LJ Idol Season 8 Week 3 Coprolite
Moving from the bustling corridor of Thomas County Teaching Hospital, a small group of first year residents huddled into the x-ray viewing room on the surgical unit. Dressed in blue scrubs, they were anticipating morning rounds with their Chief of Surgery.
Yawning broadly and stretching his lanky arms, Charlie Allen complained, “ Man, I sure did not get enough sleep last night. I can't believe I'm even on my feet this morning, “
"Well, I was out like a light after my 36 hour rotation this week. You can trade shifts with me anytime if you like," spouted Maureen Baker. Maureen was the girly-girl of the group with a moppet of springy auburn curls framing her face. She leaned against the wall and absentmindedly picked up the patient’s record and began flipping through the pages as the others continued to chatter away.
Abby Crane, the most reserved member of the group managed to interject, “ Hey guys, I hate to break up the fun but the Chief will be here any minute, so we better all look alive if we can."
"Look alive and make sense too!" piped Freddie Danforth.
After a little more teasing back and forth to help quell the anxieties of the day, Charlie muttered, "So what do we know about this patient we are rounding on this morning anyway? Where is the chart?"
"Right here", Maureen smiled." I just finished reviewing her history and physical and the lab reports. There isn't any x-ray report yet. She was admitted last evening with belly pain and her white count is elevated. It could be…”
Her words were cut off as the reading room door swung open. A sober faced x-ray technician came in and slapped a couple of films up on the viewing board and flicked on the light. "Here you go, boys and girls. Have fun with this one!" She giggled and marched out of the room stepping to one side just as Dr. Webster strode through the door.
The Chief of Surgery was a rather heavyset older man with a well-trimmed beard and slightly balding head. He had an aura of wisdom and experience about him. His glasses rode down on his nose a bit so he appeared to be looking over his glasses at the residents waiting in trepidation.
"Good morning, ladies, gentlemen,” he nodded. “I trust you have all reviewed the record.
Who would like to present the patient?"
The residents hesitated, looking at each other and then Charlie, Freddie and Abby each looked to Maureen. She was quick to sense that they all wanted her to step up. She had been the only one to look at the patient’s record so far. She was quiet for a moment, hoping they would get the hint to be more prepared in the future, then composed herself and looked at the chief.
"Irene K, is a 55 year old white female admitted yesterday evening through the ER with a complaint of abdominal pain. She has a history of chronic constipation and occasional laxative use. She has a low grade temp but her other vital signs are within normal limits. Her labs show an elevated white count indicative of a possible infection. The physical exam revealed right lower quadrant pain and rebound tenderness on the left."
"And what are we thinking for the differential diagnoses, given what we know so far?” Dr Webster pressed.
"It might be her appendix, but we can't rule out diverticulitis, or an ovarian cyst, or any of several other bowel or pelvic problems." Maureen surmised.
At that point, Dr. Webster asked, " What about the x-ray report?"
"There was no report in the chart yet but the tech just put some films up before you came in, sir." Abby offered.
The entire group turned and intently studied the gray and white images on the black screen. "Well, well, well. What have we here? Dr.Webster said in a very intriguing tone. Who would like to tell me what they see?"
Abby ventured, “I believe this x-ray is showing a fecaloma in the appendix!"
"Excellent observation, Crane!" You have correctly identified the culprit in our case." It is a coprolith.”
"Excuse me, sir, but could you explain a little more to us about this finding?" Freddie queried.
"Of course. This is a good teaching moment! A fecaloma, also called a fecalith or a coprolith, is a stone made of feces. Whenever chronic obstruction of transit occurs inside the human colon, the feces can harden into lumps of varying size. A small fecalith could cause either appendicitis or acute diverticulitis depending on the location of the stone. Our patient's history of chronic constipation, often due to inadequate roughage or fiber in the diet, probably contributed to this."
"So an appendectomy will be the treatment of choice, sir?" asked Maureen.
