The mother’s gaze was as piercing as a hawk’s. “My daughter has never been like this,” she told me evenly. “This is not her.” I glanced at the nurse’s ER triage note: “Rita Suarez, 26-year-old, insulin-dependent diabetic, confused since this morning.”
Forewarned, I turned to the thin, pale woman on the stretcher who squirmed like an overtired child. “I feel so bad,” she mumbled.
“Ms. Suarez,” I asked, “does anything hurt you? Your head? Chest?”
My patient moaned and curled into a ball. Was she just being difficult? Sometimes patients treat questions as impositions, their attitude being, “You’re the doctor. You figure it out.”
The mother must have sensed my skepticism: “She woke up like this.”
“Was she OK last night?” I inquired neutrally.
“Fine,” the mother replied. “No fevers, no headache, sugars were fine. Her normal self.”
Ms. Suarez had been an insulin-dependent diabetic since childhood. She still lived with her mother, who by all indications took very good care of her.
My initial guess—hope, really—was that she was suffering from low blood sugar. But the nurses beat me to it: Her finger-stick glucose was normal. Still, I told myself, this must be a complication of the diabetes. Maybe her brain was reeling from too many sugar highs and lows.
“Has her sugar varied much lately?” I asked. “Any episodes of coma or confusion this past week?”
Mom thought for a moment. “One time, years ago, she fell into a hypoglycemic coma, but nothing since. Her glucose has been steady.”
“Please forgive my asking: Any drugs? Any chance of alcohol?”
The mother answered, evenly again, “I understand. No.”
Trying to be gentle, I pulled back the sheet and took a stab at listening to Ms. Suarez’s lungs and heart; she did her best to avoid me. Awkwardly I held her head and bent it toward her chest to check for neck stiffness. This can be a sign of meningitis, an often lethal infection of the lining of the brain and spinal cord that can cause mental confusion.
“Leave me alone,” she muttered, pushing away.
My malingering radar lit up. If you’re coherent enough to say you feel bad, then you should be able to cooperate with a physical exam. Was she giving me the runaround?
The mother caught my skeptical look. The hawk eyes came back. “Something’s wrong,” she intoned…
Image: The thyroid gland, shown here magnified 49x, produces a hormone that regulates the body’s metabolism. Steve Gschmeissner/Photo Researchers Inc