Note: This is a story for medical fetishists (dr/patient role play) like me. If you read it then please leave a comment. There is an element of voyeurism and incest but it is very mild. If u don't have medical fetish, then you might not enjoy it.

It was a warm sunny day and I had just come to re-opened my clinic at about 5 pm in the evening. The helper Radha-bai had already opened the main door and some patients were waiting when I entered the clinic. To my surprise there were many more patients today than usual. A construction worker had been injured and bleeding in his left thumb. There were 3 more people in the waiting room. A mother with her 12 year old son, a young woman of about 33 years and an older man in his late fifties.

I opened my consulting room and called in the worker who was injured. He needed the treatment first. I asked him his name. His name was Kashappa. He had been working on a nearby construction site. He hit his left hand with the hammer while driving a nail. The thumb was crushed, but thumb nail was not broken. I thought that surgery was not required, wound dressing with antiseptic would do. I applied anti-septic and dressed his wound. I then prepared a 5ml injection of Tetanus and injected him in his right arm. The man thanked me and asked for fees. I said, he can give me whatever he can afford to, but take care of his thumb till it heals completely. He thanked me profusely and left.

I called the next patient. The lady entered with the boy. She showed me a prescription which I had written for her mother. She said she had come to say that her mother was now alright and if she needed to continue taking the medication. I read the prescription & reduced the dosage, but asked her to continue taking it for another 5 days before stopping if everything was good. She then left with the new prescription after paying my fees.

By the time I had finished with this patient, our helper Radha-bai came in with some supplies that she was supposed to bring. There was some grumble going on outside as Radha-bai entered. Mostly the patients were new to clinic & did not know that Radha-bai was helper.

The door opened from behind. It was opened by the man who was sitting outside. He sai:. 'Sir, we have been waiting from 4 pm, it was our turn, but... ' .

I told him. Yes I know, please come in. Radha-bai is our helper. I guess by the time he entered and saw Radha-bai arranging the supplies in the cupboard he must have realized it. He balked and stopped. I told him. 'Please come in Sir.' He turned back, seemed to say something to the other person outside and then turned back towards me and continued. 'I am sorry, Sir. I thought she was a patient also.' I called him ' Please take a seat. Tell me how can I help you’.. By that time the 33 year old girl had walked in to the room'. The man continued. ‘She is my daughter Neeta, We are here for her today'. I said hello, to which she respectfully said ' hello Sir' and sat down on the chair besides her father.

Neeta was a young woman of 33 years. She had smooth dark brown skin & was of average height - about 4.5 feet. She was not over-weight but not skinny and her curves showed well. She appeared to have medium sized breasts - about say bra size of 32B and almost flat stomach. She had tied her hair in a pony and they were of shoulder length and straight. She was wearing a blue colored nylon sari( an Indian women wear) with a matching blouse.

I continued ' Neeta, so what's bothering you'.

Neeta: Sir, I have been having numb pain in my abdomen from a long time. It’s been like more than 3 years now that this pain exists. It is mild, numb but always there.

Her father interrupted

Sir, She lives in Mysore ( a nearby city) with her husband and works as a primary school teacher there. She has shown it to many doctors there. We also showed it to doctors here but there is no relief. Some say it is muscular pain, other say it is due to acidity but nobody solves this problem. We have done multiple ultrasound scans but nothing has been found. My friends referred me to you saying that you practice clinical medicine and you can help us. So we came in to show this problem to you. We hope we will know what's wrong with her.

Then I continued:

Neeta, So this pain has been for so long. Where exactly is this pain?

Neeta: Here sir ( She pointed with her right hand, to the region around liver and lower right side of chest). I cannot say that it is at some point but I feel it all around this region. She was showing the complete region extending from mid chest level to the level of umbilicus (navel) .

Me: I see. So you have discussed this problem with many doctors.. Do you have their prescriptions or test reports.

Neeta: Yes Sir. (She reaches for her purse and pulls out a file & hands it over to me)

I open the file, and take a look. It has 3 ultrasound reports - last taken a month ago. There is a liver function test report about the same time. There is general blood test (RBC, WBC count) .. I look through them..

As I look through.. Neeta continues..

