A missed diagnosis?

"Come, I want to show you something."

These are the words that I dread, especially since coming from my attending, they usually mean some kind of test. So far, doing rounds in the hospital has been fun because the challenges have been reasonable. Take a history. Conduct a physical. Present findings to the attending. Check, check, and check. I'm beginning to sound like I know what I'm talking about. "CBC creat and BUN are high, but not stable so I'd hesitate to calc a GFR. Crit's high, and she's hypenatremic; I think she' dehydrated. We should watch her drip, and monitor that IV antibiotic dose... "

This case, however, was something else.

"Come on, I want to show you something."
"Okay. Should I grab the chart?"
"No, just come. She' my patient. I want you to do an H&P on her. Right now."
"Right now...in front of you? And everybody else?"
"Yes. You up for it?"
"[me thinking: OMF...shit.] sure!"

Half an hour later, I had no idea what was wrong with her. Imagine my relief when the attending himself admitted he didn't know what was wrong with his patient. Still, it was a peculiar case: young mother comes in with diffuse, non-radiating abdominal pain for past 72 hours. Has not had a bowel movement due to her pain. Urination and urinalysis was normal. Abdominal CT scans were unremarkable. Blood count was normal. Electrolytes were normal. No burst appendix. No signs of appendicitis. Everything was so normal, in fact, that there was nothing we could do but give her a morphine drip for her ever present, ruminating, tear inducing pain.

She was a young, pleasant woman, just delivered twins via C-section four weeks ago. She said everything was fine until 2 nights ago when she woke up with 'extreme abdominal pain'. Apart from the stress of dealing with twins and a five year old daughter, she seemed a happy new mama. My attending was flummoxed. The radiologists who looked at her CT scans were flummoxed. Surgeons were coming in droves to examine her, checking out the C section although her scar was healing nicely. By the time my shift ended, we still didn't know what was wrong with her. The attending promised me he would let me know what happened. And I went home.

It wasn't until I was well on my way that a question I'd brushed aside earlier bubbled up to consciousness: "What was that bruise on her belly?". It was the size of a fist, no evidence of skin break indicating that it mostly likely was a blunt trauma of some kind. But I didn't ask her about it. I don't think my attending asked either. We had noted it on the physical, but both of us ignored the finding and continued to look elsewhere for clues: in her lab results, in her CT, in her history...everywhere but the place that now seemed ripe with clues. Come to think of it, the bruise looked to be about several days old--its edges have begun to heal, but the center was still a deep purple. How could it be that numerous other doctors before me had examined her and not a single one remarked on her charts the patient's explanation for her abdominal bruise? Did all of us forget to ask?

A recent article in the Boston globe criticized doctors for a phenomenon call 'attribution'. It was basically an attack on the way doctors think, the way we are taught to think along the lines of stereotypes, salient classic associations that help us make standard diagnoses but too easily make us miss other important clues. Sure, the bruise could have been nothing. But I doubt anyone of the doctors know for sure. I don't know what happened in this case, but I suspect that had she been black, young and poor as opposed to white, suburban, and well to do, many more doctors would have paid more attention to the orange-size bruise on her belly and asked more questions about the stresses that can wreak havoc on a young family regardless of race or socioeconomic. They would ask if only to rule out a diagnosis of domestic abuse. In retrospect, it could have been the most important question of all.