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Diagnostic Illness Script Problem

Summary Data Acquisition Management Plan
Accuracy Concordance Representation

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DATA ACQUISITION

Efficiency
42% KEY  MATCHED

Thoroughness  MISSED
69%
 NOT SELECTED BY THE EXPERT

EXPERT'S DATA FEEDBACK

TRIAGE

 Age - Elderly (>65 yrs) Overview::

 Chief concern - Abdominal pain Acute abdominal pain with low blood pressure and tachycardia - an "acute abdomen" - is a critical
presentation requiring immediate evaluation. Potential causes include hemorrhagic conditions like
 Setting - ED ruptured abdominal aortic aneurysm; bowel or stomach perforation; inflammatory processes
including appendicitis, cholecystitis, and pancreatitis; ischemic events like acute mesenteric
 BMI - Obese ischemia; and non-specific or rare conditions. The diagnostic approach necessitates a detailed
BP (90-119 / 60-79) - Low history and physical examination, followed by targeted laboratory and imaging studies. The

diagnostic process must be individualized and adapt to the clinical context, recognizing that this
 HR (60-100 bpm) - Elevated schema is not exhaustive. Critical challenges include possible misdiagnosis due to overlapping
symptoms and the urgent need to identify the underlying cause to initiate appropriate treatment.
 RR (12-18 br/min) - Elevated

 Temp (36.6-37.8 C) - Normal Small-bowel obstruction (SBO): 30%

The severity of the pain and abnormal vital signs, especially hypotension, should signal emergent
 Sex - Female MISSED evaluation for life-threatening causes that cannot be missed. In an older woman with acute-onset,
Time - Winter generalized abdominal pain, SBO is a significant concern. A prior history of abdominal surgery is

the major risk factor for SBO and must be ascertained.

Acute mesenteric ischemia: 25%

Acute mesenteric ischemia is a diagnosis that cannot be missed. Acute, generalized abdominal
pain can signify acute mesenteric ischemia, especially in older patients with a history of atrial
fibrillation. However, we do not yet know this patient’s medical history.

Ruptured abdominal aortic aneurysm (AAA): 20%

Although less common in women than men, new-onset abdominal pain with hypotension and
tachycardia raises concern for a vascular catastrophe such as a ruptured AAA and must be
evaluated. AAA rupture is a diagnosis that cannot be missed.

Acute diverticulitis: 10%

Complicated intraabdominal infection with progression to peritonitis can present as an acute
abdomen. In the elderly, diverticulitis can manifest with left-lower-quadrant pain that progresses to
diffuse pain if there is perforation. However, this diagnosis is less likely given the patient’s
generalized abdominal pain.

Acute pancreatitis: 10%

Pancreatitis usually manifests with epigastric pain radiating to the back, so this diagnosis is lower
on the differential; however, peritonitis can cause diffuse abdominal pain. Tachycardia and
hypotension also fit with this diagnosis.

Other: 5%
At this point, the differential is broad, and other diseases (beyond those considered above) may be
contributing to the patient’s presentation. Acute appendicitis is rare in this age group.

Degree of concern: HIGH

The patient’s older age, tachycardia, and hypotension make me very concerned about a possibly life-
threatening illness. The patient must be emergently evaluated.
 TRIAGE SUMMARY: You scored 8/9 in thoroughness and 8/9 in efficiency.

HISTORY

 Colonoscopy - 5 years Acute mesenteric ischemia: 35%

 Rx - No anticoagulants The history of atrial fibrillation without anticoagulation therapy increases the likelihood of acute
mesenteric ischemia from embolization. Aspirin is only marginally effective at preventing
 Medical Hx - Hypertension thromboembolism and should not be considered protective against systemic embolization.

