Saturday, May 24, 2014

Interesting cases part one

For those of you a bit queasy, this post is not for you. This is for those either a)medical or b)interested in medical stories.




This is a photo depicting the leg of a young girl, I believe she is 11 years old. The probe is in her femoral vein, if I remember correctly. She presented with a swollen, painful right calf. Two weeks prior she had cut her foot on a piece of a tin can. The cut on her foot had healed, and did not look infected. We did an ultrasound to look for DVT, but unfortunately did not look high enough in her leg (only looked from about the calf down, since that is where the swelling was). The next day she was admitted to the ICU with tachycardia, hypoxia, and right heart strain. She also developed high fevers. We did a more thorough ultrasound and found a large thrombus in her femoral vein. With all her signs and symptoms, we suspected a septic thrombus. We put her on heparin, but without thrombolytics, there wasn't much else we could do except amputate the leg above the thrombus. We did an amputation of her right leg, and this photo shows the amputated portion. When we cut into the vein, there was pus that came out. She improved dramatically in the days following the amputation. Clearly the surgery saved her life. She did fairly well emotionally too. Her father has some form of deformity in his legs (I can't recall what), so the idea of a person walking with crutches for their whole life wasn't foreign to her or her family. I think this helped her to cope, and had it not been the case, I'm not sure her parents would have agreed to the surgery. Dr Lindsey is looking to see if it will be possible to obtain a prosthesis for her.


This next photo is the leg of a sweet little girl who fell at least a year prior, and sustained an open tibial fracture. Obviously it wasn't well reduced (often a result of traditional treatment), and resulted in part of the tibia sticking out of the leg. We gave her anesthesia and pulled out the dead bone you see here, then put her in a cast to stabilize the leg as the remaining healthy bone heals in. I suspect her fibula will tibialize to support her weight. 


This little boy presented with abdominal pain, fever, and a distended abdomen. While the first concern from the history was for peritonitis, further physical exam and ultrasound confirmed a large abscess between his abdominal muscles and skin, which extended down into his scrotum. It required a very large incision to drain. This photo is after several dressing changes, when it was starting to heal. Soon after, we were able to close the skin secondarily, and he was able to go home.


This young lady, in her mid 20's, sustained this ankle fracture in a motorcycle accident.  (Which is where most of our Ortho cases come from.) She presented several months after the accident. This was beyond our ability to treat, as ankle/foot fracture of this nature are a challenge even to orthopods and podiatrists. When we told her we wouldn't operate, she fell to the ground, crying and pleading that we would do something for her. Then we called in her mother to console her, and when we informed her the same news we told her daughter, she also fell to the floor and did the same. They weren't without hope, as there is a doctor in a nearby town who was willing to operate, but they were hoping they would have something done at Nyankunde.



I came in one morning to see two of the Congolese doctors attempting a D&C for a retained placenta. They were using ultrasound guidance, and found the placenta seemed to be oddly placed...very superior in the fundus, and no plane of separation. This is because she had placenta increta, where the placenta has grown into not just the endometrium, but the myometrium (uterine wall) as well. Thankfully it wasn't through the serosa (which would make it placenta percreta), as that is more difficult to treat. Kimiko and I are doing a hysterectomy in this photo.
This young 40 something year old presented with early satiety and an abdominal mass. She was also anemic and appeared mildly malnourished. The mass you see in her abdomen is her spleen. The following photo is her spleen after we removed it. I believe it weighed at least 5 lbs! It was heavy, at any rate! It's not often we do a splenectomy for splenomegaly, but in her case, it was definitely warranted.





This x-ray is from a young man who presented with shortness of breath. Diagnosis? 
He felt much better after we placed a chest tube. 


This 30-something year old man came in with a leg mass that he had for at least 2 years. It has progressively increased in size. We offered to do surgery to remove the mass (it appeared well-circumscribed, no boney involvement) but he never returned for surgery. I'm not sure if he was still looking for money to have the surgery done or he decided to go elsehwere.

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