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The big and the little

Maurer, Brian T. PA-C

Journal of the American Academy of Physician Assistants: August 2017 - Volume 30 - Issue 8 - p 58
doi: 10.1097/01.JAA.0000521151.63195.28
The Art of Medicine

Brian T. Maurer has practiced general pediatrics for more than 30 years. He is the author of Patients Are a Virtue and blogs at http://briantmaurer.wordpress.com. The author has disclosed no potential conflicts of interest, financial or otherwise.

Tanya Gregory, PhD, department editor

[She] is a riddle wrapped in a mystery inside an enigma; but perhaps there is a key.—Winston Churchill, BBC broadcast, London, October 1, 1939

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Stated simply, the question at hand seems to be straightforward: Given the results of her latest urine culture, does this child require treatment?

The laboratory report bears the numbers along with a presumptive identification of the microorganism: 100,000 colonies, Gram-negative rods, E. coli. At first glance, it seems to be a no-brainer: the criteria for diagnosis of urinary tract infection are met; therefore, treatment is indicated. But not all things are expedient, I remind myself; not all that glitters is necessarily the gold standard.

The patient squats by the step stool in the examination room, peering at pictures as she turns the pages of the little big-book. She squeals with delight at the moo cow; she claps her tiny hands at the puppy dog and looks up at me expectantly to validate her joy.

Her mother sits in the chair opposite, leaning forward, elbows resting on her knees, only the hint of a smile on her face. “So what do we do this time?” she asks in a slightly defeated tone of voice.

I shift my weight from one foot to the other and clear my throat. “I understand that this was a bagged specimen,” I begin. “We know that she had several episodes of diarrhea at the time. You say that the assistant at the urgent care center didn't clean her off before the bag was applied, and it took some time—maybe 20 minutes—before she peed.”

The mother nods her head. “That's right,” she says. And then she adds: “I didn't know.”

“It's not your fault,” I say, this time with a bit more firmness in my voice.

The little girl rises to her feet and waddles over to where I stand, holding the little big-book up for me to see. She grunts an unintelligible string of sounds and smiles. Blue eyes, red hair, peaches and cream complexion, and at 2 years of age, just 28 in tall.

The backstory is more complicated, of course.

Over the first 3 months of life, she developed macrocephaly. An ultrasound study of the head demonstrated hydrocephalus. She went to surgery, where a ventricular-peritoneal shunt was placed. As her linear growth slowed, a dysmorphic body habitus developed. She had all the appearance of a dwarf, but genetic studies came back inconclusive. Endocrine and renal studies were likewise unhelpful in arriving at a definitive diagnosis. Lately, over the course of the past several months, she had developed bouts of excruciating abdominal pain that the gastroenterologists and the pediatric surgeons were unable to sort out.

Through it all, the mother had complied with each step, followed through with each recommendation, each consultation, each laboratory and radiologic investigation, each subsequent procedure. Nearly every possible diagnosis had been entertained and ruled out, leaving only a sea of frustration in its wake.

And now here we were today, attempting to sort things out in the aftermath of a weekend visit to a local urgent care center: a positive urine culture in hand, staring at the face of an asymptomatic little girl whose major concern in life seemed to be alerting me to the mysteries of the moo cow in her little big-book.

“So what do we do now?” the mother asks, leaning back in her chair, hands spontaneously splayed apart, unknowingly demonstrating what might be taken clinically as a residual Moro reflex, the universal sign of helplessness.

“I'd hate to put her on a course of an antibiotic for no good reason,” I muse. “If you took her to the bathroom here in the office and washed her bottom, do you think she might be able to give us a midstream clean catch specimen?”

A momentary smile flashes across the mother's face. “We can give it a try,” she says. “Come on, munchkin. Let's see if you can pee in a cup for mommy.”

I watch the child waddle by her mother's side as they move down the long hallway toward the bathroom, still clutching the little big-book in her hand. They're bonded together, this child and this little big-book, each one an early childhood riddle wrapped in a mystery, presently unwilling to reveal the full extent of their enigmatic shrouded secrets.

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