A SHORT CASE (CONQUEST OF DEATH 23)

A SHORT CASE

The out-patient department of our hospital was crowded. I was late   in starting my work. In my cabin, I was busy examining the patients. Anon entered my house surgeon and said,

“The boss has told you to examine this patient and present to him as a short case. From the point of view of examination, this is a long case, but you will have to convert it into a short case. You are allotted fifteen minutes. After fifteen minutes, the boss will examine you.”

“OK” I said.

I finished the interrogation and examination of the patient in time. Then I went to sir’s cabin and said,

“Sir, I am ready”

“Narrate the important points in the history, positive findings, important negative points and the diagnosis” He instructed.

I nodded and started the presentation-----

“A 35-year-old female complains of:

Dull backache

Burning micturition

Increased frequency of micturition.

Day to night ratio of voiding frequency is 1.5:1. Passes adequate quantity per act of voiding.

The urine is amber colored and clear.

No straining while passing urine.

No thinning of the stream of urine.

No hematuria (passing blood in the urine).

No history of perceptible fever but does get night sweats on and off even in the cold season------“

“Really?”, Sir interrupted and asked.

“Yes sir-----“

“Hmmm-----I did not ask this point. Good. Go ahead”, he said.

“All these symptoms have lasted 8 to 10 months”

“She is lean, underweight, undernourished and anemic. Her pulse rate is 90 per minute. Her B.P. is normal----“

“How much?”, he asked

“140/90 mm. of Hg.” (That was the time when age plus 100 systolic and proportionate diastolic i.e. 90 was considered to be normal. Today the recommended normal reading for B.P. is: 120/80 mm Hg. A patient with kidney disease today will be treated aggressively to maintain the pressure at 120/80 mm Hg or even slightly lower).

“O.K.”

“She has lumps in both the flanks; they have regular, smooth surfaces and are mildly tender”.

“Your diagnosis?”, he asked.

“Bilateral hydronephrosis (enlargement of the kidney).”

“What would you like to do?”

“Investigations to prove the diagnosis and other supportive investigations to plan the management”

“First the X-ray KUB (Kidney-Ureter-Bladder)”

“Here it is.”

“The x-ray shows soft tissue shadows in both the flanks.”

“Next?”

“If blood urea and creatinine are normal then IVP.” (Intravenous pyelography. Now this investigation is known as IVU i.e. Intravenous urography. In this investigation, a radio opaque dye is injected intravenously. By using the contrast medium, x-rays of the urinary tract are taken. (Ultrasonography was not even introduced in the realm of medicine at the time.)

“Here are the pictures.” While mounting the plates on the viewing box, he said “Your analysis------“

“Non-functioning right kidney, markedly enlarged and distorted left kidney, ‘beaded ureter’. The bladder capacity seems normal. My diagnosis: tuberculosis of the urinary tract.”

“How would you manage?”

“If the labs show that she is fit for surgery, then we will start anti-tubercular treatment and advise ‘right nephrectomy.’ (Removal of the kidney)”

“I have already investigated her. I have already started anti-tubercular treatment. Post her for the operation on the next operation day”, the chief said.

“Yes sir”, I remarked.

I then explained the plan of management to her and to her relatives.

They agreed to follow the plan religiously.

“She will be posted for surgery on the next operation day” I said.

“Will be fine”, they all said

I admitted her in the hospital.

On the stipulated day, we started operating. I assisted my chief surgeon. The surgery was successful. Her post operative recovery was uneventful. I continued anti-tubercular treatment.

Subsequently, my boss went out of town to attend a medical conference. On the tenth postoperative day, I removed the stitches.

Because of some family problems, she requested me to discharge her from the hospital.

“Let sir return, I shall ask him and then you may go home” I said.

“I have some genuine difficulty in the family. Please let me go. I shall attend the outpatient department (OPD) regularly.” She earnestly requested.

I honored her request.

Four days later, my boss returned to town. Not finding this patient in the ward, he was annoyed.

“You should have not discharged her”, he said.

“Sir, she had some genuine family difficulty. She promised me to attend the OPD regularly for follow up. She will attend the OPD day after tomorrow.”

“I am worried. She has only one kidney which is also severely damaged. We have to protect it. To protect such a damaged ureter and kidney, the urologists now suggest wrapping of the omentum (the curtain of fat in the abdomen) around the ureter. I think we should advise her to undergo this particular surgery.”

