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The Art of Medicine

Déjà vu all over again

Maurer, Brian T., PA-C

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Journal of the American Academy of PAs: October 2013 - Volume 26 - Issue 10 - p 65
doi: 10.1097/01.JAA.0000435000.17223.20
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Simultaneously, two charts plunk into the box outside my office. One patient, a 2-month-old infant, is here for well child care. The other, a 5-year-old girl whom I haven't seen in several years, is sick. Unlike the infant, the girl's name does not appear on my schedule.

“She was booked with the doctor, but they insisted on seeing you,” the medical assistant explains.

Just what I need, I muse, two patients scheduled in the same time slot; one well, one sick. Better to see the sick first; the infant will take more time. New mothers always have lots of questions.

After a quick rap on the examination room door, I step across the threshold and enter a different time, a different place. The little girl sits on the lap of her grandmother, a woman I have not seen in a decade. Off to the side, the girl's mother stands, waiting expectantly.

“Well, hello!” I say with a smile. “It's been a long time.”

“Yes, I suppose it has,” the grandmother replies, even though I sense that years have suddenly telescoped for her as well.

“What's up?” I turn to the child's mother. She must be in her early 20s now. The face is so familiar, so similar to those of her older sisters, I recall.

“Ashley's been throwing up for three days,” the mother says. “She can't hold anything down. We tried juice, ginger ale, sports drinks—nothing works. I'm afraid she might be dehydrated.”

“How many times has she vomited over the past 24 hours?” I ask.

The young mother looks at the grandmother, then says, “Maybe four or five times.”

“And when was the last time?”

“Early this morning. She hasn't had anything to eat or drink since then.”

I make a note of the numbers. Then I ask, “When was her last stool?”

Again the eyes of the two women meet. “Last night, I think,” the mother says. “She had a regular poop—maybe a little on the loose side.”

“Any fever?”

“No, no fever so far.”

“Good. Well, let's have a look.”

I reach for the throat lamp and a tongue blade. Immediately, the child shrinks into her grandmother's arms. “It's okay, the doctor won't hurt you,” the grandmother says. “He's a nice man.”

I take it slow, first showing the child the light. When I give her the opportunity to touch it, she pulls back. It takes some doing, but finally I succeed. “There, that wasn't so bad, right? Now open your mouth wide.” I check the mucous membranes and peer into her throat.

Next I step back to feel her neck. Carefully, I palpate below the jaw and down each side. Small shotty nodes roll beneath the pads of my fingers. The grandmother studies my face but says nothing.

“Pull up your top and we'll listen to you.” This time the child complies readily. Breath sounds are clear; heart sounds are normal. “Okay, now lie back in your grandma's lap so I can feel your belly.”

Gently, the grandmother eases the little girl back against her chest. I listen for bowel sounds—they are abundant—and feel below the costal margins for a liver or spleen edge.

As I drape the stethoscope around my neck, the grandmother speaks. “How is she? Any nodes or spleen?”

“No, no big nodes, no spleen or liver enlargement.”

The grandmother lets out a long slow whispering breath. If I didn't know better, I'd say it was a prayer.

“Ashley's got a tummy bug that's hanging on,” I say. “I'll give her some medicine to quiet the nausea. Meantime, keep pushing fluids. If we can hydrate her up a bit, she'll do fine.”

I write the prescription and hand it to the mother. “It's a dissolvable pill. Just pop it on her tongue and it will disintegrate immediately. She can chase it with a sip of water.”

“Zofran?” the grandmother asks.

Of course, she would have known. “Yes, Zofran.”

Briefly, our eyes meet; and we both know why.

“Call tomorrow to let us know how she's doing,” I say in my most reassuring voice.

“Thank you,” the mother says.

“Yes, thank you,” the grandmother says. “Once again.”

Twenty-five years have passed since I diagnosed her first daughter with acute lymphocytic leukemia; within months the child succumbed. Eight years later, her second daughter developed the same illness; once again, I was the one who delivered the diagnosis. I know what this grandmother must have been thinking today: déjà vu all over again. I read the look in her eyes, the concern on her face. But this time the diagnosis was much different, even if the treatment was partly the same.

© 2013 American Academy of Physician Assistants.