Dr. Karl Newman

A proper and thorough patient assessment always includes a rectal examination. The "rectal" is uncomfortable for patients, and can be a source of anxiety for junior medical trainees.

Q Fever!'s I&R correspondent, Dr. Karl Newman, presents a practical approach to the rectal examination.

Back when I was a medical student, my surgery resident always used to say that there are only two reasons not to do a rectal exam: "no rectum in the patient, or no fingers on the doc!" And it's still damn good advice. But it's also important to remember that lots of other good reasons are available too, including:

•	Glove box is empty
•	ER doc already did it
•	Med student already did it
•	Patient's spouse or significant other already did it
•	Possibility that broken glass is present in the rectal vault
•	Just ate/just about to eat
•	Going into ophthalmology next year
•	Wearing good shoes/tie/cuff links/chunky gold bracelets
•	Patient wearing complex leather/metal undergarment or chastity belt
•	Overwhelmed by gorgonzola-like odor as patient drops drawers

But I digress. 'Cause today, we're gonna talk about how to do a good rectal. If you gotta. And sometimes, you just gotta. It's like my Uncle Moe used to say:

Just because you're standing in the barnyard with the pigs and chickens, that don't mean you gotta be sheepish.

1) Put the patient at ease

What you say? Yeah, you heard me the first time: put 'em at ease. How would you like it if someone told you to bring your knees up under your chin, and then proceeded to slide a lubricated digit into your tush? OK, bad example. But take my word for it, if you think you're nervous doing a rectal, it's probably twice as bad for the patient. So I try to get 'em to relax. Ideally, put on a nice CD with some of that 60's Brazilian music…the Girl From Ipecac, and such. A soothing herbal tea may help. The least you can do is not heighten the patient's anxiety… for example, while it's already generally not appropriate to wear a latex monster mask while examining a patient, it's especially inappropriate during a rectal exam.

2) Wear appropriate gloves

Whuzzupwidat? Yeah, that's right, mister. Use the right tool for the job. Latex gloves work best. Woolen mittens, which are preferable for the purposes of wintertime hand-warming, are almost never appropriate for a rectal exam. Other types of gloves, including welder's gloves, fielder's mitts, and hockey gauntlets, are likely to cause patients substantial discomfort. Always use a water-soluble lubricant. If there is no water-soluble lubricant available, I recommend running your glove through the hair of my friend Dr. Allan Cheng, the pathology resident. If he is not immediately available, you may have to page him.

3) Murmur reassuringly during the exam

WhatyoutalkinboutWillis? You know it, baby. Always tell the patient what you're doing. Making little jokes (e.g. "So that's where I left my keys") will help time to pass quicker. Never say things like "Christ, What the… ?!" or "Oh my God, it's got my FINGER!" Similarly, you should avoid low whistles or, making any sort of noise meant to convey deep, intense pleasure until the patient is again fully dressed. If you feel something abnormal, document the finding by making a plasticine replica of the patient's rectum, and placing a salted peanut in the area where you thought you felt something. Offer a peanut to the patient, too.

Follow these simple tips, and in no time you'll be probing your way around the rectum in the glorious tradition of Oscar Wilde and Lord Alfred Douglas.

That's all the time we have for today, kids! So, 'till next time…

Just tell 'em Dr. Karl sent ya!

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