A Headache at the End of the Day

Howard Brody

doi:10.1370/afm.603

Abstract

This essay presents a family medicine office visit with a child and both parents; details have been modified to protect patient and physician confidentiality. A child’s headache, which has gone away before the start of the office visit, provides a window into the relationship between the parents and into the sources of their worries about their child’s health. The essay highlights the multiple medical and behavioral concerns that the physician must keep in mind during relatively brief office encounters, and the intellectual challenge of maintaining appropriate attention to all these threads, and understanding their interactions, while completing the visit in a timely fashion.

Glance down at the bottom of the schedule to see who’s the last patient. Larry Wong, headache. Not one of my regular patients; a sick call. Hope it’s quick. Tonight I have to meet my wife for dinner. For some crazy reason, I am nearly on time finishing up with my next-to-last patient. I see the encounter form on the door of the other examination room, but the room is empty. “Your last patient isn’t here yet,” says the aide. “His father checked him in, but he’s coming with his mother, and they’re not here yet.”

Father? Mother? I figured it must be an adult, coming in with a headache. Nope—here it is, 5 years old. Not too many 5-year-olds complain of headache. Wonder what’s going on. Both parents coming, too? A big deal. At least their being late is no problem; I can work on my notes for other patients.

Okay, he’s finally here. Encounter form says they usually see Dr Price. Say hello—great, the parents speak good English. Shake hands with Larry. First agenda: establish rapport, I am going to treat him like an adult, I’ll take him seriously. Next agenda: support the relationship with the primary doc, don’t get into competition with my partner. “I’m sorry that Dr Price must have had a full schedule today; I’ll try to fill in as best as I can till you can see him.”

So now, what’s the problem? I look at Larry, but it’s unlikely a 5-year-old will start talking with both parents in the room. Sure enough, Dad takes over. A 2-day history of complaints of frontal headache, swollen and red left eyelid, feeling tired, no fever. Took him to the lake yesterday, Sunday, but he said he felt tired and sick, and kept putting his hands in front of his eyes as if the light hurt. This morning, got up, the swelling was gone. Now he says he feels fine, they report. Mom is holding tight to his 2 medicines—a corticosteroid inhaler and a bottle of nonsedating antihistamine tablets. They didn’t give him the tablets this morning, she says, they were worried the tablets might be causing his headache. Hmm. The antihistamine may be pricey, but it hardly ever causes headaches that I’ve heard. Why would they think it was the culprit?

Glance at the computer screen while they are talking. Problem list: mild intermittent asthma, allergic rhinitis, history of pneumonia. No clear reason why they’d be bringing a child in to the doctor when his problems had gotten better on their own. A lot of visits recently for a pretty healthy kid, too. Mom seems worried. She throws in something about him not eating right.

Next agenda: the differential. Nothing is coming to mind that’s serious and that would cause a headache like this that seems to have gone away on its own. Light hurts—photophobia. Migraine? Unlikely at this age.

Dad is still talking, and now Larry starts to say something. I’ve got to keep my promise to Larry to take him seriously, but I want to hear what Dad is going to say. I am still trying to get a handle on what the parents are worried about. Look Larry in the eye: “Larry, I need to let your Dad finish, and then it will be your turn.” He looks me back in the eye. Great, he buys it.

Now Dad’s finished. “Okay, Larry, now it’s your turn.” Showing him I’ll keep my promises at least. Larry is a typical 5-year-old, runs to Dad to whisper in his ear, won’t tell me directly. Uh oh, trouble—Dad is telling Larry he should talk to me, not be afraid. Worried his kid is embarrassing the family in front of the doctor. Touchy. I have to give Larry breathing room but not seem to be undermining Dad’s authority. Give it a shot: “Dad, I want to ask you for a big favor. It’s real normal for 5-year-olds to be pretty shy in the office here—it’s not their usual environment.” Try to normalize the behavior—nothing to feel ashamed of. “So maybe you could let him whisper to you and then tell me.” Relief: Dad is taking it all right, he does not look upset. Larry whispers to Dad and Dad starts to tell me, and as I expect, Larry breaks in and tells me anyway. No biggie, just wants to change the order in which he had the symptoms—says he felt tired first and then had the headache later. “Do you feel okay now?” The parents already told me that, but now we have Larry’s role in the conversation established, so that’s good.

Next agenda: I’m an unknown, not their usual doctor. They are worried. Gotta’ do a pretty thorough physical or they won’t be satisfied. Also on the agenda: standard 5-year-old stuff, get the kid to cooperate and have fun with the examination.

Head is normal, I don’t see any redness or swelling of the eyelids. Neck is supple. Pupils equal and reactive to light, discs look fine. Larry’s cooperating nicely as I would have expected. “How wide can you open your mouth?” Plenty wide, no need for a tongue depressor. “When Dr Price looks in your ears, does he look for anything special? Frogs? Butterflies? Potatoes?” Larry looks from me to his Dad—why are you letting this lunatic examine me? “Well, okay, we’ll just look in and see what we see.” He holds still just fine. “You’re right—no frogs or butterflies.” Ears are clear bilaterally. Throat is normal. Neck has no nodes.

“Take big breaths in and out like this.” No wheezes. “Great—he sounds fine”—to Mom. “Do you know where your heart is?” Larry points. “Great—let’s listen. I’ll listen first and then you can.” I take the ear pieces out of my ears and hand them over to Larry while holding the diaphragm in place. Dad is now into it and helps Larry put the ear pieces in his ears. Larry grins as he hears the heartbeat. Okay, just about done, abdominal examination and we have probably done enough to make the parents happy. Everything normal. Still no clue as to what the real worries are. Gotta’ get to that next—maybe now the parents will trust me enough to say what’s on their minds.

