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Physical Exam: Abdomen at Work (Repost)

It came to my attention that some of my old posts were missing!  A couple of the key "Physical Exam" series of posts were lost in the process of transferring my old posts to the "more distractible" site.  I cried out my misery on Twitter and was saved by a Tweep who pointed me toward, which is proof that nothing is ever lost in the tubes. So, to get the library back where it should be, I will put them back on the blog.  The links may not all work, but the content will seem fresh and new.   All that, and I won't tax my currently exhausted brain cells.  Reading them makes me yearn for the days I did more humor and less reality.  Surgical blogger Sid Schwab once called me the "Dave Barry of Medical Bloggers."  That was nice, but I told him I really wanted to be the "Hulk Hogan of Medical Bloggers."  No such luck.  I guess it still gives me something to strive for.

First, we start with the physical exam post on the abdomen, which originally appeared on December 15 of 2008.



beerbelly It has been a while since I last posted in this series.  I have nothing against this series; I have nothing against the abdomen.  I just got distracted.

So on our journey down the human, we have now reached the abdominal exam.  The abdominal exam is the part of the exam of which I have had the most people ask me “what are you looking for?”  This post is an answer to those questions.

The abdominal exam is put into the patient chart as follows:

Abd: Soft, NT, Normal BS, no HSM or masses.

This translates to:

The abdomen is of normal consistency and there is no pain when I push on it.  The noises in the stethoscope are of normal pitch and frequency.  The liver and spleen are not enlarged and I don’t feel anything that shouldn’t be there.

You see why it is abbreviated.

The abdominal exam is marked by two of the largest medical mysteries:

  • What is tickling all about?
  • What makes an “innie” and “outie” bellybutton?

Tickle Me Doctor

tickle_me_elmo-264x300Tickling is not just a side issue (no pun intended), it is a very touchy subject (OK, I did intend that one) that is frequently encountered.  First, ticklish patients are very difficult to examine.  They immediately tense up their abdominal muscles and make feeling masses or enlarged internal organs nearly impossible.  This is uncommon in the elderly (I don’t know if I have ever encountered it), but very common in children.

This problem is exaggerated by the fact that I am “The Tickle Doctor.”  For the past six years (or so), I have been using my talent in the rib, underarm, and flank exam to tear down walls of doctor-phobia.  I love it when kids laugh in the exam room – except when I need them to be serious.  This is a hazard of being “The Tickle Doctor” that I guess I am willing to live with.  But what is tickling all about?  Here’s what I found on Wikipedia:

In 1897 psychologists G. Stanley Hall and Arthur Allin described a “tickle” as two different types of phenomena. The first is a sensation caused by very light movement across the skin. This type of tickle, called knismesis, generally does not produce laughter and is sometimes accompanied by an itching sensation. The second type of tickle is the laughter inducing, “heavy” tickle, produced by repeatedly applying pressure to “ticklish” areas, and is known asgargalesis.

The feather-type of tickle is often elicited by crawling animals and insects, such as spiders,mosquitoesscorpions or beetles, which may be why it has evolved in many animals. Gargalesis reactions, on the other hand, are thought to be limited to humans and otherprimates; however, some research has indicated that rats can be tickled as well.

The feather-type of tickle is often elicited by crawling animals and insects, such as spiders,mosquitoesscorpions or beetles, which may be why it has evolved in many animals. Gargalesis reactions, on the other hand, are thought to be limited to humans and otherprimates; however, some research has indicated that rats can be tickled as well.


I have to say, I like this Stanley Hall guy.  he gave some very interesting names to ticking types:knismesis and gagalesis.  I think I have taken care of some kids by that name – but that is another post….  I also like the fact that rats may be ticklish.  My experience with rats does not back this up, but I was not making much of a tickling effort.

There are several other interesting ticking facts:

  • Few people can tickle themselves.  I suspect that those who can tickle themselves get a limerick written about them.

There was a man once who self-tickled Whose friendships just came at a trickle He’d sit and he’d sit With hand in his pit His fingers eventually pickled

  • The better you know someone, the more ticklish you are to them.  This is why armies don’t disable enemy soldiers by ticking.  This is too bad – there would be many fewer war casualties if this weren’t so.

One way to avoid ticking a person is to examine through their shirt.  Another way is to hit them on the head with a club.  The latter works better but is not recommended.

Navel Academy

april-2008-250I was disgusted upon graduating from medical school when I realized I was never told why some people have “innie” bellybuttons and some have “outies.”  It is another example of how far America has slipped in its educational process.  Fortunately, I have since discovered the reason (and feel incredibly fulfilled because of it).