 Medical Hx - Hyperlipidemia
Small bowel obstruction: 20%
 Medical Hx - Atrial fibrillation In an older woman with acute-onset, generalized abdominal pain, small-bowel obstruction
continues to be a concern. She notes she has had children via cesarean section, increasing her risk
 Surgical Hx - C-section
for adhesions and SBO. Although she denies constipation and admits to passing flatus, partial SBO
 Abd distention (history) - Yes can allow patients to pass some gas and stool, and increased compensatory peristalsis distal to the
obstruction can cause the bowel to evacuate feces and mislead clinicians into discounting
 Abd distention onset - Hours obstruction.

 Abd pain aggravator - None

Ruptured abdominal aortic aneurysm (AAA): 15%
 Abd pain alleviator - None Although less common in women than men, new-onset abdominal pain with hypotension and
tachycardia raises concern for a vascular catastrophe such as a ruptured AAA and must be
 Abd pain location - Diffuse
evaluated. The patient is at increased risk for AAA given her history of hypertension.
 Abd pain occurrence - Hours ago
Acute diverticulitis: 10%
 Abd pain progression - Progressive
Acute diverticulitis is common in elderly patients and remains on the differential diagnosis.
 Abd pain quality - Sharp However, it more commonly presents with left-lower-quadrant pain rather than diffuse pain.

 Abd pain radiation - No

Acute pancreatitis: 10%
 Abd pain severity - Severe Acute pancreatitis usually manifests with epigastric pain radiating to the back rather than diffuse
pain, so this diagnosis is lower on the differential. However, peritonitis can cause diffuse abdominal
 Abd pain tempo - Persistent pain. Tachycardia and hypotension also fit with this diagnosis. A common cause of acute
pancreatitis is gallstones in the common bile duct obstructing the pancreatic duct, an entity
 Abdominal pain - Yes
referred to as gallstone-associated pancreatitis. Acute pancreatitis should remain on the differential.
 Food aversion - Yes
Peptic ulcer disease (PUD): 5%
 Heartburn - Yes
Peptic ulcer disease can be complicated by bowel perforation. A history of frequent aspirin and
 Heartburn onset - Years alcohol use increases the risk of PUD. Perforation can occur in up to 14% of patients with PUD
[reference] and presents with acute-onset abdominal pain, tachycardia, and hypotension.
 Hematemesis - No

 Hematochezia - No Other: 5%
At this point, the differential is broad, and other diseases (beyond those considered above) may be
 Nausea - Yes contributing to the patient’s presentation.
 Stool color - No
Degree of concern: HIGH
 Hematuria - No The patient has acute abdominal pain with tachycardia and hypertension. She must be emergently
Alcohol use - Occasional evaluated to rule out life-threatening intra-abdominal disease.


