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.)
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. ;)
- Cranquis: Ok, sir, let's examine your painful testicle.
- 20-something male patient *obviously embarrassed, stands there delaying without pulling pants down*: Ohhh-kay. Not really looking forward to this.
- Cranquis: Well, I don't know about YOU, but this is the only reason *I* came to work this morning.
- Patient: HA! Ok, thanks for easing the tension, doc. Let's get this over with.
- CS Prof: ...and you feel for the point of maximal impulse at the 4th-5th intercostal space near the mid clavicular line.
- Female student: um, where would the PMI be on a female patient?
- CS Prof: Same place. Women's hearts are in the same place as men's, believe it or not.
- Female student: well yeah, but I mean...er... how do we get to it? What if their breast is in the way?
- CS Prof: Oh, ok, well you see, you take your hand like this (cups his hand), and you MOVE THE BREAST OUT OF YOUR WAY!
- Student: Oh...umm...*blushes*
- CS Prof: Oh for heaven's sake, it's just a breast. If you're going to be a doctor, you gotta learn how to touch a boob!
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The Dichotomy of Diagnosis.
A classmate of mine sent this to me to my amusement. I have written in the past about my feelings on the importance of a good physical exam but sometimes it does make you wonder if it is worth doing. In medicine, they continuously tell you to “treat the patient, and not the numbers;” I think that expression extends to this realm too. There is something to be said about a physician’s clinical experience and the ability to assess patients through the five senses that a machine simply cannot translate to you. Instead, machines should act as a supplement to your own clinical abilities.
*s-s-snap goes the rubber glove! s-s-squirt goes the lube!*
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.
What is it? It’s the moment when I reach out to examine a toddler, either on the exam table or in their parent’s arms, and the toddler lifts his/her arms up to me in an obvious invitation to be picked up. I never turn that down.
I lift them into my arms, and sit down on my bench. The child sits happily, often yanking on my nametag, or pulling my pen from my breast pocket. The stethoscope is particularly attractive to these friendly ones, and they like to pull on the brightly-colored tube, stretching my ears as I auscultate their lungs. It takes a bit of careful juggling to use an otoscope on a child sitting on your own lap, but I’ve learned that skill.
(I still hand them back to the parent for the throat exam, though — eventually, reluctantly, wishing that this quiet peaceful moment of simple trust could extend through the rest of the workday.) :)
Abraham Verghese: A Doctor’s Touch from TED Talks.
Modern medicine is in danger of losing a powerful, old-fashioned tool: human touch. Physician and writer Abraham Verghese describes our strange new world where patients are merely data points, and calls for a return to the traditional one-on-one physical exam.
Anonymous Asks:
We've learnt some nifty examination skills in my course, one of them being an abdomen examination and basically I was just poking around on my own stomach and found that just under my right rib cage I *think* I can feel an extension of hard something. Could it possibly be my liver? Should I be considering going to see my GP (family doctor)? I am a typical British medical student and do drink quite a bit, but at 19 and having not drunk for a great length of time I'm not sure if I should be worrying?
cranquis Said:
Hello there, Parson Paranoia (Founding Father of the Cult of Cranquis) —
I love paranoid self-exam findings (like the xiphoid process!). It COULD be your liver, all bloated and distended after years of existing inside a “typical British med student”, or…
- perhaps you’re feeling the tips of your floating ribs?
- a lump of poo in your colon’s hepatic flexure?
- a subcutaneous cyst full of pork tapeworms (cysticercosis)?
- an Alien chestburster that got lost on the way to your sternum?
Ok, I’m not really helping, am I?
Here’s what I think you should do — next time that you’re in physical examination class, volunteer to let the instructor demonstrate an abdominal exam on you, and see what he/she thinks. Meanwhile, maybe lay off on the pints, and monitor for yellowing of the skin or eyes. And see your doctor if the “hard something” is getting bigger/tender/other changes.
Cheers! (Well, not in that way… for now.) ;)
***Pending Cranquis-Mails: 16***
Anonymous Asks:
random question. has anyone ever 'gotten off' during a pelvic or rectal exam?
just super curious!
cranquis Said:
And this month’s winner of the “Made Dr. Cranquis Throw Up a Little in His Mouth” award is: YOU, Speculative Speculum!
In the 100’s of pelvic, testicular, rectal, and breast exams (and foot, elbow, and nasal exams, if that’s what turns you on…?) that I have performed in my medical career, I have never had someone go all “Meg Ryan eating ice cream” on me, nor have I heard “Bow-chikka-bow-wow” music playing in the background. I suppose it’s possible that some of my patients have had some psychological “secondary gain” reasons for coming in with a pelvic/rectal/whatever complaint, but I’ve never noticed anyone actually getting all hot and bothered during the physical exam.
However, that is one of the reasons that I always have a nurse “chaperone” in the room with me when I do a pelvic/breast/rectal exam on a female: it turns a potentially “sexually-charged” experience into a clinical/scientific therapeutic procedure/evaluation, as it should be. As a male doctor, I choose to minimize my male patients’ discomfort during rectal/testicular exams by NOT having a nurse in the room with me, unless I get a weird vibe from the patient beforehand (but that rarely happens – the only times I recall that happening was when I was rotating through county ERs as a resident).
One of my classmates in med school taught the rest of us a tough lesson about the importance of always having a “chaperone” present during any genital/rectal/breast exams when you are a medical student. A hospital patient accused him of fondling her during a pelvic exam, and he hadn’t taken a nurse in to the hospital room for the evaluation. Our med school kicked him out of school! (There may have been more to the decision than that, but that’s the only explanation we were ever given.) So learn your lesson now, future/current med-students: BE WISE, ALWAYS GET SUPERVISED! :)
***Pending Cranquis-Mails: 21***
- 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?
Favorite line: Use of antibiotics to fight a viral infection is “like trying to fight a puma with a fog machine“… haha!
This is a surprisingly accurate article, from my perspective.
I have my health assessment midterm at 6pm tonight and I am so anxious! How am i going to be a good nurse practitioner when I can’t even do a pretend clinical exam on a classmate?!!!
I think the hardest part is being observed by my professor, who sits with a clipboard and checklist making sure I…
Man, I haven’t used a tuning fork in YEARS. And I don’t use a reflex hammer — I just use my fingers or the edge of my stethoscope bell. But you’re right, nursling: “Performing The Textbook Physical Exam” is one of those classic hoops all medical practitioners are expected to jump through on the road to being able to just do what actually needs to be done. Good luck!
