Medicine is not a precise science; certainty is impossible to guarantee. Doctors are fallible. When making a diagnosis, we play the odds, treating what is most likely, with an eye out for rare conditions which we shouldn’t miss. “Common things are common” is a truism, but “when you hear hoofbeats, think of horses, not zebras.” (Well, perhaps not in Zambia.) But even unusual versions of common diseases are more likely than rare diseases.
Kutupalong health facility, November 2017. I was called into a consulting room to give a second opinion. The nurse told me that the patient had pus coming from both eyes for three years.
“Three years?” I asked. “On and off for three years or every day?”
“Every day,” replied the nurse.
That’s very unusual. Sometimes patients exaggerate the length of time they have symptoms. Perhaps the lack of medical care in northern Myanmar for Rohingya people was a factor, resulting in chronic infection or conjunctivitis.
I looked at the patient. Her eyelids were coated with yellow discharge and her conjunctivae were inflamed.
“What do you think is wrong?” The nurse didn’t reply, she is very shy.
I gave her a short tutorial on different causes of conjunctivitis and asked her which was the most likely.
“None of them. She has dacryocystitis,” she said.
“If she had inflammation of the nasolacrimal duct, there would be swelling here,” I said, pressing the patient’s face, just by the nose and below the eyelid. A spurt of pus welled up over her eyelid and ran down her cheek. A bit like the egg I now had on my face.
“Dacryocystitis is very rare in adults, but your diagnosis is spot on here. Good call. Why did you ask for my opinion?”
“Because I don’t know the best way to treat it,” said the nurse. Fair enough. The patient needs some delicate surgery to sort out the problem.
The medical assistant called me to the Emergency Room. “Acute appendicitis,” he said. I asked him to present the history. He had recently joined the team and was unused to speaking English. Perhaps lacking in confidence, he repeated, “Acute appendicitis.”
“What about the details, when did the pain start, where is it, did anything make it worse, did anything make it better, any other problems? You know how to do this,” I asked.
“She had pain for ten days, and fever before then. She is tired and has lost weight.”
“Isn’t ten days a bit long for acute appendicitis?” I asked.
Silence. “Anything else?” I enquired.
The doctor reached out with pointed fingers and prodded the patient’s abdomen. “See, McBurney’s positive!” he said.
Ouch. It even made me grimace. “OK, let’s start by introducing ourselves and putting the lady at ease.” Then I kneeled down by the bed and gently touched her abdomen with the flat of my hand. Her tummy was soft, with no muscular guarding, no signs of peritonitis and I could press down over where her appendix should be (McBurney’s point) without her flinching. But there was some liver enlargement which had gone unnoticed. This clearly wasn’t appendicitis. It wasn’t even an acute abdomen.
“Why do you think she’s breathing so fast?” I asked.
“Because she has abdominal pain,” he replied.
“But the pain isn’t making her anxious. Could it be something else?”
“Pneumonia?” he offered.
“But her blood oxygen saturation is 99%. Her chest is clear. She sounds as if she is breathing like a steam train. We call this Kussmaul respiration. Perhaps she has a metabolic acidosis and she is breathing out more carbon dioxide to compensate. Have you checked her blood glucose? Or her urine for ketones?”
A random blood glucose was more than twice the upper limit of normal – she was diabetic. She didn’t have acute appendicitis. Her abdominal pain was caused by diabetes. Sometimes you have to look beyond the obvious to find the cause of a patient’s symptoms.
The little boy had not passed urine for a day. He was in a lot of discomfort caused by a grossly swollen bladder. The foreskin was very tight, so the doctor thought this could be the problem.
“OK, try getting the finest nasogastric tube into the penis to drain off the urine,” I said.
“Not possible, because the foreskin is swollen.”
“Let’s try to reduce the swelling then – try ice packs, covered in cloth,” I replied.
The ice pack was successful. The doctor pulled back the foreskin, inserted the tube and out flowed the urine. He proudly showed me his handiwork.
“Well done, but don’t forget to pull the foreskin forward again. We don’t want to convert a phimosis into a paraphimosis (where the foreskin is stuck in the retracted position),” I warned.
“No, it is better to leave it like this. If we pull it forward, it will cause urinary retention again,” said the doctor.
“Hmm, I would prefer it if you pulled it forward,” I said.
I don’t like saying “I told you so” but the next morning, the same doctor came up to me and said, “You told us this would happen,” showing me the swollen retracted foreskin. “Back to the ice packs,” I said.
“If this fails, should we insert needles into the skin to allow the oedema fluid in the prepuce to escape?” asked one enterprising doctor.
“How on earth did you discover that trick?” I asked. Not on earth – it was via the internet.
“Hopefully we won’t need to insert any needles.”
But I was wrong. This time, ice packs didn’t work and the doctor had to stick needles into the swollen skin. Enough tissue fluid oozed out, allowing him to ease the foreskin forward again into its usual position.
“What do we do now?” the doctor asked.
“Well, he is almost three, that’s when he would normally be circumcised. This would provide a definitive solution. Can you ask the father to arrange for this to be done?”
“Good idea, doc.”