Case 5

42 year old Thai male

C/o abdominal pain for 2 days.

Temp 37.9, BP 110/65
Not jaundiced
Diffuse tenderness on palpation of abdomen

What is the diagnosis?
How would you manage this patient?


Answer: Perforated hollow abdominal viscus

There is free air under both the hemidiaphragms in this erect CXR. Most commonly due to perforated peptic ulcer, but can also result from perforation of diverticula, Meckel's diverticulum, appendix etc.

Approach

• Manage as a P2 case.

• Large-bore IV access with crystalloid resuscitation
• Take blood for FBC, UE, GXM, PT/PTT, LFT and amylase
  
• If patient is in shock, consider supplemental O2 and urinary catheterisation
• Keep patient nil orally (not that he would have much of an appetite) and insert nasogastric tube
  
• Start IV antibiotics
• Inform surgeon stat and arrange for admission/ surgery

I'm always terrified when I see Thai or Myanmese patients at the A&E (and it's not because of the need of double-gloving mind you). They are usually extremely stoic characters so when they are unwell enough to come to the emergency you'd better search for some serious pathology as hard as you can, rather than just send them home with Panadol.

On the other hand, patients from the South Asian region (e.g. Indians, Bangladeshis) seem to project their symptoms in a rather melodramatic fashion, especially in their response to pain. I used to think it was related to their education level (e.g. the construction worker writhing in an agonized near-faint from a superficial finger laceration), but I've also seen senior bankers behaving in the same manner. It's probably more a product of their socio-cultural upbringing I guess, and we must be cognizant of this.

In short, beware the Thai patient with abdominal pain!