The perf

Every once in a while you end up with a patient so oblique in their presentation that discerning symptoms is a murky affair even before you get to the signs. I end up with one such patient at the end of a busy take and try and review what the PRHO has told me; it all sounds a bit fudgy. Non specific abdo pain on a background of chronic pain. Dementia. A partially treated UTI.

The PRHO feels the abdomen is tender and has guarding with peritonism. I distract the patient and palpate through the guarding. Tender in the right iliac fossa yes, but not peritonitic, I’m content. Afebrile, a low B/P that has come up with resuscitation, and a raised WCC – about 20. Anyhow, at ASA Grade 3 with raging CCF, it’s unlikely we could do anything for say, acute cholecystitis, anyway.

I conclude she probably has a partially treated UTI, and script a letter while waiting for radiology to come back. She’ll go home and finish a course of trimethoprim away from this nasty place. I’m pleased at myself for holding her hand, making her smile, avoiding an unnecessary admission for a nice lady.

I’m at home when the radiograph comes back to the juniors with about half a litre of air under the right hemidiaphragm and she’s admitted to the ward. True, we can’t offer anything but a bed, but it’s arguably better to have morphine than go without. I apologise to the family the next morning for rushing into a hasty diagnosis without waiting, and feel an inch tall under their generous magnanimity.

She dies three days later.