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The Art of Medicine

Hidden agendas

Maurer, Brian T. PA-C

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Journal of the American Academy of PAs: December 2014 - Volume 27 - Issue 12 - p 60
doi: 10.1097/01.JAA.0000456585.66432.ab
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The pupil and the teacher working together on the same lines, only one a little ahead of the other.... —William Osler

The woman with the electronic appendage in her ear slips into the examination room and pulls the door closed behind her. The physician with whom she just finished speaking beckons me. “This mother is concerned about her daughter's pica,” he whispers. “So after you see the girl, order the labs—CBC, comprehensive metabolic panel, lead level—and we'll review them when they come in. Just don't bring up the subject in front of the girl—it will upset her. Oh, and take the student with you when you go in.”

He hands me the 7-year-old girl's chart. I look at him, dumbfounded. “How am I supposed to address an issue that I can't talk about with the girl?” I ask him.

My supervising physician looks at me as though I were crazy. “She's not here for an evaluation for pica,” he says. “She's here because she hurt her foot.”

The student has heard all. I knock on the door—two quick raps—and usher him inside. I introduce myself and the student to the woman, who sits in the chair by the window, and to the girl, who sits in the chair by the door, quietly looking at a picture book in her lap. “I understand you hurt your foot,” I say. “What happened?”

“A boy in my class shoved the bookcase on wheels, and it fell over on top of my foot,” the girl announces, not looking up from the book.

“I found out about it after school yesterday,” the mother says. “She's walking on her heel this morning, so I thought it best to have it checked.”

“I see. Did you put ice on it or give her anything for pain?”

The mother shakes her head.

“How did she sleep last night?”

“How did you sleep last night?” the mother asks the girl.

“Fine,” the girl says. She continues to study the book.

“She was whining last evening,” the mother says, “‘Get me some ice, get me a drink!’ But I'm hurting quite a bit myself. I can't be up and down running to the refrigerator, waiting on her hand and foot.”

“Which foot got hurt?” I ask the girl.

“My right one,” she says.

“Hop up on the exam table and we'll have a look at it.”

Gingerly, the girl rises from the chair and climbs up on the examination table, bearing weight only on the heel of her right foot. She carries the book with her and opens it again in her lap.

“Bring your feet together,” I say, squatting down to study them. There is no bruising, no discernible swelling, no limited range of motion, no point tenderness. “Come down off the table,” I direct her.

Reluctantly, she lays the book to the side and hops down onto the floor.

“Let's see you walk down the hall.”

The student and I watch the girl amble down the corridor on the heel of her right foot. “That's fine,” I say. “Come on back.”

She turns and runs back to where we stand outside the examination room, sweeps by us, climbs back up on the table, and opens the book.

“I think she's going to be fine,” I tell the mother. “Just a little bruise.”

“You don't think she needs an X-ray?”

“I don't think an X-ray is necessary at this point. Take her home, put some ice on the foot, give her some ibuprofen. Call us if she's not better in 2 days.”

The mother looks at me with questioning eyes.

“Ah, yes,” I say, reaching for a laboratory slip from the overhead cabinet. “You can take her to the lab at your convenience. We'll call you when the results come in.” I hand her the form.

“Can I have a lollipop?” the girl asks.

“Sure,” the student says. “Come with me.”

The girl follows him out, bouncing down the hallway.

The mother rises to her feet and shuffles out the door. “The amount of pain I'm dealing with—you don't know,” she says.

The student follows me into the office to discuss the case.

“You probably picked up on the mother's comments,” I begin.

“Yeah—when I saw the foot, I thought, no way is this a fracture,” he says. “So what tests did you end up ordering for her pica?”

© 2014 American Academy of Physician Assistants.