Red Herring

If you see a patient with bilateral leg swelling and redness up to the knees, right iliac fossa pain and bile vomiting, all for the last 3 days, what would your differential diagnosis be?


In this story of mine, the doctors in the emergency department (ED) put left leg cellulitis as the impression of the case and discharge him home.

The next day, he came back again to the ED and this time he was put on ventilation mask 40%, his vital signs were to be monitored and his case was to be referred to the medical department. He was not admitted to the medical ward. He was discharged. The impression was:

1. TRO PE (Well's score 7.5)
2. UTI
3. Left leg cellulitis
4. AKI secondary to poor oral intake

At 3.36 am the following day, he was brought to the ED for the third time. He had sudden onset shortness of breath for 1 day. From the yesterday's report we could deduce that he already had his dyspnoea yesterday or else the doctors' plan would not include putting a ventilation mask. From respiratory examination he showed bilateral right lower zone crepitation. Now, the impression has changed to:

1. Acute abdomen
2. Left leg cellulitis
3. AKI secondary to sepsis
4. Aspiration pneumonia with Type 1 respiratory failure

Immediate investigation tests were ordered, also fluid challenge and antibiotics were started. He was urgently admitted into medical ward under acute bed and the surgical team was referred.

At 11.39 am the findings of abdominal examination from medical team include distended, guarded, and tenderness over umbilical, suprapubic and right iliac fossa. Diagnosis was TRO acute abdomen with intraabdominal sepsis.

Surgical team came at 2.28 pm and their diagnosis from the abdominal examination was peritonitis. They reviewed the abdominal X-ray done on the first day of admission to the ED and found dilated descending colon. Repeated X-ray showed the dilatation has increased.

Now that they know peritonitis was happening they had to rule out the cause. Their differentials include perforated appendicitis, bowel ischaemia, and perforated tumour. He was scheduled for an urgent laparatomy.

Report from Operation Theatre (OT) at 6.49 pm on the same day showed that he has intraabdominal sepsis secondary to perforated sigmoid diverticulum. So the surgery done was to create an opening (stoma) from the sigmoid to outside of the abdomen (sigmoid loop colostomy) and peritoneal washout.

I was there with the surgical team when they went to medical ward and review the patient. I even examined him and also more or less was able to elicit the tenderness and guarding of the abdomen. I remember him as he kindheartedly allowed me to examine him. I did not see his operation, though.

Further report from surgery in OT was that he was to be transferred to ICU for post-op stabilization. 

The next day around 7.05 am, I followed ward round with Mr M (as usual!) and in the HDW (High Dependency Ward) we came across this one patient with worsening condition. This man has nil urine output and in persistent hyperkalemia state. His ABG was:

• pH 6.84
• p02 82
• pC02 48
• HC03 4.3
• BE -25
• Lactate >15

So his ABG showed that he has lactic acidosis (defined as lactate levels >5 mmol/L and pH level <7 .35="" and="" are="" body="" br="" commonly="" depleted="" fluid.="" found="" his="" in="" life-threatening.="" note="" patients="" ph="" sepsis="" severe="" severely="" that="" trauma="" very="" was="" which="" who="">
The patient was horribly familiar to me and it dawned on me that this was the patient I examined the day before! In one day he had turned from very ill to near dead condition. Mr M said to inform the relatives about his condition and that DIL (Death In Line - meaning that death is very highly likely soon to happen) is imminent.

At around 9.40 am I went back to HDW and saw another surgical specialist (Mr R) talking to the relatives. He was the one who operated on him the day before. I like Mr R. He was merciless and strict with housemen but he teaches them from time to time and he was superbly wonderful to patients and relatives. He listens well and he talks softly. He makes sure that they understand what is going on and in turn he understands the other party. He is that type of surgeon I'm inspired to be if I choose surgery later on.

Anyway, he listened to the relatives' side of the story, about how frustrated they were when the ED dismissed him twice before finally were able to see past the swelling leg and focused on the abdomen. Mr R urged them to bring this up to the management using proper channel so that the hospital will improve on its quality but they only wished that there will be nothing similar of this sort should happen again to anyone else. They accept what had happened and chose to leave it to fate.

This is the red herring in medicine where obvious things are distracting you from a really serious case that is in occult and silently happening somewhere else. It's hard not to focus on the obvious signs or symptoms the patient has but I think the right way to treat is to think of the patient as a whole and not just a chunk of leg. Think of a patient as a human being who are alive supported by various body systems; cardiovascular, respiratory, nervous, etc. We should be extra vigilance in making differential diagnosis and to be ever-watchful for red-flag signs or symptoms that herald an emergency treatment.

In the afternoon ward round we went again to the HDW and saw the bed he was in was empty, cleaned and propped up. That could only mean one thing and that he was finally succumbed and died. There's no further comment from Mr M, he just continue with his round and attended other similarly ill patients. But the case will be brought up in the mortality case report, he said. There is a certain subdued sadness upon facing deaths in the hospital, I like to think. We accept that there's a limit to what we can do to sustain life and to treat, but ultimately life and death are God's business.

Al-Fatihah to the deceased and may Allah blesses him, amin.

To Allah we belong and to Him we shall return.

Quran Surat Al Ankaboot 29:57