Date of Medical Observation: October 2008

A 38-year-old female G3P3 (2012) patient was referred by the OB-GYN Department with a consideration of Left adnexal mass probably Ectopic pregnancy; Myoma uteri, r/o Acute appendicitis.

The patient presented with tenderness of LLQ of the abdomen, febrile and with leukocytosis.   There was no RLQ tenderness, so we concluded that Acute Appendicitis could not have been the pathology.  We suggested further evaluation of the LLQ pain with serial abdominal examination.

 The OB resident did a pelvic UTZ which revealed a left adnexal mass and the pregnancy test was weakly positive.

The following day, the Department of OB-GYN decided to perform Exploratory Laparotomy with a consideration of Ectopic Pregnancy.  Upon opening, there was sudden gush of purulent fluid.  They traced the purulent fluid to the LLQ of the abdomen.  The left adnexae and uterus were noted to be erythematous and edematous with foci of blackish discoloration.

 However, they noted a reactive appendicitis thus prompting them to call for a Surgery resident for Intra-op evaluation.  I scrubbed in and found reactive Appendicitis.  Further exploration revealed multiple diverticulum on the sigmoid colon.  I was in a dilemma at first and could not pinpoint if the purulent material came from the adnexal mass, caused probably by the PID or from a ruptured diverticulitis.  However, the note of interloop abscess and purulent material extending up to the splenic flexure give us a higher degree of certainty that diverticulitis was the pathology.  And indeed, perforation on the wall of the sigmoid colon near the base of a diverticulum cinched the diagnosis.

After confirming the diagnosis we did a Hartman’s procedure.

INSIGHT

• Physical, Ethical, Psycho-social
• Discovery, Stimulus, Re-enforcement

The pattern for the diagnosis of Diverticulitis in this patient was evident if not very obvious.

If not for the consideration of other pathology specifically gynecologic, I would have considered diverticulitis as the most likely diagnosis.

Given these considerations, What I did was to clear the patient from having acute appendicitis.

Yet, I waited for the referring resident to decide whatsoever their plan for the patient. If they clear the patient of any obstetrics emergency or gynecologic pathology, My plan was to take the patient and manage her as Diverticulitis.

This was just a reflection of reality as far as interdepartmental referral system is concerned here in our institution. That is, if someone got the end of the rope he got the full responsibility. That is why, sometimes patients were being tossed and turned, will be Jumping and hopping from one department to another on his way to his final diagnosis.

 This is not the proper way of answering any referral. Im very certain that I will not take this kind of thinking when I go out of residency and go on with private practice. As I answer referrals I will see patients wholistically.