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Julie V, aged 6, was enjoying her summer vacation at a seaside resort when she developed severe central abdominal pain and vomiting.
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The following sad story is presented in chronological sequence.
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Day 1: Sudden onset of central to lower abdominal pain and vomiting. Patient looked pale.
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Day 2: Abdominal pain and vomiting persisted; difficulty in walking, febrile. Patient appeared very sick and pale. The doctor made a home visit, took her temperature and palpated her abdomen. ‘It could be appendicitis but it’s probably gastroenteritis. I’ll prescribe antibiotics and she should settle.’
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Day 3 am: Abdominal pain now very severe; vomiting and fever worse. Diarrhoea developed and Julie was too sick to get up. The doctor explained over the phone, ‘The diarrhoea is due to the antibiotics. I’ll prescribe an antidiarrhoea mixture’.
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Day 3 pm: Mother phoned the doctor to say how concerned she was because Julie was getting worse by the hour. She asked whether Julie should be taken to hospital. ‘It’s not necessary. They’d only do what you’re already doing at home.’
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Day 4 (Saturday) am: Patient worse: very pale; diarrhoea now almost continuous. Mother visited doctor’s surgery and was told, ‘These gastro things can go on for a few days’.
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Day 4 pm: Parents took Julie to a base hospital about 30 km away. The casualty doctor diagnosed acute appendicitis and peritonitis. At surgery a perforated gangrenous appendix was removed and a pelvic abscess drained.
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Day 10: Julie was discharged home, very lethargic and weak with residual abdominal pain.
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Day 12: Julie developed abdominal pain, fever, nausea and diarrhoea. I was called to see her for the first time. Examination revealed a tender abdomen and a tender boggy mass was palpable per rectum. A diagnosis of pelvic abscess was made and the patient was hospitalised under the care of her surgeon.
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Days 13–18: Pain, fever, nausea and diarrhoea persisted. Conservative treatment was given but the patient grew weak and wasted.
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Day 19: Spontaneous discharge of pus per rectum relieved her symptoms over the next two days.
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Days 22–41: Julie went home and gradually improved, despite intermittent bouts of colicky abdominal pain.
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Days 42–151: Julie was very healthy and normal, free of abdominal pain.
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Day 152 (Sunday): Julie had a sudden bout of agonising abdominal pain followed by vomiting. As I was unavailable at the time, the locum service was contacted. A young locum appeared at the door of the house and was told the history, with the suggestion that this new development could be related to the previous illness. ‘Do you want me to stay or go?’ he asked. He stayed and examined Julie’s ears and throat; palpated her abdomen; and asked her to walk, hop on one leg and then jump. (She failed the latter tests.) He then announced confidently, ‘There’s absolutely nothing wrong—she’s possibly coming down with a gastro thing. That will be $90.00’. All in 3 minutes!
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Day 153: The patient remained in bed, sleeping almost constantly and moaning occasionally with pain. She had no bowel movement. Her temperature started to rise in the evening and she grew pale.
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Day 154: She developed very severe pain and had a possible haematemesis at 1 am. She was visited by her regular doctor and admitted to hospital at once. After several hours of resuscitation in intensive care, being treated with intravenous fluids and antibiotics, she was taken to theatre for a laparotomy. A loop of small bowel, obstructed by adhesions, was found to be gangrenous and perforated leading to blood-stained faecal peritonitis. The section of bowel was removed, an end-to-end anastomosis performed, and the abdominal cavity carefully cleansed with cephazolin solution.
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Days 155–180: Julie had a long convalescence in hospital with treatment for a subphrenic and a pelvic abscess.
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For the next 12 years, Julie continued to have problems after further surgery for adhesions and intra-abdominal abscesses. Medical litigation was instituted and a settlement was eventually reached. Now, as an adult her main problem is sub-fertility.
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DISCUSSION AND LESSONS LEARNED
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Appendicitis should never be underestimated, especially in young children. It should be foremost in mind when ‘gastroenteritis’ appears to be getting worse.
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A rushed physical examination, especially in the home, can be full of hazards. In particular the all-important rectal examination gets neglected.
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In this case the previous history appears to have been ignored. Any current illness should always be assessed within the context of the past history.
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The importance of continuing care by the same doctor is obvious. Perhaps we should make ourselves more accessible after hours to these patients and families.
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We should be considerate of the difficult position of parents with sick children and be sensitive to pleas for help. Unfortunately, the many anxious calls for help in this case resulted in angry responses.
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It’s easy to be wise after the event.