Dr. Cranquis' Mumbled Gripes
(Disclaimer: Questions related to medical topics will be answered to the best of Dr. Cranquis' (and Google's) knowledge, but the internet-delivered wisdom on this blog CAN NOT AND SHOULD NOT SUBSTITUTE for your Real-Life Doctor's personal attention + examination, and your own common sense too! If you think you're having a medical emergency, hang up and go email 911. The author of this blog takes no responsibility for any medical, relationship, scholastic, financial, or other decisions you may make based on information found in this blog.)
And since people seem to be a bit confused about this: any "real-sounding" patients names are just horrible puns, and not HIPAA violations.
Got a great question from Not That Kind of Chronic (whose sense of humor in blog naming I quite enjoy)
Your recent post mentioned not to wear nail polish to a rheumatologist. I always have a manicure. Can you tell me what my nails might show?
The first time you see one, yes. It’s not absolutely necessary to remove your polish, but the condition of your nails can tell your rheumatologist about the state of your health, and many doctors will examine both your fingernails and toenails… It’s particularly important if you are seeking a diagnosis from a rheumatologist, gastroenterologist, or other specialist for a systemic disease!
Here’s why:
- Nail Pitting — can be indicative of psoriasis (important for patients with Psoriatic Arthritis), Reactive Arthritis, and other connective tissue diseases
- Spoon Nails (Koilonychia)— can be indicative of Systemic Lupus, Raynaud’s, and anemia
- Yellow Nail Syndrome — occurs in Rheumatoid Arthritis patients or often the result of infection or medications, both of which are relevant to Autoimmune Arthritis patients.
- Splinter Hemorrhages— small blood clots under the nail can indicate Systemic Lupus, Rheumatoid Arthritis, Antiphospholipid Syndrome, Psoriasis, Vasculitis, and Scleroderma (all rheumatology-related).
- Nail Clubbing— can occur with Irritable Bowel Disease (e.g., Crohn’s, Ulcerative Colitis), liver disease, and pulmonary diseases.
- Both Discoid and Systemic Lupus can cause nail changes such as cracking, curling, and even complete loss of nails.
- Rheumatoid Vasculitis or Nail Fold Vasculitis— can cause pitting, sores, redness, and infarcts of the nail-bed (not a pretty picture).
- Nail health can also reveal possible vitamin deficiencies and malnutrition, both important when treating rheumatological diseases.
A terrific summary of nail-related findings of chronic disease, by the ever-excellent “dealing with chronic diseases” blogger Chronic Curve!
Always a little awkward: Performing a digital rectal exam.
Awkward multiplier: When the flustered patient says “Thank You” at the end.
Awkward cubed: When you reflexively reply with “No, Thank YOU.”
Ladies, a moment of your time please. (Gentlemen, you might not [or might…perv?] want to read further — cuz we’re gonna talk about pelvic exams for a moment.)
A very creative ad for an app from RethinkBreastCancer.com which uses “hot guys” (ARE they hot? I couldn’t say.) to remind women to check for signs of breast cancer.
Thanks to Cranquistador R. “It’s not porn, I SWEAR” H. for the link! And yes, I agree: the scene with the two guys checking each other out would’ve been GOLDEN if it starred Hugh Laurie and Robert Sean Leonard…
(This is one of those moments when I am particularly glad that I have a pseudonymous blog — cuz as HILARIOUS as this movie is, there’s no way I’d post it on my IRL Facebook. Watch through to the closing credits and you’ll see why.)
The Everyman Patient.
Almost every day, I see a patient that has such a large spectrum of co-morbidities that to consolidate the information neatly and concisely is an undertaking in itself. There are patients who have allergies or complications to most of our treatment medications, leaving us few options. There are the frequent history or physical findings that do not match up with my attending’s findings. And yes, there are fall risks.
This is a small sample of the common trends I see on the ward but you know, with a bit more tongue-in-cheek humour.
“Oops. That was close. NURSE!” LOL!!!
It doesn’t happen often. In fact, I can only recall it happening 3 or 4 times in my entire career as a resident and physician. But when it DOES happen, it gives me a feeling of simple delight that stays with me through the next few days, and comes back to mind to encourage me after some of the less enjoyable experiences of doctoring…
This just happened again yesterday, for the first time in months — man, I love being a doctor!
One of the residents I did call with told me about this website she had come across that might be of use to me, given my string of patient refusals. The Beautiful Cervix Project describes itself as a grassroots movement celebrating the beauty and intricacies of women’s bodies and fertility.
The centrepiece of the website, that which the resident thought I could use as a resource was the gallery, a small collection of both normal and abnormal cervixes on speculum exam. (Not safe for work)
For the female readers of this blog who might be curious or interested in what it is that we inspect and exam during these exams, you might learn from this website as well.
Or maybe it is just too much information.
Cranquis (examining a 10-year old child’s hand after a fall): Well, nothing seems to hurt you during the exam, so that’s good. I don’t think we’ll need to get an xray.
Mother: OH HANG ON A SECOND DOCTOR ARE YOU SURE YOU’RE CHECKING IT RIGHT BECAUSE WHEN I TOUCHED HER HAND BEFORE SHE SAID IT HURT!