“O.K.” I said.

As promised, she attended the OPD.

My boss explained the situation to her and advised her to undergo this surgery. She agreed.

We performed the surgery. Her post-operative course was uneventful. She attended the OPD regularly. She recovered from this life threatening illness completely.

It turned out that when I shifted my residence, this particular lady was also staying in the same new locality as mine. She used to greet me many a times.

Later, because I was busy in establishing my practice, I could not meet her.

Almost twenty years lapsed. One day my receptionist knocked the door of my consulting room and said,

“Doctor, phone for you”

“Who is it?” I asked

“Your doctor friend”

“Do you remember this case? She says you have performed two operations on her” asked my friend as I replied his call.

“Certainly yes,” I said

“She complains of urinary infection. What should I do?”

“Get urine culture and antibiotic sensitivity done and report to me.”

However, I did not hear back about her.

To this day, although I still possess her x-rays as documentary evidence, I have certainly lost a valuable, living direct evidence of “CONQUEST OF DEATH.”   

A TRUE STORY IN REAL LIFE!

A DRAMA IN MY LIFE!!

A QUANDARY (CONQUEST OF DEATH 13)

ACUTE CONSUMPTION

Weary, sullen, mournful face
A tale of internal disturbance tells
Perhaps of some chronic illness,
Or of current affairs!

Dark rings around the eyes
Malar prominence and sunken cheeks,
Malar flush of high fever,
Makes the diagnosis more clear

Clinicians! Beware! Pay attention!
It may be acute consumption!

(Note:--The first episode of acute consumption i.e.  Acute miliary tuberculosis may masquerade as Acute Bronchitis.)

I had written this poem and shared it with my students to make them aware of the uncommon presentations of common diseases.

I myself was caught unawares in a similar quandary.

I was called to give opinion on a patient admitted to the female ward.

“Nurse, where is the patient that is referred to me?” I asked the nurse in charge of the ward.

“Bed number eighteen.” She replied

“Nurse, will you please chaperon?

She did.

The patient was a middle aged woman. I started asking her history. Wasted, weary and wan, she hardly had enough energy to answer my questions. With great effort she pointed to her abdomen and said,

“p-a-i-n--- s-u-d-d-e-n--- p-a-i-n--- h-e-r-e”

The nurse started narrating-----

“About a month back, she was admitted for high fever.”

“How high?’ I enquired.

“102 degrees F. She used to have fever every day. So her Widal test (a blood test for typhoid fever) was done. It was positive. So antibiotics were started. Even after five days, her fever has not come to normal. Now since the last two hours, she has developed abdominal pain along with some distension of the abdomen. We gave injection to relieve her pain but no relief----“

She was emaciated, her eyes sunken, her cheeks sunken, her tongue dry and pale but definitely not coated, her nails pale, her abdomen scaphoid (concave abdomen)-----

Obviously, she was chronically malnourished. Her ‘general look’ was ashen, cadaverous.

Her abdominal signs were suggestive of perforation.   

”Typhoid perforation?” I raised a suspicion.

“That is what our doctors suspect”, the nurse added.

“Let us get an x-ray of her abdomen done” I suggested.

“Meanwhile, tell me about the pattern of her fever” I asked the nurse.

“Every day, exactly at 11 A.M., she starts getting high fever up to 102 degrees F. Throughout the day, the fever remains high. But surprisingly in the morning, she has no fever. Up to 11 A.M, her body temperature remains normal”, replied the nurse.

“This means that at some time in the night, her fever abates” I commented.

“Yes”, the nurse agreed

“Do you sweat at night?”, I asked the patient.

She nodded.

This made me skeptical about the diagnosis of ‘typhoid fever’.
The wet plate of her x-ray film was ready. The signs of perforation were inviting me to explore her. I decided to discuss the problem with the physician and the anesthesiologist on duty.

“What is the cause of the perforation?” I raised a question.

“Typhoid!”, exclaimed the physician. “Her Widal is positive”.

“We don’t treat reports; we treat patients” I started arguing “Clinically, the pattern of fever does not fit in with the ‘typhoid type’! If this is typhoid, she should have responded to the therapy, but she has not! When well selected drugs fail, we should revise our diagnosis!! Positive Widal could be an example of anamnestic reaction (false positive)!!---“

“Well, well, she needs exploration! No question about it!!”, the anesthesiologist intervened. “With a calculated risk, I shall give anesthesia! You do a fast job! OK??” 

