Posted by Dr. Aditya Sharma, MD
A 35 year-old female from a village in Achham was carried to our clinic by stretcher. She was brought here by several family members, including a healthy husband, just after the outpatient and delivery services had ended for the evening. During the previous two weeks, she had significant weight loss, abdominal swelling, and persistent vomiting.
Two auxiliary nurse midwives (ANMs) quickly obtained the patient’s vitals, which were worrisome because she had a high fever (103F), abnormally low blood pressure, and an unusually high heart rate. She appeared to have extreme physical wasting and was unable to lie flat on her back because of immense pain in her abdomen. We quickly inserted a large-bore IV and began early goal-directed therapy for sepsis with fluids and antibiotics that target a wide range of disease-causing bacteria. As her vitals improved, we carefully examined her markedly distended abdomen. We found a large semi-mobile mass, about the size of a volleyball, surrounding the entire circumference of the navel. Using our recently acquired ultrasound, we discovered that the mass was actually multiple pockets of fluid.
Ultrasound image of the fluid pockets that made up the abdominal mass
We tapped this fluid, revealing a thick yellow-white substance which was likely to be pus. Our provisional diagnosis was that the patient had an abscess in the abdominal area (or specifically, an intraperitoneal abscess).
While interviewing the patient, we learned that the she had burned her abdomen several months ago and had chronic secondary open wounds, which were left untreated. Given how superficial the mass was, it is possible that that the abscess was actually a large infected collection that resulted from the initial untreated burn.
During the laboratory examination, we found that the patient was HIV+. She and her family were unaware of this. Using the I-Stat machine which was recently donated to us, we also diagnosed the patient with hyponatremia, a condition in which the plasma sodium concentration is low. We proceeded with treatment to slowly correct her hyponatremia. At this point, it was clear that she needed urgent referral for both complete drainage of the large abdominal abscess and additional management for septic shock. We informed the family of the need to transfer the patient. They were initially reluctant because they believed she would be fully recovered once evaluated and treated by our clinic staff. However, they agreed to the transfer as we explained the urgency of her situation and advised them to immediately take her to the nearest hospital for complete management. We also instructed the patient and her family to return to our clinic upon their return from the hospital so that we can begin the relevant outpatient services for her, particularly regarding her HIV+ diagnosis.
Due to the ultrasound and I-Stat machines, we were able to correctly diagnose the patient and quickly find the optimal treatment for her. This case also demonstrates the multiple difficulties faced by many of our patients and the urgent need for the hospital renovation we are aiming to complete in the coming year so that we are able to provide our patients with necessary surgical services.
Good Work!