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!!