Re: GYN: RV fistula
From: Garry E. Siegel, M.D. (garrys@mindspring.com)
Thu Sep 1 17:29:40 2005
I just got a return phone call from her son, and intend to call him
today.
Thanks to all,
Garry
At Thu, 1 Sep 2005, art fougner, md wrote:
>
>Diverting colostomy might provide a bit of dignity in the last days ...
>the MRI might be another matter... Any input from the family?
>
>Art
>
>At Thu, 1 Sep 2005, Richard Chudacoff, MD wrote:
>>
>>With all do respect, depending the patient, this patient may just require
>>comfort care and hospice. If this patient has multiple morbidities, and
>>already near death, is the resources used for the MRI and surgery necessary
>>or best used somewhere else?
>>
>> .
>>
>> _____
>>
>>From: ob-gyn-l@obgyn.net [mailto:ob-gyn-l@obgyn.net] On Behalf Of Atkinson,
>>Samuel M
>>Sent: Thursday, September 01, 2005 1:57 PM
>>To: Multiple recipients of list OB-GYN-L
>>Subject: Re: GYN: RV fistula
>>
>>must consider colon carcinoma. needs MRI and Surgery (Colostomy)
>>
>> _____
>>
>>From: ob-gyn-l@obgyn.net on behalf of Dr. Ainsworth
>>Sent: Wed 8/31/2005 11:19 AM
>>To: Multiple recipients of list OB-GYN-L
>>Subject: Re: GYN: RV fistula
>>
>>Love those nursing home consults with not equipment available. You
>>described my experiences to a "T." I think you are exactly right, she
>>needs a colonoscopy, exam under anesthesia and would probably benefit
>>from a diversion, which could be temporary if you find a repairable RV
>>fistula and no malignancy. Inflammatory bowel disease is also a
>>possible cause. At her age with poor surgical risks, she would more
>>likely be a candidate for a permanent diverting colostomy.
>>
>>>84 YO P2002 in nursing home (unsure why) was hospitalized a local small
>>>hospital with severe pneumonia, and is just out of ICU. My practice was
>>>called for a consult for severe vulvar pain and a history of an RV
>>>fistula. All things considered, the patient is a pretty good historian,
>>>and that is pretty much where my information is from.
>>>
>>>She had an RV fistula diagnosed by the "nurse" at the nursing home in
>>>March, 2005. She is incontinent of stool, had vaginal deliveries, and
>>>never has had radiation, etc. Since March, she really hasn't had much
>>>vulvar irritation or pain except once, and now since being in the
>>>hospital.
>>>
>>>This is about all the history I took, frankly.
>>>
>>>On exam in the hospital bed on an inverted bedpan (no pelvic tables in
>>>this hospital, and the only light is with a flashlight), there is stool
>>>everywhere. After cleaning up (several nurses/aides/me), the vulva is
>>>diffusely edematous and erythematous, and the perineal body is intact.
>>>On a spec exam with a plastic, lighted ER speculum, stool immediately
>>>fills it. On a digital exam, there is a hole in the vaginal floor,
>>>around 1.5 cm., just below the cervix.
>>>
>>>So. . .
>>>
>>>Does anyone have any suggestions here? Obviously, it would be nice to
>>>examine her properly, I suppose, and see if there is a reason
>>>(malignancy) for the fistula. She is really not a surgical candidate,
>>>and I have zilch experience here. There is a part of me that almost
>>>thinks she needs a diversion. . .
>>>
>>>In the meantime, I made the assumption that this is probably yeast that
>>>has gotten bad after the antibiotics killed her flora, and thus I have
>>>given her Diflucan 150 mg. every 3 days for 3 doses, and suggested
>>>Mycolog II cream and trying Silvadene.
>>>
>>>Any thoughts on comfort measures or anything else welcome.
>>>
>>>Garry
>>>
>>>--
>>>Garry E. Siegel, M.D.
>>>Private Practice
>>>Roswell, GA
>>>
>--
>art fougner, md
>
> "If you don't know where you are going, you will wind up somewhere else."
>Lawrence Peter Berra
>
--
Garry E. Siegel, M.D.
Private Practice
Roswell, GA
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