I started the exploration. She had a stricture (narrowing) in the terminal ileum (far end of the small intestine) and a perforation proximal to it. The findings of exploration were suggestive of tubercular perforation! I sutured (stitched) the perforation and performed ileotransverse anastomosis (joined the end of the small intestine to the transverse portion of the large intestine). I washed the peritoneal cavity (the cavity in which the intestines are contained), put a drain in the peritoneum and closed the abdomen.

I sent her blood for bacterial culture for typhoid. I started empirical treatment for tuberculosis. In due course, her blood report arrived. It was negative for typhoid!

So my diagnosis was correct.

She tested all of us right from the word go. Her wound healing was delayed. This was understandable because she was severely malnourished. Even after correct diagnosis and treatment, not only did her fever not abate but it also remained at a higher level. Well, in tuberculosis, especially with toxemia (toxins circulating in blood), the fever lingers longer, and also goes at a higher range.

Against all odds, about six weeks later, her fever abated and she started picking up health.

After about ten weeks later, we discharged her. She attended the clinic for follow up regularly.

Though it took quite longer than expected, she recovered very well from her ‘typhoid’, AKA TB, the great masquerader!!

A TRUE STORY IN REAL LIFE

A DRAMA IN MY LIFE!! 

CONQUEST OF DEATH 18: A FUNNY CALL

A FUNNY CALL

Every Sunday, many doctors attend medical seminars in various institutions.

One Sunday, after the seminar, our group was recollecting memories of our student days and cracking jokes.

Suddenly my colleague, Dr. Harish Walawalkar, who also happened to be my medical officer at the time, asked me

“Do you remember that funny call?”

“Which one?”

“That one from the gynaecology ward?”

“From the gynaec ward? For me? But, I was in surgical ward!” I said.
“A patient had undergone hysterectomy (an operation for removal of the uterus), did not pass urine till late evening, the nurse on duty in the gynaec ward sent you an urgent call:

“The operated patient did not pass urine, please come and pass urine!!……..” he continued.

Soon our giggles turned into guffaws.

“Yeah---- yeah! I distinctly remember!!”

As the surge of laughter ebbed, I narrated the incident.

I received that call from the gynaec ward. Sensing something amiss, I rushed to the ward.

“Nurse, what is the problem?” I asked the nurse on duty.

Taking me to the bed of the patient she said,
“This patient was operated in the morning but has not yet passed urine.”

I looked at the patient, she was restless. She was getting a dull ache in the loins.

I examined her. Her urinary bladder was empty. To confirm it, I passed a catheter. Not a drop of urine could be drained.

That was ominous!

“During the operation, probably both the ureters (the tubes conducting urine from the kidneys to the urinary bladder) were inadvertently ligated”, I mused to myself.

I discussed the emergency situation with the radiologist on duty.
After discussion, he injected a radio-opaque contrast medium to delineate the urinary tract (IVU).

The x-ray picture was beckoning me for urgent surgical intervention.
I informed the chief surgeon. He decided to undertake an emergency exploratory operation.

I explained the situation to the patient and her relatives. They consented for the operation.

We began the exploration immediately; it was midnight by then.

“There it is”, I exclaimed with joy, as I located the ligature (stitch) on one side. The ligature was holding up the urine by tying and obstructing the ureter at the place.

The chief could cut the ligature and relieve the obstruction.

Oh! We all heaved a sigh of relief.

The other ureter was dilated but we could not locate the ligature.

“On this side, we will have to implant the ureter in the bladder and fix the bladder. Isn’t it?” said the chief.

“Yes” said I. “B—u—t in an emergency, do minimum!” he exclaimed.

“Sir, if the patient is stable, let us finish the job. Why explore the second time?” I said.

“She is quite stable.” succinctly said the anesthesiologist.

We decided to proceed with the plan. It took a long time to complete the operation.

A life threatening debacle was averted.

The postoperative recovery was uneventful.

After ten days, she was discharged from the ward.

I picked up the call book and showed the call message to the gynaec registrar. She could not contain her snigger.

I remarked,

“Now that your patient has been able to pass urine, I need not come to your ward to pass urine!” and left the ward.

A DRAMA IN MY LIFE!!