 Drug use - No

 Abuse - No

 Appetite - Decreased MISSED

 Chills/rigors - No MISSED

 Fatigue - No MISSED

 Fever - No MISSED

 Night sweats - No MISSED

 Belching - No belching MISSED

 Bloating - No MISSED

 Constipation - No MISSED

 Diarrhea - No MISSED

 Dyschezia - No MISSED

 Early satiety - No MISSED

 y y

 Jaundice - No MISSED

 Sick contact - None MISSED

 Smoking - No MISSED

 Family history - Heart disease

 Drug allergy - NKDA

 Rx - Metoprolol

 Rx - Statins

 Rx - Acetaminophen

 Rx - ASA

 Rx - HCTZ

 Rx adherence - As ordered

 Covid - No

 Hospitalization - No

 Medical Hx - OA

 Trauma recent - No

 Surgical Hx - Remote THR

 Abd distention course - Stable

 Abd distention frequency - Persistent

 Abd distention location - Generalized

 Food aversion onset - Hours

 Heartburn aggravator - Chocolate

 Heartburn aggravator - Spices

 Heartburn duration - Hours

 Heartburn migration - No

 Heartburn temporal pattern - Intermittent

 Reflux - Yes

 Reflux alleviator - Nothing

 Reflux duration - Minutes

 Back pain - Yes

 Back pain aggravator - Nothing

 Back pain alleviator - Aspirin

 Back pain course - Stable

 Back pain duration - Days

 Back pain location - Lower

 Back pain onset - Years

 Back pain quality - Dull

 Back pain radiation - No

 Back pain severity - Moderate

 Back pain temporal pattern - Intermittent

 Joint pain - Yes

 Joint pain location - Knee

 Dysuria - No

 Flank pain - No

 Diet - Normal

 Recent food - Normal



 Exercise - Active

 Animals - Dog

 Exposure - No environmental exposure

 Ethnicity - White

 Living situation - Family

 Relationship status - Monogamous

 Residence history - Suburban

 Travel - None

 Ectopic pregnancy - No

 Sexual partners - One

 Sexually active - Yes

 STIs - No

HISTORY SUMMARY: You scored 29/43 in thoroughness and 29/83 in efficiency.

PHYSICAL EXAM
 Abd bruits - None Acute mesenteric ischemia: 60%
 Bowel sounds - Decreased Acute, generalized abdominal pain out of proportion to the physical exam in the context of the
patient’s symptoms, risk factors, and abnormal vital signs makes acute mesenteric ischemia the
 Abd shape - Distended lead hypothesis on the differential diagnosis. Her stool is guaiac-positive, a sign that bowel
ischemia and necrosis may be occurring.
 Abd distension - Distended

 Abd guarding - Absent Small bowel obstruction (SBO): 20%

In an older woman with acute-onset, generalized abdominal pain, small-bowel obstruction
 Abd organomegaly - Absent
continues to be a concern, although on her physical exam bowel sounds are present and normal in
 Abd pulsation - None quality, rather than absent or high-pitched, thereby reducing the likelihood of SBO. Her apparent
ability to pass flatus and stool also makes SBO less likely. The current constellation of pain out of
 McBurney - Negative proportion to exam with guaiac-positive stool is concerning for ischemia and bowel necrosis, which
is atypical in SBO.
 Murphy's sign - Negative

 Carotid pulses - Irregularly irregular Peptic ulcer disease (PUD): 5%

Peptic ulcer disease can lead to perforation and manifest with acute abdominal pain. Perforation
 Stool rectal exam - Normal
could manifest with acute-onset abdominal pain, tachycardia, hypotension, and guaiac-positive
 Abd percussion - Normal MISSED stool. However, a patient with PUD and a perforation would be more likely to present with
peritoneal signs than a benign abdomen.
 Abd tenderness - None MISSED

Abd rebound tender - Negative MISSED Ruptured abdominal aortic aneurysm (AAA): 5%

A ruptured abdominal aortic aneurysm remains on the differential diagnosis. Although one expects
 Obturator sign - Negative MISSED a pulsatile abdominal mass in patients with a ruptured AAA, this is found in only 22-68% of
patients. Pain, abdominal distention, and large abdominal girths limit the sensitivity of the physical
 Psoas sign - Negative MISSED exam. This diagnosis cannot be missed and remains on the differential diagnosis.
 Rovsing's sign - Negative MISSED
Acute pancreatitis: 5%
 Composure - Discomfort MISSED
Acute pancreatitis usually manifests with epigastric pain radiating to the back rather than diffuse
 Abd fluid wave - Absent pain, so this diagnosis is lower on the differential. The absence of peritonitis suggests an alternative
diagnosis.
 Cardiac S1 - Normal

 Cardiac S2 - Normal Other: 5%

Diverticulitis can cause diffuse abdominal pain when large perforations lead to peritonitis. However,
 Cardiac S3 - Absent the patient's relatively benign exam argues against this. The data acquired so far may suggest a lead
diagnosis. Still, it is essential to remain vigilant for other illnesses that may be contributing to the
 Cardiac S4 - Absent
patient’s presentation and thus avoid premature closure.
 BP bilateral - Symmetric
Degree of concern: HIGH
 Orthostasis - Normal
The history and physical exam raise serious concern for bowel ischemia related to acute mesenteric
 JVP - Normal ischemia — an emergent diagnosis requiring immediate management.

