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The Art of Medicine

Regression

Maurer, Brian T. PA-C

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Journal of the American Academy of Physician Assistants: April 2020 - Volume 33 - Issue 4 - p 58
doi: 10.1097/01.JAA.0000657228.79637.e0
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“Your next patient is waiting in Room 2,” the nurse says, handing me the chart. “He's a 6-year-old, but he's acting like he's 3. I couldn't get him to cooperate for the eye test, he wouldn't sit still for a blood pressure, and I barely got his height and weight.”

“Due for any vaccines today?” I ask.

“Thank God, no! Good luck.”

“If it's okay with you,” the student says, “I'll work up your next patient. A 9-year-old with a rash. I've seen plenty of well-child exams this week.”

“That's okay by me,” I say. “A youngster with a rash might be more interesting.”

I turn my attention to the 6-year-old's chart. Quickly, I review the vital signs, glance at the growth curve, then step into the room.

The couple sits in the orange plastic chairs, mother and father, side by side. The father exhibits several days of gray stubble on his unshaven face; the mother wears a tight black leather turban around her head. The boy lies curled up on the examination table next to his father. When his eyes meet mine, he makes mewing animal sounds and paws his face.

“Stop that now, the doctor's here to give you your checkup,” the father says. “Sit up and pay attention.”

“Are you having a bad day?” I ask the boy with a smile. “You didn't want to come in to see us?”

The boy ogles my face but remains silent. “Sit up and answer the doctor,” the mother says, looking up from the partially completed form on the clipboard in her lap. “He's been giving us a hard time lately,” she explains, “almost like he wants to be a baby again.”

“How did the school year go?” I ask.

“Initially, it was tough. He cried every day the first 2 weeks, refused to go. Finally he settled down, made some friends; eventually got along well with the other kids and finished out the kindergarten year fine.”

“So, soon you'll be starting first grade!” I say. “Are you excited about going back to school to see your friends?”

More animal sounds. “Sit up, please,” the mother says. The father leans over and lifts the boy onto his lap. “Now, listen to the doctor,” he says.

Gingerly, I slide over on my stool and begin the examination. The boy fights me the whole way. I decide an abbreviated version is in order. Finally, we finish. I push back, exhausted from the fray.

“It's been a tough summer,” the mother says. “We tried to tell him the best we could; we kept it simple, but he doesn't understand.”

I raise my eyebrows and silently wait for the pronouncement.

“I was diagnosed in June, 2 months ago. They cleaned me out inside. All my female parts are gone. He'd been asking for a little brother, but I told him Mummy can't have any more babies now.” Her voice thickens. “I started my third round of chemo this week—stage 3 ovarian cancer.”

Her words hang heavy in the air; the diagnostic label clouds the room.

The father breaks the silence. “My son goes over to my mother's a lot,” he says. “He plays with his cousins. My sister's been good to us. Sometimes she has him over for sleepovers; my brother-in-law takes him for hikes in the woods. He's better when he's out of the house.”

I take a deep breath. “It's great that you've got the extended family to help out,” I say. “You've got a lot on your plate. The stress must be overwhelming for the two of you at times. Even though your son's a kid, he feels it too. That's why he's been acting out—it's his way of dealing with the stress.”

“I think you hit the nail on the head, Doc,” the father says.

“You may want to consider some short-term counseling at some point. I can give you the names of a couple of good people in the field—just let me know.”

The couple nods in agreement. “Thanks, Doc,” the father says. He shakes my hand as they amble out.

“How did that go?” the student asks in the back hallway.

“It went okay,” I say. “Sometimes in a well-child exam it takes a bit to figure out the dynamic; but when you do, it all comes together. Now then, what did you think about that 9-year-old's rash?”

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