Sir, everything seems to be normal according to reports. One lady doctor told me that it must be due to muscular strain and recommended an ointment. That did not help at all. I tried to tell her that I feel like a balloon or something inside but she did not listen. This was before I came to Bangalore & dad decided to take me to the gastroenterologist. We met Dr Dube a few days back. He asked for a new USG and also did an endoscopy. But nothing was found. He said It might be due to anxiety and prescribed some psychological drug, which i did not want to take.

Me: I see. These reports look normal, Neeta. Going by these reports you seem to be in pink of your health. By the way do u have the endoscopy report.

Neeta: Sorry. I thought it was in the file.. (She searched for her purse & pulled out another envelop & handed it to me)

I looked at it - and said ' Ah. This is normal as well'. But you feel the pain. I will need to see what’s wrong with you.

Neeta just smiled and her father looked at her and nodded.

Neeta, since you have come to my clinic for first time & your reports all seem to be normal, I want you to tell me everything about your health. So I will ask you a few questions about your health but you have to tell me detail - all problems small or big that you have. Don’t hesitate and think that it is not related to this complaint. I want to assess your complete health.

Her father intercepted. Thank you Dr. . We were in search of someone who would be sympathetic to our concern. We are really grateful.

I continued, Neeta, by the way did u have any Chest X-Ray done?

Neeta: No Sir, Nobody asked for it.

Me: I see. Any ECG or lung function test?

Neeta: No Sir. But I do feel suffocation in breathing, which I have been telling the doctors.

Me: (I look at her father) I think we should take an ECG on her & also do a chest X-Ray. All investigations about her abdomen look fine and its only been a month.

Her Dad: I see what you are seeing, but....

Me: No I mean we will not rule out abdominal problems. I will clinically examine her for everything...

Her Dad: Yes Dr. please thoroughly examine her and tell us what could be the problem.

I look at Neeta, and continue:

Neeta, Can you come this side of the table and sit on this stool (I have a stainless steel rotating stool besides me to my left side.

Neeta walks accords the table and sits on the stool. She smiles at me. Her dad is now on the opposite side of the table and facing her. His face bears a concerned look.

I look at Radha-bai, and ask her to get a new case paper. She brings in the case paper. I move away my stainless steel stethoscope away from writing area and start filling in new case paper.

Neeta, Whats your full name ?

Neeta: Mrs Neeta Kumar.

Age?

Neeta: 31 Sir.

Any known problems? : BP/ Diabetes

Neeta: No Sir

I look at her Dad. Anything in the family - heart problems or cancers?

Her Dad: No Sir. We have been a healthy family- nothing in particular.

Me: I see. That’s good.

Neeta, did you have any surgeries or operations so far?

Neeta: No Doctor.

Me: Good. (I look at her dad again) . Any child hood Or chronic illnesses?

Neeta: No Dr .

Her father: She did have a bout of rheumatic fever when she was 6 years old but nothing other than that. She quickly responded to treatment.

Me: I see. Any history of asthma or allergies.

Neeta: No Dr. But I do get occasional bouts of coughing and it persists for long time.

Me: ok. Any other medical problems / complaints that you have?

Neeta: no Dr. Nothing serious . This is the only thing that bothers me.

Her father (interrupts): Dr. She does not digest food properly. She often has trouble with gas. And also she feels weak always -lacking energy.. Neeta, tell all things to the Dr.

Neeta: I have some pain while passing motion Dr (little embraassed to mention this). But it is not too much.

Me: Neeta, please speak up openly. There is nothing to feel embrassed about. I need to know all that is bothering you. So do u have hard stools often?

Neeta: Yes Dr. I find it difficult to pass and I also have pain when I do.

Me: Did u see any blood in your stools.

Neeta: Yes Dr. Often I do. I am taking herbal medicines for it & i think it is helping me.

Me: Alright Neeta. Some time these traditional medicines are good. But have you been examined for it by any Dr?

Neeta: No Dr.

Me: Alright then, Tell me something about your reproductive health. How are your periods & when did u have your last one?

Neeta: They are normal Dr. I had my last period about a week ago.

Her Dad: Dr. She has painful periods with more bleeding. Neeta, why don’t u clearly tell everything to the Dr. You told your mom last week, that your periods are becoming more painful and irregular. Isn’t it?

Neeta: Umm... Dad, I thought I will discuss it with Sudha madam. (looks at me and smiles uncomfortably)

Me: Alright. Any children - Neeta?

Her Dad: No Dr. We are waiting from 2 years for a grandchild.

