Wednesday, December 7, 2016

Young female patient? Could be an ectopic pregnancy!!!!

Young female came with lower abdominal pain for 3 days. She gave a history of mild per vaginal bleeding few days back. She had no history of fever but had some vague symptoms suggestive of urinary tract infections. However she was afebrile. No abdominal tenderness on examination. However her urine pregnancy test/ HCG was positive. She underwent an ultrasound scan which revealed NO intra-uterine pregnancy. However no free fluid in abdominal cavity!!!

Next day also she underwent an ultrasound scan & came the same results. Her CRP (inflammatory marker) came as 22 (<5- normal) which is little high.

Mind you that unlike in developed countries, serum level of beta-HCG is not freely available at peripheral hospitals in our country. In addition it is costly & poor people usually cannot afford. So she was managed as completed miscarriage or urinary tract infection. She was not started on antibiotics as she was allergic to many drugs.

By the time she was seen by me, urine full report was not available. Apparently the sample was misplaced or something has happened. She was insisting on going home as she felt much better & for something in her job.

Now already 2 scans have been normal. But CRP was high. No urine full report. No way to get done serum beta HCG. Junior doctor who saw in the morning too suggested me to send her with antibiotics. However I was not happy to send her home as I had no proper diagnosis.  Although the patient & her family members insisted, I decided to keep her in the ward till everything is clear.

So the patient stayed in the ward & at the middle of the same day night, she developed a severe pain & when scanned again there were free fluid in the abdomen !!!
Immediately she was taken to the operation theatre & laparotomy was done. It was a leaking tubal ectopic with nearly 600 ml of blood inside the abdominal cavity !!!

Surgery was successful & her recovery was uneventful.

We all make mistakes. Sometime lack of facilities may lead you through a wrong diagnosis. Had I sent this patient home with antibiotics, concerning her job & future in a humanitarian view, she would have died during her job interview !!

Lesson. - In a female patient with abdominal pain, unless proven otherwise it is ALWAYS an ectopic pregnancy.

Monday, April 25, 2016

Unresponsive? Check sugar ..Check sugar..

This has not happened to me. But to one of my senior doctor. 
It was a rural hospital with minimum facilities. The doctor was called to attend an unresponsive patient. He has checked airway, breathing , circulation. Yes. fine. He immediately filled the transfer form & arranged the ambulance to transfer the patient after discussing with seniors & destination hospital.

For some reason, without any cross questioning his transfer also approved by a senior doctor. Now the destination hospital is waiting to intubate the patient & busy with arranging ICU. Once after they started the journey, that junior has suddenly remembered something & checked the sugar. It was 25mg/dl !!! Patient who was about be intubated in few minutes woke up with few milliliters of dextrose & went SEATED to the destination!! 
Same happened to me sometime back. I was almost about to jump on one unresponsive patient's chest to give CPR & to break all his ribs.. He was lucky. I was figured to check RBS.. Oh.. 35 mg/dl..
He could save his rib cage with life after few milliliters of dextrose.

Lesson- Stick to the basics. A-B-C-D (Dextrose).
Unresponsive patient -always check the sugar level.

Sunday, April 24, 2016

If the symptom is life threatening, monitor the patient...monitor the patient...monitor the patient...

He was a known de-compensated chronic alcoholic liver cell disease patient who gets admitted to the ward regularly for peritoneal tap to relieve difficulty in breathing. One day his complain was different. He complained of per rectal bleeding.
Variceal bleeding in alcoholics is not uncommon. But in that particular patient had undergone colonoscopy within last 6 months & had been normal. His PR bleeding also was only 1 episode in early morning & seemed it has stopped after that. Unfortunately he has eaten beet-root day prior which sometimes gives red color stools.
He was nicely walking here & there. No abdominal pain. Since one episode of PR bleeding, he worried & got admitted. On examination he was not at all pale. Blood pressure pulse also normal. No hemorroids or any masses were found. Ok..what to do..With the reassuring clinical findings, he wanted to go home. But he was admitted by the junior doctor & blood pack was preserved in case if needed. His blood investigations also were sent. It was around morning 10 am. In the evening around 4 pm , the patient was lying on the bed & talking with the bystander. Suddenly he has become unresponsive & immediate CPR started. When transferring the patient from the bed to trolly, they have seen massive amount of blood has soaked the garments of the patient.

Lesson- By the time of examination, patient may be stable. But symptoms which can be life threatening, these patients can go bad at any time. Therefore monitor the patient. Atleast keep them in near by nursing station & order a monitoring chart.
If the symptom is life threatening, monitor the patient...monitor the patient...monitor the patient...

Basics are THE basics. No matter how senior you are.

Once there was a patient came to a clinic complaining of abdominal discomfort for some time. Past surgical history was significant for 2 lower segment caesarean sections. She was seen by some private practitioners & since she was not improved with their treatment, she was referred to us.
Oh.. ultrasound abdomen showed a massive cyst measuring 17x 9 cm. But fortunately no ultrasound features of malignancy & CA-125 also came normal. She was given a date for laparotomy.
She admitted to a the ward for the surgery in some weeks after. Usually all the patients are admitted for surgery will be re-scanned once after the admission. Since it is difficult to go by patients in busy wards, all the patients need to be scanned are asked to come for scans after the ward rounds.
Patient was put on the bed & done a transvaginal ultrasound (TVS) by a senior doctor.
Cyst is 3x3 cm !!!! Cyst size has reduced ??
She is planned for laparotomy on next day !!! There will be a big cut on her tummy next day!!
What to do? Senior doctor who performed the scan, documented his findings & informed the consultant gynecologist .
Consultant gynecologist  went though the patient & palpated the abdomen. It was like 24 weeks size mass !!
What a puzzle. There is a mass clinically, but not ultrasonically.. !!
Well experienced consultant gynecologist who believed his clinical sense gave an explanation (which I am not mentioning now) & wanted LAPAROTOMY.
She was underwent laparotomy next day. Yes it was a large cyst of 17x9 cm !!!  In left adenexia another cyst 3x3 cm..!!
So who is correct??
Actually what happened was when she underwent a TVS, it has shown the small cyst & due to the large size the bigger cyst was missed. Had he done a trans-abdominal scan at the time of confusing scan findings he would have easily detected. Furthermore had he at least touched the patient's tummy (History > Examination > Investigations) he would not have missed this.
Fortunately nothing bad happened to the patient, The doctor who performed a TVS was a well experienced  though he made this unfortunate simple mistake. I still believe he is a good doctor & no question about it. But it is worth mentioning that "once a senior doctor makes a such mistake, will other junior doctors & ward staff follow his patient management without any hesitation?".

Lesson- Basics are THE basics. No matter how senior you are. Stick to basics.    

Mistakes Mistakes Mistakes... Why am I writing this?

We humans are not perfect. I have made thousands of mistakes during my life. Well then, why am I writing this?

My career as a doctor began few years before in a tertiary care hospital in Sri Lanka. To become a doctor is requires enormous dedication & hardship which cannot be written in books. In my career as a doctor as well as a medical student, I myself have made many mistakes some ultimately caused serious consequences in patient management. I do not think it is necessary to mention the names or locations, but these stories are not fake ones.
The purpose of writing these notes, is just to guide junior doctors, medical students who will follow this path in future, not to do the same. 

Learn form mistakes. Be a perfect doctor.