“Just as you suspected”—let’s make it partly their idea—”Larry checks out just fine now. Plus his asthma seems to be under good control with the medicines.” Now Dad pipes up, wants to know more about the asthma. Oh—he was away in China when they made the diagnosis, this is his first visit to the office since Larry was labeled an asthmatic. Bingo. Goes off to China and his kid is fine, all of a sudden his kid is sick, running back and forth to the office, has a major illness label stuck on him. No wonder he’s worried. It’s starting to make some sense. Thank goodness they’re the last patients of the day; I’ve got time.

How to get Dad to feel back in the loop? Well, computers always know the answers, right? Time for the electronic record to strut its stuff. “Here, let’s pull up to the computer screen and we’ll look at the recent office visits one at a time and figure out just what happened in order.” Stupid me, too busy getting my other charts done, didn’t bother to read the previous notes before going in the room. Figured it was just a routine sick call and I could wing it. Gotta’ get back on track. “Well, first thing we see is that Dr Price has called it mild intermittent asthma. That’s the least serious kind.” See if that helps. Yes, he looks relieved. “It looks here like they did some lab tests”—elevated IgE—”plus Larry seemed to have a cough that held on for a long time after he had a cold, often that’s the first sign of a mild asthma. Now here, he came in to see Dr Burns for a sick call, he tried an albuterol inhaler, and the cough got a lot better, it says.” Mom nods. “So that also goes along with a mild asthma.”

So why did they jump right in with an inhaled corticosteroid? “Here’s the next note, back with Dr Price. It says that Larry was going to go to China too, and they were worried about the air pollution making the asthma worse, so he decided at least for a while to use the daily medicine. Larry, did you go to China?” No, says Mom, we were too worried about him getting sick; right after his diagnosis of asthma, he came down with a cold, so we canceled the trip. Whoa—major big-time anxiety here. Probably whatever is at the bottom of this is a lot more than I can handle in 1 sick call visit. Now I understand what Dad is worried about. He was planning to see his wife and kid, having them join him in China; all of a sudden the kid is too sick to come, he’s halfway around the world and can’t do anything. No wonder he freaked. Is his wife upset with him, putting his career first and leaving her with all the child care responsibility? Forgot to ask what work he does; he looks like a university professor type, which is typical for our practice. Stupid me again—should have asked to be sure. Don’t want to change the subject just now, though.

Next agenda: see what I can do by way of reassurance as the nonprimary doc. “I wonder if you folks have had the same experience as a lot of parents that we see. Just by bad luck, a healthy kid has a few illnesses in a row. Then in just a couple of months, he’s back to being healthy as usual. But the parents get worried and are afraid that he has something wrong with him, like an immune deficiency or something. But really it’s just temporary bad luck.” They’re nodding, maybe they buy it. “Plus I think it’s perfectly okay to go back to using the antihistamine, because this is the allergy season and if he has worse allergies, his asthma might get worse again. I don’t think that the antihistamine was the cause of his headache.” Maybe better back off a little, don’t seem to be contradicting them too much. “Of course, if you go back on it and he has another headache, and then his headache gets better if you stop it again, then we’ll think differently.” That should cover the bases, show I’m keeping an open mind.

Dad now wants to know, if asthma is an immune reaction, and the antihistamine works for allergies and asthma, won’t it suppress his immune system too much, maybe he’ll get more colds? Bingo again. Now we know why they were so worried about the antihistamine. Sounds perfectly logical when you think about it—I wonder why no other patient has ever asked me that. Good thing I said the magic words “immune deficiency”—maybe that triggered them asking what was really on their minds. If so, I stumbled into that one by pure dumb luck. “You know, that’s a really good question. The good news is that the antihistamine is a very targeted drug—it shuts down the one part of the immune system that’s directly related to allergic reactions, but it leaves alone all the parts that fight infection.” Should I go into mast cells and histamines? No; it looks like he’s satisfied.

Okay, back to the primary doc agenda. “Would it be all right if I set up an appointment for all of you to see Dr Price again as soon as he has an opening? We want him to check up on how Larry’s asthma is doing, plus he may want to take him off the steroid inhaler for now, since he didn’t end up going to China and won’t have to deal with the air pollution. I’ll sure write a careful note today to let Dr Price know all that we talked about.” That works, they seem fine with that. Now it’s the big ceremony of the Sticker Drawer for Larry, and they’re out of here.

Did I help out at all, really? First I’m pretty sure that Larry’s not sick and the headache is no big deal. Did I do anything to reduce the parental anxiety level? Probably not. I still don’t know what’s going on in Mom’s head. Or for that matter what the real relationship is between Mom and Dad. She may be back in with Larry in 3 days with another minor complaint. Gotta’ remember to ask Price to keep me posted on how these folks do down the road. And better write a more detailed note than usual.

Speaking of writing my notes, what time is it now? My gosh—I spent half an hour with them, when I was supposed to be getting out of here on time. Now, just why did I spend that extra time? I thought that the parents needed to be reassured, plus I had to be sure we included Larry in the visit, too. These things take time; you can’t always rush good family medicine.

Then it hit me. The other reason why I took the extra time: I was enjoying myself. In fact, I was having a ball in there.