.

By Daniel Munoz, M.D. '04

Sometimes we do the most for people when there’s nothing left to do. I realized this during a recent rotation on the neurology service when a grandmother from rural Maryland became my patient.

To my initial relief, Mrs. King didn’t look sick. In fact, she looked quite at home in the hospital. Less than an hour had passed since she’d arrived in the inpatient neurology unit on a quiet Saturday afternoon. As I entered her room, a rare March thunderstorm pounded her window with a driving rain. The light was off, and a dense fog outside her window seeming to spy on her movements. Her belongings were neatly arranged on the windowsill, including a get-well crayon drawing that looked like a grandchild’s work.

Already wearing a warm, pink flannel robe with matching slippers, her graying hair neatly braided in rows, Mrs. King looked straight out of a Norman Rockwell painting. All she needed was a fireplace and a book.

“Oh hello, doctor. How are you doing today?” she offered politely.

Looking into her eyes for the first time, I was struck by this woman’s  facial expression. She smiled, but I saw unmistakable strain. Her furrowed brow communicated disquiet.

“Do you know what I’m doing here?” she inquired.

As it turned out, the answer was buried in the question. For the past five months Mrs. King’s family had noticed that something was off. A working woman in her mid 60s, she was becoming easily confused. Her memory seemed clouded. She talked about socializing with people who had died—like her mother and her husband. She no longer could balance her checkbook. And at work, she was leaving simple tasks unfinished and treating old colleagues like new acquaintances.

One thing was clear. Everyone who knew Mrs. King was worried. Now, after months of subtle symptoms and a fairly complete examination by her local doctors, she’d been transferred to Hopkins. We were to review her case and answer some fundamental questions: Had her local doctors missed anything? What might be causing her confusion and her flickering memory? And finally—is this what we fear it is?

Physicians jest that there are three fundamental questions they ask in diagnosing a neurological problem: What’s the deficit? Where’s the lesion? What’s for lunch? It’s a jaded saying that makes a serious point. Medicine’s ability to diagnose far exceeds its ability to treat certain diseases. Still, when you come face to face with this chasm in treating your own patient, it’s frustrating.

For seven days, our team started from scratch to diagnose Mrs. King’s problem. We didn’t ignore  the results of her workup by her local doctors, but we did set them aside. Our investigation included the most advanced brain imaging in our arsenal and the most sophisticated array of blood tests at our disposal. A few days into her stay, I performed a lumbar puncture at the bedside, sending samples of her cerebrospinal fluid to the Hospital laboratory for in-depth analysis. Mrs. King was entirely cooperative and chatted comfortably during the 20-minute procedure. There was only one problem. Later in the day when I checked in on her, she didn’t remember undergoing the spinal tap.

Part of me hoped that we would discover that Mrs. King had an identifiable pathogen. A positive test would give us a target, a direction in which to aim our therapeutic efforts. But seven days of testing turned up nothing. This particular enemy appeared faceless. Reluctantly, we were forced to settle on a diagnosis for which there is little treatment: Mrs. King was likely suffering from an early form of dementia. I felt an unsettling blend of sadness and helplessness in not being able to offer a therapy.

Perhaps the lasting lesson for me was that even though I couldn’t fix her illness, I could try to help her family cope. In the last few days of Mrs. King’s hospitalization, we counseled her, but we also counseled her family about the sobering realities of her situation. We gave them time to make arrangements for her safety at home and time to stomach the bitter pill of a diagnosis that meant an immediate, irreversible life-changer for all of them. The irony was that out of everything we did with Mrs. King, those last 48 hours were the most useful.

It speaks to the general decency of people that, at a time when anger and frustration would be natural, the Kings thanked us. They were simply grateful for our efforts, for our honesty and for our concern about all of them.

The day Mrs. King left, she still didn’t look sick. But now I knew better. I remembered how on the day I’d met her, her hospital room had shielded her from the storm and the fog outside. That task would now fall to her family.

Dan Munoz is a second-year resident in the Department of Medicine.