SCENARIO: A 43-year-old high school teacher and former marathon runner presents to a post-COVID recovery clinic 18 months after a three-week ICU stay for COVID pneumonia with ARDS. She reports persistent fatigue, brain fog, exertional dyspnea, and POTS-like symptoms. Her employer has questioned her disability accommodations. Her pulmonary function tests are normal. She brings a folder of normal test results and says, 'Nobody believes me.'
Before You Read
What to Look For
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The Binder as Diagnostic Sign: The SOAP note lists normal PFTs, echo, and MRI as negative findings. The prose sees the binder itself as pathognomonic: 'the binder of a patient who has been disbelieved, who has organized her suffering into tabbed sections because no one will take her word for it.' The container tells a story the contents cannot.
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Normal as Verdict: Every test in the chart says 'normal.' The prose reframes normal as a miscarriage of evidence: 'the nothing has become its own diagnosis.' The poem places the honest act elsewhere entirely — in the disability letter, 'the first honest thing / medicine has offered her / in eighteen months.'
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The Distance Between Two Selves: The SOAP note records '6MWT: 380 m (predicted 520-580 m)' — a deficit. The prose translates: 'She ran marathons. She says this twice, not as a boast but as a coordinate.' The poem compresses the same loss: 'she used to cross / finish lines — / now the finish line / is the top / of the stairs.' Three calibrations of the same distance.
Lens I
SOAP Note (EHR)
AI-generated for educational purposes. Not a clinical document.
SUBJECTIVE:
Presents for evaluation at post-COVID recovery clinic, 18 months after hospitalization (21 days in ICU, 14 days intubated, proned, ARDS requiring paralytics). 'Before COVID, I ran three marathons. I taught AP Biology full-time. I never missed a day of work in 15 years.' Current symptoms: fatigue 8/10 daily, unrefreshing sleep despite 10 hours, 'I lose words mid-sentence — I can't grade papers for more than 20 minutes,' gets short of breath climbing one flight of stairs, dizziness on standing, palpitations with position changes. Brought a binder of prior workups — PFTs, echo, chest CT, blood work, brain MRI — all normal. Her employer's HR department has requested 'objective evidence of disability' to continue part-time accommodations. Tearful: 'I have a folder full of normal tests and I'm still not the person I was. Nobody believes me.' Says her husband 'tries to understand but I can see him getting frustrated.' No depression prior to COVID. PHQ-9 today: 14. Has stopped running entirely. Has stopped coaching the track team.
OBJECTIVE:
VS: Supine - HR 68, BP 118/74. Standing (3 min) - HR 112 (+44), BP 108/70. Pt symptomatic on standing: lightheaded, diaphoretic. 6MWT: 380 m (predicted 520-580 m for age/sex), significant dyspnea and fatigue, HR recovery delayed. SpO2 maintained >95% throughout. Gen: well-appearing woman who appears her stated age. Neuro: MoCA 24/30 (lost points: delayed recall 2/5, serial 7s, fluency). Cardiopulmonary exam: normal. MSK: no deconditioning atrophy evident. NASA lean test: positive for POTS (HR increment >30 bpm within 10 min standing).
ASSESSMENT:
43-year-old woman, formerly high-functioning marathon runner and teacher, presenting 18 months after severe COVID hospitalization with persistent fatigue, cognitive dysfunction, and autonomic symptoms. 1. Post-acute sequelae of SARS-CoV-2 (PASC / Long COVID) - 18 mo post severe COVID with ARDS. Presenting with post-exertional malaise, cognitive dysfunction, and autonomic dysregulation (POTS confirmed by NASA lean test). 2. POTS, likely post-viral autonomic neuropathy - HR increment of 44 bpm on standing with symptoms. 3. Cognitive impairment - MoCA 24/30 with deficits in recall and processing, consistent with published PASC neurocognitive profiles. 4. Functional limitation - 6MWT 65-73% predicted, consistent with significant exercise intolerance despite normal PFTs and echo. 5. Secondary depression - PHQ-9 14, likely reactive to functional losses and loss of identity.
PLAN:
1. POTS management: fludrocortisone 0.1 mg daily, compression stockings 20-30 mmHg, salt supplementation 3-5 g/day, counter-maneuver education. Increase oral fluids to 2-3 L/day. 2. Graded exercise therapy with POTS-aware PT - begin recumbent (recumbent bike, swimming), advance per Levine protocol. Explicitly avoid 'push through' approach - will worsen PEM. 3. Neuropsych referral for formal cognitive testing and compensatory strategy training. 4. Disability documentation: I will write detailed letter for employer documenting PASC diagnosis, objective findings (POTS on tilt, 6MWT reduction, MoCA deficits), and medical necessity of continued part-time schedule with cognitive rest breaks. Discussed with pt that 'normal' standard tests do not capture her disability - provocative and functional testing does. 5. SSRI consideration for depression - discussed, pt prefers to defer and reassess after POTS treatment initiated. Agrees to counseling referral. 6. Support group referral - Long COVID peer support, local chapter meets biweekly. 7. CPET (cardiopulmonary exercise test) ordered to quantify exercise limitation and further document functional capacity for disability purposes. 8. RTC 6 wks. Will coordinate with PCP on ongoing management.
Lens II
Narrative Medicine: Prose
Eighteen Months Out and Still Not Back
AI-generated for educational purposes. Not a clinical document.
She has brought a three-ring binder. I have seen this binder before, not this specific one, but its kind: the binder of a patient who has been disbelieved, who has organized her suffering into tabbed sections because no one will take her word for it. She opens it on the exam table and walks me through the normal results the way a defendant presents evidence: PFTs here, echo here, MRI here, blood work here. All normal. Every test designed to find something wrong has found nothing, and the nothing has become its own diagnosis, a verdict of wellness delivered to a woman who can no longer climb a flight of stairs without stopping.
I ask her to stand, and within three minutes her heart rate has climbed from 68 to 112 and her forehead is shining with sweat. She grips the edge of the exam table. This is the test that matters: not the ones in the binder but the one that measures what happens when she does the simple thing her body used to do without thinking. She ran marathons. She says this twice, not as a boast but as a coordinate, a way of marking where she was so I can understand the distance to where she is now.
I tell her I believe her. I say it plainly, without qualification, because I have learned that for patients like her the most therapeutic intervention is not the fludrocortisone I am about to prescribe but the sentence that says what is happening to you is real, it has a name, and I can see it. She cries, and I understand that she is not crying because she is sad, or not only because she is sad. She is crying because someone has finally agreed that the person she used to be and the person she is now are not the same, and that the distance between them is not laziness or anxiety or a failure of will. I write the disability letter before she leaves. She should not have to prove her suffering with a binder.
Lens III
Narrative Medicine: Poetry
AI-generated for educational purposes. Not a clinical document.
She brings a binder
of normal results
tabbed and labeled
the way a teacher
would organize anything,
even her own undoing
stand, I say,
and her heart
runs a race
her legs
no longer can
she used to cross
finish lines —
now the finish line
is the top
of the stairs
I write: this patient's
disability is real
and the pen feels
like the first honest thing
medicine has offered her
in eighteen months