When the umbilical cord dries up and comes off, it leaves a scar.  Some people get bigger scars than others – some babies develop umbilical granulomas which are red, weeping scars at the site where the cord was.  Outie bellybuttons are largely due to this scar tissue.  Umbilical hernias also play a role, although they are not responsible for the classic “alien coming out” appearance that the outies I remember as a child.  They scared me a little.  I am a proud innie.

Probably the biggest downside of being an outie (other than complete ostracizing as a child) is that outie bellybuttons don’t collect lint.  Navel lint was the subject of research by Dr. Karl Kruszelnicki of the University of Sydney, Australia.  Wikipedia gives a good summary:

  • pi052804a1-300x225Navel lint consists primarily of stray fibers from one’s clothing, mixed with some dead skin cells and strands of body hair.
  • Contrary to expectations, navel lint appears to migrate upwards from underwear rather than downwards from shirts or tops. The migration process is the result of the frictional drag of body hair on underwear, which drags stray fibers up into the navel.
  • Women experience less navel lint because of their finer and shorter body hairs. Conversely, older men experience it more because of their coarser and more numerous hairs.
  • Navel lint’s characteristic blue-gray tint is likely the averaging of the colors of fibers present in clothing; the same color as clothes dryer lint.[2]
  • The existence of navel lint is entirely harmless, and requires no corrective action.

Dr. Kruszelnicki was awarded the Ig Nobel Prize for Interdisciplinary Research in 2002.

Wikipedia goes on to describe another Australian who became famous over navel lint:

Graham Barker of PerthWestern Australia, is in the Guinness Book of Records as the record holder for collecting navel lint. He has been collecting navel lint almost every day for over 20 years since 17 January 1984. He collects about 3.03 mg per day. Contrary to the research of Dr. Kruszelnicki, his lint is in a particular shade of red, even though he rarely wears red clothes.

wennholmes3-774131-229x300This makes one wonder several things about the Australian people:

  1. Is there a higher innie/outie ratio in Australia?
  2. Do Australians have too much time on their hands?
  3. What kind of of underwear do Australians wear that would cause such an infestation of lint?
  4. Would you buy a red sweater made in Australia?

I am personally glad the article points out the harmlessness of lint.  I had previously told someone they had only two months to live because of their navel lint, but I will stop that practice from this point on.

Well gosh, I have spent all this time and have yet to get to the exam itself.  I guess you’ll have to wait until I get a chance to write the next installment.  That may be a while, because I have some serious lint harvesting to do.

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Real Meaning

The following was originally posted on 12/22/2008 (and again in 2010).  Given the tragic events of the past week, many might see a disconnect between the Christmas Story and the events of the real world.  How can there be joy to the world when the world is one in which children are murdered?  How can there be peace on earth?  I hope this post will encourage you, whether you are celebrating a religious holiday, a family holiday, or not celebrating at all.   -----

Every day I go to work and spend time with suffering people.  They come to me for help and for comfort.  They open up to me with problems that they would not tell anyone else.  They put trust in me – even if I am not able to fix their problems.  I serve as a source of healing, but I also am a source of hope.

Christmas is a moving season for many of the same reasons.  No, I am not talking about the giving of gifts, or the time spent with family.  I am not talking about traditions, church services, or singing carols.  I am not even talking about what many see as thereal meaning of Christmas: Mary, Joseph, shepherds, wise men, and baby Jesus.  The Christmas story most of us see in pictures or read about in story books is a far cry from the Biblical account.  The story we see and hear is sanctified, clean, and safe.

Before I go on, I want to assure my readers that I am in no way trying to persuade them to become Christians.  I am a Christian, but whether or not you believe the actual truth of the story, there is much to be learned from it.  I find it terribly hard to see the real Christmas story here in a country where the season is filled with so much else – much of it very good.  It is far easier to just be happy with family, friends, giving gifts, singing songs, and maybe even going to church, than it is to contemplate the Christmas story.  I think the Christians in our culture have gotten way off base on this – much to our shame.

Christmas is not about prosperity and comfort, it is about help to the hopeless.  The central doctrine to this season is the incarnation: God becoming man.  God didn’t become a man because he thought it would be nice to spend time with us; he did so because we were hopeless.  He didn’t come to live in comfort, but to be poor.  He didn’t come to help good people, but to rescue the outcast.  He didn’t come to hear cheers for saving people, he came to be rejected and so to identify with rejects.  He scorned the self-righteous, and embraced the shameful.

What about the Christmas story itself?  Mary got pregnant out of wedlock and Joseph chose to bear the social shame.  They were in a country that was occupied by a foreign empire, ruled by self-seeking despots and self-righteous religious leaders.  Jesus was born in a barn -  not the clean manger scene we are used to.  The birth was announced to shepherds – people who were scorned by the “good” people of society.  The local ruler was so worried the messiah would overthrow him, he sent death squads to murder all children under two in the town where Jesus was born.

