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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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Blast from the Past: Taco Time

Time to lighten things up.  Since I am a bit weary (and more than a bit lazy), I'll repost one of my favorites: ---------------

Well, let's get this thing off the ground. Right off the bat, Awesome Mom asked in incredibly good question:

"Why does my husband think that putting ketchup on tacos is a normal thing to do?"

Given the fact that I happen to have spent some time doing basic taco research, and that I have eaten both tacos and ketchup (although not simultaneously, I must admit), I am the perfect person to answer this question (although a guy in a taco suit may also be a good candidate).

Most men do not put ketchup on tacos. It is actually a condition that occurs in 1 in 5,000 people, with a preponderance of these being men. The taco/ketchup combination is what is known as a x-linked recessive genetic disorder.

Genetically, the difference between men and women is that women have two "X" chromosomes, while men have one "X" and one "Y" chromosome. The x-chromosome does not, in fact, look like an "X" at all, but instead looks like a worm with a waistline (as pictured above). Why is it named "X" then? Well, it has a tendency to get tangled up with the other x-chromosome and so when researchers first saw it, it looked like a "X." Besides, "worm with a waistline" chromosome would just not have sounded very good.

The y-chromosome is much smaller than the x-chromosome, and does not look like a "Y" ether, but instead looks like a much shorter worm with a much lower waistline.

You may have noticed that these chromosomes are striped. Those stripes are things called genes. Genes have a tendency of alternating between black and white, which has made it much easier for scientists to crack the genetic code. Another thing that made it easier to crack the code were the little lines with numbers and letters. Nobody knew what these numbers and letters meant for many years, but through painstaking research, they have determined that these letters are a code that tells your body how to be either a man or a woman.

You may have also noted that x-chromosomes have many more genes than y-chromosomes. Many scientists believe that the feeling by many women that jeans make them look fat comes from the fact that there are more genes in a women's body, and this is actually a cry for help from the chromosomal level. Other scientists think these scientists are just full of hooey.

We get one set of chromosomes from our mother, including one x-chromosome, and one from our father: either an x or a y. For a trait to be expressed on the outside of a person, it must (in most cases) be present in both sets of chromosomes. X-linked conditions occur when a genetic trait is expressed on the the x-chromosome. The y-chromosome is too wimpy to put up much of a fuss, so a man with a trait on the x-chromosome will have the genetic trait. For a women to express the trait, both x-chromosomes have to carry the gene for that trait.

A good example of this is the most common form of color blindness. If a man has this trait on the x-chromosome, he will be color blind. For a woman to have the same type of color blindness, she must have the gene on both of her x-chromosomes. That means, a man will get his color blindness from the x-chromosome of his mother (since he had to get the y from his dad). This can be seen in the diagram below.

So it should be becoming obvious that putting ketchup on the taco is a x-linked disorder. It is, in fact, carried on the Xp-11,12 gene. This means, Awesome Mom, your mother-in-law is responsible for passing this gene on to your husband. Some have postulated that this too is a bunch of hooey and that the whole x-linked theory was made by some angry woman scientists who wanted to blame things on their mother-in-laws.

What can be done about his taco/ketchup tendency? Gene therapy is something that could help. To do so, you can either take a virus that goes for the x-chromosome and alters the Xp-11,12 gene to no longer favor this combination, or the virus can tell the y-chromosome to stop being such a wimp and stand up to that nagging x-chromosome. Since scientists are not sure what trouble an embarrassed y-chromosome would cause, this latter solution is not favored.

Putting down the toilet seat, by the way, is a trait carried on the x-chromosome as well, but the y-chromosome is sick of being pushed around in most men and makes a stand when it comes to putting the toilet seat down. Sorry, there is little hope for that one.

So that is the first installation of "Ask Dr. Rob." Hopefully it will not be the last. If you have other questions that need answering, please send an e-mail to

Thanks Awesome Mom!

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