Specificities of the Initial Physical Exam in Refugee Patients

Overview

Because the medical history can be limited by language or educational barriers, a complete physical examination is especially important in refugee patients.

On the first visit, perform: head and neck, cardiac, respiratory, abdominal, and skin exams. Routine genital, rectal, or neurological exams are not performed without clinical indication.

Dental Examination

Always perform a brief oral exam to look for obvious dental caries and significant oral disease. Refer patients with findings to a dentist. Counsel on dental hygiene if needed.

Heart Murmurs

Asymptomatic heart murmurs are commonly discovered in refugee patients. Always investigate appropriately. The prevalence of rheumatic heart disease is significantly higher in low- and middle-income countries. A newly discovered murmur warrants echocardiography referral.

History of Physical or Sexual Abuse

Be aware that refugee patients may have a history of physical or sexual abuse, torture, or conflict-related violence.

*     Always obtain consent before examination

*     Perform genital exams gently and ideally not at the first visit

*     Male practitioners examining female patients should offer a chaperone

*     Document physical findings carefully. For refugee claimants, physical exam findings can support their claim.

Hepatosplenomegaly

Always palpate the liver and spleen. Multiple tropical illnesses including malaria, schistosomiasis, and visceral leishmaniasis can cause hepatosplenomegaly.

Skin Examination

Offer a general skin examination to look for:

*     Skin infections such as scabies. Look for burrows between fingers, on wrists, axillae, and groin.

*     Signs of violence or torture including burns, bullet wounds, old fractures, surgical scars, and rope marks

*     Signs of physical abuse in children: multiple bruises in a pre-mobile child, bruising to the ear/neck/torso/buttocks, sharply demarcated burn marks, oral injuries

Always obtain consent before performing the skin exam. Document findings thoroughly in the chart.