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Sun Apr 19 16:18:16 BST 2009

As a surgeon u made the right diagnosis and the right referral. They blew it and the surgeons were left cleaning up their disaster.  Am I missing something?dn
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-----Original Message-----
From: saad shebrain <shebrain1 at yahoo.com>

Date: Sun, 19 Apr 2009 08:08:06 
To: Trauma and Critical Care mailing list<trauma-list at trauma.org>
Subject: Re: Advice wanted from a Resident Surgery.

First I am Not Expert;

But I have some points to say;

This patient presented to ER with some suprapubic tenderness, fever, and marked leukocytosis. I think the DD list is reasonable but I should add Recurrent diverticulitis with its complications in my mind (perforation, absces, fistula with urinary tract, etc), in addition to obtain UA to R/O UTI  or peylonephritis. and always, fever and high WBC is pus under pressure until proved otherwise. The patient history of 7-10 days of symptoms might me misleading to say is ot an acute event. Also I should put IUCD infection on the list (?Actinomycosis etc).

And Obtain CT scan if you can. HERE in USA, CT scan and CBC are considered the standard of care in diagnosing diverticular disease.

Now communication with OB/GYN is always difficult, you will never get anything from you. You see a pt with huge ovarian cyst and RLQ pain and you ask them for possible torsion and they will write the best note in the world to nconvince you that it is not and they have no buisness with the pt. and you stuck now, you take the pt for diagnostic laparoscopy and then you call them for dealing with twisted cyst and emabrasse them.

Now in your case, you did not benefit from OB/GYN resident. He/She cleared the patient from their side, by their note. Now they put it on your shoulder.

Did you get CT scan? Did you double check your decision why this patient is going home with marked leukocytosis and fever that have not been invistigated very well? this patient could be just heding the door of Septic shock but still compensating, or early? We understand that when you on call after midnight our (RAS: reticular activating system) start to shut down, but when this happen, the price is high on the patient side.

Did you consider even diagnostic laparoscopy as last invasive procedure if you do ot want to observe the patient at least in the hospital on antibiotics? and if not why?  and did you send blood cultures? etc.

Then Did you talk to your attending that night and explained your thought? It is not your job to talk to OB/GYN attending if they have respresentitive (resident) unless you are NOT Comfortable with the resident decisions.

SS

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--- On Sun, 4/19/09, Dr.Asif .H.Ansari <asifhansari at yahoo.com> wrote:

From: Dr.Asif .H.Ansari <asifhansari at yahoo.com>
Subject: Advice wanted from a Resident Surgery.
To: trauma-list at trauma.org
Date: Sunday, April 19, 2009, 6:23 AM

Hi everyone,

I am a resident in surgery and with 3 yrs + work exp. I need
some advice from the seniors with regard to a case for which I and others might
be investigated.

Day 1

A 38 female servant comes to ER c/o pain lower
abdomen-7-10days, nausea, burning urine, no constipation/diarrhea. Previous
surgery 4 yrs back  c sec. periods
normal. Preg test –ve. No known medical or surgical conditions.

History takin was difficult as pts was of sri lankan.

o/e febrile 38.5 C, puls- 90-95bpm, BP 120/80 mmHg

      Chest-nad

     Abd- not
distended, soft like cotton! , no guarding, no rigidity, ONLY Tendernes in
Suprapubic region, Bowel Sounds- normal. PR- NAD

Labs- White cell count- 20,000, other labs within normal
limits.

So my plan was to admit her after doing an  Chest and abdomen X ray.

My D/D was  1.Urinary
tract infection/cystitis

                        2.
PID

So after the xray, Chest Xray-nad, no free gas

                           Abdomen x ray showed  IUCD in situ!!!! When I asked here when put
in , she said 4-5 yrs, I think.

On co-relating all the above I thought of referring the case
to OB/Gyne resident to rule out IUCD related infection/perforation.

She saw the patient, wrote soft/lax abd. No IUCD
perforation. Gave D/D of UTI.  And
referred the case to next day clinic OBY/Gyne.

Patient came back and gave her Bactrim DS bid and Buscopan
tabs and gave her clinic next day morning to Urology.

I had discussed the case with my on call gen.surg
registrar  BUT NOT with Urology on call!

Day-2

Patients comes to OB/Gyne clinic, seen by registrar and discharged
home.

Day-3 

Patient presents to ER again,this time c/o vomiting and pain
upper abdomen. BP-90/60 mmHg,tender epigastrium, white cell 20,000.

So seen by Meidcal resident and Admitted as Septic Shock ,
morning 3 am.

Patient was badly managed and refrred to Surgery after
admission. USG abdomen-free fluid.

Day 3 -9 pm

When the surgeons took her to OR on inotropes, laparotomy
,showed thick pus inside, but no perforation or any other pathology. They said
most probably IUCD related ascending infection. No rupture/infection of
fallopian tubes.

Don’t remember how much was the urine output.

Patient post-OP was in ICU after 4 hrs arrested and declared
dead.

Now the sponsors of the servant lodged a complain and want
an enquiry into the case.

Please let me know how I can defend myself and what are the
strong points in favour of me that I decided to discharge the patient. i know deep down that i shudnt have discharged her,, but i just want to ask was  my judgment right to send her home with clinic next day.

 Thank You,

Dr.Asif Huda Ansari

 Please send a copy to e-mail listed below, so that I can reply at the earliest.

1. asifhansari at gmail.com

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Advice wanted from a Resident Surgery.