In medicine, we are obsessed with normal anatomical and normal physiological variations. The medical peculiarities that aren’t really peculiarities but are things that exist simply because the complexity of human development didn’t read the textbook properly.
The liver is impalpable in a normal abdomen, say the books. Maybe, but finding a liver tip on deep inspiration is nevertheless nothing to start a panic over. A normal blood glucose is <5.5mmol/L, say the reference ranges, which are all based on fasting samples in healthy individuals and flash alarming colours as soon as a patient in medical receiving is found to have a blood glucose of 5.9mmol/L. How many sick people do you know who would dutifully fast for twelve hours before they took themselves off to their local friendly A&E to get that crushing chest pain seen to? No, I wouldn't either. Myself, I have an abnormal finding in both little fingers and you would be forgiven for thinking that I must have had a hideous accident with a chopping knife, but I've simply never had that tendon and nor have twenty percent of the population.
The ability to tell the physiologically abnormal from the pathologically abnormal is a skill called on surprisingly often in general practice. I'm not that good at it yet. It usually takes me all my time to identify the textbook normal.
Except for the patient who was concerned because one of her sternoclavicular joints, the knobbly bit on the collar bone, was, quote, bumpier than the other one. I felt fairly confident in telling my supervisor that this was probably a normal finding.
The gentleman in my morning surgery gave a vague history of feeling just not quite right for the last few days. As he shuffled up onto the trolley, he told me that he was a bit sore in his lower left abdomen. You don't start at the sore spot. At least, not unless you want not to find anything useful and make your patient hate you at the same time. I laid a hand on his lower right abdomen and immediately had a craggy mass filling my palm. I hadn't expected that. I palpated gingerly and it didn't move. When I had gone over the rest of his entirely unremarkable abdomen, I came back and palpated again and it was still there. (Yeah…). As bells rang and warning lights flashed and I swore inside my brain, I turned and said very quietly to the real doctor, “I’m palpating a really quite big mass in the right iliac fossa.” I didn’t quite wave my hands around my head, but it was a close thing.
He looked worried and came forward and did it all again. The patient was by this time starting to give us funny looks — we must both have seemed to be spending an awful lot of time on somewhere other than where he had said his pain was.
How do you tell someone who came in with nausea and lethargy and a guilty feeling that they were wasting someone’s time that they’ve actually got a mass in their colon? How can you ever adequately prepare a person for that? And when you’re not in medical receiving with access to a surgical opinion and a CT scanner but in a GP practice in the remote Scottish Borders, what do you do next? All of those were the things I was thinking about. They’re important questions and ones worth considering, but they were not the questions that I got an answer to.
The GP turned back to me with an air of profound relief.
“It’s OK. You were palpating his hip,” he said. “The iliac crest is just in a weird position. It’s like that in some people.”
Ah. I’ll just hold off on that colonoscopy then, shall I?