Images in Clinical Medicine Lost in Communication

Lost in communication This is a case of a 95 year lady who was brought to the accident and emergency department with vague right hip pain. She was deaf and mute and taking history from her was like " mission impossible " !. She was conformable in bed and initial examination was documented " unremarkable " apart from right hip tenderness on movement. Her old notes indicated that she had intra-medullary nail for femoral neck fracture in the past; Therefore, pelvic and right hip X-rays were requested to rule out any fracture. No fracture was found but, surprisingly, pelvic X-ray (figure 1) showed dilated small intestinal loops. On re-examination, her bowel sounds were exaggerated and she had a tender small swelling in the right groin. Her plain abdominal X-ray and CT scan (figure 2) confirmed the presence of small bowels obstruction [1,2] due to an obstructed right femoral hernia. Figure 1 Pelvic X-ray: no evidence of fracture. However, there are dilated intestine loops. Figure 2 abdominal X-ray: dilated small intestine loops that confirm small intestinal obstruction Figure 3 Abdominal CT scan: dilated small intestinal loops. Learning points 1. One should be prepared for the challenge of dealing with patients who cannot give proper history. 2. Proper full examination is very important particularly in patients with limited abilities. 3. Not to be misled by pre-existing medical condition as there may be something else more serious.