Trefor wrote:
>In a message dated 12/07/96 19:04:33, Armando writes:
>
>I thought that there was a computer algorithm written by someone from my part
>of the world (Beighton, S. Yorks UK) that was a better predictor of acute
>appendicits on history and examination than doctors... (snip)... the author
was Professor De Dombal
Don't know the algorithm, but I read a superb little book by De Dombal on
abdominal pain. I can get the reference if someone is interested
(McGraw-Hill, I think). I still remember that most emphasis was on history
and physical, not on tests. I would like to know more about that algorithm!
>
>Are you saying that history and simple physical examination are all one needs
>and the intimate examination is irrelevant tothe decision to refer?
Well, to me, what you call "intimate examination" is as much part of a
physical examination as, for instance, the search for a Blumberg sign. I can
accept, though, that certain technical gestures encompass more work, time
and embarassment than others. It is only natural, then, that we keep their
execution
for the moments we feel they are absolutely necessary. So, it really depends
on the situation. Of course some situations may be so clear just from
history (vaginal candidiasis, for instance) that we can skip the
examination. On the other hand, I feel exactly like Andrew Oakford - I do
not refer a prostate case without a rectal exam, except if the patient
enters my office the first time already with an ultrasound prostate scan in
his hands! And I simply do not trust PSA screening. Too many false positives
and negatives, poor predictive values.
I would
>agree with a comment on this thread that the result of the VE/PR in acute
>abdominal pain is not going to influence management, if there is a chance
>that it is an ectopic pregnancy, I would'nt do a VE to find out, if the
>choice is between appendix and pelvic inflammatory disease then the appendix
>wins (i.e. off to the surgeons and let them decide).
I agree.
>
>Intimate examinations in acute abdominal pain are the remit of secondary
>care, if it's not acute then a chaparone can be arranged - discuss
I don't think there is any examination belonging exclusively to secondary
care. It all depends on your setting (just think of our Canadian and
Australian colleagues in the middle of nowhere... they *are* the secondary
care too!). I work in inner city practice, 10 minutes from a university
hospital with emergency room, so I could agree with you... But I think we
must keep on our toes and be ready to do anything if necessary.
The chaperonage problem, along with being a cultural question is also an
organizational one. I admit I would like to have a chaperone for every of
this so-called intimate examinations. We simply don't have enough people
(nurses, staff, whatever). The alternative would be to do without the
examinations... a possibility I am not ready to accept (yet). This is the
average attitude around here, so far that I know. I don't remember more than
a couple of sexual harassment charges in Portugal in years (one in a
hospital, another in GP).
Nice thread this one! :-))
Armando
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Armando Brito de Sa'
Lisboa, Portugal
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