All for Want of a Rectal Exam

In January 2008, a man presented to the emergency department (ED) of a Florida hospital with complaints of headache and rectal pain. He was seen by Dr. C., who did not perform a rectal exam and discharged the patient with a diagnosis of acute headache.

The following day, the man returned to the ED with right lower quadrant pain. He was evaluated by a PA, who noted painful urination and erythema in the groin. The PA diagnosed dysuria, tinea cruris, and “probable exposure to sexually transmitted disease.”

Two days later, the patient went to the ED again, complaining of severe bilateral abdominal pain, rectal and head pain, and shortness of breath. Dr. N. evaluated him and ordered labwork, including a complete blood count and d-dimer qualitative study, and CT of the pelvis. These revealed an elevated white blood cell count and extensive soft tissue emphysema in the pelvis. The radiologist reported concern about a “perineal soft tissue infectious process” and noted that he and another radiologist had reviewed the findings with an ED physician.

The following morning, Dr. O. assessed the patient and admitted him with a diagnosis of possible cellulitis. The patient was then transferred to another hospital.

The plaintiff filed a lawsuit claiming that he actually had a necrotizing infection and that the delay in diagnosis resulted in the development of disseminated intravascular coagulation with thrombocytopenia. The plaintiff required numerous surgeries and wide local debridement of the tissue of his perineum, scrotum, rectum, and preperitoneum. He developed multiple life-threatening complications, underwent hyperbaric oxygen therapy, endured five months of inpatient care, and required placement of a long-term colostomy.

The plaintiff’s initial claims included many defendants. Several settled for undisclosed amounts; others were dismissed. The action proceeded to trial against hospitalist Dr. O. and his medical practice.

Continue for outcome >>

OUTCOME

A defense verdict was returned. The defendants were granted fees and costs in the amount of $54,000.

COMMENT

This is a case of Fournier gangrene. We are not told the patient’s age, and we don’t know if he had a history of diabetes, alcoholism, or other factors that would have made the diagnosis of Fournier gangrene more likely.

Fournier gangrene, a life-threatening urosurgical emergency, is a necrotizing infection of the perineum caused by a mix of aerobic and anaerobic bacteria. It may be generally expected in immunocompromised patients. Less commonly, it affects otherwise healthy patients with urogenital trauma, such as piercings¹ or excessive masturbation.² It is named for a Parisian venereologist who, in 1883, differentiated cases associated with alcoholism, diabetes, and immunocompromise from those associated with trauma to the urogenital tract caused by instrumentation, ligation of the foreskin (for enuresis or to avoid pregnancy), or placement of foreign bodies within the urethra. (At the time, Fournier implored clinicians to obtain confessions of “obscene practices” from patients.³)

This case raises three points:

Address all patient complaints in the history, physical, and disposition. Force yourself to do this to avoid dismissing a symptom that does not fit neatly into your perception of the puzzle. Here, the first clinician did not address the complaint of rectal pain at all, choosing to focus on the patient’s headache—and by so doing, missed the diagnosis. Don’t blow off the symptom: Divergent complaints require investigation. 

Next, don’t skip difficult exams just because they are unpleasant or a “time burglar.” On my first day as a student in clinical rotations, I saw a patient with right upper quadrant abdominal pain and a perfect story for biliary colic. As fast as my overstuffed short coat could carry me, I rushed out to present the case. The attending asked, “Rectal?” I replied that I felt the presentation was clear enough to defer. His response? One of those pearls of wisdom you keep with you for your entire career: “There are two occasions you don’t need to perform a rectal examination on a patient with abdominal pain.” He paused as I prepared to take notes in the blank pages of my copy of Scut Monkey, then continued, “If you don’t have a finger, or the patient doesn’t have an anus.” I unclicked my pen and prepared for my humbling return trip to the patient, hoping I would be vindicated because the patient, in fact, did not have an anus. Alas, this was not the case, and I became a better clinician that day for it.

Humor aside, the attending’s point was valid. The echo of that voice has compelled me to argue against that time-conscious demon on my shoulder whispering: “Just write ‘deferred,’ just write ‘deferred.’” 

Let’s be honest: The rectal exam is not pleasant for anyone, patient or clinician. Because of the explanation required, it is moderately time consuming; it is uncomfortable; and it may require the burden of finding a chaperone. You must locate fecal occult blood test cards and lubricant (which is never where it is supposed to be). Patients hate it; clinicians hate it—rectal deferred. 

