clever patient...

It was 6am in the morning....I had a good night sleep, 3 patients seen (and they all came within the same 30 mins) and no call from the ward after 2am. The patient was a 60+ y/o male sent into ED by the local 911 ambulance. The nurse had told me that the patient claimed that he had an intestine rupture. I looked at the patient behind my desk when the nurse told me that complaint. The patient is bed-ridden and he doesn't look like a "medicine man". "Another clever patient..." I grumbled as I walked toward him.
The history taking was long and unpleasent as the patient is a case of old stroke, bed-ridden and suffered from dysarthria. It tooke me a while before I get a incomplete image of what had happened. He claimed that he had constipation problem and use to enema himself. During the enema he had heard a "pop" sound and severe pain was noted over his lower abdomen. Indeed, he had an distended abdomen c rebound. But I also notieced he had a over filled bladder(up till the umblicus). I ordered a urinary catherization and gave him an NSAID jab. The catherization produced around 500cc of urine and his pain was not relieved. I ordered an abdominal cat scan and managed to get the full story this time. He did not use a glycerine ball nor evac enema(bottle of 118cc of glycerine) for enema instead he slided a hose(yes water hose) connected to a tap and inserted the other end into his anus. "Holy XXX" , he is right,  definitely a rupture in the colon. What amazed me was he had left side weakness and his left upperarm was contracted.

 I gave him 50mg of pethidine and called the surgeon. No free air was seen on the CT scan as I expected. The surgeon came and concurred with my decision. He was sent to OT and Hartman procedure was done.

 
Well, you don't need a scan sometimes - proper history and physical examination concluded your diagnosis. Sometimes I would tell my patient and their family - I take the image because I want to let you see the lesion....most of the time it was waste of money and time but it protect my ass  ....