DR. HEMANT VINZE

Wrong Diagnosis

Wrong Diagnosis

“Doctor, I get stomach upset repeatedly, gas trouble, sometimes diarrhea, sometimes constipation, loss of appetite, bitter taste in the mouth------,‘ one of my patients was narrating.
I interrupted and asked him,
“Since when do you get these symptoms?”
“About five or six months.”
“How old are you?”
“Forty seven.”
“What is your occupation?”

“We own an orchard of grape vines”
“Do you yourself do manual work? Or-----“
“Very rarely. We have employed peasants.”
“Have you lost weight?”
“Yes!”
“How much and in how many days?”
“Eight kilos in six months”
“Tell me about your family?”
“WE are four of us; myself, my wife, a daughter and a son.”
“Please lie on the examination couch. I will examine you”

In proportion to the weight loss, he was not emaciated and malnourished. His vitals were normal. He had a firm mass in the right lower quadrant of his abdomen, at the junction of the large and small bowel.
“Some times I get water brash, retching, sour taste----,“He started narrating some more symptoms as I was examining him.
“Okay,” I said. 
After the examination, I explained to him my findings and said,
“Let us get barium films of the intestines (Ultrasound and CT Imaging were not around at that time), a chest x-ray and other basic investigations done. After that, I shall be able to decide further line of treatment”
“OK”
Four days later, he brought the reports. His chest x-ray and lab reports were normal. His barium study was abnormal. I mounted the x-rays on the viewing box and started explaining -----

“This is the small intestine and this is the large intestine. This is the junction of the two. We call this as the ileo-cecal junction. This ghastly looking shadow at this junction is ominous. This requires to be removed by an operation. After that, I shall send this for a pathological examination called as ‘biopsy’. On the basis of the report, I shall decide the plan of further treatment.”     

“Doctor, how much time it will take for the operation?”
“About two to three hours”
“Is this a major operation?”
“It is!”
“Doctor is this ‘cancer’?” He asked anxiously
“How can I say? The ‘biopsy’ report will tell the tale.”
“What if it is ‘cancer’?”
“Let the ‘biopsy’ report prove it first. Why fret about a non existent danger??”

He did not report for a week. When he came to decide for the surgery, he had ‘stomach upset’, gas trouble and diarrhea.
“We cannot perform surgery during an acute attack of dysentery.” I said. “You take the medicines which I prescribe now, let the attack abate, and then we shall plan the operation. OK?”
“OK!” He said. “How long should I take these medicines?”
“You report to me after three days. I shall assess the progress and then decide.”
Three days later, he came to report. He was improving
“You continue these medicines seven more days. So totally take them for ten days; and see me there after.”

“OK! Doctor, may I go to my native place and come back?”
“Sure!”
“Thanks a lot”
“You’re welcome!”
He went to his native place only to return after seven months.
“How are you?” I asked.
“Much much better! My appetite has improved, the bitter taste in my mouth has disappeared, my stomach upset is almost non existent now-----“
“Wonderful!” I said.
“Let me examine you.” I said.

His face had a sheen now. His expression was cheerful. Obviously he was in pink of health. His abdominal lump had disappeared now! I was surprised!!
“Let us get your follow up barium study done” I said.
“Ok”
Three days later, he brought his barium x-rays. That ghastly looking lesion had disappeared.
“Cheers!” I said. “You are perfectly normal now. You do not need any treatment”
Saying, “Thank you doctor” he went away.
Weird thoughts set my mind in a tumult!

“Was my diagnosis wrong then?”
“Indeed it was!!”
“What if he were to develop an acute attack of dysentery immediately after the operation??”
“It would have been a disaster!! The result would have been horrendous!! He would have developed a very bad sepsis! And may be I would have lost him-----“
“What if this really was a ‘cancer’ and still I had still not advised surgery??”
“His condition would have been worse! He would have died a miserable death!! The medical fraternity would have ridiculed me. I would have my neck in shame. There would have been a storm of criticism against me!!”

The acute attack of dysentery not only averted a debacle but saved his life too!!
There is an unwritten dictum in medicine:
“ERR ON SAFER SIDE!!” (It is better to err on the side of caution.)
“Did I not err on safer side then?”
Most certainly I did!!

A TRUE STORY IN REAL LIFE!

A DRAMA IN MY LIFE!!

DR. HEMANT VINZE