But in this case, “rectal deferred” resulted in a missed chance to pick up Fournier gangrene three days earlier—potentially sparing this patient substantial morbidity. The rectal exam likely would have revealed tenderness and referred pain suggestive of the primary acute underlying process. Don’t skip burdensome exams.

This plea goes for all time-­intensive exams (pelvic, visual acuity for ocular complaints, etc), and carries over into making sure the patient is adequately undressed so you can conduct a proper examination. Don’t skip an exam that shouldn’t be skipped. Jurors will expect a full exam, and the plaintiff’s attorney will hammer you for shortcuts.

Lastly, consider symptoms individually, as unrelated entities, as well as together to explain a single disease. The concept of a synthesist versus reductionist applies. A synthesist or “lumper” seeks to explain signs and symptoms as related to one disease and “lumped” to a single diagnosis. A reductionist or “splitter” aims to separate symptoms into individual diagnoses. The respective questions: Could these complaints be related? Could this complaint be merely incidental to the patient’s other symptoms? Ask both.

The second clinician attempted to split the symptoms into a variety of diagnoses: dysuria, tinea cruris, “probable exposure to a sexually transmitted disease,” and abdominal pain. The result of oversplitting was a missed opportunity for a diagnosis.    

Is a good clinician a “lumper” or a “splitter”? It seems the best are both and will constantly switch back and forth between possibilities, viewing a constellation of symptoms through both lumper and splitter diagnostic lenses.  

In this case, a lumper may have viewed the right lower quadrant pain, rectal pain, perineal erythema, and dysuria, as suggestive of a deeper intrapelvic process.  The lumper would have difficulty accounting for headache, which can be split from the rest and on retrospect was incidental. 

The case concluded with multiple defendants paying to settle the case. The defense verdict for the first hospitalist (who admitted the patient with cellulitis) may have been based on a short time interval between the hospitalist’s underdiagnosis and the correct definitive treatment.

In sum, in an acute setting, address all complaints. Don’t skip an exam just because it is a time burglar—time spent answering lawyer calls and attending depositions and trial is far greater. Consider using different diagnostic lenses to assess if a patient’s symptom complex can be explained by one diagnosis; but don’t be hidebound either—some symptoms are simply unrelated or incidental. —DML

References on next page >>

REFERENCES

1. Ekelius L, Björkman H, Kalin M, Fohlman J. Fournier’s gangrene after genital piercing. Scand J Infect Dis. 2004;36(8):610-612.

2. Heiner JD, Eng KD, Bialowas TA, Devita D. Fournier’s gangrene due to masturbation in an otherwise healthy male. Case Rep Emerg Med. 2012;2012:154025.

3. Pais VM Jr, Santora T, Rukstalis DB. Fournier Gangrene. Medscape. http://emedicine.med scape.com/article/2028899-overview. Accessed April 9, 2014.

In January 2008, a man presented to the emergency department (ED) of a Florida hospital with complaints of headache and rectal pain. He was seen by Dr. C., who did not perform a rectal exam and discharged the patient with a diagnosis of acute headache.

The following day, the man returned to the ED with right lower quadrant pain. He was evaluated by a PA, who noted painful urination and erythema in the groin. The PA diagnosed dysuria, tinea cruris, and “probable exposure to sexually transmitted disease.”

Two days later, the patient went to the ED again, complaining of severe bilateral abdominal pain, rectal and head pain, and shortness of breath. Dr. N. evaluated him and ordered labwork, including a complete blood count and d-dimer qualitative study, and CT of the pelvis. These revealed an elevated white blood cell count and extensive soft tissue emphysema in the pelvis. The radiologist reported concern about a “perineal soft tissue infectious process” and noted that he and another radiologist had reviewed the findings with an ED physician.

The following morning, Dr. O. assessed the patient and admitted him with a diagnosis of possible cellulitis. The patient was then transferred to another hospital.

The plaintiff filed a lawsuit claiming that he actually had a necrotizing infection and that the delay in diagnosis resulted in the development of disseminated intravascular coagulation with thrombocytopenia. The plaintiff required numerous surgeries and wide local debridement of the tissue of his perineum, scrotum, rectum, and preperitoneum. He developed multiple life-threatening complications, underwent hyperbaric oxygen therapy, endured five months of inpatient care, and required placement of a long-term colostomy.