Neeta: I had a pre-mature termination last year Dr.

Me: I see.

Me: Neeta, Tell me about your food habits. Are u a vegetarian? Regular eater?

Neeta: Yes Dr. We are vegetarians. I take care of my food, more so after this trouble began. I eat breakfast & lunch and take light food in the evening. I go to bed after taking a glass of warm milk.

Me: good. That’s nice. Do you exercise, Neeta?

Neeta: No Dr.

Me: Do you feel any exertion when you climb stairs etc

Neeta: Yes Dr. I feel exhausted and begin panting if I climb even a few stairs or walk fast for 10 minutes..

Me: Any chest pain?

Neeta: Cannot really say. But I do feel pain on right side of my chest often.

Me: Ok then, I think I have taken enough of your medical history. Your chief complaint is pain in upper right abdomen extending into lower chest. You also have shortness of breath, and exhaustion. In addition, you feel you are not digesting your food properly, have hard stools, pain while passing motion, painful periods and feel very low on energy most of the time.

Her father (Interrupts): Yes Dr. You have summarized all that we wanted to say. Thank god, we found you

Me: Sir, that’s ok. Let’s see what ails this young lady now.

I move my chair towards Neeta. And bring in my sphygmomanometer (bp apparatus) towards the edge of the table. I wear my stethoscope around my neck.

I touch her forehead with back of my palm, to see her temperature. Then do the same on her cheek and neck. I pull her lower eyelids down with both my hands & say.. Neeta, See up... I look at the sclera to see if she is anemic. I then pull the upper eyelids and say. Neeta, look down. I palpate her sinuses - the eyebrows and press down her cheek bone.

Me: Do you feel any pain here?

Neeta: No Dr

Then I take my torch & stainless steel tongue depressor.

Neeta, Open your mouth for me please

She opens her mouth..

Say Ahhhh.

Says Ahhhh... I light the torch and shine it to inspect her throat.

I then put the tongue depressor in her mouth and press her tongue down.

I take out the tongue depressor and put it aside. Take the wooden one and check for inners of her oral cavity pushing the cheek muscles to a side.

Neeta: Can you show me your tongue..

She put out her tongue.. It is covered with white film and is little pale in color.

Neeta: Can you just hold ur tongue out but straight for 2 minutes.

She does. I observe there is no tremor.

I then look for my otoscope. I go closer to her & say. Neeta, Let me see in your ears.

I hold her right pinna. She turns slightly towards the left. I insert the specula and see the ear lining.

Neeta, Now the left ear. She turn other way. I repeat it. Your ears are clean. I smile. She responds back.

I replace the speculum of otoscope. I hold her head from behind & insert the speculum in her left nostril and examine it. Then I repeat it again with her right nostril.

I then move on to examine her lymph nodes in the neck & thyroid. I palpate the below her jaws and around the neck simultaneously on both side using both my hands. I hold my hand on her thyroid gland and ask her to swallow . She does . Thyroid looks normal. I take my stethoscope from my neck and wear the year plugs. I auscultate her thyroid at three points on her neck, twice on left side, once on right. I take away my stethoscope and wear it again around my neck .

I update her file, with conclusions of exam conducted thus far. I move back and hold both her radial pulses and palpate them bilaterally. I press the finger nails to see the blood flow.

Neeta, Do you have any swelling on your legs and thighs?

Neeta, No Dr.

Neeta . please pull up your sari from your legs a bit .

She does as told, & pulls up her sari up to her knees and removes her foot ware.

I press to see if there is any edema (swelling). There is some slight edema and it can be seen. I record this observation.

I turn to her dad & say. She has edema on her legs and appears to be slight anemic.

Neeta, Let's see your Blood pressure. She extends her right arm. I secure the BP cuff on her arm, take my stethoscope from the neck. I palpate her radial pulse as I inflate the cuff. I take an approximate reading. I put on my stethoscope in my ears and listen to her brachial pulse. I measure her Blood pressure to be 124/78.

Good, Neeta: Your BP is 124/78 which is normal. Let’s see it in your other arm.

She extended her left arm. I secured the cuff and pumped it up. I measured the BP in this arm. It was 115/76. BP her is 115/76 Neeta, which is not of much concern.

I put on my stethoscope again. I moved my chair near her, held her shoulder with my right hand on her right side. I started to listen to her back. She was facing her dad..

