syncope. to rectalize or NOT to rectalize?

[Painter1]

do you guys rectalize your syncope patients? i'm not talking about the 19yo with vasovagal, but rather the run of the mill old patient we see every day who comes in for syncope.

my thought was that if there is no evidence to point to a gi bleed (e.g. no hx of gi bleed, not pale-appearing, not tachy, not hypotensive, no report of black or bloody stools, no isolated azotemia etc) then I wouldn't.

what are you guys' opinions?

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[Rendar5]

I'm not sure I would do a rectal exam to find a specific source of anemia when I don't even know if they're anemic in the first place. Now if they're anemic, sure, I would look for a source and that w/u might include a rectal exam. But as far as I'm aware, anemia and not bleeding is a cause of syncope (not counting vasovagal when looking at yourself bleeding)

 

[southerndoc]

I found the cause of one syncopal patient by doing a DRE during residency (my attendings wanted them done). When I did the DRE, the guy went unresponsive and had a 10 second asystolic pause. Turns out he had sick sinus syndrome, and the DRE caused a vagal episode that led to the prolonged sinus pause. Bought him an ICU admission and a box (pacer).

As an attending, I never do them unless someone is profoundly anemic or symptomatic (melenic stool, coffee ground emesis, etc.).

 

[Jeff698]

I can't say that it has ever occurred to me to do a rectal on a syncope patient in whom I am not suspecting a bleed.

Southern, I thought for a minute there your story was headed in a WAY different direction as you described watching your pt vagal from your exam.

"So, Mr. X, what were you doing just before you passed out? You put WHAT WHERE?"

Take care,
Jeff

 

[GeneralVeers]

I can't say that it has ever occurred to me to do a rectal on a syncope patient in whom I am not suspecting a bleed.

Southern, I thought for a minute there your story was headed in a WAY different direction as you described watching your pt vagal from your exam.

"So, Mr. X, what were you doing just before you passed out? You put WHAT WHERE?"

Take care,
Jeff

The only thing I do a rectal on any more is complaint of "rectal bleeding". Anything else, there's no point. It is uncomfortable for the patient and doesn't change management.

You're anemic? Great, either you're getting admitted to the hospital, or you get a referral to GI to follow up with. No finger necessary.

 

[WilcoWorld]

Allow me to summarize/editorialize:

If you are experienced/sophisticated enough to explain why the results of your rectal exam wont change your management then you don't need to do one. If the results may change your management, then you should do one. If I don't know yet whether the results will change management (HR = 92, bp = 102/60, maybe pale, but it's a soft call, and orthostatic, but only mentioned on ROS, and no CBC yet) then I'll do a rectal to avoid having to waste time by going back to the room later.

I'll also do a rectal if I think they're full of ****; Literally or figuratively, either way it accomplishes something.

 

[SoCuteMD]

I'm an intern. The only excuses for me not to do a rectal are: a) the patient doesn't have a rectum or b) I don't have a finger. Since b is definitely false, that leaves option a as my only excuse.

 

[hurricanemd]

When I read the title of this post, my first thought was "is there anything we wouldn't put our finger in someone's @$$ for?" Now, after reading through the posts, it all makes sense.

 

[docB]

I don't routinely do a rectal for syncope.

Two points:

Academic attendings sometimes do a little more rectals and pelvics that those in private practice because for them doing a rectal means telling a resident to do a rectal. Actually doing the rectal is time consuming. Pelvics even more so.

Second, if you are just looking for occult fecal blood and don't need to know about the prostate, rectal tone, tenderness, etc. the admitting doc can just order a stool guiac when the patient provides a nugget. This is becoming more prevelent especially because many hospitals are restricting the use of bedside guiacs due to concerns about lab certification. Believe it or not one hospital I work at is so paranoid about their lab certification that they make us put the poop on the card and bag it and send it to the lab. We get a formal result in 1 -2 hours. Stupid? Yes. But that's the future.

