Indexing Title: RJPeralta’s Medical Anecdotal Report 08-08
MAR Title: Storm
Date of Observation: September 2008
Three days ago, I assisted on a case of a 49-year-old male diagnosed as Acute Appendicitis,
anterior Neck mass, to consider Diffuse Toxic Goiter. The patient was admitted
five days ago and was delayed for Appendectomy because he cannot be “Pre meds”.
Why the delay? Because we are still waiting for the results of the thyroid
function test. Again why? Because
there is an anterior neck mass and a history of thyroid storm six years ago. The
Surgery residents have been trying to talk with the Department of Anesthesia to forego the thyroid function test results because
firstly the patient have no funds for the tests,and most importantly, our plan for appendectomy would not change whether the
patient is hyperthyroid or euthyroid. But they cannot because they are contemplating
that the patient might go into thyroid storm. At the wards, the patient had been
complaining of increasing severity of abdominal pain, right lower quadrant area without associated complaints. At the 5th hospital day, the patient was complaining with increased severity of the right lower
quadrant pain, with direct and rebound tenderness with muscle guarding. At that
point, we are entertaining acute appendicitis, probably perforative. We decided
to direct the patient to the OR. The whole procedure went well and the patient
was discharged yesterday.
Insight: (Physical,
Ethical, Psychosocial)
(Discovery, Reinforcement, Stimulus)
Helping
a patient get well with minimal cost in the shortest possible time has been one of my guiding principles in practicing Medicine.
In
this situation, what the patient needed is an Emergency Appendectomy and that should be addressed immediately but what complicates
the matter is his having a history of thyroid storm which lead the other department in requesting the thyroid function test. I understand their concern but would the patient benefit or suffer from the delay
of treatment? I mean, two days have elapsed before the said examinations
were done because of the lack of funds. Would the management change if the results
of the thyroid function tests are normal, elevated or decreased? In my patient,
the results were decreased TSH, elevated FT3 and FT4 but we still operated on the patient but before the Appendectomy even
without the benefit of the thyroid function test, we prepare 600 mg PTU, Esmolol and Dexamethasone, just in case. As a surgeon, I would still perform the appendectomy from day one whatever the results maybe because number
one there have been no objective findings that the patient would go into thyroid storm while in the wards but I’m not
saying he won’t, second, I would still perform the appendectomy whatever the results are, and lastly, we prepared for
it.
