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Good clinical examination clinched the diagnosis

Greetings of the day 

Down the track of Memories

Another  story  from PGIMER Chandigarh

Years back , while working as a DM student.

Mr. Paul  Singh (name changed) a 49 year old thin built person presented to our  clinic at PGI Chandigarh with pain abdomen off and on for  the past 12 months .Pain was   intermittent and diffuse. He had lost around 14  kilograms of weight during this period.For these complaints he had consulted a lot of doctors. Apart from baseline investigations he had undergone UGI endoscopy twice, Colonoscopy once and all other investigations  required for evaluation of an unintentional weight loss. Based on a few small lymph nodes in his CT scan abdomen , Anti tubercular treatment  had been started by some doctor .The patient had continued treatment for 2 months without any  relief and  stopped it in despair. Ultimately Mr.  Paul Singh had been  started on anti depressants   as no definite cause  could be  ascertained by the doctors.Finally he came to PGI.

That day Prof SK Sinha saw the patient in the new OPD block at  PGIMER ChandigarhAfter a  detailed history he  scrutinized his thick file quite meticulously. Soon after his clinical examination Prof Sinha called  us (DM residents) to his OPD room.“Please examine his abdomen individually but do not discuss it with each other “, Prof S K Sinha said in his usual  soft tune.Three of us examined the patient. Yes guys, what  did you find ? Prof Sinha inquired after sometime .Sir, the abdomen is soft , it is not distended and is not tender. There is no organomegaly. There is no free fluid .All of us had a similar description of  our respective   clinical examination findings .Prof Sinha  went on listening keenly to our findings and finally glanced at all of us and smiled .Yes, he just smiled.There was a power behind his smile .His unique smile would play with one's adrenals and adrenaline thus leaching would leave the student's heart racing, motivating one to read and understand the subject. I must say, he would never scold anyone on rounds or during endoscopic procedures.Ibrahim! What are the steps of abdominal examination? Prof Sinha inquired.Sir, Inspection, Palpation, Percussion and Auscultation. " I replied.

Did u auscultate? Yes sir, the bowel sounds are normal, I replied.Prof Sinha, smiled again.

Now all of us were sure that things were not as straightforward as they seemed to be."Aisya to nahi chalaga" (Things won't work  like this) .He whispered softly.Then he put his stethoscope on the patient's abdomen somewhere near the  belly button. While holding the bell of the stethoscope he asked all of us  to listen one by one .We did so.

"Shoo, shoo. shoo" there was a soft low pitched bruit(noise produced due to turbulent flow) audible there. Nevertheless, it needed a very good amount of concentration and focus in order to listen. This bruit  was produced by the blood flow through narrowed segment of mesenteric vessel(Abdominal vessels feeding intestines) Patient's mesenteric angiography was done, narrowing demonstrated and a stent was placed across, to take care of the blood flow in the  vessel .Following this procedure Mr.  Paul Singh   became perfectly fine  and progressively gained weight. Thus Mr. Paul Singh had neither malignancy nor depression. He had mesenteric vessel insufficiency leading to on and off  pain abdomen while eating. His narrowed abdominal vessels were not able to provide extra blood flow to the gut, normally required during  eating. So he would get a pain abdomen and avoid eating. A vicious cycle of food pain relationship  had started for the past one year  leading to his weight loss.This phenomenon was  picked up by our great Professor during a routine clinical examination. Kudos! By Wednesday of the fourth week Mr. Paul Singh came smiling and respectfully greeted Prof Sinha in his OPD. He thanked him wholeheartedly.All of us were thrilled to see him. He had no more a skinny look as he had regained his facial sheen. He had added 6kgms to his weight, just after a month post procedure.Above all, he was pain-free after a year long suffering. Great old days!

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Comments

  1. Good One sir......we had a similar case where I had not done a full clinical examination and based on reports had determined a patient to be having depression but turned out he has lymphoma.

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