Why Kan’t Doc Zoe Write?

About 5 minutes later, Johbert, my clerk, came up to me because of a referral from Internal Medicine. Mr. A is an 83y.o. gentleman who came in because of abdominal pain he described initially as burning, then colicky. It has been bothering him for 5 days. The pain was continuous, with bouts of severe pain. There were no other problems such as difficulty in urination or changes in bowel habits, or changes in shit character. That kinda rules out obstruction. He had fever early this morning, and his abdomen was now as rigid as a board. The plain abdominal x-rays did not say much, but it didn’t matter. What he needed was a chest x-ray. It’s because we were considering a perforated peptic ulcer. In such cases, air will come out of the stomach and would find its way under diaphragm above the liver.

However, chest x-ray was negative.

Still, we had every indication that this was surgical because of the history and abdominal findings. The family wanted to monitor. We couldn’t go against their wishes, as long as this was informed consent. They have agreed on admission, so Medicine admitted him in the ICU, and will refer to us.

That afternoon, we were still advising surgery. But Medicine was considering a ruptured abdominal aortic aneurysm (AAA). We can’t totally rule it out, but to us, it’s just a differential. We still think it was infection coming from a ruptured hollow viscus (like the intestine) or a ruptured appendix that’s doing this to him. If it were ruptured aortic aneurysm, his BP would be low and his heart rate would shoot up, not like his condition where his BP was low but his heart rate was mega-normal. The patient’s wife was so stubborn that she didn’t want surgery, especially since she heard of this new differential. Medicine suggested having an Ultrasound (UTZ) to check the abdominal aorta. We were fine with that. The earlier you get over this differential, the earlier you can realize that he has to undergo surgery stat.

But still, we maintained that we still felt that this was more of a picture of an ongoing infection brought about by a ruptured hollow viscus. Once its contents have spilled, an infection will ensue.

Guess what they found? An intact aorta.

Since my seniors have left me in charge, I told the family it wasn’t a ruptured AAA. And it’s still surgical. They wanted to decide as a family. I reminded them again that they’re working against time, and they understood. The nurses, intern or clerk will page me once they have a decision.

That was between 6-7pm.

I went about my usual chores. By 1030pm, I was done for the night! That’s early! I’m usually done around 11pm. Now all I have to do is have dinner and check if the family decides to have that surgery. Honestly, I was hoping that they would make that decision in the morning only so I could rest at night and have surgery in the morning when I wake up. That, or they should make a decision now before things get worse.

On the way back to the Surgery Office, I bumped into Dr. H. “’E’ Thoracotomy for a stab wound at the E.R. Standby!”

Grumble… (Ok, that wasn’t my tummy).

30 minutes later, mi tummy was full and ready to roll.

However, I got a message from my clerk in the ICU: Mr. A’s family decided to have the surgery NOW.

WHAT?!!!!

After some phone calls, it was scheduled at 1:30am, after this thoracotomy.

So how did Mr. A’s suffering conclude? With a diagnosis of a ruptured appendicitis.

SCORE!

This post is tagged elderly, Medical Tales, ruptured appendicitis, ruptured viscus