Cannot Miss Diagnosis

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A Problem of serious concern in all Age Groups
Cannot Miss Diagnosis No.9
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Section Editor: Prof. T.K. Partha Sarathy

A 6-year-old boy was brought to the family practitioner’s office for cough, cold and fever. On arrival the boy appeared to be somewhat withdrawn and was only answering the questions in monosyllables and was always looking at his parents, perhaps due to fear. His temperature was 100oF with a pulse rate of 128/mt. There was some nasal congestion as he was obviously having a cold. The neck was supple and the cardiac status was normal. Breath sounds were heard normal on both sides.


The examination of the abdomen was essentially unremarkable and the genitalia was within normal. However, the family practitioner noticed ˝ to 1 cm red ulcerations in 5 areas of the body- 2 over the abdomen, one on the right thigh, one over the left foot dorsum and one over the back. The ones over the abdomen appeared somewhat infected, whereas the others were just early red ulcers. The mother said that he has scabies for which treatment was given in the past and he gets this on and off. The family practitioner was not impressed with the diagnosis of scabies, and he was unable to connect the cough, fever and cold with the findings of these ulcers. Although some of them were red, raised crusted areas a couple of them showed gross infection with exudate. The doctor ordered a complete blood count and urinalysis and while awaiting the results, he was thinking as to what could have gone wrong with this child.
A 74 year old lady was brought by her son and daughter-in-law to the practitioner’s office with a history of dizziness on and off for almost an year. A CT scan, ECG and carotid doppler studies done a few months ago by a neurologist in a hospital were found normal. The neurologist had advised her to take "anti-vert" when the symptoms get worse, thinking that it may be due to vertigo. Recently these episodes have became more frequent. The practitioner examined her thoroughly and found out that her cardiorespiratory status was normal for her age. Her BP was 146/90 mmHg and the pulse rate was 78/mt and regular. Breathsounds were heard all over the lung fields and were within normal. Neurological examination including fundoscopy were normal. Her plantar responses were flexor. However during the course of a complete physical examination the doctor noticed multiple black and blue areas in several parts of her body, particularly in the arms, lower legs and in the hips. The doctor considered the possibility of subcutaneous, spontaneous hemorrhages with ecchymosis; but the patient denied any fall or injuries and was not on any anticoagulants, aspirin or any other medications.
A 21 year old female was brought to the emergency department with a history that she fell forward hitting her face and got injured. She had a fair amount of swelling in the region of the jaw on the left side and one of the pre molars was broken resulting in bleeding of the gums. There was considerable redness and ecchymosis on the left side of her face partially covering the left eye and the eyelids were swollen. She denied any history of dizziness or epileptic attacks. While examining the patient the doctor found that there were many areas of redness and ecchymosis over her body, particularly over the chest and back. Examination of the lower extremities also revealed swollen bruised areas. Her left foot was swollen on the dorsal aspect and there was bony tenderness. The whole case was somewhat puzzling and the practitioner was convinced that all these injuries could not have happened at one time and due to a single fall. Much against the wishes of the husband the doctor recommended hospitalization of the patient for further evaluation and care

Discussion
There seems to be a common pattern in all of the three cases cited above. Obviously there are changes in the skin to suggest tramatic etiology . The history was by no means forthcoming and the clinical presentations were not based on a single incident. Obviously all these patients were physically abused. In the case of the child it is entirely conceivable that he has been burnt with cigarette butts by some one in the family; most often one of the parents.The elderly lady does not want to talk about the abuse she is receiving from her daughter-in-law frequently for the things that she has done or has not done. Slaps – kicks and throwing things at her were almost a everyday occurrence.
The young lady was only married for a few years and she soon realized that her husband was an alcoholic, perhaps also a sadist. He was hitting and kicking her frequently and many times he assaulted her with whatever he had in his hands.
If one carefully looks at these extraordinary manifestations of injuries it is obvious that the age of different injuries are different and they happen because of some one in the family has been physically abusing them. The family practitioner has to be aware that such a condition called "family violence and physical abuse" exists. It is very difficult for the family practitioner to come to any conclusion as to who was actually causing these physical abuses to the patient. He should think that he has two patients in his hands to deal with; one the injured and the other one who is the abuser and who probably has psycho-neuro and/or alcohol abuse problems requiring treatment. That means the history is absolutely important and may not be forthcoming candidly in the first visit particularly in the presence of others. It may be necessary to admit these patients and in privacy with concern and care it may be possible to get an insight into the problems as well as the specific history of who is causing these abuses. In the case of the child the child should be absolutely reassured that he/she will not be let down and the doctor will not cause any problem to him/her. Only after such assurances the child may even want to mention about who is causing these problems. The fear of being even more abused if the abuser comes to know about his/her talking to the doctor is always present.
The young woman who suffered abuse from her husband does not see any life beyond the family and her husband. Perhaps there are other factor like she has no other place to go to or the in-laws are less responsive to her problems etc. It requires a lot of emotional support, reassurance and some psychiatric counseling to make a woman stand up to her rights and seek help to prevent future abuses.
As far as the old lady is concerned; the situation is even worse. Old people are towards the end of their lives and are entirely at the mercy of whoever is taking care of them. The daughter-in-law in this case was giving her the food for sustenance. Otherwise she may have to starve to death and cannot even say too much to anyone because of the fear of being abused even more. She has to grin and bear the torture at the hands of her own son’s wife.
The family practitioners must have the time and patience to deal with such complex home situations. Unfortunately he is the only one who can really counsel the members at home and do something about it. In the case of the old woman her son was not aware of his wife’s cruelty to his mother and when the doctor explained to him the situation he was able to understand the same and as a first step placed his mother in an old age home where she would be treated with dignity. He then took his wife for psychiatric counseling. He agreed that his wife was emotionally irritable even at slight provocation.
The doctor treating the young lady was able to refer the lady to a "Feminist group" and with their help he was able to provide some justice to her. Although lost for follow up it is believed that she received some help from the law and also from social workers. The problem of the child does not stop easily. More often it is the father and at times the mother who hurts the child for reasons beyond the scope of this article. It is entirely possible that only one child among several children in a family will be treated like this and it will be impossible to comprehend the reasons unless appropriate psychiatric evaluation is obtained. It is very difficult to establish that the person who assaulted the child does not love the child. More often the mistake is compounded because of the guilt feeling after hurting the child.

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Monte 

probably i m also facing the same problem since yesterday, so can you tell me about the duration until which such torsions in testes are reversible. please reply me quickly. here also the swelling is observed first time in my 19 years & is a bit painful too.

soroush 

it was better if you mentioned that his pain was acute onset or not

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