Medicine on Vacation

Hello friends, Just got back from a refreshing five week vacation in India.  During my stay there trying to get away from medicine, I found myself involved in a fascinating case.  I was staying at a town outside the city of Kolkata, which is a gigantic metropolis with population of at least 5 million people.  The house we lived in had two stories, and one evening around 6 pm, I was talking to our neighbors downstairs, when the man mentioned that his wife was having chest pain.  He knew incidentally that I was in medical school, and after hearing about the chest pain, I went downstairs - very nervously - to take a look at his wife.  Turned out that his wife was not just having some chest pain but very significant chest pain.  She was diaphoretic and thrashing in bed in agonizing pain.  She is a 45 year old woman with absolutely no past medical history.  She is usually very active, and starting from the night before, she abruptly started experiencing constant chest pain in the middle of her chest.  The pain did not radiate and did not worsen with exertion.  She had some difficulty taking a deep breath, and sitting up in a bent position worsened her pain.  My first instinct was to say that she needed to go to a hospital.  But, in India, hospital stays are usually paid out-of-pocket, and the decision to go to a hospital is hardly casual in terms of financial cost.  The husband asked if this was a heart attack.  However, given the age group, lack of any medical history, and constant non-exertional nature of pain, my instinct was that this was not a heart attack.  So, she stayed in bed tossing and turning during the night, and I advised them to see a "real doctor" the next morning.

The next morning, the pain changed.  In fact, she no longer had chest pain but rather had diffuse, non-focal abdominal pain.  There was no rebound tenderness, rigidity, hematemesis, or crampy quality to the pain.  They went to see a local doctor and came back with a diagnosis of "gas" along with antacid prescriptions.  The day went on, and despite the antacids, the pain did not decrease.  She also developed anorexia and nausea with one episode of vomiting.  By this time, they had also called their nephew, who had just graduated from medical school.  The nephew and I consulted together and agreed that she probably did not have an acute abdomen.  We were not sure what she had.  Since in India diagnostic tests don't need doctor's referral, we both decided to pitch in tests that we thought she needed - I voted for an abdominal ultrasound and the nephew wanted an abdominal X-ray (for probable obstruction).  They got the ultrasound, and it turned out that she had acute cholecystitis.  The next day when I left, she was getting ready to have an operation at a hospital.

The story is sort of crazy from a U.S. perspective because the whole process would be conducted in a hospital here.  But, in an effort to be economical, we made the diagnosis at home.  I learnt two lessons from this experience.  One is that epidemiology helps.  The patient was female in her forties with two children.  Despite her initial presentation of chest pain, gallbladder should remain high on the list.  Second lesson is that being a doctor is so much fun!!!