What Diagnosis

It’s always nice to make a diagnosis, and have it confirmed, but that does not always happen. All too often we are left wondering what the diagnosis really is. ​ Fifteen year old Mellisa came in at about eight o’clock one night accompanied by her parents and complaining of abdominal pain. I was not working that night but was day shift next day. The doctor who saw her considered there was something going on in her abdomen but not life threatening or urgent. He gave them a request form to have an ultrasound done next day and told them to return to ED after it was done. The trio returned late in the morning after Mellisa had the ultrasound examination and it was my lot to see her. Before looking at the ultrasound report I revised the history with Mellisa and her parents, finding nothing that differed from the previous doctor’s notes. I then examined her and the crucial finding was rebound tenderness. This is elicited by gently placing the flat of one’s hand on the exposed abdomen and tapping the middle finger gently with the same finger of the other hand. When I did this over the right lower abdomen she winced and reflexly pushed my hand away. It obviously hurt and this, for all intents and purposes, told me that the peritoneum – the lining of the abdomen - was inflamed. The most likely cause in a fifteen year old girl was appendicitis but ectopic pregnancy, ruptured ovarian cyst and pelvic inflammatory disease were among the alternative diagnoses. Hoping that the answer would be in the ultrasound report I got it up on the computer and read it. It was entirely normal apart from the presence of a small amount of fluid in the pelvis. All that did was confirm my clinical diagnosis of an inflamed peritoneum but did not narrow it down at all. ​ I had a frank discussion with Mellisa and her parents. Mellisa was remarkably mature in her response giving frank, direct answers to my questions around the possibility of pregnancy. She denied any such possibility stating she had never had sexual intercourse. The parents, too, were mature about it all and understood that I had to explore the possibility. It is not always so. Anyway, I advised we now needed to do some blood tests to see if the white cell count was elevated, which it usually is with appendicitis and pelvic inflammatory disease, and a pregnancy test on blood. I told them I would have a chat with the radiologist, (x-ray specialist), about the ultrasound. I did this and he recommended an CT scan of the abdomen sharing my view that the clinical findings were strongly suggestive of an inflamed peritoneum. So I started the ball rolling on a CAT scan as well. That will give me a definitive answer – I thought. ​ Several hours later I had all the new information. The blood tests were entirely normal and pregnancy test negative. The CT scan merely showed the presence of a small amount of fluid in the pelvis and nothing else abnormal. We were, as they say, up a gum tree – all four of us – Mellisa, her parents and me. In days gone by the options would be to wait and see or to look and see. That is, a senior and experienced surgeon would decide to wait and see if the pain resolved without interference or further developed into a state where a reliable diagnsosis could be made. A brash, enthusiastic young surgeon would decide to take the patient to theatre and do a laparoscopy – that is, operate and try to find the cause of the problem. If the appendix was normal it would be removed while they were there anyway. ​ If any studies were done on such situations I doubt there would have been much difference in the outcomes. Most of the wait and see patients settled down over the next few days. Most of the operative patients settled down over the few days following surgery. Rarely would a definitive diagnosis be arrived at in either case. Mellisa still had her abdominal pain, but it had got no worse and had probably improved somewhat in 24 hours. The best, modern technology could not help with a definitive diagnosis. I suggested the parents take her home and wait and see. I advised them to return with Mellisa if they thought she was not improving in 24 hours, or if she was in any way worse. We waited but I did not see the outcome due to the vagaries of shift work. ​ People often speak ill of doctors in such circumstances but even more so if the patient returns to hospital and sees another doctor. “That brilliant doctor Watsisname just took one look at her and sent her for an MRI scan straight away. The other clown reckoned there was nothing wrong with her.” ​ Dr Whatsisname has several factors in his favour. Firstly, the condition may well have developed to the point where the clinical signs become distinct. Secondly, he has the advantage that the routine tests have been done and proven unrewarding thus leaving only the MRI scan as the investigation of last resort. Thirdly, the previous investigations may have ruled out all of the likely diagnoses leaving only one to be confirmed and at a later stage in the illness. And the retrospectoscope is generally acknowledged to be the most accurate instrument any doctor can possess. ​ It is not uncommon for a gall stone to cause severe colicky abdominal pain radiating into the chest and between the shoulder blades with vomiting thrown in just for good measure. But, sometime between being examined by the doctor and before the CAT scan is done the pain and vomiting suddenly stop. Patients with little faith will naturally consider the doctor’s clinical diagnosis of biliary colic to be hogwash and that consideration will be compounded by the CAT scan finding no abnormality. The fact of the matter is that the gall stone has tracked through its course from gall bladder to intestine, stretching and dilating the bile ducts along the way and causing them to go into the most painful spasm then popped into the intestine which is too wide for the stone to dilate. When the next attack occurs, perhaps even years down the track, the patient may have cause to revise their opinion of the doctor.