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Carrying out a physical examination

This is usually a crucial component in formulating a reasoned diagnosis. It may seem that the patient has told you all you need to know in order to make a diagnosis, but a physical examination may provide you with more information, or at least confirm your initial impressions from listening to the history.

The cases we see at MPS where a failure to examine has proved crucial are usually where the practitioner has avoided a rectal or genital examination (as in the case reported below), but there are also plenty of cases where the doctor failed to examine a patient’s throat or the fundus of the eyes, or to palpate an abdomen or listen to chest sounds, and therefore missed important clues.

It may seem that the patient has told you all you need to know in order to make a diagnosis, but a physical examination may provide you with more information

Case report: Lax examination

Mr B, a 46-year-old taxi driver, consulted his GP, Dr K, about pain in the rectum and constipation. He mentioned that he had had infected piles before, for which he’d been prescribed antibiotics. Dr K was satisfied by the explanation of symptoms and wrote a prescription for laxatives and antibiotics. She did not examine the patient.

Three days later Mr B visited Dr K again, complaining of worsening pain and feeling unwell. He reported profuse sweating and rigors. He said he had passed a small amount of motion, but was still experiencing rectal pain. Dr K checked his temperature and examined his abdomen, chest and ENT, which were all unremarkable.

She diagnosed resolving constipation and coincidental viral infection and advised Mr B to continue the antibiotics. She thought that the sweating might be a side effect of the Prozac Mr B was also taking and changed his prescription.

The following evening, Mr B’s wife drove him to the emergency department as he was experiencing intense pain in his rectum. The cause was quickly diagnosed as a rectal abscess. Admission to hospital was organised and aggressive surgical treatment was required. Mr B subsequently sued Dr K.

A GP expert was critical of Dr K for her failure to carry out a rectal examination, which delayed the discovery of the abscess. The claim was settled for a substantial sum because Mr B would have required less radical surgery if he had been referred earlier.