Perianal Abscess

Last night a hispanic couple shows up with their 11 month old to the ER complaining that the infant has had a fever of 101 for 2 days and has been vomiting and having diarrhea for 2 days as well. The ER docs examine the patient and decide to admit the patient for fever of unknown origin and infection of unknown source. 

The infant was admitted to the pediatric floor where 3 residents and 1 attending physician each examined the patient separately and came to the same conclusion as the ER doctors. I came in this morning and the patient was assigned to me so I proceeded to examine the patient. As part of the exam I begin to remove the child's diaper and the mother started to protest and ask why I was removing the diaper. I explained that in order to do a full exam and to attempt to determine the source of the fever and the infection it is crucial to examine the entire body. I was able to comfort her and explain what I was doing. She explained that none of the other doctors did this but ultimately gave me permission to continue my examination. Patients often protest to having to be fully examined, most time the parents are fine with the doctor examining the baby naked but even they protest at times. Many doctors will not do a full exam for this reason. They wont ask the patient to disrobe for a full exam even if it would be relevant to the exam. Obviously you do not have a patient disrobe for a flu shot but many exams to be complete should include inspection of all the areas. 

As soon as I removed the child's diaper and began to examine the baby I noticed an inflammed area right next to the anus. Upon further examination I was able to determine that the baby had a perianal abscess which was most likely the culprit for the infection. As I palpated it I could tell that it was large, tender and warm to the touch (I could feel the warmth through the gloves). There are many ways a child can develop such an abscess and they are often missed by the parents because unless you a really looking carefully at the anus it will appear normal to them. I brought in my chief resident showed her my triumphant finding. We had already started the baby on antibiotics but now we were able to aspirate the abscess and send the fluid to the lab to be cultured and upon the results we may start a different antibiotic depending on what kind of organisms are present.

The whole experience reaffirmed the importance of being thorough and also not being thrown off by the patient's or the patient's complaint about part of the exam. You have to have permission but you also do what you are trained to do and remember that the patient is not the one who went to medical school or the one who is liable. One great doctor I have worked with was great at explaining to the patients why a certain exam or test was necessary and ultimately was successful in gaining permission. I asked him what he does if ultimately the patient refuses the exam and he told that he tells the patient to find a different doctor, in a nice way of course. In talking to the residents they mentioned that the mother protested many parts of their attempted  exams. The doctors who examined the patient before me were not bad doctors at all, in fact they are good doctors but they did not want to make the patient, or in this case the patient's mother uncomfortable so they failed to do a complete exam and thus failed to make a diagnosis by allowing the patient's mother to run the exam.