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The Art of Medicine

Cutting remarks

Maurer, Brian T. PA-C

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Journal of the American Academy of Physician Assistants: February 2020 - Volume 33 - Issue 2 - p 58
doi: 10.1097/01.JAA.0000651772.45600.82
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“I don't know why this patient is on your schedule,” the nurse says, handing me the chart. “The other providers know her well. You're going to be tied up in there a long time.”

Hesitantly, I open the medical record to scan the contents. “Why is she here today?” I ask.

“She needs an exam before she can start clinicals in her CNA program next week. I don't know how I'm going to do her PPD. She's already weepy about it.”

I make my way down the long corridor to Room 8, rap on the door, and push it open. Despite the nurse's admonition, I'm not entirely prepared for the portrait before my eyes.

A young woman sits cross-legged on the examination table, hands resting in her lap. Long thin bleached hair frames her round face to the shoulders. Pale white arms protrude from a black sheer sleeveless blouse. Both forearms are riddled with row upon row of linear keloid scars. The mouth is pursed; her lower lip trembles ever so slightly.

I offer a hand and introduce myself. “I understand you're here for a physical exam,” I say.

“Yes,” she says, “I need it for my nursing program. But I'm really freaking out about the PPD test. I've got OCD, and if it bubbles I'm afraid that I'm going to pick and pick at it, and it won't be good.”

“Will an alternative tuberculosis test do?”

She wrinkles her brow. “What sort of test are you talking about?”

“It's called a QuantiFERON-TB assay,” I say. “It's a blood test. You'd have to go to the lab for a blood draw.”

“I wouldn't have to have a bubble injected in my skin?”

“No, the test is run on a blood sample.”

“Well, I'd much rather have blood drawn than have that bubble under my skin. I don't like the way my skin responds to trauma.”

I swallow hard and work to hold her gaze. “I can certainly order that test for you instead of the PPD,” I say. Almost immediately, the tenseness dissipates from her face.

“Now tell me—it's been a while since you've been here—what's been going on in your life?”

“I spent the last 15 months in residential psychiatric facilities,” she says. “The first one was out in the Midwest. From there I was transferred to one in the South, and then I went to one on the West Coast. I came back home to see if I could find a job. I heard CNAs were in demand, so I applied to a program and got accepted.”

“When does your program start?”

“I've been in class for the past 2 weeks, but now I'm due to start my clinical rotations. That's why I need the physical exam—and the tuberculosis test.”

“Are you taking medication of any sort?”

She nods her head and ticks off a litany of no less than five psychotropic drugs.

“Who is your prescriber?”

She recites the name, spelling it out when I ask her to; but I don't recognize it. “Actually, I don't really care for him,” she says. “He's not very good. I need to find another psychiatrist.”

I choose not to engage her on this last point and move on with the physical examination. She trembles when I touch her ear to insert the otoscope. I note minute fasciculations of the tongue when she thrusts it out. Her lungs sound clear; I feel a mass in the left lower quadrant of her belly. “How are bowel movements?” I ask.

“Usually once a week,” she says. “I take medicine for that, too, but it doesn't seem to work.”

I motion for her to sit up. “When was your last menstrual period?”

“Three years ago,” she says. “I've got an implant.”

“Are you in a relationship?”

“Long distance,” she says. “Really long distance—like Midwest long distance.”

I nod my head. “Let's have a look at your back,” I say.

She slides off the examination table, turns and bends over. I lift her blouse to check her spine and note several prominent linear scars just above the beltline.

“Everything checks out okay,” I say. I hand her a signed laboratory slip for the TB test. “As soon as the results come in, we'll append them to your form. It should be ready by next week.”

“Thanks,” she smiles. “I really appreciate you suggesting that other test. I don't think I could have handled the bubble.”

One suggestion, interpreted as a small act of kindness. Perhaps it was. I only know that that night I slept fitfully, unable to dismiss those pale white scars from the dark recesses of my mind.

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