Indexing Title:

JMDEGUZMAN’s Medical Anecdotal Report [05-05]

MAR Title: “Déjà vu!”

Date of Medical Observation: June 2005

Narration:

            Chances do come in succession. Not too long ago a 31-year-old female was brought in with pelvoabdominal mass detected by physical examination but not noted by ultrasound. Unfortunately with the sudden turn of events she died shortly after admission not being operated.

            During my previous tour of duty, a 38-year-old nulligravid female was referred to our service. She had signs and symptoms of progressive intestinal obstruction. She had changes in bowel movement for the past 3 weeks, passing only small amount of fecal material twice in that span and the last bout was 2 days ago progressing to unable to pass flatus to date. Even with a distended abdomen, we palpated a huge pelvoabdominal solid mass. A collapsed rectal vault was noted on digital rectal examination. For courtesy, I referred her to the Department of Obstetrics and Gynecology for my finding of a mass in the pelvic region in a 38-year-old female. They did an abdominal ultrasound but failed to demonstrate the mass, hence the patient was returned to my care unscathed.

            With the unrelenting intestinal obstruction, I decided to operate on the patient after a good fluid resuscitation. My pre-operative diagnosis as to the cause was in question. My first consideration was Gynecologic pathology although it would seldom cause intestinal obstruction even malignant. There was no absolute in medicine. Second an inherent intestinal pathology separate from the gynecologic pathology. With these in mind I proceeded with the primary goal of relieving the obstruction. Intraoperatively we noted that the uterus was enlarged to 20 x 15 x 15 cm with multiple myoma and a sigmoid mass causing complete obstruction of the intestines. We did a Hysterectomy and Sigmoidectomy with end to end anastomosis. 

Insights: (Discovery, Stimulus, Reinforcements) (Physical, Psychosocial, Ethical)

            We must remember that each patient is distinct; no two are alike even with the same disease entity. But our actions and attitudes towards them may sometime comparable. On these two cases I find similarity, déjà vu! All the while we were insisting that these were gynecologic in nature based on our physical findings. The difference was we failed to step up on the first case. Yes, we took the responsibility of admitting the patient but for what? The truth was we never had a decision on what to do. What could have had happened if we took a step higher? We could only guess.

Responsibility is the key. Be able to stand up to your decision and be active. This must however be supported with good patient management process. We are fortunate to have one, use it wisely and may the force be with you.