75
From other pages
P R O B E
• V o l . L I I I • N o . 3 • A p r – J u n 2 0 1 4
I didn’t realize how deeply I have
internalized this example until I
caught myself imitating it when the
roles were reversed and I was once
again ensconced in my white coat
and wielding my own stethoscope.
My patient was an elderly woman
hospitalized for heart failure
secondary to amyloidosis. Clearly
fatigued, she still smiled at me when
my clinical preceptor asked if I could
perform a brief history and physical.
As I carefully palpated for lymph
nodes, my fingers discovered a hard,
irregular lump just inferior to her
left mandibular angle. Perplexed,
I probed further, all attention
diverted by this unknown physical
finding. Was it a lymph node? A cyst?
Perhaps a tumor? Before jumping to
conclusions I decided to be systematic.
For comparison I checked her right
side—and to my elation there was a
matching lump. Despite my constant
feelings of bumbling inadequacy, had
I found the submandibular glands?
Then my internal reverie derailed as
the patient’s reaction broke through
the walls I had constructed to hear
myself think. Her breathing was
faster now, more shallow despite the
supplemental oxygen, and beneath
my fingers the delicate tremor of a
previously stable pulse betrayed a
panic I knew all too well. I may have
been just one of a parade of people
entering and exiting with each new
hospitalization, but prepared or not, I
had introduced myself wearing a white
coat that stands as a universal symbol
of knowledge. When I frowned
in confusion and spent extra time
palpating her neck, there was a reason
why. It wasn’t until I saw the fear
lurking behind her eyes that I realized
I knew what I was looking for—but
she didn’t. And, even more than her
disease or discomfort, that uncertainty
made a difference.
“I’m not sure,” I told her, “but I think
we’ve discovered your submandibular
glands, one of your sets of salivary
glands. There are lots of lymph nodes
in your neck too,” I said, “So it could
be those instead, but since I can feel
one on each side I think they’re the
salivary glands.” It was a reflex, a
response to the question I knew she
was asking herself although she hadn’t
said anything to me, and as soon as
the words were out of my mouth I
watched her relax. “Really?” she said,
with the slightest of smiles and a hint
of awe, as if the panic of the previous
moment had never existed.
“I had no idea.” And as the pieces slid
together, all I could do was smile back.
Source
: Redig AJ
JAMA
. 2006;295(4):363–364.
