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MERCED/Danielle Ofri For this is the end ofexaminations For this is the beginning oftesting For Death will give thefinal examination and everyone will pass John Stone, Gaudeamus lgitur "This is a case of a twenty-three-year-old Hispanic female without significant past medical history who presented to Bellevue Hospital complaining of a headache." The speaker droned on with the details of the case that I knew so well. I leaned back in my chair, anticipating the accolades that were going to come. After all, in a roundabout way I'd made the diagnosis. I was the one who had had the idea to send the Lyme test in the first place. Mercedes had been to two other ERs before showing up at Bellevue three weeks ago. I'd only been doing sick call that day because one of the other residents had twisted his knee playing volleyball. She was a classic aseptic meningitis, the kind that you'd send home with aspirin and some chicken soup, but the ER had decided to admit her to the hospital. Her CT scan was normal, and the spinal tap just showed a few lymphocytes, but the ER always overreacts. They gave her IV antibiotics even though there was no hint of the life-threatening bacterial meningitis. One of the emergency room docs had scrawled something about "bizarre behavior" on the chart, then given her a stat dose of acyclovir. Another ridiculous ER maneuver; this patient had no signs of herpes encephalitis. I'll admit that I was a little cocky that day. But I was just two months short of finishing residency, and I knew a lot more medicine than those ER guys. I chewed them out for admitting Mercedes and made a big show of canceling the acyclovir order. When I met Mercedes that first day, she was sleeping on a stretcher in a corner of the ER. I had to wake her up to take the history, but after a few shakes she was completely lucid. With her plump cheeks and wide brown eyes, she didn't even look seventeen, much less twentythree . The sleeves of her pink sweatshirt were pushed up past her elbows. A gold cross with delicate filigree was partly obscured by the folds of the sweatshirt. "Doctor, you have to believe me," she said, pulling herself up on the stretcher. "I've never been sick a day in my life. It's only this past The Missouri Review ยท 89 month that I've been getting these headaches. They come almost every day, and aspirin doesn't do anything. I came to the ER yesterday, but they said, 'You got nothin', lady/ and just gave me a couple of Tylenols." Dark, mussed curls spilled over her pink shirt. While she spoke, one hand wove itself absentmindedly in and out of the locks. "So, what made you come back today?" I asked. "This headache, it didn't go away. And then my arm. It got all pins and needles for a few minutes. Just a couple of minutes, but now it's fine." Mercedes smiled slightly, and two tiny dimples flickered in her cheeks. "I guess they got tired of me complaining, so they decided to let me stay." I did a thorough physical exam, spending extra time on the neurologic part. I checked every reflex I could think of: biceps, triceps, brachoradialis, patellar, plantar. I examined all twelve cranial nerves. Everything seemed normal. I tried to do all the obscure neurological tests I could remember from Bate's Guide to Physical Examination and History Taking, but nothing seemed amiss, and the patient was certainly not behaving bizarrely. From talking to her, I learned that Mercedes was a single mother with two children, aged three and four. She lived with her own mother but still maintained a close relationship with the father of her children. She worked as a preschool teacher in upper Manhattan. She'd been born in Puerto Rico, but since moving to the U.S. at age two had never left the country. I questioned her extensively about possible exposure to viruses or atypical organisms: travel to the countryside, recent illnesses, recent vaccinations, outbreaks...


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