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Wednesday, January 13, 2010

Why we require to do a thorough Physical Examination every time.

A patient from out of town was in the clinic the other day with complaints of an unyielding fever and chills. She was a diabetic and usually was under good control. She was also obese and was considering bariatric surgery. On examination, she seemed to be fine other than the fever and a mild congestion. She was put on antipyretics and told to follow up again in a day or two.

She came back and the fever was higher. It had not gone down to normal at all. This time, we were sure that we had to find the focus of infection, it had to be somewhere. We did what we should have on the first day. Took a more detailed history and did a complete physical examination.

It was carefully tucked away, hidden by her overweight thighs, at the perineum. It was an acute perineal abscess. It was inflammed, almost pointing, gasping, waiting to be let out. She needed an incision and drainage and we knew it. Her blood sugar was high (as expected). We did the surgery, she felt better and was able to travel back to her home town in 2 days.

The question here is, should the patient have come clean about the boil she knew was festering in her perineal region (undoubtedly a very private place but....) or should we have insisted on a complete exam? The thing is, in India, where cultural influences are so strong, almost all women and most men will still not feel comfortable about their bodies being exposed even if it is for medical purposes!
In the west, I assume the Doctors are more cautious, what with the malpractice race closing in on them all the time. Here it's more the patient's unwillingness to admit something could be wrong in "that" region.

I would love to have a middle ground and say that its our duty to inform the patient that a complete medical examination is required, but how many would agree to strip down completely for 'just a fever'??

Any ideas??


Unknown said...

Yes i totally agree with you that doctor should strip down the patients male or female completely if doctor feels it is necessary..but it is not possible in our indian senario..But as a doctor it is ones own responsibilty to deal with the embarracing situation

Anonymous said...

I've never worked in India, but have worked with Indian patients.It's a tough situation, but I think all you can do is act like it's completely normal for you. A chilled doc goes someway towards a chilled patient

Dr. Thunder

Techknowdoc said...

@MIB Well said @ Dr. Thunder Sometimes acting chilled out gives the patient the wrong impression that we're too casual with their problem so its a catch 22!

Ananya said...

How about telling that patient, 'listen this is what I am looking for (rash/boil/pus whatever' and even if it's in your naughties I need to know because you could die if that is the case!!' and then tell them that you know they could be uncomfortable and if they first wanted to show it to a female doc/nurse if that option is available at that time.

Techknowdoc said...

Ananya thats all well and good but at times there is no way to know what we are looking for unless we get a good history out of the patient. Thats the 'ART' part of medicine, but if a patient is too conscious as this one was, she won't even tell you if she has it!

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