The plaintiff’s initial claims included many defendants. Several settled for undisclosed amounts; others were dismissed. The action proceeded to trial against hospitalist Dr. O. and his medical practice.

Continue for outcome >>

OUTCOME

A defense verdict was returned. The defendants were granted fees and costs in the amount of $54,000.

COMMENT

This is a case of Fournier gangrene. We are not told the patient’s age, and we don’t know if he had a history of diabetes, alcoholism, or other factors that would have made the diagnosis of Fournier gangrene more likely.

Fournier gangrene, a life-threatening urosurgical emergency, is a necrotizing infection of the perineum caused by a mix of aerobic and anaerobic bacteria. It may be generally expected in immunocompromised patients. Less commonly, it affects otherwise healthy patients with urogenital trauma, such as piercings¹ or excessive masturbation.² It is named for a Parisian venereologist who, in 1883, differentiated cases associated with alcoholism, diabetes, and immunocompromise from those associated with trauma to the urogenital tract caused by instrumentation, ligation of the foreskin (for enuresis or to avoid pregnancy), or placement of foreign bodies within the urethra. (At the time, Fournier implored clinicians to obtain confessions of “obscene practices” from patients.³)

This case raises three points:

Address all patient complaints in the history, physical, and disposition. Force yourself to do this to avoid dismissing a symptom that does not fit neatly into your perception of the puzzle. Here, the first clinician did not address the complaint of rectal pain at all, choosing to focus on the patient’s headache—and by so doing, missed the diagnosis. Don’t blow off the symptom: Divergent complaints require investigation. 

Next, don’t skip difficult exams just because they are unpleasant or a “time burglar.” On my first day as a student in clinical rotations, I saw a patient with right upper quadrant abdominal pain and a perfect story for biliary colic. As fast as my overstuffed short coat could carry me, I rushed out to present the case. The attending asked, “Rectal?” I replied that I felt the presentation was clear enough to defer. His response? One of those pearls of wisdom you keep with you for your entire career: “There are two occasions you don’t need to perform a rectal examination on a patient with abdominal pain.” He paused as I prepared to take notes in the blank pages of my copy of Scut Monkey, then continued, “If you don’t have a finger, or the patient doesn’t have an anus.” I unclicked my pen and prepared for my humbling return trip to the patient, hoping I would be vindicated because the patient, in fact, did not have an anus. Alas, this was not the case, and I became a better clinician that day for it.

Humor aside, the attending’s point was valid. The echo of that voice has compelled me to argue against that time-conscious demon on my shoulder whispering: “Just write ‘deferred,’ just write ‘deferred.’” 

Let’s be honest: The rectal exam is not pleasant for anyone, patient or clinician. Because of the explanation required, it is moderately time consuming; it is uncomfortable; and it may require the burden of finding a chaperone. You must locate fecal occult blood test cards and lubricant (which is never where it is supposed to be). Patients hate it; clinicians hate it—rectal deferred. 

But in this case, “rectal deferred” resulted in a missed chance to pick up Fournier gangrene three days earlier—potentially sparing this patient substantial morbidity. The rectal exam likely would have revealed tenderness and referred pain suggestive of the primary acute underlying process. Don’t skip burdensome exams.

This plea goes for all time-­intensive exams (pelvic, visual acuity for ocular complaints, etc), and carries over into making sure the patient is adequately undressed so you can conduct a proper examination. Don’t skip an exam that shouldn’t be skipped. Jurors will expect a full exam, and the plaintiff’s attorney will hammer you for shortcuts.

Lastly, consider symptoms individually, as unrelated entities, as well as together to explain a single disease. The concept of a synthesist versus reductionist applies. A synthesist or “lumper” seeks to explain signs and symptoms as related to one disease and “lumped” to a single diagnosis. A reductionist or “splitter” aims to separate symptoms into individual diagnoses. The respective questions: Could these complaints be related? Could this complaint be merely incidental to the patient’s other symptoms? Ask both.

The second clinician attempted to split the symptoms into a variety of diagnoses: dysuria, tinea cruris, “probable exposure to a sexually transmitted disease,” and abdominal pain. The result of oversplitting was a missed opportunity for a diagnosis.    

Is a good clinician a “lumper” or a “splitter”? It seems the best are both and will constantly switch back and forth between possibilities, viewing a constellation of symptoms through both lumper and splitter diagnostic lenses.  

