The Consultation Room

Prof. Dr. CMK. Reddy

General & Vascular Surgeon, Halsted Surgical Clinic, Chennai, Tamilnadu, India

Chapter 21: Making notes & plans

The consultant’s memory is fresh about the entire picture, soon after the initial interview. Subjected to the results of the investigations, that is the best time to formulate a tentative prescription in his notes. When the patient returns with all the reports, if they are found to be normal, prescription can be simply copied from the notes, if necessary with some modifications.

Any future plans for more studies or consultations may be noted in the file and accordingly patient briefed, so that he’d come prepared for them, if necessary. Important health events in the past have to be noted for future reference or correlation with the present illness.

History of co-morbidities, relevant family history and known allergy to drugs have to be written in bold in the patient’s file, to attract our attention every time we write a prescription for him.

“Yes this is a family practice, but you’ll have to make separate appointments.”

Chapter 22: Reliability of history

By and large the history given by the patient or parent/guardian, can be taken for granted and any wrong information given is usually by oversight and not intentional. However there may be some situations, the Doctor has to be very cautious.

We all know the story of Munchausen, a laparotomophilic malingerer, who presented to various hospitals at various times, with ‘typical’ symptoms and signs of surgical diseases, luring them to carry out multiple laparotomies, for no organic illness, before the days of noninvasive imaging technology.

Besides this, deliberate misleading history may be given in medicolegal matters, insurance coverage reasons, workmen compensation purposes, parental disharmony (as in battered child syndrome) and so on. In such situations high index of suspicion is necessary, especially if you have to issue any certificate, so as not to allow yourself supporting unscrupulous elements.

Chapter 23: Physical examination

When any patient voluntarily walks into your consulting room, it implies that permission is given to elicit history and perform physical examination on him. However, it’s prudent to deliberately ask for permission and record the consent. Special permission may be required to examine pectoral region / breast / axilla of women, genitalia and do digital pelvic (vaginal) or rectal examination. It’s logical not to perform vaginal examination in a virgin (or unmarried) woman.

The physical maneuvers that impress the patient most about the ‘thoroughness’ of your examination are : tongue & throat, eyes for pupillary reflex (or even fundus, if you have an ophthalmoscope and trained to do), auscultation of chest (to pick up respiratory adventitious sounds or cardiac murmurs), & neck (carotid bruit), tendon reflexes and digital pelvic & rectal examination.

This approach is very useful, if you are dealing with a psychosomatic disorder, to gain confidence of the patient, which makes your prescription work. Most of them are easy to perform, may be a bit time consuming in the midst of a busy clinic, but worth the effort, if you have to score over other Doctors, who treated the patient earlier.

‘If you don’t want to put your finger in the rectum, you may have to put your foot in it’ – Hamilton Bailey

Surprisingly, women don’t hesitate to undergo pelvic (PV) examination by a male Doctor in the consultation room, provided you are ‘senior’ enough and have a female assistant with you. During our training in USA, our teachers impressed upon us the value of pelvic examination to a ‘general’ surgeon, since for any patient referred to us for evaluation of vague unexplained abdominal pain, our opinion as to its cause, should be final, hence our examination had to be comprehensive (literally no stone unturned). Of course, we should always do PV before PR, if we have to do both, for hygienic and esthetic reasons.

Remember the saying ‘don’t insult vagina, by doing rectal examination first’. If prostatic carcinoma is suspected, it’s advisable to have the patient’s blood sample collected for the estimation of serum acid phophatase (SAP) and prostate specific antigen (PSA), before carring out PR, since they may be elevated (transient) after prostatic massage even in benign conditions.

The examination coach should be so placed in the room, so that the patient can be examined standing on his right, however if you are left-handed, you have to stand on the left of patient. Certain clinical tests are better avoided; examination in knee-elbow position (inconvenient) and Kocher’s sign for tracheomalasia, in long standing large goiters (risk of producing acute airway obstruction).

This was how physicians used to hear lung and heart sounds before Laennec invented stethoscope in 1816. Doctors over centuries never forgave him for his invention.

Chapter 24: Gender precaution

Male Doctor should have a female nurse or attendant, while interrogating and examining a female adult or while a female Doctor examining a male adult.

Of course, parents or some elders in the family may be allowed with their children of any gender.

Not observing this precaution has been a common cause of litigation, arising in consultation rooms.

If you can provide a screen or curtain, isolating the exam coach in your room, any male attendant of a female patient may be allowed to stay in your room. Sense of security is maximum for a woman being examined by a male Doctor, if her husband or father is with her in your chamber, of course with a female assistant standing by you.

“She allowed this when we told her that this is antiviral software.”

Chapter 25: Investigations & interpretations

There has always been a public hue and cry that too many unnecessary investigations are being done by the Doctors, with some unholy nexus with diagnostic centres. Over the years, a few Doctors have given room for such criticism against the ‘noble profession’, though many still observe strict ethical values in ordering investigations.

To say that this is a universal phenomenon, is of no relief to an individual patient, who spends twice the amount for any scan, as against it’s actual cost nor is an excuse for an individual Doctor. An investigation, which doesn’t influence the management (either in diagnosis, treatment or prognostication), is considered academic and only adds to the cost of medicare.

Unfortunately, there is no law preventing a Doctor doing any investigation, but he may be questioned if a particular investigation wasn’t done in time, which would have identified the disease earlier. This has become very convenient in a corporate set up, which believes in carrying out ‘thorough’ investigations for any patient, even apparently with a common ailment.

Consumer activism also played its role in encouraging commercially-oriented Doctors to over-investigate, so as not to miss a disease, which may occur in one out of hundred such patients. This is the main reason why in most of the western countries, especially in US, the medicare is very expensive and by and large considered cost ineffective.

It’s very useful to have the urine sugar of a known diabetic patient checked by your assistant or nurse, at least by the stick test, before he is allowed to see the Doctor. Any alteration in the anti-diabetic treatment may be made accordingly. As a rule, less expensive and noninvasive investigations have to be done first and resort to more expensive or invasive ones, only if the earlier tests couldn’t clinch the matter, to proceed with treatment.

We should avoid carrying out investigations, which are considered non-reproducible. A test giving different results in the same patient at different times, such as random plasma glucose or gastric analysis, have limited diagnostic significance.

Nowadays, we don’t ask for motion examination as a routine, for aesthetic reasons and the inconvenience involved, unless we are looking for something specific. It’s very important to establish tissue diagnosis in cancers, before offering treatment.

One elderly patient came to us, after getting discharged from a ‘teaching’ hospital, with a label of advanced cancer of lung, diagnosed by a CT scan. Since his daughter’s wedding was to be performed a month later, they just wanted my help to keep him alive till the ceremony was over.

While perusing the hospital records, to my surprise, I found the diagnosis was not clinched by histopathology. On careful examination, he had a palpable supraclavicular node; we did excision biopsy, reported as tuberculosis. Now, after 5 years, the patient is well, playing with his grandchildren. While looking at an x-ray or scan, always verify the name and date printed on it, to avoid studying the report of a wrong patient.

“When it comes to bustin’ a kidney stone, the old methods are still the best.”

The Consultation Room