By Stacey Kusterbeck
Patients who present with nonspecific, mild, transient, and atypical symptoms, along with diseases in the “wrong” age groups, are more likely to be misdiagnosed in EDs, according to a recent AHRQ analysis of 279 studies.1 For instance, patients who present with fatigue, malaise, or generalized weakness might receive a final diagnosis of myocardial infarction, stroke, or sepsis.
ED Management (EDM) spoke with Stephen Colucciello, MD, FACEP, clinical professor of emergency medicine at Wake Forest University School of Medicine, about reducing risks for ED patients who present with atypical symptoms. (Editor’s Note: This transcript has been lightly edited for clarity.)
EDM: How can ED providers change their mindset to avoid misdiagnosing these patients?
Colucciello: Common things present in uncommon ways more often than rare things present in a classic manner. This is because they are just so prevalent. We need to think about common diseases and conditions. What are the atypical presentations? If you see a patient who has “lockjaw,” it is probably not tetanus. It is more likely a dystonic reaction to a psychiatric medication or antiemetic.
A common precept in emergency medicine is “worst first.” But when you do “worst first,” it has to be a reasonable diagnosis. To be on a differential diagnosis, if it’s a lethal or serious condition, it should be at least 1% likely. Something less than that probably doesn’t need to be on your differential. If the patient has fever and red eyes in the U.S. and there was no travel to Africa, don’t think about Ebola.
The other consideration is: Is it treatable? Having rabies on your differential diagnosis for altered mental status is fine, but recognize that you can’t treat that. I wouldn’t put it first on your differential. Another consideration is: Is it time-sensitive? Meningitis is much more time-sensitive, in general, than a brain tumor.
EDM: In your clinical experience, what is the single biggest miss in ED patients with nonspecific symptoms?
Colucciello: It’s probably sepsis. For the patient with weakness, nausea, vomiting, and maybe even diarrhea, we immediately jump to an easy “GI bug” closure, when this actually is a common presentation of sepsis. Don’t ignore the possibility of sepsis just because there’s no obvious source. At least one-quarter of sepsis patients initially have no obvious source.
EDM: What are important considerations if patients come to the ED with nonspecific presentations?
Colucciello: Always think about age. Atypical presentations abound in the elderly and the neonate. Infection at either end of life’s spectrum may present with vague, nonspecific changes noted by families or caregivers. “Fussiness” may be sepsis in the first several months of life. Even some seasoned emergency physicians may be surprised that the No. 1 presentation of pneumonia in elderly patients is not cough, fever, or shortness of breath; it’s confusion.
You always want to consider comorbidities. If somebody’s young and healthy with atypical symptoms, that’s one thing. But if somebody’s had a liver transplant, that’s totally different. You need to know about medical history. Asking “Do you have any medical problems?” is often surprisingly unhelpful. It has always amazed me how many people forget about a prior transplant or splenectomy. Better questions to ask are “Are you taking any prescriptions?” or “Have you ever been in a hospital overnight?”
Immune suppression of any cause — IV drug use, liver disease, diabetes, implanted devices such as ports, hemodialysis — ups the ante on occult infection. Any source of infection, any suppression of the immune system is very important when nonspecific symptoms are in play.
Another thing we often overlook that we shouldn’t is medications. Always go to the medication list. Ask if patients are on any new medicines. Did they recently run out of or stop any medicines? Are they on high-risk medications (like digoxin) or medicines that require a level (like Dilantin or valproate)? Are they on medicine that can cause hyponatremia (like oxcarbazepine) or hyperammonemia (like valproate)?
A lot of the new biologics, where people are getting injections once a month, can suppress the immune system and set them up for unusual infections, like tuberculosis or less common infections. IV drug use is a big risk factor for infectious complications. We should not only ask about, but also do a good skin exam for, evidence of needle tracks or evidence of skin “popping.”
In general, when we look at the workup of nonspecific symptoms, we probably order way too many CBCs. However, a very high WBC or bandemia (or toxic granulations) should give you pause.