Neeta, Take some deep breathe through your mouth.

I put the chest piece with my left hand, on her left side of back, then on the right side, little below. I auscultated till I reach the base of her lungs. All the while she was seeing her father and breathing through her mouth. He was watching his daughter being examined.

Then I reached her right hand & asked her to put it up on her head. I listened to the sides. First base of chest then up in middle and in right armpit. Then I moved her hand back to normal position. I asked her to turn my side by pushing her lightly on her shoulder. She turned. I took the chest piece in my right hand now and with left hand raised her left arm. I began auscultating her left side and again three positions, base, middle and then in left armpit.

I dropped my stethoscope. I turned her back facing her father. I moved my chair behind her. I put my palms on her ribs from behind to gauge for expansion symmetry. Please take a deep breath.. She did and it appeared symmetric. I then proceeded to percuss her back in regions blouse did not cover it. Then I said to her

Neeta, I want you to say a as I will put my stethoscope on your back again. ok? She said yes Dr. I put in my ear pieces and started listening to her back again. One , Two ... so on.. On both sides till the base of chest again. I repeated the whole process by having her say 'toy-boat' to gauge for tactile fremitus. Then I asked her to cough.. Again listened to her back bi-laterally. I then moved my chair back and recorded my observation.

Neeta, Are you alright?

Neeta: Yes Dr.

Her father: Any problem Sir?

Me: Well, let me complete examining her before I can discuss the result, but I do see some congestion in her right lower lobe of lung. I need to confirm it by listening anteriorly.

Ok Neeta. So we will proceed. Lets do the same thing anterior now. Can you drop your sari from your shoulder. So that I can see your breathing..

Neeta was taken little aback. She was not expecting this. There was nothing wrong for a doctor to ask her to do so, but she had not been asked by any other. Little hesitant, she looked at her father. He was still in his chair facing her. Before she could speak anything, he said to her

Neeta, please do as the Dr says. We have to know what is making you ill. Neeta was reluctant but she also knew that it was for her own benefit. But many thought crept her mind. May be she was comfortable with the Dr alone. But her father was not keen on leaving the room either. I am not sure how open they were with such matters between them. However, she dropped her pallu(part of sari on her shoulder) down. . She was not naked but in blouse. Her abdomen was not covered & because reset of sari was tied below navel, she was kind of exposed up to the waist even through not completely exposed. She kind of looked away from her father towards the wall. He was still keen about seeing her examination.

I put back the ear plugs of my stethoscope and moved closer to her. I started with her collar bone on the left side. Neeta, take deep breaths from mouth for me please. I listened longer for a minute or so. then on right side. Then moved down a little. It was her bare skin above the blouse , so the listening was not impeded by the cloth rub. I listened on the left side, then on right side a little below towards the crease of the blouse. Then right side again but on the blouse. I was now listening over her breasts. Then left again. Then slightly below. Horizontally I listened to 4 points at every vertical elevation. I listed just above the nipples, Then at the nipple level. I pressed her breast with my stethoscope. She was breathing from her mouth. Her breasts rising and falling with her breaths. My stethoscope pressing hard against the soft mounds. She was a bit embarrassed. Never in her life was she examined in this manner. Then I moved towards the base of the breasts and listened to 6 points in horizontal row. I then repeated the tactile fremitus with toy-boy and 'A'->'E' sounds and listened to almost 20 points on her chest again.

Ok Neeta. Now I am going to examine your heart. You can breathe normally. I then put back my stethoscope and started to listen to her heart. I put it on Aortic area, then pulmonic, tricuspid, mitral & apical in that order. I realized that this young woman needs to be evaluated more carefully. She had congestion in right lower lobe. Her heart can't be listened to with bra and blouse. I told her father.

Sir. I think she needs a more thorough investigation. Neeta, I will need to take an ECG immediately.

Neeta: Ok Sir.

Her father: Sir , Please conduct all necessary tests and examine her thoroughly. We are lucky that we came to a doctor like you.

Neeta, you can lie on the examination couch, so that I can take an ECG. Please take off any metal ornaments etc including hair pins you might have and leave it with your dad. Also take off your blouse and bra.

