There are occasions, in the midst of examining a patient, when I am caught off guard by some meaningless observation or physical finding.
For example, I never would have guessed that an 80 year-old grandmother named Bertha would have a tramp stamp. But, a few weeks ago, there it was, a four-leaf clover tattooed right on the small of grandma's back. It distracted me from appreciating her diamond-studded nose-ring, I'll tell you. A few days later, I treated a very pretty college student who made me wince when she shook my introduction hand within her own man-hand. And, on the same shift, I treated a college guy who didn't have one hair on his entire body, thanks to an overactive Gillette razor. Not one. Heck, even the 50 year-old conservative business man surprised me with his bilateral nipple piercings (I am thinking "ouch" even as I type that). Impressive what a double-breasted suit can hide.
These physical findings rarely play any part in treating a patient or making a diagnosis. They are simply observations that happen to be noticed during the course of a thorough physical exam. Nothing judgemental. No prejudices. Just an aspect of a patient's physicality that jumps out at you when you aren't expecting it. To each their own, I say. Whatever makes you happy and isn't harming the next fellow human being.
I think anyone who does a patient exam can relate to these surprises, though. If nothing else, these findings keep me on my toes. If truth be told, I like these unexpected discoveries--these little secret gems that a patient would probably not commonly share with his fellow man. Seriously.
Picture it. "Um, yeah, Darryl," I imagine a patient confessing at a tavern, an empty pitcher of Guinness sitting between him and his good friend, "I need to tell you something. I have seven toes on my right foot. And, I have your wife's initials trimmed in my chest hairs." Yeah...I don't think so. Lucky me, though--I get to discover those initials when I auscultate this patient's heart.
The other day, I was privy to one of my more favorite observations. Like a rare bird, the sighting of one of these is few and far between. In fact, I can count on two hands how many times I've seen this characteristic in my career. It was very exciting.
I can just picture you now, sitting on the edge of your seat, saying to yourself, "What is it? What did he see?"
Okay. I'll spill. It was the famous (drum roll, please)... "double crack."
Walking into Room 31, I had no reason to suspect that I would, in a few short minutes, be giddy over seeing another double crack. It had been a few years, easy, since my last sighting. And, to be honest, this patient did not fit my usual perception as to who would possess the double crack.
I introduced myself to this patient. A very nice person who had been suffering with some dizzy spells and a chronic cough. Nothing major, but just enough of an annoyance that, after a few weeks, he wanted to be "checked out." After a satisfactory interview, we moved on to the physical exam. Vitals were reviewed. An HEENT exam was normal. Throat and neck, good. The heart, steady and strong with a regular rhythm and no murmurs appreciated.
And then...the spotting of the double crack.
After listening to the patient's heart, I had the patient, who was in a gown, sit up in his cot, leaning forward so that I could auscultate his lungs from a posterior approach.
I had my stethoscope in my ears, listening as I had the patient take several deep breaths in and out, when I casually glanced down along the patient's mid and lower back. And there it was, the double crack, staring back at me, waiting for me to discover it's existence.
To explain the double crack, I am taken back to the first time I had to explain to my giggling kids, at a local zoo, why the baboons' bottoms were bright red. You know that color--the inflamed, captivating shade of a deep, rich sunset. "It's just part of being a baboon," I told them. No other explanation, really, was needed. The baboons' bottoms were what they were. And, as I told my kids, I don't even know if the baboon knew his own bottom makes a bright-red firetruck look dull.
Note to self--don't forget to do a google search on the baboon's red ass.
But, just like the baboon's ass, it is very hard for me to take my eyes from the double crack. And to explain why it exists? I can't. It just does.
So, as I tracked along this patient's vertebrae with my eyes, I spotted his double crack in the lumbar region. Whether it was the way this patient's skin folded, or the way the patient sat, or the way his supporting muscles ran longitudinally along his spinal column, or just where his body decided to deposit some extra fat, I really couldn't tell you. But, when I had this patient sit up in his cot, the sides of his lower back tissue folded up to meet at the mid line, creating a perfect replica of an ass crack.
I kid you not.
Starting around the upper lumbar area, the deep fold ran the length of the lower back, ending just before the tailbone region. There, a gap of about two inches of regular anatomy existed, giving good pause between the impostor crack and the beginnings of the patient's real buttock's crack. Yep, the real crack poked out of this patient's droopy underwear, challenging the impostor crack to a face-off. I couldn't have picked the better crack. Deeply creased and pressed together, that impostor crack looked like the real thing. Perfection, almost.
Thus, the double crack.
I had the patient take a few extra breaths, relishing my sighting while I made sure the patient had good air movement within his lungs.
Like the baboon and his fiery red ass, I don't think this patient knew what he was in possession of. Maybe a good thing, really. I sure wasn't going to tell him.
Could I even bill for that diagnosis? Any coders out there? Acute double crackitis. Code 191.22.3?
I came home that night and looked at my lower back in the mirror. I sat down. I stood up. I rotated. I side-bended. Nope, no double crack on me. I even made my wife look, but she couldn't spot one, either. Darn it. I secretly wanted my own double crack.
"Sorry, Jim," she said, laughing, "you'll just have to suffer through life with one crack."
I guess I'll just have to make myself an appointment to get a tramp stamp.
As always, big thanks for reading (and in this case, tolerating my silly, indecent humor). The well ran dry from a busy weekend, so I took Monday off. Thanks for understanding. See you Friday...