made my day (its the small stuff)

I had a small moment of victory in clinic today amid a morning of mysterious and difficult cases. A young man came in with a week of pain in the right abdomen. No fever, no nausea, nothing else. Just pain. On exam he was tender in the exact right spot for appendicitis. McBurney's point. At this stage, many surgeons would feel comfortable going straight to the OR to operate for appendicitis (although in the States we would check the white blood cell count, the urine, and might still get a CT scan or ultrasound).

Well, I tried the "just operate" approach yesterday. First for a man with almost the same story and pain in the same place. But, when I operated I found not appendicitis but typhoid that was almost perforated. I had to make a second incision to fix his intestines. Not only did he get two incisions, but it was a bit frustrating and made the operation last longer.

Next, I operated on a little boy whom I thought had appendicitis, but his story and physical exam weren't as clear. I tried to ultrasound but couldn't see the appendix. Since I didn't want to end up making two incisions again, we just started with the bigger incision (its not that common here to have straightforward appendicitis, anyway). Turns out it was ruptured appendicitis.

So, with my patient today I was determined to try to find the appendix on ultrasound again. Third times the charm, right?! After just a few minutes with the probe on his belly, I almost couldn't believe my eyes. There it was!  So clearly! A thickened, inflamed appendix.  I could even see the hardened stool ball (fecalith) blocking the appendix and causing his appendicitis. Look!:

see the appendix?! It measured 1.2 cm in diameter.

I sent him over to the operating room to have his appendix removed. There was a lot more to be seen in clinic, but nothing a straightforward as the appendicitis. Here are a few pics:

For seven years this man has had a growing mass dangling off the first part of his arm. What is it? I do not know, but we will take it off and see. 

This man showed me these stones that had come out in his urine six years ago. (He saved them a long time!)

Unfortunately, he now has more stones. (those bright round things).

Mouth tumor...I'm so happy that we have a head and neck surgeon coming to visit us in just a few weeks!!!

large, fixed chest wall mass, there for two years and growing...should we try to take it off?

another one for the urologist...a narrowing of the urethra (stricture) so this man has to urinate from a tube in his bladder