Case Highlights the Importance of Not Rushing Into Judgment With Patients
One physician assistant reflects on how one's gut instinct is not always correct.
My patient was a pre-med student in his early 20s who came in complaining of left-sided neck pain. He wasn't sure how it started, maybe after playing golf or after staring down for hours while writing a paper. Going to the chiropractor had not helped, nor did a course of steroids and NSAIDs.
He is “never sick,” and his mom is a nurse and wanted him to come to the ER and get checked out. When I went through the review of systems, he seemed to say “yes” to everything. He had cold-like symptoms and may have had a few pounds of weight loss but thought it could be stress from school or a few low-grade fevers, etc.
Knowing that when I was a student in the medical field I would tend to overexaggerate when I was feeling sick, I just listened and nodded, and in the back of my mind thought everything is probably fine. I started my exam. First his neck, then his heart and lungs.
“When I take a deep breath, it kinda hurts here,” he said, pointing to the left side of his chest. After I finished the rest of my physical exam and got a little more information, we started our workup and decided to do imaging of his neck, and because he happened to mention pain with inspiration, his chest.
While all other studies were normal, the chest X-ray seemed suspicious and the radiologist suggested a CT. We waited for the results, and finally the report came back. The pre-med student, who came in complaining of neck pain, had a 12-cm mass in the left side of his chest. I immediately felt awful, as I initially thought he was exaggerating. In PA school you hear about horrible things, and when you sneeze you think, “Oh no, I have cancer.” However, in his case he actually might.
We went in to tell him the news. His wife and parents came in, and we went over our findings with them. They fought through tears to ask questions and understand how a seemingly healthy person could have something so dangerous. We couldn't answer many of their questions at the time and reassured him that now he could get the help he needed. Rather than starting his next semester at school he was referred to oncology to have the mass removed and begin treatment.
Is it rare to have a patient with neck pain end up having a 12-cm mass? Absolutely. But on this day I learned to listen and not let my bias take over. I learned that sometimes your gut and initial ideas could be wrong. And I learned that it can be a simple answer or exam finding that can lead you down a completely different path.
I won't forget this patient, his case, or the lessons I have learned. In the future, I will keep my thoughts as thoughts and not allow myself to rush into judgment. My patients will know their bodies better than anyone else. I will never forget to listen.—Nicolle Gale, PA-C, West Palm Beach, Fla.
These are letters from practitioners around the country who want to share their clinical problems and successes, observations and pearls with their colleagues. We invite you to participate. If you have a clinical pearl, submit it here.