Cranquis (pointing to child’s hand): Can you find the painful spot for me?
Mother (taking hold of MY hand): WELL I WAS GRABBING HER HAND LIKE THIS…
Cranquis:
Mother: …AND THEN I SQUEEZED LIKE THIS…
Cranquis: 
Mother: …AND I THINK THE PAIN SPOT WAS RIGHT HERE…
Cranquis: 
Mother (finally letting go of my hand): …SO YOU SHOULD CHECK RIGHT THERE. OR NO, WAIT, MAYBE IT WAS… (reaches for my hand again)
Cranquis: 
you won’t remember me.
fumbling to position my hands,
as i check in your ears and
shine lights in your eyes,
treating your body like fine china,
delicate to the point of fault.you won’t recall the silly
questions, asked to your parent
out of order, lacking pattern
or structure, vaguely medical.you won’t know of the
smile which you gave me
when your little hand
grasped my finger,
the warmth from which
melted morning frost
on windshields.you won’t realize that
i held your entire body
in my palm, my other hand
ran along the segments
of your spine, checking
alignment and symmetry.it was a week before your
eyes made contact with mine,
and i’ll never forget that second.these lessons will be a foundation
from which i’ll build my skills,
future patients of your size,
will be familiar territory.i might see you at age 2,
taking steps in a shopping mall,
and while you may smile at me again,
you won’t remember me.
*sniff sniff, surreptitious eye-wiping*
Beautiful.
lawenlovescats replied to your post: Well, turns out the American Sign Language sign…
cranquis, how was it doing your first rectal exam? i am so scared. i’m only a 1st year so i have a while to wait but i know 2nd years are embarrassed to even practice on a fake body… i can’t imagine
I learned to do male digital rectal (“finger up the poop chute”) exams in 2nd year, on a mannequin named “Cheeks-Up Charlie”. It was just another awkward socially-bizarre experience, along with checking inguinal lymph nodes on your classmates or learning how to examine breasts on a teaching-patient who talked you through the entire hands-on process. Honestly, the fact that the properly-positioned patient can’t see you during the rectal exam made it easier for me, compared to doing a female pelvic exam or a male testicular exam.
I did my first real-live DRE on general surgery rotations in 3rd year. When a trauma patient hits the ER, the DRE is an important part of the initial assessment — and the least-experienced person on the totem pole (me, in that scenario) usually gets shafted (heh heh) with that assignment. But when the patient is bleeding from the open fracture in his thigh (“his leg bone is poking out through the skin”), screaming bloody murder and fighting the nurses, nobody cares about the social ramifications of prodding around the rectum with your gloved finger. (Except for the patient, who cursed me out for “butt-raping” him. He should’ve been more grateful, because at least the DRE distracted him from the simultaneous Foley-catheter placement.)
Well, turns out the American Sign Language sign for “digital rectal exam” is exactly what you would think.
- Ah, 10 blessed seconds of silence!
- I thought this lady would never stop talking.
- Whoops, almost bumped her boob there.
- Gotta remember to say “take a big BREATH”, not “BREAST”.
- Whew, I didn’t say BREAST!
- What’s that buzzing sound in her thorax?
- Oh, it’s the cellphone in her sweater pocket.
- She told me she “needs to be scared into quitting smoking”.
- I wonder if I should pretend to hear lung cancer, just to be helpful?
- I could say, “Oh my” and then not say anything else for 15 seconds.
- And then just kinda mutter, “Hmm… is that lung cancer?”
- And then she’d be all hyperventilating, and I’d be like, “Oh, nope, it’s just your lungs yelling QUIT SMOKING!”
- I wonder how hard she would slap me then?
Someone asked us:At Planned Parenthood, can I bring my boyfriend in with me for my pelvic exam?
A lot of people feel a little nervous before a pelvic exam, especially if it’s their first time getting one. And holding someone’s hand always helps when you’re freaked out at the doctor’s…
Personally, I’ll let a partner stay in the exam room if (1) they’re mature enough (no cracking jokes or making the patient feel even MORE nervous), (2) the patient requests it, and (3) I don’t detect a need to ask “risky” private questions, such as “So do you think your vaginal discharge is an STD?” or “How do you think you got herpes?”
(What drives me nuts is when mothers bring their brood of kids with them for a visit that obviously requires a pelvic exam, and then don’t want to let them sit in the waiting room/hallway with a nurse during their exam.)
Um so yeah — if you got your belly-button pierced secretly, and didn’t want your mother to know about it, here’s a couple things to consider:
- If you’re coming in to see the doctor about “stomach pain”, the doctor will most likely expose your belly button region during the abdominal exam.
- If you’re old enough to see a doctor without your parent in the room, but you have Momma come in to the exam room anyways, Momma is probably gonna notice your honkin’ HUGE belly-button charm when the doctor does his exam thang.
- The doctor is not going to apologize for this situation. In fact, he will find it pretty amusing.
- It’s kind of hard to auscultate for heart and lung sounds when the patient and her mother are having an argument.
60-something male patient, bemoaning his doctor’s masculine hands.
Which reminds me of Dr. Cranquis’ Rule of Thumb for Rectal Exams: If the doctor’s index finger is as thick as your thumb, you might want to reconsider dropping your drawers. ;)