In this case, a lumper may have viewed the right lower quadrant pain, rectal pain, perineal erythema, and dysuria, as suggestive of a deeper intrapelvic process.  The lumper would have difficulty accounting for headache, which can be split from the rest and on retrospect was incidental. 

The case concluded with multiple defendants paying to settle the case. The defense verdict for the first hospitalist (who admitted the patient with cellulitis) may have been based on a short time interval between the hospitalist’s underdiagnosis and the correct definitive treatment.

In sum, in an acute setting, address all complaints. Don’t skip an exam just because it is a time burglar—time spent answering lawyer calls and attending depositions and trial is far greater. Consider using different diagnostic lenses to assess if a patient’s symptom complex can be explained by one diagnosis; but don’t be hidebound either—some symptoms are simply unrelated or incidental. —DML

References on next page >>

REFERENCES

1. Ekelius L, Björkman H, Kalin M, Fohlman J. Fournier’s gangrene after genital piercing. Scand J Infect Dis. 2004;36(8):610-612.

2. Heiner JD, Eng KD, Bialowas TA, Devita D. Fournier’s gangrene due to masturbation in an otherwise healthy male. Case Rep Emerg Med. 2012;2012:154025.

3. Pais VM Jr, Santora T, Rukstalis DB. Fournier Gangrene. Medscape. http://emedicine.med scape.com/article/2028899-overview. Accessed April 9, 2014.

In January 2008, a man presented to the emergency department (ED) of a Florida hospital with complaints of headache and rectal pain. He was seen by Dr. C., who did not perform a rectal exam and discharged the patient with a diagnosis of acute headache.

The following day, the man returned to the ED with right lower quadrant pain. He was evaluated by a PA, who noted painful urination and erythema in the groin. The PA diagnosed dysuria, tinea cruris, and “probable exposure to sexually transmitted disease.”

Two days later, the patient went to the ED again, complaining of severe bilateral abdominal pain, rectal and head pain, and shortness of breath. Dr. N. evaluated him and ordered labwork, including a complete blood count and d-dimer qualitative study, and CT of the pelvis. These revealed an elevated white blood cell count and extensive soft tissue emphysema in the pelvis. The radiologist reported concern about a “perineal soft tissue infectious process” and noted that he and another radiologist had reviewed the findings with an ED physician.

The following morning, Dr. O. assessed the patient and admitted him with a diagnosis of possible cellulitis. The patient was then transferred to another hospital.

The plaintiff filed a lawsuit claiming that he actually had a necrotizing infection and that the delay in diagnosis resulted in the development of disseminated intravascular coagulation with thrombocytopenia. The plaintiff required numerous surgeries and wide local debridement of the tissue of his perineum, scrotum, rectum, and preperitoneum. He developed multiple life-threatening complications, underwent hyperbaric oxygen therapy, endured five months of inpatient care, and required placement of a long-term colostomy.

The plaintiff’s initial claims included many defendants. Several settled for undisclosed amounts; others were dismissed. The action proceeded to trial against hospitalist Dr. O. and his medical practice.

Continue for outcome >>

OUTCOME

A defense verdict was returned. The defendants were granted fees and costs in the amount of $54,000.

COMMENT

This is a case of Fournier gangrene. We are not told the patient’s age, and we don’t know if he had a history of diabetes, alcoholism, or other factors that would have made the diagnosis of Fournier gangrene more likely.

Fournier gangrene, a life-threatening urosurgical emergency, is a necrotizing infection of the perineum caused by a mix of aerobic and anaerobic bacteria. It may be generally expected in immunocompromised patients. Less commonly, it affects otherwise healthy patients with urogenital trauma, such as piercings¹ or excessive masturbation.² It is named for a Parisian venereologist who, in 1883, differentiated cases associated with alcoholism, diabetes, and immunocompromise from those associated with trauma to the urogenital tract caused by instrumentation, ligation of the foreskin (for enuresis or to avoid pregnancy), or placement of foreign bodies within the urethra. (At the time, Fournier implored clinicians to obtain confessions of “obscene practices” from patients.³)

This case raises three points:

Address all patient complaints in the history, physical, and disposition. Force yourself to do this to avoid dismissing a symptom that does not fit neatly into your perception of the puzzle. Here, the first clinician did not address the complaint of rectal pain at all, choosing to focus on the patient’s headache—and by so doing, missed the diagnosis. Don’t blow off the symptom: Divergent complaints require investigation. 

