Please avoid the nipple

It’s back to school and that means back to more awkward clinical examinations.

Last week, we had our last practice session with a simulated patient.  From here on out we’ll be going to the General Hospital with only real patients.

Our simulated patient was a 70 year old man, who worked as a gardener.  We decided to practice going over the examination for the central nervous system.  We started with the mini-mental state exam, which is what it sounds like.  One of the questions to test higher functioning is to ask to hear “world” spelled backwards.   Our patient hesitated for a long while but couldn’t do it.   We tried the other test, which is to count down from 100 by 7.  He said “100.. 97…”, he had memorized the answer to the other version of the test, which was to count down by 3.   Some of the people in my group felt uncomfortable and laughed to cover it up, which stirred something in the patient.  To his credit, my group member who was actually doing the test didn’t laugh and just waited patiently for his answer.  The patient had been sitting quietly during the entire exam, but spoke up to say, “Let me tell you something.  My mother abandoned me when I was three weeks old.  I was raised by an adoptive family.  So they didn’t teach me to spell such words.”  The room was quieter after that.

We moved on to testing the sensory system, and the tutor reminded us to test dermatomes T4 and T10, which are at the level of the nipple and umbilicus, respectively.  My group member doing the test opened up the gown and picked up the opened up paperclip that we use to test the pain and crude touch sensations.  He told the patient to let him know if he felt a sharp touch (end of the paperclip) or a dull touch (the bent end of the paperclip) and went ahead and poked the patient with the sharp end right on the patient’s areola.  “Sharp or dull?”   He went on to poke the other nipple with the bent end.  Our tutor told us that we should try to avoid the nipple.   This poor 70 year old man.  My group member went on to test for fine touch, which is done with a cotton wisp.  Again, he went right for the nipple and brushed it with the cotton wisp.  “Do you feel anything?”  My tutor said, “Again, please try to avoid the nipple.”

Sometimes when you’re doing an exam it’s hard to keep things straight.  You’re taught to do things that you’d think would hurt (sticking your fingers way into someone’s neck to feel their thyroid, tugging hard at someone’s knee to test their cruciate ligaments), and common sense easily goes out the window for things you clearly shouldn’t be doing (tickling someone’s nipple with a piece of cotton).

Medical verbal diarrhea

Since coming home I can’t help but bring things I’ve learned into every-day conversations.  I’m starting to realize that not everyone is necessarily always interested in being counseled.

Par example:

At a baby shower for my close friend.  It’s my first time getting to catch up with friends from home, and I go get the attention of M, who has a strange skin rash that hasn’t gone away in weeks.  Since we didn’t cover Skin in Pathology, I tell her what I heard from my brother (a doctor) about rashes: that generally speaking if it’s itchy it’s not life-threatening, that if it’s been hanging around for a long time it’s not life-threatening, and that often they don’t bother finding out exactly what it is, but they will prescribe first a steroid and then if that doesn’t work, an anti-fungal.  At least the last part is helpful for M, who thought the doctor was just humoring her by prescribing an anti-fungal when they still weren’t sure what it was exactly.

Later in the shower, Ktown, M and I are talking about high blood pressure.  M is worried because she has had a couple slightly high readings in the past few times.  Eager to ease her worries, Ktown suggests she shouldn’t have to worry because her eyes aren’t bloodshot.  M agrees; her eyes are not puffy like her father’s – he has high BP – and so she probably doesn’t need to worry so much. Later in the day I realize I never made it clear to them that hypertension is typically totally silent and doing it’s damage over the long term while the person is totally unaware until it’s well advanced.  I write a message to both M and Ktown clarifying this and saying that maybe it’s something she can talk to her doctor about.  Ktown responds thanking me for clearing it up and letting M know she probably doesn’t have much to worry about, but later cheerfully tells me that she was kind of perplexed why I sent the message that would likely just make M worry more.

Another conversation Ktown is telling me about, a silly one, about circumcised and uncircumcised penises.  She’s recounting this conversation, laughing at the awkwardness, where basically it comes up that a couple people we know are uncircumcised.  I can’t just laugh at this, but I have to bring up how circumcision isn’t just a matter of religion, there are also health benefits such as avoiding phimosis and paraphimoses, preventing HIV transmission, and decreasing the chances of smegma buildup which would lead to squamous cell carcinoma of the penis (the latter is something I didn’t quite understand until a fellow student kindly explained the whole concept of foreskin and the gunk that gets stuck under it – smegma – to me using his arm, his t-shirt sleeve, and the appropriate theatrics).

How doctors learn to do pap smears and pelvic exams

Stephanie: in lab the other day
Stephanie:  we did our first pelvic exam (ie genital!)
Stephanie:  but on models
Stephanie:  but the vaginal model was kind of weird to watch classmates do
Stephanie:  feeling around, rectal exams pap smears and feeling uteruses
Stephanie:  our model wasn’t working right so our tutor had to stick his hand in it to work it properly
Stephanie:  and he had his arm up to the shoulder in this fake lower body model
Stephanie:  and then my friend had his hands in the other end
Stephanie:  it was just kinda weird
Ktown: oh myyy

Ktown: you must get quite comfortable around each other
Ktown: so the model like looks and feels real?
Ktown: i guess that is a silly question
Stephanie:  it looks real
Stephanie:  and kinda feels real
Stephanie:  but it’s not flexible, it’s kind of rigid
Stephanie:  so when we were trying to get the speculum in for pap smear
Stephanie:  you had to really force it
Stephanie:  and it seemed really violent, painful
Stephanie:  or pulling it out, people were like wrenching it out
Ktown: ahhhhh omg
Stephanie:  then it fwapp’d back
Ktown: fwapp’ed?
Stephanie:  the noise it made
Ktown: i wont even ask

Stephanie:  you’re supposed to inspect the rectum and the vagina at the same time at one point
Stephanie:  like have two fingers on the same hand in both
Stephanie:  it’s basically the shocker
Stephanie:  and did you know there’s a special order to which finger you take out first? (the vaginal one)
Stephanie:  and my friend was too shy to say vagina or anus
Stephanie:  so he was trying to describe his finger that was in the anus the longer one
Stephanie:  to avoid saying anus
Ktown: oh my

Ktown: youve shockered a fake girl!
Stephanie:  it was for science!

Ktown: why must you do both at the same time?
Stephanie:  it’s to feel the septum between them
Stephanie:  it’s supposed to feel like the webbing between your thumb and first finger
Stephanie:  (i bet you just felt it! because i did in class when i heard that)
Ktown: i see
Ktown: felt what?
Stephanie:  the webbing on your hand
Stephanie:  nevermind i was wrong!
Ktown: i was thinking about feeling my finger webbing
Ktown: then i read that and freaked
Stephanie:  it’s hard not to. I’m just curious!
Stephanie:  (i was anyway. In class i tried to hide that i was feeling it. I don’t know why i cared!)
Ktown: i keep thinking your talking about the other one