OpenHealth Q&A

Is It Possible for a Doctor to Make a Diagnosis Without a Thorough Examination?

**Background Information:** I'm a 21-year-old male, standing at 174 cm and weighing 85 kg (down from 94 kg earlier this year). I'm from Austria, with no history of medication use, either currently or in the past. As a Caucasian individual, I lead a clean lifestyle—never smoking, drinking, or using drugs. My only health concern has been persistent back pain since I was 16 years old. **The Situation:** Recently, I consulted a physician about two key issues: - Continual back pain - The necessity for new orthopedic insoles due to my diagnosed flat feet and fallen arches Prior to the appointment, I shared an X-ray report from 2021, which clearly indicates "severe flatfoot" alongside "lower back pain." However, the entirety of her so-called physical assessment included: - A series of movements: bending forward, reaching upward, standing on tiptoes, and lifting each leg—**all conducted while I was fully dressed and wearing shoes**. - Concerning my feet, which were central to my visit: she suggested I take off my shoes but allowed me to keep my socks on. She only glanced at my feet from a good distance of about 2 meters. There was no hands-on evaluation, no arch examination, or any component resembling a legitimate assessment. **The Odd Part:** In her official report, however, she provided a **comprehensive analysis of my feet**—detailing axis deviation, foot structure, and joint flexibility. It strikes me as highly unlikely she could accurately make such observations from afar, through socks, without any physical examination. Unless, of course, she possesses x-ray vision—if so, that’s quite impressive! Even more perplexing was her assertion that my **finger joints display arthritic changes**, despite her never examining my hands and my not reporting any discomfort in that area (I have no issues with my fingers at all). To my knowledge, they appear perfectly normal. In conclusion, she labeled my issue as merely “lack of fitness.” Although she recommended massages, the experience felt rushed and seemed to prioritize form over genuine care. **Now, I have several questions:** - Is it common practice for a doctor to document findings that were neither discussed nor examined? - Should I consider lodging a formal complaint? - Could this inaccurate report have negative repercussions down the line (e.g., with insurance or medical records)? - Or should I simply dismiss the incident and move on? Any advice would be greatly appreciated, as I’ve never encountered a situation where a physician recorded unverified details in this manner.

Answers (1)

7/21/2025, 9:40:46 AM

OpenHealth AI

It's understandable to feel frustrated and confused after experiencing what seems to be a rushed and incomplete examination. Here's a breakdown of your concerns:

Main Points

1. It's generally not considered standard practice for a doctor to document findings that were not directly observed or communicated during the appointment.
2. If you believe the documentation is inaccurate, it's reasonable to consider addressing your concerns formally.
3. Misreporting could have potential implications for your medical records and any subsequent care or insurance matters.

Explanation

Doctors typically conduct a thorough examination to base their findings on actual observations. For instance, assessing foot structure should ideally involve a closer examination of your feet and even walking tests. If your doctor made notes regarding conditions or observations that were not performed or discussed, this can lead to misunderstandings about your health status.

Next Steps

1. Review the Documentation: First, carefully read through the doctor's report. Identify specific inaccuracies or concerns you'd like to address.

2. Contact the Doctor's Office: Reach out to the office to express your concerns about the accuracy of the findings and seek clarification. This could be through a phone call or written communication, whichever feels more comfortable for you.

3. Consider a Second Opinion: Given your ongoing back pain and the concerns about flat feet, consult another healthcare provider, such as a specialist in orthopedics or a podiatrist. This second opinion can provide you with more confidence in your diagnosis and treatment plan.

4. Consider Formal Feedback: If you're not satisfied with the response, you have the option to lodge a formal complaint with the medical board in your region. This formally documents your experience and can help improve the standards of care.

5. Monitor Your Health Records: Keep an eye on any potential implications regarding your medical records and insurance, especially if any inaccuracies are documented. Ensure your records accurately reflect your health status.

6. Focus on Self-Care: In the meantime, continue managing your back pain with appropriate self-care methods such as postural exercises, stretching, and ensuring you wear suitable footwear that supports your flat feet.

Your dedication to understanding your health is very important, and following these steps can help clarify the situation. Remember, it's always within your rights to seek the care and clarity you deserve. If you need more help or guidance, feel free to ask.