summary of Digital Rectal Exam.

This is the Summary of Digital Rectal Exam.

it is a component of GI, and should be done during semester 3.

flow of events;

1. GIEP - Emphasis on Explanation
2. positioning of patient and getting ready
3. put gloves on.
4. inspection of the perianal area
5. insert finger
6. palpation of the anal canal
7. assess anal tone
8. extract finger and wipe perianal area, put blanket back.
9. inspect your finger,
10. dispose glove
11. report
12. thank patient, leave room

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Explanation

Digital Rectal Exam is an opportunity where we're required to show high levels of professionalism in presenting the patient with sufficient explanation, and asking for consent.

basically what you're going to do is sticking your finger up the patient's ass.

(in your explanation, it is referred to as "the back-passage".)

therefore, the patient should (MUST) be given sufficient good reason for it to be done.

explain throughly - about what you're going to do - how it may feel - how it will be done discreetly - how the patient will be provided with chaperon if she deemed so

Good morning, my name is --------, i am a - year medical student.
Today, I will be carrying out a digital rectal exam on you.
this will involve me inserting my finger through your back-passage, to feel for any irregularities.

during the course of this examination, you may feel as if you're passing motion.

you may feel uncomfortable, but should it cause any pain, please do not hesitate to stop me.

if you feel uncomfortable, you may ask for a cheperon.

Is that fine for you?

something like that. the patient may ask several questions like "why do I have to do this" or "is it really necessary" but we need to use our common sense (if we have one) or empathy skills (as if we have one) on this.

think - what if you were required to go through this DRE? would you be satisfied with what you said?

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Positioning of patient

now that we have convinced the patient to face his doom, we need to instruct the patient to position him/herself for a suitable position.

the position is called a left lateral decubitus. basically the patient will lie like a fetal position on the bed, back-passage towards you, hugging his/her knee.

now, in IMU, we're only going to talk to the butt (the Digital Rectal model) so what you're really doing is explaining to the butt where to move, as you reposition it yourself.

Could you please lie flat, shift to my side, then turn to your left? please hug your knees, thank you.

now that you have the butt in place, you will have to carefully expose the butt to reveal the back-passage ONLY. there is a penis stuck on the rectal model. cover it. the model needs some privacy. (and no i am not joking. it is to minimize the patient's embarrassment.)

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put on your gloves.

put on your gloves. both hands. disposable gloves.

Q - why disposable and not sterile gloves?

A - since when was the rectum sterile? and disposable gloves are cheaper.

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inspection

before you stick your finger in - hold your horses.

you need to inspect the perianal area.

inspect for;

• anal orifice - is it patent?
• anal tone - is it normal / Lax? (the model has a lax anal tone (gaping anal) - he may have a spinal cord injury, not surprising since he has no upper body)
• any piles/hemorrhoid
• anal fissures
  (the model may have an anal fissure due to repeated manhandling by medical students. comment on it, the examiner will be pleased to know that we actually look at things, and realize how we abuse our models.)
  (if you find a fissure in a real patient, feel sorry for him/her. this is going to hurt.)
• warts
• ulcerations
• extra orifice, fistula, etc
• surgical scars
• swelling
• discolouration

and so on.

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Insertion of the finger

now you finally get to insert your finger. but there are several steps you must take, to ensure that the patient won't be scared/in pain/scarred for life.

1. lubricate your index finger - not the whole hand, you're not FISTING the patient -
2. place your index finger (NOT MIDDLE) on the anal margin (just posterior to the anal orifice), with your other fingers clenched. the other hand is lightly pulling on the buttock of the patient. wait for the anal sphincter to relax.
   (your hands must be clenched since if your hands are splayed, you may grab some... stuff)
3. once the anal sphincter relaxes, pass your index finger into the anal canal into the rectum.

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ask the patient to squeeze your finger to assess anal sphincter tone.

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1. sweep the mucosa through 360 deg. checking for any masses, stricture, points of tenderness.
2. identify the prostate in men, and uterine cervix in women.
   the Prostate should form a rubbery, firm swelling about a size of a large nut. run the finger on each of the lateral lobes, and feel for the medial sulcus - which is a faint depression running vertically between each lateral lobe.
   In carcinoma of the prostate, the prostate becomes hard, lobes become irregular and nodular, and thee is distortion or loss of median sulcus.

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1. gently pull out the finger.
2. assure the patient that its all done,
3. wipe the anal region.
4. cover the model.
5. tell the patient it is over, and be careful to roll to supine position as they're near the end of the bed.
6. look at the finger that was inserted. if in doubt, wipe onto a tissue.
   comment for presence of pus, blood, or mucus.

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report after you have disposed the glove.

people won't want you to fling that finger about while you're reporting.

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thank the patient, wash hands, leave.

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