Index Title:  RDELEON’s Medical Anecdotal Report [05-09] 

MAR Title: The Midnight Referral 

Date of Observation: July 2005 

Narration: 

            I was not on duty that night, and after doing some reading, I decided to go sleep to early. It was 10 pm then and I thought to myself it would be nice to have a good night rest.

             It was around midnight when my mother woke me up and told me I had a phone call. I asked who it was and she said that it was important. So I got up and answered the phone.

             As I answered the phone, I recognized the voice. It was coming from a classmate of mine from medical school. From what I’ve gathered, she was on duty on a private secondary hospital and been on moonlighting seen she passed the medical board.

             She said her apologies for waking me up and told me that she had a referral for me. I said it was ok and asked what the referral was. It was a case of a 65-year-old   female who presented with a right lower quadrant (RLQ) pain of 1 day duration with accompanying nausea and vomiting with dysuria but no fever and no anorexia. The patient had previous history of having the same abdominal pain and was previously diagnosed to have recurrent urinary tract infection (UTI).

             I asked her what her physical findings were. She told me that the abdomen was flabby, with normoactive bowel sounds, direct tenderness on the RLQ and hypogastric area. She added that the patient was positive for rovsing’s sign, obturator sign and psoas sign.

                        I asked her to describe the abdominal tenderness, if there was rigidity or guarding. She said that board like tenderness. I know from the way she was telling me the data and giving emphasis on the RLQ tenderness that her impression was an Acute Appendicitis (AP). She asked me if she will schedule the patient for operation.

             As I was processing the data she gave me, my impression was not of an AP but rather it was one of the considerations or differential diagnoses. I was thinking more of a UTI or even pyelonephritis. Since we can not total rule out an AP I told her to observe the patient.

             I explained to her our observation scheme for an acute appendicitis and if during the observation the pain decreases the more likely that it was a UTI and if the pain persisted or increased in severity then AP was the most likely the diagnosis.

             She said thank you and apologized once more for disturbing me and she said good night and hang the phone. I went back to sleep. The following day, I gave her a call and asked how the patient was, she told me that I was right, that the patient was suffering from a pyelonephritis. At the back of my mind I was thankful and relieved that I was able to help her in managing the patient.

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

            This experience somehow showed me and took me a glimpsed of the situation of our consultants. Regardless of the time of the day and regardless of where they are, our consultants answers and never stop assisting us. They are always there to guide us and help us in managing our patients.

            For us residents it is just right for us to give our consultants the respect that is due to them. Respect in the form of giving them the accurate data of the patient we are referring. Try to be complete and thorough in our history taking and physical examination. It is the “name” of our consultant “on line” every time we refer. And it is just right for us to give them all the correct data.