I ask her if she's been scratching it.
And is there any history of skin cancer in her family?
Sitting next to me with his yellow legal pad on the table in front of him, Denny's holding one end of a cork over his cigarette
lighter, turning the cork until the end is burned black, and Denny says, "Dude, for serious." He says, "You've got some weird hostility tonight. Did you act out?"
He says, "You always hate the whole world after you get laid."
The patient falls to her knees, her knees spread wide apart. She leans back and starts to pump herself at us in slow motion. Just by contracting her butt muscles, she tosses her shoulders, her breasts, her mons pubis. Her entire body lunges at us in waves.
The way to remember the symptoms of melanoma is the letters ABCD.
Asymmetrical shape.
Border irregularity.
Color variation.
Diameter larger than about six millimeters.
She's shaved. Tanned and oiled so smooth and perfect, she looks less like a woman than just another place to swipe your credit card. Pumping herself in our faces, the murky blend of red and black light makes her look better than she really is. The red lights erase scars and bruises, zits, some kinds of tattoos, plus stretch and track marks. The black lights make her eyes and teeth glow bright white.
It's funny how the beauty of art has so much more to do with the frame than with the artwork itself.
The light trick makes even Denny look healthy, his chickeny wing arms coming out of a white T-shirt. His legal pad glows yellow. He curls his bottom lip inside, biting it as he looks from the patient to his work, and back to the patient.
Pumping herself in our faces, yelling against the music, she says, "What?"
She looks like a natural blonde, a high risk factor, so I ask, has she had any recent unexplained weight loss?
Not looking at me, Denny says, "Dude, do you know how much a real model would cost me?"
Back at him, I say, "Dude, don't forget to sketch her ingrown hairs."
To the patient, I ask, has she noticed any changes in her cycle or in her bowel movements?
Kneeling in front of us, spreading her black-polished fingernails open on either side of herself and leaning back, looking down the arched length of her torso at us, she says, "What?"
Skin cancer, I yell, is the most common cancer in women between the ages of twenty-nine and thirty-four.
I yell, "I'll need to feel your lymph nodes."
And Denny says, "Dude, you want to know what your mom told me or not?"
I yell, "Just let me palpate your spleen."
And sketching fast with the burned cork, he says, "Do I sense a shame cycle?"
The blonde hooks her elbows behind her knees and rolls back onto her spine, twisting a nipple between the thumb and forefinger of each hand. Stretching her mouth wide open, she curls her tongue at us, then says, "Daiquiri." She says. "My name's Cherry Daiquiri. You can't touch me," she says, "but where's this mole you're talking about?"
The way to remember every step to a physical examination is CHAMP FASTS. It's what they call a mnemonic in medical school. The letters stand for:
Chief Complaint.
History of Illness.
Allergies.
Medications.
Past Medical History.
Family History.
Alcohol.
Street Drugs.
Tobacco.
Social History.
The only way to get through medical school is mnemonics.
The girl before this one, another blonde but with the kind of hard old-fashioned boob job you could chin yourself on, this last patient smoked a cigarette as part of her act, so I asked if she had any persistent back or abdominal pain. Had she experienced any loss of appetite, any general malaise? If this was how she made her living, I said, she'd better make sure and get regular smears.
"If you smoke more than a pack a day," I said. "This way, I mean."
A conization wouldn't be a bad idea, I told her, or at the very least a D and C.
She gets down on her hands and knees, rotating her open butt, her puckered pink trapdoor in slow motion, and looks back over her shoulder at us and says, "What's this 'conization' scene?"
She says, "Is that something new you're into?" and exhales smoke in my face.
Sort of exhales.
It's when you razor out a cone-shaped sample of the cervix, I tell her.
And she goes pale, pale even under her makeup, even under the wash of red and black light, and pulls her legs back together. She puts out her cigarette in my beer and says, "You have one sick issue with women," and goes off to the next guy down along the stage.
After her I yell, "Every woman is just a different kind of problem."
Still holding his cork, Denny picks up my beer and says, "Dude, waste not..." then pours everything except the drowned butt into his own glass. He says, "Your mom talks a lot about some Dr. Marshall. She says he's promised to make her young again," Denny says, "but only if you cooperate."
And I say, "She. It's Dr. Paige Marshall. She's a woman."
Another patient presents herself, a curly-haired brunette, about twenty-five years old, exhibiting a possible folic acid deficiency, her tongue red and glazed-looking, her abdomen slightly distended, her eyes glassy. I ask, can I listen to her heart. For pal- pitations. For rapid heartbeat. Has she had any nausea or diarrhea?
"Dude?" Denny says.
The questions to ask about pain are COLDERRA: Characteristics, Onset, Location, Duration, Exacerbation, Relief, Radiation, and Associated Symptoms.
Denny says, "Dude?"
The bacteria called Staphylo coccus aureus will give you STAPHEO: Skin Infections, Toxic Shock Syndrome, Abscesses, Pneumonia, Hemolysis, Endocarditis, and Osteomyelitis.
"Dude?" Denny says.
The diseases a mother can pass to her baby are TORCH: Toxo-plasmosis, Other (meaning syphilis and HIV), Rubella, Cytomegalovirus, and Herpes. It helps if you can picture a mother passing the torch to her baby.
Like mother, like son.
Denny snaps his fingers in my face. "What's up with you? How come you're being like this?"
Because it's the truth. This is the world we live in. I've been there, taken the MCAT. The Medical College Admission Test. I went to the USC School of Medicine long enough to know that a mole is never just a mole. That a simple headache means brain tumors, means double vision, numbness, vomiting followed by seizures, drowsiness, death.
A little muscle twitch means rabies, means muscle cramps, thirst, confusion, and drooling, followed by seizures, coma, death. Acne means ovarian cysts. Feeling a little tired means tuberculosis. Bloodshot eyes mean meningitis. Drowsiness is the first sign of typhoid. Those floaters you see cross your eyes on sunny days, they mean your retina is detaching. You're going blind.
"See how her fingernails look," I tell Denny, "that's a sure sign of lung cancer."
If you're confused, that means renal shutdown, severe kidney failure.
You learn all this during Physical Examination, your second year in medical school. You learn all this, and there's no going back.
Ignorance was bliss.
A bruise means cirrhosis of the liver. A belch means colorectal cancer or esophageal cancer or at the very least a peptic ulcer.
Every little breeze seems to whisper squamous carcinoma.
Birds in the trees seem to twitter histoplasmosis.
Everybody you see naked, you see as a patient. A dancer could have clear lovely eyes and hard brown nipples, but if her breath is bad she has leukemia. A dancer might have thick, long, clean-looking hair, but if she scratches her scalp, she has Hodgkin's lymphoma.
Page by page, Denny fills up his pad with figure studies, beautiful women smiling, thin women blowing him kisses, women with their faces tilted down, but their eyes looking up at him through falls of hair.
"Losing your sense of taste," I tell Denny, "means oral cancers."