Lee got the first lady’s permission to conduct a more thorough physical exam before he asked Cam to put on a hospital gown in a private changing area. Lee took Cam’s vitals—blood pressure a healthy 114 over 65, heart rate sixty-five, temperature and respirations all normal. Cam said he took no prescription medications.
All visual field tests, eye movement, speed, and quality came out normal, and Cam’s pupils were equal and briskly reactive to light. Using an ophthalmoscope, Lee examined the retinas of Cam’s eyes so he could directly observe the arteries, nerves, and veins, looking for evidence of papilledema—swelling of the optic nerve head that might indicate increased pressure within the skull. The marginated optic nerve and the visible pulsations of retinal veins were normal and reassuring, but did not exclude an underlying tumor.
No sign of one-sided facial weakness. Touch felt equal on both sides of his face, no signs of any sensory loss.
“Can you hear this?” Lee asked as he ever so gently rubbed his fingers together beside each of Cam’s ears. He got a thumbs-up. No problem there.
Next, Lee aimed his penlight inside Cam’s mouth, checking the soft palate, the back of his throat, and seeing Cam’s uvula rise symmetrically and stay midline when he said, “Ahhhh.” The gag reflect was as expected. Cam hated that test. That was expected, too.
Lee asked Cam to stick out that slightly large tongue of his once more, and noted it did not deviate to one side or the other. His neck muscles were strong and equal. After finishing the cranial nerve examination, Lee directed his attention to the remainder of the neurologic exam. Motor function, fine. Strength, good. Coordination intact. No involuntary movements or tremors. With Cam’s eyes closed, Lee tested for sensation, touching a light cotton swab gently over his limbs.
“You feel that?”
“You mean the cotton swab?”
Passed.
All other sensory tests were normal: vibration, joint position sensation, temperature, and the like.
“Now let me see you walk,” Lee said.
Lee could glean plenty of information by observing a patient’s gait. Was there a subtle drag of the leg? Were there signs of imbalance? Did he have equal and normal arm swings? Everything checked out fine.
Lee tested Cam’s reflexes. Those were normal, too. He finished with a general examination, listening to the heart and lungs, palpating and listening to the belly, looking for any unusual skin rashes or lesions or birthmarks, finding none. Physically, everything appeared normal, except for his slightly enlarged tongue and complaint of occasional blurred vision. Lee could hardly be sure those were even signs of any significance.
But that did not mean Cam Hilliard was out of the woods.
When the exam was over, Cam dressed in his street clothes and went back in the waiting room with Lapham and Duffy. Lee felt almost sad to see him go, because he was unsure if their paths would cross again. He had come to like Cam in the short time they’d spent together. The boy was witty, sweet-natured, and obviously exceptionally intelligent.
Ellen Hilliard and Dr. Gleason returned to the exam room, but the president did not join them.
“The president has a meeting he cannot miss, but I’m to report your findings to him.”
Lee wondered if Gleason had encouraged the president to brush off his debrief, and got the vibe he was prowling in the territory of the alpha male. His preference was to speak to both parents, but no matter. The mother was here and Lee had findings to share.
The three sat in a circle facing each other. Ellen’s blinking was rapid and nervous, her jaw firmly set.
“Well, I didn’t find anything physically wrong in my exam, but I’m concerned. Cam told me he’s been waking up some mornings feeling confused and extremely tired, with sore muscles.”
Ellen seemed baffled. “He never said anything to me. You, Dr. Gleason?”
Gleason shook his head. “Don’t we all have those days?”
Lee had seen this coming.
“Yeah, but he’s only sixteen, and these episodes seem to come out of the blue,” Lee said.
“Have you ever been depressed, Dr. Blackwood?” Gleason asked.