Next, don’t skip difficult exams just because they are unpleasant or a “time burglar.” On my first day as a student in clinical rotations, I saw a patient with right upper quadrant abdominal pain and a perfect story for biliary colic. As fast as my overstuffed short coat could carry me, I rushed out to present the case. The attending asked, “Rectal?” I replied that I felt the presentation was clear enough to defer. His response? One of those pearls of wisdom you keep with you for your entire career: “There are two occasions you don’t need to perform a rectal examination on a patient with abdominal pain.” He paused as I prepared to take notes in the blank pages of my copy of Scut Monkey, then continued, “If you don’t have a finger, or the patient doesn’t have an anus.” I unclicked my pen and prepared for my humbling return trip to the patient, hoping I would be vindicated because the patient, in fact, did not have an anus. Alas, this was not the case, and I became a better clinician that day for it.

Humor aside, the attending’s point was valid. The echo of that voice has compelled me to argue against that time-conscious demon on my shoulder whispering: “Just write ‘deferred,’ just write ‘deferred.’” 

Let’s be honest: The rectal exam is not pleasant for anyone, patient or clinician. Because of the explanation required, it is moderately time consuming; it is uncomfortable; and it may require the burden of finding a chaperone. You must locate fecal occult blood test cards and lubricant (which is never where it is supposed to be). Patients hate it; clinicians hate it—rectal deferred. 

But in this case, “rectal deferred” resulted in a missed chance to pick up Fournier gangrene three days earlier—potentially sparing this patient substantial morbidity. The rectal exam likely would have revealed tenderness and referred pain suggestive of the primary acute underlying process. Don’t skip burdensome exams.

This plea goes for all time-­intensive exams (pelvic, visual acuity for ocular complaints, etc), and carries over into making sure the patient is adequately undressed so you can conduct a proper examination. Don’t skip an exam that shouldn’t be skipped. Jurors will expect a full exam, and the plaintiff’s attorney will hammer you for shortcuts.

Lastly, consider symptoms individually, as unrelated entities, as well as together to explain a single disease. The concept of a synthesist versus reductionist applies. A synthesist or “lumper” seeks to explain signs and symptoms as related to one disease and “lumped” to a single diagnosis. A reductionist or “splitter” aims to separate symptoms into individual diagnoses. The respective questions: Could these complaints be related? Could this complaint be merely incidental to the patient’s other symptoms? Ask both.

The second clinician attempted to split the symptoms into a variety of diagnoses: dysuria, tinea cruris, “probable exposure to a sexually transmitted disease,” and abdominal pain. The result of oversplitting was a missed opportunity for a diagnosis.    

Is a good clinician a “lumper” or a “splitter”? It seems the best are both and will constantly switch back and forth between possibilities, viewing a constellation of symptoms through both lumper and splitter diagnostic lenses.  

In this case, a lumper may have viewed the right lower quadrant pain, rectal pain, perineal erythema, and dysuria, as suggestive of a deeper intrapelvic process.  The lumper would have difficulty accounting for headache, which can be split from the rest and on retrospect was incidental. 

The case concluded with multiple defendants paying to settle the case. The defense verdict for the first hospitalist (who admitted the patient with cellulitis) may have been based on a short time interval between the hospitalist’s underdiagnosis and the correct definitive treatment.

In sum, in an acute setting, address all complaints. Don’t skip an exam just because it is a time burglar—time spent answering lawyer calls and attending depositions and trial is far greater. Consider using different diagnostic lenses to assess if a patient’s symptom complex can be explained by one diagnosis; but don’t be hidebound either—some symptoms are simply unrelated or incidental. —DML

References on next page >>

REFERENCES

1. Ekelius L, Björkman H, Kalin M, Fohlman J. Fournier’s gangrene after genital piercing. Scand J Infect Dis. 2004;36(8):610-612.

2. Heiner JD, Eng KD, Bialowas TA, Devita D. Fournier’s gangrene due to masturbation in an otherwise healthy male. Case Rep Emerg Med. 2012;2012:154025.

3. Pais VM Jr, Santora T, Rukstalis DB. Fournier Gangrene. Medscape. http://emedicine.med scape.com/article/2028899-overview. Accessed April 9, 2014.