Immigrant refuses appendicitis care

A patient came into our clinic after recently relocating from another country. Her daughter accompanied her and acted as her interpreter. The patient's complaint was abdominal pain that she had had for several days. She had a fever of 101° F, midabdominal pain, cramping and some nausea. She had never had abdominal surgery. Her other health problems were noncontributory.

On exam the patient was guarding; bowel sounds were silent and she had rebound tenderness. There was also a small mass palpable in the right lower quadrant. Based on these findings I referred her to our local ER, but she didn't want to go. Instead the patient asked me to “fix it." I felt this was a surgical abdomen, so I called ahead to the ER and spoke with the triage nurse. The patient was concerned about the expense she would incur when going to the ER. I assured her the hospital would gladly make payment arrangements, but that she needed to be seen and evaluated for an acute abdomen.
 

While being discharged the patient asked if she could "have her money back" as I "didn't do anything for her." I responded that my experience and the physical exam indicated an acute surgical abdomen – this was the my very best clinical advise and she wouldn't be getting her money back. She left unhappy but did go to the ER, where they immediately performed an abdominal CT scan, verifying a walled-off abscess and acute appendicitis. She was taken to surgery and admitted to the ICU for several days with IV antibiotics. 

This is something I couldn't fix. But I could evaluate the patient's symptoms, and because of this her life was saved. This is well worth the $56 office visit to provide the best care possible from start to finish.

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