Lee gave the question some thought. On the life happiness spectrum, he typically swung pendulum-like from full-on joy to a bit morose, but never manic, and never so low that he could not pull himself out of a tailspin dive. Sure, he would like to find love again, have some sort of companionship. His last girlfriend, a nurse from the MDC named Bethany, had recently ghosted him. At first Lee thought she might have lost her phone, until his son Josh explained “ghosting” as the process of suddenly ceasing all communication in an effort to end a relationship without hurt feelings. Soon after Bethany went radio silent, Lee spotted her out on the town with an orthopedic surgeon. Bethany had never struck him as the materialistic type, but not many family docs cruised around in an eighty-five-thousand-dollar Mercedes, either.
Despite Lee’s dismal love life and the stresses of a diminishing medical practice, he had managed, miraculously even, to live a relatively happy existence.
“I have never had depression,” Lee finally answered.
“But you do realize fatigue, morning aches, are symptomatic of the condition?”
“I’m well aware,” said Lee. “But there is another, more sensitive matter Cam was reluctant to discuss.”
Ellen folded her arms across her chest, bracing herself for the news. “What did he say?” she asked.
“He told me that he wet his bed at night. He said it happened only once, and I’m inclined to believe him.”
Ellen seemed bewildered, but also relieved Lee’s discovery was not worse.
“He’s never been a bed wetter,” she said, “but one time, an accident, a really deep sleep maybe, it’s not so remarkable.”
“I agree,” Lee said. “But it’s also unusual, and I’m here looking for anything unusual that might give us a different window into what’s troubling your son.”
“And has this window shown you something?” Ellen asked.
“I saw nothing in my exam to indicate the presence of a tumor, but I’m worried that Cam might be having seizures during sleep. I thought his tongue was a little generous in size, possibly from having bitten it at night, and waking up tired and achy, the bedwetting, those are all possible indications of nocturnal seizure activity.”
“Are you diagnosing Cam with epilepsy?” Dr. Gleason’s voice had a harsh edge.
“I can’t tell you that, but I do think he needs to see a neurologist, and he needs more tests.”
Ellen pressed her palms together, fingertips to her mouth as though in prayer.
“What does it mean?” she asked. “There’s no history of epilepsy in either of our families.”
“At this point, having a seizure doesn’t mean having epilepsy. If the findings are indicative of seizures, those could be affecting his mood as well.”
“What could cause that?” Ellen asked.
“Scarring in the brain, perhaps, or a genetic predisposition of some sort.”
Ellen shook her head in disbelief, unsure how to process this information. She eyed Dr. Gleason as if to say, How come you didn’t know all this?
“No offense, Dr. Blackwood,” Gleason said, “but I believe you’re in over your head here, and I’m afraid you’re alarming the first lady for no particularly good reason. Now, hats off to you for getting Cam to open up, but nothing you’ve described makes me think anything different.
“If you take into account all the evidence—Cam’s moodiness, the behavioral changes, and now add bedwetting to the mix—I think you’ve helped to bolster my case that the real culprit is anxiety and stress. I think we should rule that out before we make Cam any more anxious with what may be unnecessary tests,” Gleason said. “Then, I guess, we could let someone who knows the brain take a look at him.”
With all the evidence he had presented, just about any doc Lee knew would be willing to suspect seizures, but not Gleason. Again, Lee caught the strong scent of Gleason’s alpha male aura. If Cam was going to receive a neurological consult, it would be at Gleason’s direction, not Lee’s.
“Cam’s not had any previous problems, and he says he’s not under any undue stress,” Lee said. “Something else may be going on here.”
“Your exam was normal,” Gleason said.
“That doesn’t rule out anything. You have his visual complaints to consider as well,” said Lee. “I think you should rule out all medical issues before declaring him in need of psychological help.”
“Dr. Gleason, what are we going to do here?” Ellen asked. “All I hear is you two arguing, and that’s not helping my son.”
Her eyes bored into Gleason. She was task-driven, Lee could tell. She wanted clearly articulated next steps and a resolution.
Dr. Gleason returned a wan smile. “We will certainly take Dr. Blackwood’s assessment under careful advisement. I want to thank you for your time today. You’ve been of great service.”
There were more thank-yous after that, and a lengthy handshake with the first lady, and a promise to let Lee know he would be called upon again if they felt he could be of further help.
Lee was not expecting his phone to ring anytime soon.