Neeta put back her pallu again & was taking off her bangles, chains and hair pins. She then went to the examination table and climbed it. I got up from my chair and stated the ECG machine and sorted the electrodes. Neeta was about to lie down. I interrupted her and said:

Neeta, you will also need to take off your blouse and bra. There was no curtain covering the exam table. She was embarrassed about doing this. But she also had no choice. Her father was still sitting on the chair but was looking now towards us. He told me ..

Sir. Do u think she could have a heart problem. We were all the while thinking it was an abdominal issue.

Me: See I cannot comment about these things before completely examining her. She does have some chest congestion but how serious remains to be seen. I need to still examine her for most of her complaints.

By this time I was ready with electrodes. Neeta, r u ready?

Neeta: Yes Dr.

Me: Ok.

She has indeed removed her blouse and bra but still had the sari cover her as she lay on the table.

I moved close to her and put the ground clips on her wrists and legs. Then I moved to pull her sari off from her chest. and put it below her waist. She understood that it was necessary to expose her to apply the electrodes. But now she was thoroughly embarrassed. She had never had an checkup like this or at least did not expect this one to be so. Her father remained in the room & since the patient was not asking him to leave, I did not insist.

Now that she was completely exposed up to her waist, I could see her perfectly formed right brown breasts. She had rather large perky brown nipples. They were getting erect and I could sense her embarrassment in going through this entire ordeal. I put the ECG paste and attached the electrodes on her. I switch on the machine and ECG was recorded. Then I wrote her name and date on the data, cursorily looked at it and put it in the file of her case paper.

I had found minor valve issue in her heart. This could be because she had rheumatic fever as a child. But that was not related to her current complaints directly. I went back to her and removed the electrodes . I removed the clips and gave her a paper towel to wipe herself. I removed clips from her ankles and wiped them myself.

As she was done wiping. I took my stethoscope from my table again. I wore it. I took the BP apparatus again to the exam table. She realized that exam was continuing and not over. I wrapped the cuff around her right arm and started inflating it to measure the lying BP. I recorded normal values.

I had a grim look on my face. I could see that she was worried too. She said:

Dr, Anything with my heart.

Neeta, I am going to listen to your chest again. Please take deep breaths for me.

Neeta: Ok Dr.

I positioned both her hands to her sides and began auscultating again. I put the stethoscope in the same positions as before but now on bare chest. I listened from side to side. First above breasts, then over them, in armpits moving her arms away, then again under the breasts.

Finally I came to listening again to heart. I listened to all 5 points with diaphragm. Then repeated with bell. I listed to carotid arteries in her neck. .

Neeta, Can you turn to your left side for me please?

Yes Dr. She turned. I first palpated her apical pulse and then listed to it by lifting her left breast using upper side of my hand.

Ok. Neeta , Can you just sit up for me.

I helped her to sit up. Now please lean forward.

By that time, her father had actually come over to see the exam and was watching it from behind me. She was already scared probably because of expression on my face and was not too bothered at the moment. However, she was being excited and her nipples were becoming even more erect.

I put back my stethoscope on her chest and listened again with bell and diaphragm. The atmosphere was quite serious.

Neeta, You can now lie back again. Let’s see your abdomen.

Neeta laid back BP pressure cuff still wrapped around her arm. I pulled her sari down a bit to expose her abdomen completely. It was just above the pubic hair.

I listened to the four quadrants of her abdomen. Neeta, When did u have your food before you came in.

Neeta: about 2:30 pm Dr.

Me: And what was it?

Neeta: I had some curd rice Dr.

I continued to listen for about 5 minutes in each quadrant. The bowel sounds were normal. Then I listed to the arteries with my bell. First aorta, then Renal artery to kidneys (both sides), followed by iliac arteries and then femoral. I lifted her sari and skid my stethoscope beneath it to listen to bruit in femoral arteries. She was again embarrassed since no-one before had listed to her femoral arteries. I listen to them on both sides.

Neeta, Now I am going to percuss your abdomen. You will find me tapping to see if there is any fluid accumulation. Is it ok?

Neeta: Ok Dr.

I started to percuss generally. First over all the quadrants, then over lower abdomen and bladder.

Me: Neeta, Can you turn to my side please.

She did as instructed,

I positioned her left hand over her head & percussed her spleen region. Then moved her back to proper supine position.

I then percussed the liver from pelvic bone to mark the lower border. I continued to percuss from above (right nipple) downwards to find the upper border of liver. I marked and measured her liver. It was slightly larger. It was 8.5 cm (female average being 7 cm). It could be a pathology but then such deviations are also possible in normal run.