 JVP with inspiration - Decreases

 Carotid pulses - Tachycardia

 Pulsus paradoxus - Absent

 Optic disc - Normal

 Adnexa - Normal ovaries

 Cervix - Normal

 Uterus - Normal

 Palpation rectal exam - Normal

 Cervix - Normal cervix

 Vaginal vault - Normal

 Gag reflex - Normal

 Babinski reflex - Normal

 DTRs - Normal

 Discriminative sensations - Intact

 

 Pain sensation - Intact

 Proprioception - Intact

 Temperature sensation - Intact

 Vibration sensation - Intact

PHYSICAL EXAM SUMMARY: You scored 11/18 in thoroughness and 11/37 in efficiency.

DIAGNOSTICS

 CT Abd aorta - Normal Acute mesenteric ischemia: 95%

 CT Angiogram - Mesenteric artery occlusion Acute mesenteric ischemia is the lead diagnosis. Acute, generalized abdominal pain can be a sign
of acute mesenteric ischemia. With findings of “pain out of proportion to physical exam,” atrial
 CT Appendix - Normal fibrillation, and lactic acidosis, the diagnosis was very likely. The patient’s stool is guaiac-positive, a
sign that bowel ischemia and necrosis may be occurring. The CT angiogram of the abdomen
 CT Bowels - Bowel wall Thickening confirms the diagnosis by showing a sharp cut-off of the superior mesenteric artery, presumably by
CT Pancreas - Normal thromboembolism. The small bowel edema indicates there is already bowel ischemia occurring,

and emergent intervention is indicated. Of note, this diagnosis could easily have been missed if one
 CT Biliary tree - Normal MISSED had ordered a CT of the abdomen and pelvis that was not specified as a CT angiogram. In a CT
angiogram, the contrast is timed to highlight either the arteries (arteriogram) or veins (venogram)
 CT Bowels - No SBO MISSED of interest. If angiography is not specified, the IV contrast is administered to be present within the
capillary bed of the soft tissues.
 CT Gallbladder - Normal MISSED

 CT Kidney - Normal MISSED Other: 5%

CT Ascites - Absent The imaging shows no sign of small-bowel obstruction and instead points to acute mesenteric

ischemia. The imaging also shows no sign of pancreatitis, abdominal aortic aneurysm, bowel
 PaCO2 - Low perforation, or intra-abdominal abscess related to diverticulitis. Although there is a confirmed
diagnosis, it is essential to remain vigilant for coexisting diagnoses that may be contributing to the
 pH - Low patient’s presentation.
 AG (blood) - Elevated
Degree of concern: HIGH
 HCO3 (blood) - Low The patient has acute mesenteric ischemia, and there appears to be impending bowel necrosis in
the SMA territory. This is a medical and surgical emergency; emergent intervention is needed.
 Lactate - Elevated

 Lipase - Mildly elevated

 WBC (blood) - Elevated

 FOBT - Positive

 Total bilirubin - Normal MISSED

 Alkaline phosphatase - Elevated

 CBC diff: Lymphs - Low

 CBC diff: Neuts - Elevated

DIAGNOSTICS SUMMARY: You scored 13/18 in thoroughness and 13/17 in efficiency.

FURTHER STUDY
Diagnostic Schemas Acute abdominal pain |  View PDF

NEJM RESOURCES

Intestinal Ischemia Fast Facts Mesenteric Ischemia

J. Thomas LaMont, MD Daniel G. Clair, M.D., and Jocelyn M. Beach, M.D
 View Resource  View Resource

OTHER RESOURCES

ACG clinical guideline: epidemiology, risk factors,

 g p gy, ,
patterns of presentation, diagnosis, and
management of colon ischemia (CI)
Lawrence J Brandt 1, Paul Feuerstadt 2, George F
Longstreth 3, Scott J Boley 4, American College of
Gastroenterology
 View Resource