“Madison?” I asked the girl sitting on the exam table.
Madison nodded without speaking. Her look said: I’m not feeling hostile, but I’m not feeling particularly friendly either.
Her mother sat in the corner and seemed poised to answer my questions, but I kept my gaze on Madison and asked, “You’ve been having chest pains? Can you tell me about that?”
“A thirteen-year-old with chest pains. That should be interesting for you,” Dr Whitman had said, looking at me briefly before handing over the girl’s chart.
It was the same look he had been giving me all day, since I had made the mistake of telling him, “I don’t really do physical exams. Yet. On my own.”
“What -- do -- you --mean?” he asked slowly. Dr Whitman enjoyed placing long, drawn-out pauses between his statements.
“Well, I usually like to go in and, um, do them with you?”
“Oh, we don’t do that,” he chuckled, his tone conveying all of the experience his full head of white hair suggested. I spent the rest of the day trying to make up for that moment, including spending my lunch hour reading tomes from his office shelf.
Madison was Dr Whitman’s last case of the day. After handing me the chart, he walked away, and I turned my attention to the patient. A 13 year old with chest pains, I thought. This should be interesting.
“Well, I was at a dance competition last weekend,” Madison explained without explaining anything.
“You like to dance?” I asked, thinking, I used to dance, too. Except I was that chubby, uncoordinated kid they stuck in the back. She looked more like one of the girls who danced front and center.
“Yes,” Madison answered. She had been dancing for 10 years, 3 nights a week and on weekends. She also danced as a cheerleader last year.
“And so what happened last weekend?”
“After the last number, I was walking offstage and … I noticed that my chest was hurting.”
“Well, yeah. I’d just finished dancing, and my heart was beating kind of fast, and–”
“She collapsed!” her mother burst in. “They said when she got offstage, she was clutching her chest,” her mother raised a hand to her breast for emphasis. “And then she collapsed!”
“Oh,” is all I managed.
“But what I’m really concerned about,” she continued (something more concerning than a 13 year old collapsing while clutching her heart?), “is her weight.”
“She’s gotten too skinny,” her mother persisted. “I looked at her the other day, and I could see her ribs. Look how pale she is. And she has dark circles under her eyes.”
I looked at the girl on the table, but I couldn’t see the helpless waif her mother was describing. Were my observation skills so poor? Maybe she looked a little pale.
“I first noticed a few months ago,” her mom was explaining, “before Christmas. She’s always been a healthy eater. No junk. She’s my good eater. But I don’t think she’s eating enough at school –”
“Yes I do!”
“No, you don’t. I don’t think she eats enough at lunch,” she looked to me expectantly.
I could do this, I thought, taking a deep breath. I could talk to this girl about her weight, how she eats, and why. This is why I wanted to become a pediatrician. I could do this.
I looked down at her chart, but all it told me was that she weighed 105 pounds. There was no graph to tell me what in the world that meant for a 13-year-old girl. One-hundred-five pounds… too skinny? Just right?
I had no idea if she was too thin.
I realized my own heart was racing, but I took another deep breath and tried to direct my next question to Madison. Concentrate on taking a good history, I told myself.
“What do you usually eat for lunch?” I asked her.
“A banana … two Fig Newtons … some nuts,” she answered politely.
“And what do you eat for breakfast?”
“A bowl of cereal.”
“How about dinner? Do you usually eat dinner together?” I opened this question up to the mother, as well.
“She eats well at home,” her mother answered without answering. “She’s always been a good eater.”
“So she eats all of her dinner?”
“She’s very healthy. She always eats lots of vegetables, especially broccoli. And salad. No snacks.”
“Sometimes I have cereal when I get home from school,” Madison offered.
“All right,” I said. This wasn’t getting me anywhere. I had no idea what was normal. A banana, two Fig Newtons, and some nuts sounded on the light side to me. But I wasn’t sure. I just wasn’t sure. The only thing I was sure about at this point in my education was how a body makes energy from glycogen and how to ask questions about pain. So I stuck with what I knew:
“I’m still very concerned about this chest pain, Madison. Can you tell me a little more about that?” And I proceeded to ask her if the pain was sharp, shooting, or stabbing. Did anything make it feel better? Did anything make it worse? These were questions I had asked a hundred times. When did it start? When did it end? Had anything like this ever happened before?
No, nothing like this had ever happened before, she told me.
And almost a full hour after entering the room, I left, feeling anxious and unsatisfied with myself.
I found Dr Whitman in his office and rushed through the history as fast and as thoroughly as I could. I wanted him to answer the question in my voice with a simple statement of:
“Well, she’s clearly underweight.”
“The mother is clearly overreacting.”
But Dr Whitman stared at Madison’s chart for a few minutes before saying, with long pauses between each sentence, “She weighs 105 pounds … . She weighed the same thing last year … . Normally, we would expect a growing young girl to gain weight over the course of a year.”
This did not feel like a complete answer to me. I waited while he paused a moment more.
“Let’s go and talk to them then.”
“So I hear you’ve been having some chest pain?” Dr Whitman said to his stethoscope as he listened to Madison’s heart and lungs.
Her mother answered, “Well, yes, Doctor, but what I’m really concerned about is her weight.”
Dr. Whitman looked at the mother for a moment, but said nothing.
“Can you hold out your hands for me, please, Madison?” He examined both sides of Madison’s hands.
“Well, we would hope that a growing girl would have gained a little more weight during a year.” He paused. “Have you been exercising more?”
Madison shook her head.
“Have you changed your diet at all?”
“Have you been trying to lose weight?” he asked, in a half-joking, half-stern tone that made my stomach hurt a little.
“No!” her mother almost shouted. “It’s not that. We talked about that,” she said, giving her daughter a significant look.
“Well,” Dr Whitman decided. “We are going to draw some labs here. The nurse will be in shortly.” And then he left.
It was another 10 minutes before we returned to Madison and her mother with the normal lab results and Dr Whitman finally spoke, “There are only 3 possibilities here: She’s burning too many calories, she’s not taking in enough calories, or there is something more serious going on with her body causing her to lose weight.” He waited a few moments for this diagnosis that was not a diagnosis to sink in.
“I want you to keep a food diary of everything she eats,” he said, turning back to her chart and scribbling something down as if writing a prescription.
We all waited while he looked back up at the mother, and then at Madison, and then turned to the door. “Come back and see me in 2 weeks.”
That’s all? I thought.
And then, unexpectedly, Madison seemed to pull out of herself and, as if just remembering, added, “My heart hurt again yesterday.” Stopping Dr Whitman at the door.
Her mother stiffened. “What were you doing?”
“I was in gym. We were running sprints. I ran 21 sprints.”
“What’s a sprint?”
“You run across the gym and back.”
“You ran across the gym 21 times?”
“Across the gym and back,” she corrected with a slight smile.
Dr Whitman interrupted, “I don’t want you participating in gym again until we understand what’s going on.” Madison’s smile disappeared. There was another one of his long, deadly pauses before Dr Whitman added, “And I also don’t want you dancing.”
Madison’s whole body froze.
“No dancing?” her mother asked. “But she has practice tomorrow night. When will you know?”
“No dancing,” he repeated. “Probably not until next week.”
Madison’s small form remained perfectly still as he walked out of the room and I followed. We were a full 20 feet from the door, when it finally began—a wailing so gut-wrenchingly desperate, I wanted to fall to the floor and sob myself.