I then put back my stethoscope, positioned her right arm over her head and listened carefully to the bruit in the liver. But much of gaseous sounds were heard. That meant there was something which led to accumulation of gases in that region.

I then spoke to her.

Neeta, Your Liver appears little larger than normal. It is about 8.5 cm while the average is about 7cm. It need not mean any problems necessarily but there could be deposits. I would like to examine your breasts just to be sure that there is nothing to worry about. Is that ok with you?

Neeta, Just nodded in approval.

I helped her to sit up again. I unwrapped the BP cuff from her hand and asked her to turn towards me. Her father for some reason continued to watch the exam. She did not ask him to go out nor did he do so himself.

Me: Neeta, Please raise your arms above your head,

She did what was told.

Me: Now on your hips.

I watched symmetry of her breasts - There was no issue there.

Me: Ok press your hands on your hips..

I watched again. no issues.

Me: Ok then bend forward for me

I watched as her breasts slightly fell forward. Nipples were erect by now but there was no cause for suspicion.

I then proceeded to palpate each breast circularly in all four quadrants. Finally I palpated her armpits and lymph nodes above collar bones. I pressed the entire breast with flat palm of my hand. Then I examined and palpated her nipples. I also squeezed the region around breasts and milked the nipples to watch for discharge. She did have little milky white discharge from both breasts, which i collected on the slide for laboratory exam. This could be due to stress or medications most likely.

Me: Neeta, you seem to have discharge from your breasts. Did you observe it before?

Neeta: Yes Dr. But I forgot to mention it .

Me: How long since it has been like this

Neeta: Don’t remember Dr. But I think I have been seeing it since 2 months.

Me: Did you not consult any doctor for this then?

Neeta: Smiled and quite

Me: You should take your breast health seriously. This does not appear serious to me but what if it could be. Are you taking any medication or contraceptives?

Neeta: No Dr .. I occasionally take a cough syrup when I have bouts of it.

Me: So, when was this last episode.

Neeta: Just till a couple of days back Dr.

Me: Ok, If you are not pregnant, then that cough syrup could be the cause of this, unless you are really stressed about something.

Neeta: No Dr. I am not too stressed but I am worried.

Me: Ok. Lets proceed with the rest of your abdominal exam. Please lie back

Neeta laid back on the table. I folded her legs a little and put a pillow below.

Me: I will now press your tummy & if you feel pain please tell me. Ok?

Neeta: Ok Dr.

I started with light palpation all around her tummy. She did not show any particular expression.

Then I started to deeper palpation. First on lower left side, then on right side. As I pressed region around her ovaries, she shirked as if in pain. I immediately with drew my hand. Once she recovered, I continued more cautiously. She definitely had pain in her right lower abdomen but it was only felt on deeper palpation. I continued to palpate the rest of her abdomen. Then I asked her to turn to my side. I pressed deeply from the umbilicus (navel) towards the right lower rib. I could not palpate spleen which is normal.

Then I laid her supine again and palpated for the liver. As I pressed the liver deeply, at some point she was feeling the pain. She even burped due to flux of gas pushed out. There was something that was accumulating gas in that region and causing the pain. It could be because of slightly enlarged liver as well. I slightly percussed with clinched fist on her lower rib and she felt the same pain. It was much easier to elicit this way. I then proceed to palpate her kidneys which were normal.

I pressed the right iliac region (right lower portion) and released in quickly to ascertain what could be problem with it. She did not markedly change her expression and there was no problem with it.

Ok Neeta: I think I have examined your tummy. I turned to her dad and said, that she has pain in her lower right region. She also has complained about pain with stools. I turned to her and said, Neeta, I would like to do some internal exams if you are ok with it. Otherwise we can wrap it up here and I can send you to other doctors for further evaluation.

Her father interrupted: No Sir. Please complete the exam yourself. I am happy that we have found such a through doctor like you. I would not like to take her to another Dr.

I told him what Neeta thinks is important and it is her choice to proceed or stop. I turned to Neeta. She asked me.

Neeta: Dr. Is this going to be painful? I said, may be. If you have fissure in your anus then you might feel some pain.

She continued. ...

Dr, I don’t want to go to another Dr for this tests. I think we can do them in one go if possible.

