A 60 year old woman came in in a wheelchair and was helped up onto the table by her two daughters. She had a very swollen abdomen (if she wasn't 60, I would have thought was about to deliver a baby). I stumbled through my Hausa phrases to find out she had had abdominal pain and swelling for two weeks (although it looked more chronic than that) with fevers, nausea, and some diarrhea. Her abdomen was pretty tender, but she didn't have obvious peritonitis.
I attempted an ultrasound and couldn't see much. Maybe some cloudy ascites or a large cystic mass? I consulted the more experienced medical doctor next door, who really couldn't tell much more by ultrasound. We thought perhaps ovarian cancer, infected ascites, volvulus...but she didn't have any signs of cirrhosis or an ovarian mass.
Another surgeon saw her, we got an abdominal x-ray and a Hct (no CBC...the CBC machine has been broken for the past week). Anemia, no volvulus, no signs of obstruction....the mystery remained. Next step, CT scan.
Just kidding. No CT scanner here (but maybe some day!).
I admitted her to the hospital and asked the gynecologists to see her the next morning. They didn't think she had ovarian cancer...so the mystery remained. Over the next two days she didn't get worse, but she didn't get better either.
Africa, ascites/abdominal fluid, fevers...hmmm. I did some reading and came up with my own presumptive diagnosis: tuberculous abdomen. It seemed to fit, despite the fact that I've never seen it before. Then again, there are plenty of diagnoses here that I have never seen before!
The resident thought she had ovarian cancer...I thought tuberculous abdomen. Really, no one knew what she had. Around here my "CT scanner" is a scalpel, so I took her to the OR. I'm starting to get used to taking patients to the OR without a clear diagnosis first...something that rarely happened during my training.
We made a "mini-laparotomy" and found a large, mass-like structure stuck up to the abdominal wall. It was covered with tiny granulomas. We couldn't see bowel or identify any other abdominal structures.
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| it looked something like this |
Josh- that's awesome...who would've thought! Next thing you know you'll be treating typhoid perforations. :)
Sarah- yes, we have a TB clinic (one guy, actually)...I think prognosis is pretty good with treatment
3 comments:
And apparently you can have third world experiences right here in the USA! I was also on call this past weekend, and am consulting on a man with miliary TB, and a distal small bowel stricture secondary to TB. If he weren't so debilitated, I would have operated, but we're trying to tune him up a bit first. I am so spoiled by that CT scanner...
what fabulous diagnostic skills you have dr. bradley! i'm so proud of you. do you at least have TB drugs to be able to treat her? does tuberculous abdomens respond to drugs?
Ahhh, so Dr. House does exist and lives in Niger! The difference between Dr. House and you is that he's got the latest equipment and tests and you've got.....the internet (hopefully).
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