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!
- 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.)
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…
Mother: …AND THEN I SQUEEZED LIKE THIS…
Mother: …AND I THINK THE PAIN SPOT WAS RIGHT HERE…
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, 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.
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:
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. ;)