As I hurry across the concrete porch of the adjacent building on my way to the office, my eyes fall upon it: there it lies, perfectly still. The olive back, the cinnamon tail, the buff breast streaked with black commas—muted colors of a century-old Audubon print—unmistakably a hermit thrush. Gently I nudge the carcass with the edge of my shoe and note the broken neck. Evidently, the bird had flown into the picture window unawares.
Shy birds, hermit thrushes generally keep to themselves. Here in New England I often hear one calling in the woods near our house in the late winter or early spring. A migratory bird like his cousin the robin, the hermit thrush is seldom seen this time of year, when the foliage has fallen and the days grow short.
Deftly I move the bird from the concrete slab onto the dried leaves in the flower bed and hurry on in through the side door of the office.
It's certainly taking the medical assistant a long time to process this mid-morning patient, I think, as my eyes drift down over the formidable schedule lying on my desk. An addendum identifies this 15-year-old girl as a former patient newly returning to the practice. She needs a physical exam to matriculate into the local school system.
The medical assistant finally appears, handing me the chart. "Sorry it took so long. She told me she thinks she's pregnant. She says an over-the-counter test was positive, so I ran another one today on her urine."
"And?" I raise my eyebrows.
"Negative. One more thing: she's wearing an electronic ankle bracelet. She's probably on house arrest."
I review the chart and note that I had seen this girl 2 years before, at which time I documented that she was sexually active and in need of contraception. I step into the room to find the girl sitting on the exam table, staring at the floor.
"Hello," I say, offering my hand, which she shyly accepts. "You need an exam to start school. Rather late this year—did you just move back to town?"
"I was away for a while," she says, looking down at the bracelet on her ankle. "Got in trouble with the law. Now I'm trying to get myself back together. How did my pregnancy test come out?"
"The one we ran here in the office is negative. When was your last period?"
"A month ago. But I had sex since then. Could I be checked for STDs?"
"Do you have any signs of an infection—skin sores or discharge?"
"No, but I want to be checked for HIV, just to be sure. And the court says that I have to have a drug test. Can you do that here?"
"We can give you an order to have those tests done at the lab. Let's have a look at you today," I say, reaching for the otoscope and a tongue depressor.
She points out the fullness of her lower lip around a recent piercing. "It's been swollen for 3 weeks," she says. "I tried to clean it, but it keeps on draining pus."
"It looks like you've got an infection there. I'll give you a prescription for an antibiotic. Are you allergic to any medicines?"
I look in her throat, feel her neck and proceed to examine her chest. She sports a tattoo across her shoulders—"DESTINY"—and two more flowery designs on the flanks of her abdomen. I also notice the faun spots on her upper chest and breasts: telltale markings of tinea versicolor.
She's wheezing throughout all lung fields. "How long have you had asthma?" I ask, popping the stethoscope out.
"My whole life," she says. "I need an inhaler. Mine ran out sometime back."
I pause to write a prescription. "Do you smoke?"
She nods her head. "Just 3 or 4 cigarettes a day. I guess that's bad, huh?"
"Smoking isn't good for anyone, especially if you've got asthma. Lie down, let's have a look at your belly."
I palpate the lower quadrants carefully and detect no uterine enlargement. The ankle bracelet bumps against the table as she sits up.
"Are you gonna tell my parents about this?"
"About what?"
"That I've been having sex and could be pregnant."
"Let's get the blood tests done and then you and I will talk. How's that?"
She raises her chin and looks into my eyes, then nods.
I stand back and look at her, this slender olive-skinned girl just 2 months shy of her sixteenth birthday who happened to land on my doorstep this late autumn morning. At her age she should be looking forward to a life beginning to blossom. Instead, she's out of season.
The picture of the hermit thrush flashes through my mind. Odd time of year to see one, I muse. Involuntarily, I turn my head and strain to hear some faint song in the stillness of the late morning autumn air, but only silence reverberates inside my head. JAAPA
Brian T. Maurer, PA-C, practices pediatrics at Enfield Pediatric Associates, Enfield, Connecticut. He is the author of Patients Are a Virtue and a member of the JAAPA editorial board. Visit the author at http://briantmaurer.wordpress.com/.