Fact or fiction, the scene was not pretty, but instead was filled with pain, despair, and hopelessness.  This is hardly what we see on TV.  This is hardly what we hear in church.  That is the setting describing the first Christmas, not a mall or warm living room with a tree.  Christmas is doesn’t hide from pain, it addresses it.

Whether you take it as truth or just as an inspiring story, we should pay far more attention to this meaning.  Yes, it is great to give gifts and be with family – I will be doing that as well.  But there is no escaping the pervasive pain and suffering in this world.  The Christmas message is not about sheltering ourselves from that suffering, but instead going out among the suffering and providing comfort.  The lonely woman weeping in the exam room or the drug-seeking addict who is trying to pry a narcotics prescription from me – they are the ones to whom this Christmas message is proclaimed.  Whether you do it to imitate God or simply to be a good person, we can perpetuate Christmas by helping instead of hiding.

To those who spend little time around the suffering of others, I urge you to break out of the cozy shell and really celebrate Christmas.  Pain and suffering are not far from you; even in our affluent society.  What I encounter in my exam room has convinced me that society is obsessed with denying this truth.  We have made Christmas into a comfy commercial family time, when the real meaning is something far more profound.  If you don’t feel adequate to help the suffering, then let me offer this: medical professionals are no more morally upright than the rest of society, yet we are honored with the task of helping the suffering.  We are no better than you are.  Really.

So go out there and have a great Christmas.




The following post was one of my most read and commented-on from my old blog.  I wrote it in June of 2008 after seeing a patient who was utterly ashamed of his obesity.  I was so struck by his self-loathing that I wrote the post within a few hours of seeing him.   My most recent post on defectiveness brings back a lot of those emotions, and I thought it would be an appropriate time to re-publish that post. ----

I saw a gentleman in my office for his sciatica.  He was having severe pain radiating from his lower back, down to his calf.

I was about to describe my plan to him when he interrupted me saying, "I know, Doc, I am overweight.  I know that this would just get better if I lost the weight."  He hung his head down as he spoke and fought off tears.

He was clearly morbidly obese, so in one sense he was right on; his health would be much better if he would lose the pounds.  On the other hand, I don't know of any studies that say obesity is a risk factor to ruptured vertebral discs.  Besides, he was in significant pain, and a lecture about his weight was not in my agenda.  I wanted to make sure he did not need surgery, and make him stop hurting.

This whole episode really bothered me.  He was so used to being lectured about his obesity that he wanted to get to the guilt trip before I brought it to him.  He was living in shame.  Everything was due to his obesity, and his obesity was due to his lack of self-control and poor character.  After all, losing weight is as simple as exercise and dietary restraint, right?

Perhaps I am too easy on people, but I don't like to lecture people on things they already know.  I don't like to say the obvious: "You need to lose weight."  Obese people are rarely under the impression that it is perfectly fine that they are overweight.  They rarely are surprised to hear a person saying that their weight is at the root of many of their problems.  Obese people are the new pariahs in our culture; it used to be smokers, but now it is the overweight.

The fear/disdain of obesity has reached into areas where it should not be.  I regularly have to tell mothers of chubby babies that it is perfectly fine for their child to be that way.  Children under three generally regulate their eating to what they need.  I do not believe a baby can become obese on breast milk or formula.  Now, if they are giving the child french fries and burgers, that is a different matter.

Instead of patronizing obese patients with a lecture, I try sympathizing with them.  Just because something is simple doesn't make it easy.  How do you quit smoking?  You just stop smoking.  We should just pull out of Iraq.  There should be peace in the middle east.  People should stop hurting each other and start being nice.  All of these are good ideas, but the devil is in the details.  Losing weight is a struggle, and it really helps to have people giving you a hand rather than knocking you down.

Don't get me wrong, I don't deny the health risk of obesity.  I do my best to work on weight loss with my patients.  But the idea that their personal worth lies on their BMI is extremely damaging.  There are a lot of screwed-up skinny people out there; just look at super-models.  It is a lot easier to lose weight when you actually like yourself and want to do something about your health.  Our culture of accusation and shame simply makes obese people hate themselves.  If you hate yourself, why should you want to take care of your body?

Is obesity a problem?  Sure it is.  But we need to get off of our self-righteous pulpits.  Obese people should not be made into a group of outcasts.  The "them" mentality and the finger-wagging are no more than insecure people trying to feel better by putting down others.

It sounds a lot like Junior High.

If we really want to help with obesity, we need to grow up.

See the old blog post for some very interesting comments.