"Yes, indeed. Surgical removal of the appendix followed by nutritional counseling postoperatively. You all did a fine job this morning. Now let's go and inform our patient."
Yawning broadly and stretching his lanky arms, Charlie Allen complained, “ Man, I sure did not get enough sleep last night. I can't believe I'm even on my feet this morning, “
"Well, I was out like a light after my 36 hour rotation this week. You can trade shifts with me anytime if you like," spouted Maureen Baker. Maureen was the girly-girl of the group with a moppet of springy auburn curls framing her face. She leaned against the wall and absentmindedly picked up the patient’s record and began flipping through the pages as the others continued to chatter away.
Abby Crane, the most reserved member of the group managed to interject, “ Hey guys, I hate to break up the fun but the Chief will be here any minute, so we better all look alive if we can."
"Look alive and make sense too!" piped Freddie Danforth.
After a little more teasing back and forth to help quell the anxieties of the day, Charlie muttered, "So what do we know about this patient we are rounding on this morning anyway? Where is the chart?"
"Right here", Maureen smiled." I just finished reviewing her history and physical and the lab reports. There isn't any x-ray report yet. She was admitted last evening with belly pain and her white count is elevated. It could be…”
Her words were cut off as the reading room door swung open. A sober faced x-ray technician came in and slapped a couple of films up on the viewing board and flicked on the light. "Here you go, boys and girls. Have fun with this one!" She giggled and marched out of the room stepping to one side just as Dr. Webster strode through the door.
The Chief of Surgery was a rather heavyset older man with a well-trimmed beard and slightly balding head. He had an aura of wisdom and experience about him. His glasses rode down on his nose a bit so he appeared to be looking over his glasses at the residents waiting in trepidation.
"Good morning, ladies, gentlemen,” he nodded. “I trust you have all reviewed the record.
Who would like to present the patient?"
The residents hesitated, looking at each other and then Charlie, Freddie and Abby each looked to Maureen. She was quick to sense that they all wanted her to step up. She had been the only one to look at the patient’s record so far. She was quiet for a moment, hoping they would get the hint to be more prepared in the future, then composed herself and looked at the chief.
"Irene K, is a 55 year old white female admitted yesterday evening through the ER with a complaint of abdominal pain. She has a history of chronic constipation and occasional laxative use. She has a low grade temp but her other vital signs are within normal limits. Her labs show an elevated white count indicative of a possible infection. The physical exam revealed right lower quadrant pain and rebound tenderness on the left."
"And what are we thinking for the differential diagnoses, given what we know so far?” Dr Webster pressed.
"It might be her appendix, but we can't rule out diverticulitis, or an ovarian cyst, or any of several other bowel or pelvic problems." Maureen surmised.
At that point, Dr. Webster asked, " What about the x-ray report?"
"There was no report in the chart yet but the tech just put some films up before you came in, sir." Abby offered.
The entire group turned and intently studied the gray and white images on the black screen. "Well, well, well. What have we here? Dr.Webster said in a very intriguing tone. Who would like to tell me what they see?"
Abby ventured, “I believe this x-ray is showing a fecaloma in the appendix!"
"Excellent observation, Crane!" You have correctly identified the culprit in our case." It is a coprolith.”
"Excuse me, sir, but could you explain a little more to us about this finding?" Freddie queried.
"Of course. This is a good teaching moment! A fecaloma, also called a fecalith or a coprolith, is a stone made of feces. Whenever chronic obstruction of transit occurs inside the human colon, the feces can harden into lumps of varying size. A small fecalith could cause either appendicitis or acute diverticulitis depending on the location of the stone. Our patient's history of chronic constipation, often due to inadequate roughage or fiber in the diet, probably contributed to this."
"So an appendectomy will be the treatment of choice, sir?" asked Maureen.
"Yes, indeed. Surgical removal of the appendix followed by nutritional counseling postoperatively. You all did a fine job this morning. Now let's go and inform our patient."