I walked through the hall in my mint green scrubs, my N95 feeling only a bit too tight, my goggles only slightly foggy. Alarms, chatter from nurses and patients, and an intercom spewing out a morning prayer mixed until I couldn’t tell them apart. Fast-moving bodies and masks made my vision blurry. It was a busy day in the ED.
I approached my preceptor, trying to focus on her paisley mask and flower-covered scrub cap rather than the mayhem around me. “Alright, I’m ready!” I told her, perhaps trying a bit too hard to sound excited to join the already overflowing department.
“I want you to go into Room 9 and take a thorough history. She’s a 67-year-old lady who’s been here for nine hours with left-sided back pain. She has a pain pump and sees a pain specialist, apparently the doctor that was here on the prior shift called her pain doctor, who said to watch her for a while and then send her over to the clinic to have her pain pump adjusted. So just go check in and see if you can learn anything else. I want to know what makes this pain different from her typical pain. And do a good physical exam, too.”
I took a deep breath and pulled out a pen before walking into the patient’s room and shutting the door to the chaos behind me.
“Hi, I’m Bailey, a fourth-year medical student working with your doctor. Is it okay if I ask you some questions about why you’re here?”
The patient nodded and we began talking. She told me about her 13-year history of chronic back pain, the relief she finally felt when she got the pump, and about the new pain she was having.
“Where exactly is this pain you’re having now?” I asked.
“It’s right here,” she said, and she moved her hand to her back near the angle of her scapula on her left side and then wrapped it around to the front of her body.
“Does it go around the side like that, into the front of your torso?”
“Yes — it almost hurts more in my stomach now.” She rubbed the area under her ribs.
I frowned. I was not satisfied that the new pain was a manifestation of her chronic back pain, but I couldn’t think of a more likely diagnosis. “Can you tell me how this pain feels different than the pain you have on a daily basis?”
“It just feels different, I don’t really know.”
I went through my review of systems, asking her about headache, nausea, vomiting, diarrhea, constipation, fevers, shortness of breath, cough, and swelling. She denied it all. My exam was unremarkable, and I could see or feel no changes to her left side as compared to her right. Before I left, I asked her one more question. “Is there anything else you can think of that I should know?”
“Well,” she said, “I am having a little bit of chest pain.”
“Oh — when did that start?”
“Maybe 10 minutes ago, I guess. But it’s not very bad.”
I thanked her and left the room to talk to my preceptor. I filled her in on the patient’s history, the hours leading up to the ER visit, and her current symptoms. We talked about her pain and realized that her pain medication had been switched the day before. Up until this point, her labs had been normal, and her exam was benign. Maybe she really did just need to go back to the pain doctor to have her medication adjusted again. Before we finished talking, I added, “Oh, she did mention that she’s having some mild chest pain, but it only started 10 minutes ago.”
“Hm,” my preceptor said. “Well let’s get a troponin just in case.”
The troponin came back at 0.48. Our 67-year-old female with chronic pain who had presented with left-sided back pain had suffered … a heart attack?
My preceptor shared the number with her colleagues. “Can you believe it?” she asked. No one could. Everyone was on edge thinking about how close the team had come to missing something so serious.
I thought of my own perceptions of the patient. Had I not taken her left-sided pain seriously because she was a chronic pain patient? Should I have realized that her symptoms, especially in a woman, might signal a heart attack? We had all heard about women with acute myocardial infarction presenting differently than men in medical school, and the American Heart Association even states on its website that in women a heart attack may present with nausea/vomiting and back or jaw pain. And yet still, here I was, guilty of assuming that the patient couldn’t have had a heart attack because her presenting symptoms were not the classic signs I was accustomed to looking for.
I am not alone in missing the signs and symptoms of heart attacks in women. A study of physicians’ perception of heart disease in women found that less than one-fifth of clinicians are aware that more women die of heart disease each year than men. In addition, studies have shown that physicians are more likely to assign women to a lower-risk category for cardiovascular disease than men, despite displaying the same symptoms. I had also been led astray by the patient’s chronic pain diagnosis and assumed that her new pain was simply a different manifestation of a condition she already had. But in fact, her chronic pain should have put me on alert for potential cardiovascular causes, as chronic pain has been linked to an increased occurrence of heart attack and stroke.
These studies, and my experience, have shown me that I need to be more aware of my own biases before entering a room. If I had been asked on a test — “What would you do with a 67-year-old patient presenting with left-sided upper back pain and low-grade chest pain?” — I would have immediately ordered a troponin and evaluated the patient for a cardiac cause. But once I learned that it was a female with chronic pain, I allowed myself to be led astray by common misconceptions rather than focusing on the differential. Instead of thinking of the diagnosis that needed to be ruled out in order to discharge the patient safely, I allowed myself to focus only on the diagnosis that I thought most likely — that her chronic pain had flared again. I will not forget this patient soon, and her entire care team learned from the experience. Clinical judgement is a large and important part of what health care workers do every day; this patient was a reminder that sometimes our judgement can do as much harm as good.
Have you ever missed a diagnosis in the exam room that you wouldn’t have missed on an actual exam? Share in the comments below.
Bailey Wolding was born and raised in Appleton, WI before attending University of Wisconsin – Madison for her undergraduate degree. She graduated in three years with a biology major and then spent one year as a sea kayak and cross country ski guide in Northern Minnesota. She is now in her fourth year of medical school at Des Moines University in Iowa and enjoys camping, canoeing, running, baking bread, gardening, and playing with her dog, Lana. She is a 2020–2021 Doximity Op-Med Fellow.