Me: Yes Neeta. That will be fine. I will just sterilize the speculum and proctoscope. You can put on your bra and blouse if you like. I started the sterilizer.

Neeta was visibly relieved. She quickly got up and started wearing her bra and blouse. She also adjusted her sari to be fully clothed again by the time the equipment was ready for use.

I laid the equipment in the tray. She was visibly frightened to see all the metal there. I said

Neeta: Now can you remove your underwear and lie down at the edge of the table. I moved to pull up the hidden stirrups with hanging leg rests made of leather. Half of the table could be folded down to make way.

Neeta removed her underwear and lay as requested. I adjusted the loops to accommodate her legs. and then helped her place her ankles in the loops - first right and then left.

Me: Neeta - r u comfortable.

Neeta: Yes Dr.

Me: Neeta, You might feel light pressure in your inside. Just take deep breaths and relax. This will not be painful.

I wore my latex gloves and lubed by finger. I pushed back her sari to her abdomen so that her pelvic region was completely visible. I inspected the vulva and clitoris. I touched her thigh to help her get accustomed to my touch. I then opened the vaginal opening and examined the outer lips with my two fingers and thumb. I then proceeded to insert by index finger and palpate the inner regions of vagina and the cervix. With my other hand, I pressed her abdomen from above and performed bi-manual exam. I then inserted the Cusco's speculum to inspect the mouth of cervix and took a smear sample for laboratory investigation. From my feeling, I thought she might have fibrosis but that will have to be confirmed by a specialist. I wanted to examine her rectum in this position but since she had specific complaints about piles or fissures, I proceeded to put her in Sims position.

I got up from my stool and adjusted the exam table to be of full length. Then I proceeded to remove her ankles from loops and asked her to lie straight and feel comfortable. I adjusted her sari back so that she was properly covered.

I put back the extended stirrups and table was back to normal. I disposed my gloves and looked at her.

Me: Neeta, Are you alright?

Neeta: Yes Dr.

Me: Ok then we will just finish your checkup with a quick check of your bottom. Now turn on your left-side and pull your legs towards your chest.

Neeta turned to her left and curled up to bring her legs to the chest. I again moved her sari upwards to expose her bottom. I wore my gloves. Her bottom was exposed. It was well formed and curvy. I wore my gloves and lubed my finger. I opened her cheeks to see the hole. Her father was curious to see as well and positioned himself as if he was more curious about the problem to be found than anything else.

Me: Neeta, R u ready?

Neeta: Yes Dr.

Me: They just relax and take deep breaths. This will be over in few minutes,

I first lightly touched her perianal skin to see the anal reflex. Then I stretched the cheeks further and closer to get clearer picture of the anal canal. There were no piles or hemorrhoids,. The opening was good. Then I just entered her anus about half centimeter and asked her to cough. She did so that I could estimate that rectal tone was ok. I then proceeded to insert the finger all the way. As I rotated my finger inside her she squirmed in pain. I had found that she had a fissure inside. I touched the region again to confirm that it was fissure. I then gradually pulled out my finger. Some stool came out which I saved for laboratory purpose. The fissure had partly healed and there was no bleeding.

But I wanted to be sure that there is no more problem inside. I wanted to conduct proctoscopy but that would be very painful for her. So I waited till she was back to normal.

Me: Neeta, You don’t have piles or hemorrhoids. What you have is a cut which we call fissure. This is because of your hard stools. But I need to see if there is something further inside. But it will be painful to you if I just introduce the scope. So what I will do is locally anesthetize that area and proceed with proctoscopy. Is that alright?

Neeta: It was very painful Sir.

Me : I know. But this fissure will heal soon. Otherwise we can do a very minor surgery to fix it. But let’s see if there is no problem otherwise.

I proceeded to bring out an 20 mL syringe. I filled it with 2% lidocaine, and then diluted it with equal amount of distilled water. I cleaned the area with antiseptic.

Me: Ok Neeta, I will now inject you now

She did not speak anything. I proceeded to inject at 6 different points surrounding the anus. This local anesthetic works well to numb the region. She felt the pain of needle prick but nothing more

After this I proceeded to insert the proctoscope and examine the internals. They looked normal except that already found fissure. I pulled out the proctoscope and wiped her bottom with tissue.

Me: Ok Neeta, we are done with your examination. You can now turn and relax.

