Thursday, December 16, 2010

The importance of being naked

In medical school, I'm a teaching assistant for the first year course in the medical interview and physical exam.  One of the things we repeat ad nauseum is that a thorough physical exam cannot be done through clothing.  We have to say it over and over because students (and many doctors, for that matter) are understandably uncomfortable asking patients to get undressed.  It's cold, and the gowns are ridiculous, and if you're a student, you're probably still nervous about your competence with the exam.

But guess what?  The moral of the story below is, you've gotta get your patients undressed.  Read on for the story.

Shortly after getting a flu shot and my TDAP booster (tetanus, diptheria, pertussis--recommended for all adults who have contact with very young children), I started to feel achy and slightly feverish.  I was a little better the next afternoon, but then my fever started to climb.  And it just got worse and worse.  That night, I had to change my pajamas because of sweating through them.

(New moms:  you'll understand that my initial reaction when I woke up soaking wet was not "oh, I have night sweats!"...but rather, "hmmm, better sniff it.  Is it breast milk?  Pee?  Spit up?  So many possibilities...").

48 hours later, with my fever unrelenting, I decided to go into a local urgent care clinic.  My temperature was 103.5.  I was convinced that I was having a really strong--and unusual--reaction to the vaccines I'd just gotten.  The doctor I saw didn't know what was going on.  She examined me, heard a bit of a heart murmur (which I'd never had before), and began to order tests willy-nilly, grasping at diagnostic straws.  I had brought my baby into the clinic with me, and mentioned several times when I spoke to my doctor that I was nursing--I wanted to be sure that any medicine she prescribed was safe to use while breastfeeding.

Finally, after putting a call into the clinic's infectious disease specialist, the doctor came back in to listen again to my heart murmur.  This time, she asked me to slip off my bra.  When I did, my nursing pads (non-moms:  you've gotta wear these to collect leaks) fell out.  And she said "oh!  you're breastfeeding!"  Which I had said at least 3 times already, but anyway.  Something had clicked in her head.  She started to examine my breasts carefully, and found a slightly red, slightly hard, wedge-shaped area on the left breast.

"Oh my god,"  she said.  "How many times do I have to learn this lesson?  Always take your patients' clothes off!"

"Huh?"  I said.

"You have mastitis!"*

Oh.  It turned out that my real, but brief, reaction to the shots had been a temporal coincidence.**   What wasn't a coincidence?  That once my doctor had finally done a thorough physical exam--with my clothes off--the diagnosis was simple.

I'll be helping to teach the physical exam next quarter; heaven help the first student I have who tries to listen to a heart through a gown or bra!

*An infection of the breast
**Or maybe not.  Baby and I were both unusually sleepy the day after the shots, nursed less often than usual, and may have brought on the mastitis that way.

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