My Emergency Medicine site evaluation was held with me and two classmates. On the first day, I presented my H&P on a patient who came in with pain that radiated from his back, to his general abdomen, and then to his epigastric region; with associated nausea and vomiting. It was an interesting case because we initially sent the patient home with a vague diagnosis of musculoskeletal pain with gastritis. The patient had returned a few days later, complaining of more severe pain, and was finally diagnosed with an H. pylori infection and bleeding duodenal ulcer. When looking back on the original visit, he did have an elevated WBC count and anemia that was not directly addressed. On the second site evaluation, there was a case presented by my classmate regarding a patient who had initially visited the ED complaining with abdominal pain and hematuria, and was diagnosed with a UTI. Two weeks later, he had returned to the hospital after his family and friends informed him that he was looking jaundiced. A CT scan was performed, which revealed cancer at the head of the pancreas. 

These were unfortunate stories of missed diagnoses in medicine. However, they reminded me of an EM podcast I listened to. It had described that not all abdominal pain complaints will be diagnosed within the first visit, and that subsequent visits with progressing symptoms often lead to the final diagnosis. I think it also taught the lesson that us, as providers, need to not only be good at diagnosing “horses”, but also look out for the “zebras”.

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