MEDICAL ANECDOTAL REPORT
Indexing Title: GPVILLANUEVA’S MAR [15-07]
MAR Title: A Good Call on Abdominal Mysteries
Date of Medical Observation: July 2015
Tag: Solving the mysteries using the patient management process
Category: Professional/ Ethical – Reinforcement
On a not so ordinary duty day, a 6-year-old female patient was referred by the Pediatrics department for evaluation of abdominal pain. The patient had her pain two days ago and was transferred from many different hospitals before coming to us. Due to the delay, the patient was already on her late stage of the disease. The abdomen was already distended and tenderness was diffuse. In addition, assessment on a child is very difficult since they are not so cooperative compared to adults. The management of pediatric patients is critical since they are more sensitive to changes in their system. Meanwhile, in our Emergency Room (E.R.), a 30-year-old male patient, diagnosed with indirect inguinal hernia, on-going clearance at the Out-patient Department (OPD) had a sudden right lower quadrant pain while noting a bulge on his right inguino-scrotal area. The patient was immediately transferred to the ER for further evaluation and management.
Both patients did not present with classical symptoms of Acute Appendicitis. We then requested for laboratories and did serial abdominal examinations. I referred it and discussed the cases with my senior, together with the supporting laboratories and agreed that both were surgical. We prepared the patients and optimized them prior to procedure. We used the patient management process considering the prevalence and pattern recognition and came up to the assumption that they can still be Appendicitis. But the approaches for both were different. The pediatric patient can be done using a right lower quadrant incision and can be extended if needed further exploration. The adult patient since he has a history of hernia would be opened midline so that the bowel can be checked to make sure if the cause of the pain is appendicitis or not.
As it turned out, both were Appendicitis and were already perforated. It was revealed to us the reason for the unique pattern of their diseases. The child had a retrocecal appendix and initially must have contained the abscess in retroperitoneal but due to the continuous inflammation leaked the fluid and filled the entire abdomen causing inflammation to the small bowels and ileus, as seen in the radiograph. The adult patient had a chronically incarcerated hernia in the right that at that time reduced to in the abdomen in the same time as an Apppendicitis is in the process.
(Physical, Psychosocial, Professional/ Ethical)
(Discovery, Stimulus, Reinforcement)
The patient management process was devised for us to be practical in the diagnostic and management process in a patient. It uses vital information from a patient in order to organize one’s thought into a sound judgement preventing unreasonable errors and negligence. Sometimes, as we learn more from our books and in a case, we become overwhelmed with the data and mix it in our thoughts. We now have to use a systemic, organized, reasonable and practical approach to come up with a decision. Operate or not to operate? Wait or do it immediately? Observe or to accept?
These questions are answered using the process being taught to us from the start of our residency training. This will justify the reasons of doing a procedure to the patient or not doing anything at all. Other medical professionals might not understand since it is not exactly taught in the medical school although coming up with the diagnosis is quite close, but not in the same process.
Learning this process equips us in cases cited above where dilemmas are encountered. It gives light in the dark times of having to observe patients and eventually operate on them. It also gives us a stable foundation on which we build our subsequent interventions, hence becoming an integral part in our overall management of patients.
ROJoson’s Notes (17feb2):
The Management of a Patient Process being referred to is this one: