Indexing Title: JMDEGUZMAN’s Medical Anecdotal Report [04-4]

MAR Title: Patient with Generalized Peritonitis

Date of Medical Observation: June  26, 2004

Narration:

            A twenty-six year old female was brought in at the emergency room last June 26, 2004. She was been complaining of abdominal pain for the past four days. On physical examination the abdomen was distended, hypoactive bowel sounds, soft, with tenderness on the right lower quadrant. Our primary diagnosis was an acute appendicitis.

With a past history of giving birth a month ago, we referred the patient to the Department of Obstetrics and Gynecology (OBGYNE) thinking of an Obstetrics or Gynecologic problem as our secondary diagnosis. However, patient was cleared. She was then observed, and with persistent and progressive right lower quadrant pain, she was eventually operated with an initial impression of Acute Appendicitis.

Upon opening through a right lower quadrant transverse incision, purulent discharge was noted intraperitoneally on all quadrants. The appendix was grossly normal. The right fallopian tube and fimbriae was inflamed while the opening of the left fallopian tube was closed with absent fimbriae. Uterus was contracted to normal size.

Again, she was referred intra-operatively to the OBGYNE, thinking that the right fallopian tube was diseased. However, they were firm and final that it was normal.

Left alone with blank as to where the source of infection was, I weighed my options, to do or not to do formal exploration. Not doing a formal exploration means sticking with my impression that it was a pelvic inflammatory disease contradicting the findings of an “expert”.

Doing a formal exploration would entail creating another incision (midline) in order for me to have a clear exposure of all the quadrants of the abdomen; it has also the advantage of easier peritoneal lavage for the difficult areas in the abdomen.

After checking the condition of the patient with my anesthesiologist, I proceeded with the formal exploration. My findings; except for the purulent non-foul smelling discharge on all quadrants and the equivocal findings on the adnexae, all the intraperitoneal organs were grossly normal.

Insights (Discovery, Stimulus, Reinforcements)

Clearly this patient had a very unusual health problem. I humbly accept my limitations ergo had to seek the help of my colleagues in the process. However, being the attending physician the burden still falls on my shoulders and final decisions is still on me. Armed with a patient management process, it helped me a lot, not only in the decision-making but also in establishing rapport to the relatives, formulating my diagnosis and treatment plans.

Have I done an unnecessary operation? Let me leave you with a phrase to ponder; “it’s the thing that you haven’t done dear, that gives you heartache at the end of the day.”

Prayer:

“Lord, grant me the
serenity, to accept the things that I can not change;

courage, to change the things that I can;

and the wisdom to, know the difference.

                                                        St. Francis de Assisi