Indexing Title: BDEVEZA’s Medical Anecdotal Report [05-10]
MAR Title : It’s Really A Temple of Surprises
Date of Medical Observation : Nov. 1, 2005
Narration :
It was another day of duty. I must admit that I was not in the mood because it was a holiday and here we are in the hospital assuming our post. But, I have to accept that because it’s all part of our service to the institution.
We accepted the endorsements and one patient endorsed was a 28-year-old female that was assessed to have Acute Appendicitis. Before she was brought to the operating room, I went to her room and checked on her. I did my history and physical examination. My physical examination findings revealed an abdomen that was flabby, soft and with direct and rebound tenderness on the right lower quadrant. There was no muscle guarding. With her history and my p.e. findings, I was convinced that it was really Acute Appendicitis. After some time, she was wheeled in the operating room. Before she was induced by the anesthesiologist, I examined her abdomen again and had the same findings as before. After a few minutes, I started the operation. I did a Rocky Davis incision. Everything went smoothly until after I opened the peritoneum. As I reached the peritoneal cavity, I noticed a glistening, black mass that blocked my view. I palpated it and it was soft and cystic in nature. It was quite large, measuring approximately 10x10 cm. At that time, I started to feel differently and questions were running through my mind and the ONE thing that bothered me most was what if it’s not Acute Appendicitis. And so I looked for the appendix and thank God, it was in its suppurative stage. After I have established that is was indeed Acute Appendicitis, I decided to do an intraoperative referral with OB-GYN. Luckily, they were just in the other room and had just finished a Caesarian section. While waiting, I informed my senior resident of my findings. When they came, they asked me a few questions. They checked on the mass that I saw and said that it was a Twisted Ovarian New Growth because of the appearance. It was a large one so they decided that they will do a midline incision. And so I closed my previous incision. They took over and did a right salpingo-oophorectomy. Likewise, they transferred the patient to their service with co-management with our department.
Insights ( Discovery, Stimulus, Reinforcements / (Physical, Psychosocial, Ethical
Time and again, history and physical examination plays an important role in the diagnosis and management of a patient. Physicians are guided by this tools so as to arrive with a sound judgment with the case at hand. If done properly and carefully, it can give you a 100% certainty. But most of the time, this is easier said than done.
My physical examination of the patient truly points out to Acute Appendicitis. I must honestly say that I was not able to appreciate a palpable mass when I examined her abdomen. It’s maybe because it was flabby and the layer of fat somehow did not allow me to delineate it. But nevertheless, intraoperative evaluation was crucial. Making the appropriate referral was the most prudent thing to do at that time. I know I have my limitations. Faced with that situation, I must say that I was able to make a sound decision.
After the operation, I still considered myself lucky for two reasons, inspite of missing that mass on physical examination. First, that it was really a case of Acute Appendicitis and second, I did not have much difficulty in referring the patient.. As I was writing my operative technique, one thing crossed my mind. Something that was taught to us in medical school…… that the ABDOMEN IS A TEMPLE OF SURPRISES !!!