She slowly turned and had her eyes closed for a brief time. I continued.

Me: Ok Neeta, Once you are ready, you can dress up and come over so that we can discuss the findings.

I went back to my table and filled up her case form. Her father was talking to her to see if she was comfortable. They both came to the chairs and settled down,

I reviewed her blood tests again and found that she was anemic and had iron deficiency.

Ok Neeta, I think there are a couple of reasons that we should worry about. One is that your liver appears little enlarged. There is a gas accumulation around that region. It could be non-alcoholic fatty liver in which case it is easy to treat. But we need to be sure. You are also anemic with iron deficiency. I will start you on iron injections and tablets. You will need to take total of 8 injections each one on alternative day. Your fatigue and weakness must be largely because of this. I have taken some samples of your breast discharge, smear and stool specimen. We will send it to laboratory and see what they find. I am not worried about the breast discharge or stool specimen. But smear test is important. I will also recommend you to a gynecologist for a thorough investigation. My feeling is that you might have ovarian cysts on your right side. This can also cause problems with conception if not treated. Of your chest exam, I definitely hear a murmur and there is some valve damage as seen from the ECG. I think we will need to get an opinion from cardiologist for this one. This does not appear to be very serious at the moment. It might have happened due to the rheumatic fever that you had in your child hood but was undetected. If it is not so serious which I believe it is not, then it will be possible to treat it without any surgery. You do have some congestion in your right lower lung. Your chief complaint seems to be a combination of that congestion and enlarged liver. Since the liver function test is normal, I will try to put you on low fat diet and medication for fatty liver. It might give you relief from these symptoms. We will need to take a chest X-ray for the infection in your lungs if it persists. I will now put you on some antibiotic course to clear that infection. We will also need to change the cough syrup that you are now using so that the breast discharge is resolved.

I write out the prescription note. I tell her that in summary she has to see a cardiologist for an independent opinion on her murmur, and a gynecologist for the lower abdominal pain. Let’s see how you respond to the treatment for other- things.

Her father: Sir, We are very thankful to you for resolving our doubts. When should she see you again?

Me: I have written the prescription for 2 weeks. She can come for a review exam after this course is done. Hopefully she will be much better by then. But fatty liver might take at least a couple of months to resolve.

Neeta: Sir, I am worried about cardiologist appointment. Do I have to undergo heart surgery.

Me: My opinion is that the defect is relatively minor and if cardiologist agrees you might not really need surgery. It is treatable with medications these days. If you like , I can write a note to eminent cardiologist Dr Dav. He will try his best to avoid any surgical option.

Neeta: Thank you Sir. But about my gynaec problem,

Me: I will send you to a good gynaec, Prof Douglas from medical school. He is experienced in handling complex cases and will definitely help you. Its better to get these things resolved than to keep them and let them grow.

Neeta seemed to be little nervous but smiled at me.. But she was also excited and even embarrassed. She was wet by the time I had her open for pelvic exam but must have come close to bursting now.

Her father: Dr, What about the iron supplements? Where can we take the injections?

Me: You can take them anywhere. May be any clinic near to your house should be fine. I can give her the first one today.

Her father: Thank you Dr.

Me: Neeta, can you lie down on the exam table. It’s a bit painful injection and I will give it to you in the waist

Neeta got up from the chair and went to the exam table. She lowered her sari and part of her left buttock was visible. She was facing me. I filled the syringe with medication. I rubbed the alcohol on her cheek and injected the needle. I slowly injected the solution inside. She let a cry as the injection sting was felt. I removed the needle and massaged the region.

I came back to my chair. She slowly got up, adjusted her sari and came to the chair. I wrote down the letters and handed them to her. I asked her

Neeta: Are you happy with the examination.

She only blushed. Her father said we are very happy about it.

She placed all reports and. my prescription in her purse. Her Dad paid my fees and thanked me again. She also said , 'Thanks Sir', and they left.

It tool almost an hour and half to completely examine her. She had a entire complicated gamut of symptoms which were often missed out because of hasty diagnosis of other doctors she visited. Clinical exam often leads us to diagnosis which cannot be covered by running a few tests. They have to be run based on clinical finding. Otherwise it is a waste of lot of money.

So this was particularly interesting case that remains in my memory, and it was already 7pm. There were few other patients waiting. I continued to treat them and my day continued!