Trouble finding patient's appendix signifies rare congenital condition

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I worked the night shift at a teaching hospital in the Midwest. My most memorable patient was young man, who in his early adulthood was admitted to the hospital for an appendectomy. The preoperation orders stated that he was to have a laparoscopic appendectomy. Whenever a patient came back onto the floor after surgery, I would assess the surgical site to document the amount of blood on the bandages.

I noted that this patient had had a traditional appendectomy, but that the surgical opening was rather large even for this procedure. I continued to assess my patient and noted that for such a young healthy looking person his heart sounded very muffled. I made a mental note to check in on him later.  

Around midnight there was usually a lull in the shift, so I would use this time to check my patients' histories. I happened to be reading my new patient's history when his surgical resident came onto the floor. The resident asked for his chart to add some surgical photos, and I took the opportunity to ask him a few questions.

“I thought that the patient was to have a laparoscopic appendectomy. Did anything happen that I need to be aware of?” I asked.

The resident answered, “I suppose that you are trying to ask in a kind way why there is such a large opening? I started with a laparoscopic appendectomy, but when I looked into the scope, I could not find the patient's appendix. A fourth year resident then looked, but he could not find it either. So we had no choice but to open him up. That's when we discovered that this patient has situs inversus.”

Everyone around the nurse's station had overheard our conversation and was looking quizzically at the resident. “Situs inversus is a condition where all of the organs are on the wrong side of the body,” he explained. I asked the resident if that could also be the reason for the patient's muted heart sound. “Yes,” he responded. “It's just like if you were listening for heart sounds on the right side of a normal person — nothing would sound right.”

My shift ended at 6:30 a.m., but before I left I assessed my patient's heart sounds, listening this time on the right side. Sure enough, his heart sounded perfectly strong. I asked my patient if he knew he had this condition, but he said no.

As I was leaving the hospital that morning, it struck me very profoundly just how many times someone comes in contact with a healthcare professional from birth to young adulthood. It surprised me that no one had picked up on my patient's condition before that visit.

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