Post-op Notes (Xanga)

26Oct04

It has been about a week since my sister-in-law was admitted due to severe abdominal pain which turned out to be a ruptured ap.

Looking back on the incident there are two things that I wish I did differently. First and foremost would have been my decision to admit her under the service of a gastroenterologist rather than a surgeon. Second, I should have trusted my findings during my PE and history. Instead, I relied too heavily on my previous experiences with this “patient”.

Preconceptions and misconceptions distorted my ability to correctly assess the patient and hence to arrive to a more appropriate treatment.

My previous experiences with my sister-in-law had something to do with recurrent bouts of delayed gastric emptying. Twice or thrice a year she would complain of belching, distended abdomen, and epigastric pain/discomfort. This is usually after eating something that didn’t “agree” with her stomach. It usually spontaneously resolved itself but sometimes a quick dose of domperidone helps. This time, her complaint is epigastric pain with vomiting PLUS right lower quadrant pain.

Bells rang in my head.

I quick PE pointed to rather tender RLQ and she couldn’t turn to side without eliciting pain.

More bells.

By this time, even a medical student would have been able to tell me that this is A-P. But I hesistated. Why? I’ll tell you later.

I tried the manuevers for A-P. Had difficulty eliciting psoas’ sign but obturator was positive. Rovsing’s was equivocal though. But direct tenderness was strongly positive. And she looked worse as compared to just having a “bellyache”. She was also complaining of urinary urgency but when she got to the bathroom only a trickle came out. I noted that as I assisted her back to bed she had a peculiar shuffle.

That did it! Bells were ringing everywhere.

I decided to have her admitted but getting a gastroenterologist as attending.

That was a mistake.

She got to the ER in severe pain and went through the usual procedure of admission. Then she was sent to her room. All this time, the RLQ pain would come and go accompanied by epigastric pain.

Early in the AM, as the doctors were making their rounds, I once again checked on my pain. She felt better and I proceeded to palpate her RLQ. Light pressure on that area was enough to make her flinch in pain. Ring! Ring! Ring!

Her gastroenterologist visited her a few moments and when she palpated the RLQ there was no more pain. Instead, the LLQ was a bit tender. That clinched it!

I already had a ruptured A-P in my hands.

The gastroenterologist then suggested a surgeon to step in. She was promptly schedule for an appendectomy 4 hours after.

This was supposed to be a simple case of appendicitis but my dillydallying led to a rupture A-P. Fortunately, peritonitis hasn’t set in yet since the pus was concentrated around the area of the rupture.

As a mentioned before, even a medical student would have caught this. Unfortunately, my ability to diagnose properly was hinder by one thing: the patient is a relative.

Though a relative not by blood she was nonetheless a relative. And I was reluctant to put a relative under the knife. It is therefore rather difficult for a physician to treat their kin. It’s either you overdiagnose or under diagnose. In this case, I am grateful things didn’t turn bad on me. Though things ended well enough this particular situation has taught me that I do not have the character or the ability a physician should possess. I erred on the side of caution.

I told my friend from New Jersey about what happened and he said if something like that came in there a CT Scan would have been immediately ordered.

I am wondering when my preconceptions and ties would hinder my ability to the detriment of those around me.

I’ll quit while I’m ahead.

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