She Never Looked Sick
we can diagnose an illness but not treat it.
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
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
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
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.