 

[SoCuteMD]

I don't routinely do a rectal for syncope.

Two points:

Academic attendings sometimes do a little more rectals and pelvics that those in private practice because for them doing a rectal means telling a resident to do a rectal. Actually doing the rectal is time consuming. Pelvics even more so.

Second, if you are just looking for occult fecal blood and don't need to know about the prostate, rectal tone, tenderness, etc. the admitting doc can just order a stool guiac when the patient provides a nugget. This is becoming more prevelent especially because many hospitals are restricting the use of bedside guiacs due to concerns about lab certification. Believe it or not one hospital I work at is so paranoid about their lab certification that they make us put the poop on the card and bag it and send it to the lab. We get a formal result in 1 -2 hours. Stupid? Yes. But that's the future.

We used two cards at my med school's hospital, one that we developed immediately and one that was sent to the lab.

 

[Stitch]

I don't routinely do a rectal for syncope.
Second, if you are just looking for occult fecal blood and don't need to know about the prostate, rectal tone, tenderness, etc. the admitting doc can just order a stool guiac when the patient provides a nugget. This is becoming more prevelent especially because many hospitals are restricting the use of bedside guiacs due to concerns about lab certification. Believe it or not one hospital I work at is so paranoid about their lab certification that they make us put the poop on the card and bag it and send it to the lab. We get a formal result in 1 -2 hours. Stupid? Yes. But that's the future.

Our hospital also does this, though the turn around is closer to 45 minutes. Still insane though. I actually managed to steal some developer and will run my own then send a card down.

 

[bulgethetwine]

I'm an intern. The only excuses for me not to do a rectal are: a) the patient doesn't have a rectum or b) I don't have a finger. Since b is definitely false, that leaves option a as my only excuse.

An oldie, but a goodie

I can remember in residency certain attendings asking me, in a patient who presented with (and evidence in bed of) rectal bleeding, what the rectal showed. Their justification, I think, was that the guaiac result wasn't as important as the act of inspecting visually to see if there is a source like a hemorrhoid. I suppose someone could argue next that a rectal might reveal an internal hemorrhoid.

Honestly, I just do 'em, even now as an attending, for most anemic patients. I carry a card and developer in my pocket, so it doesn't really cost me much time. They're probably coated in microparticles of sick people's ****. But I don't like to think about that.

 

[TysonCook]

I do a rectal IF they are anemic, or if I want to see the stool (e.g. GI bleeder).

 

[GeneralVeers]

I do a rectal IF they are anemic, or if I want to see the stool (e.g. GI bleeder).

Does it change your management?

Even if it's negative (there may be insufficient stool), I'm going to send an anemia of unknown origin to a GI physician for endoscopy.

 

[TysonCook]

yes, only if it is gross positive (not hem pos). It just gets my attention up a little when I pull out and a bunch of blood comes vs melena vs Happy-brown poo Alas, at the end of the day many of our consultants want it as well

 

[GeneralVeers]

yes, only if it is gross positive (not hem pos). It just gets my attention up a little when I pull out and a bunch of blood comes vs melena vs Happy-brown poo Alas, at the end of the day many of our consultants want it as well

Other than getting your attention it doesn't sound like it significantly changes your management.

 

[Speed Racer]

I don't routinely do a rectal for syncope.

Two points:

Academic attendings sometimes do a little more rectals and pelvics that those in private practice because for them doing a rectal means telling a resident to do a rectal. Actually doing the rectal is time consuming. Pelvics even more so.

I agree and I am calling shennanigan's on all academic attendings. I can count on one hand the number of times I have seen one do a pelvic. The thing that drives me nuts is calling a GYN consult after I have done a pelvic so that they can come down and repeat it. If I was the patient I would tell them once is enough and its all you get for $5.

 

[Apollyon]

Happy-brown poo

Brown/non-melanotic stool can have a hematocrit of 70%.