Learning objectives:
- How to distinguish red flags and warning signs in a vague patient
- What diagnostic errors are common when taking care of patients with vague symptoms
- How to prevent bias and early anchoring from jeopardizing diagnosis and management
Case information: A 33 year old Spanish-speaking woman without prior medical history, presents to the ED with multiple musculoskeletal complaints that started three months prior. She suffers from left leg burning with left foot paresthesias and difficulty moving her neck and upper spine. She grows fatigued after limited activity. Although acetaminophen helped in the past, for one week she has had no relief. Her vital signs are within normal limits. Physical examination reveals intact cranial nerves II-XII, and 5/5 strength with decreased right hip flexion and neck motion due to pain. After normal test results, she is discharged with a referral to Rheumatology and an acetaminophen-hydrocodone prescription. She returns one month later in worse condition and a thorough neurologic and musculoskeletal examination reveals hyperreflexia, mild atrophy, lack of sensation from spinal level T3, and an inability to walk due to weakness.
Discussion: This 33 year old woman seems like a different patient on her second visit. What errors in our approach prevented us from getting a more in-depth history? A language barrier could have played a role. The timing of the encounter also may have led to this. Other than multiple sclerosis, there are not many other sinister diagnoses that most practitioners would entertain in a young woman. Could her ethnicity have played a role? During the first encounter entire neurologic and musculoskeletal exams were not completed. If the physical examination revealed an unsteady gait, lower extremity weakness, hyperreflexia and Lhermitte’s sign, cervical myelopathy would have been a major concern—a different outcome may have unfolded.
See more of: The 33rd Annual Meeting of the Society for Medical Decision Making