When you have unexplained symptoms or vague symptoms, look for patterns. Ask what other signs and symptoms are “along for the ride.” If somebody has syncope and headache, the first thing we have to think about is subarachnoid bleed. If somebody has syncope and chest pain, think about acute coronary syndrome or pulmonary embolism. With chest pain plus a neurological complaint, think about aortic dissection. With vertigo plus anything else — headache or a visual complaint — it means a stroke or mass lesion until proven otherwise. If it’s altered mental status plus clonus or hyperreflexia, think about serotonin syndrome or alcohol withdrawal.
Beware of hypoglycemia and hyperglycemia, as they can present in many different ways. The first episode of diabetic ketoacidosis often presents as belly pain. We often forget hypoglycemia in patients with altered mental state who are in accidents.
If you are listening to somebody with many complaints that don’t really seem to go together, one question to ask is: How many times do you get up to pee during the night? More than once for a woman or young-to-middle-aged man is suspicious for diabetes.
Beware of “chabdomen” — chest and abdomen — complaints. Things in the belly can present as chest complaints, and vice versa. Abdominal conditions often cause chest pain or back pain. Biliary colic, blood or air in the abdomen, irritates the diaphragm and causes shoulder or chest pain. Inferior MIs often cause epigastric pain, especially in older females and diabetics. Heartburn may be acute coronary syndrome. Pneumonia can cause abdominal pain, especially in children.
Metabolic and endocrine problems often present with vague or nonspecific signs or symptoms. Most of us think “lung” with tachypnea, but it may be acidosis with compensatory deep, fast breathing.
The most common cause of someone complaining of new onset blurred vision in the ED is new onset diabetes — not an eye problem, but an endocrine problem. Addison’s disease is almost always missed in the ED. If patients are complaining of weakness, fatigue, or dizziness, see if there is a history of recent steroid use or bronzing of the skin. Check for hypotension with slight decrease in sodium and slight increase potassium.
We need to be aware of certain high-acuity, low-occurrence (HALO) diagnoses. Probably the most lethal, and common, is aortic dissection. These patients might have pain and/or loss of function — neurologic complaints. Not only are these complaints puzzling, but they change over time as the dissection moves throughout the body. Patients may present with pain or loss of function that moves or changes in nature as the dissection progresses. Another clue, apart from knowing anatomy and how things fit with the progression of dissection, is that vascular catastrophes are generally sudden in onset.
Spinal compression syndromes, such as spinal epidural abscess or cauda equina, are other HALO diagnoses. Spinal epidural abscesses are often misdiagnosed on the first visit. Patients rarely present with the classic triad of back pain, fever, and neurological deficit.
Another problematic area with nonspecific complaints is with medical clearance for psychiatric complaints. When you have a psychiatric patient and you want to send them to a psychiatric hospital or a psychiatrist, you need to see if there’s an organic reason for abnormal behavior. Look for red flags for medical etiologies of abnormal behavior. Look at the age of onset. If it’s new onset psychosis before puberty or after age 40, think medical cause. If they’re having auditory hallucinations, it’s probably psychiatric. If it’s visual or tactile hallucinations, it’s more often organic.
Psychiatric problems are usually subacute and escalating, whereas medical conditions — withdrawal, stroke, meningitis — are usually very acute with no psychiatric history. On physical exam, the organic presentation of abnormal behavior usually has abnormal vital signs, especially fever. Focus on the neurological exam, especially tremor, clonus, and hyperreflexia. Look at the pupils. Are they very small, very large, or asymmetric? Look at the skin. Are they sweating, is it hot and dry, do they have a rash?
EDM: If ED patients with atypical symptoms are misdiagnosed and a bad outcome happens, what are some factors that could determine the outcome of malpractice litigation?
Colucciello: Just because you miss something does not mean that it’s malpractice. The question is: Would a similar provider under similar circumstances have done something differently than you?
One of the biggest defenses or protections is good discharge instructions. Many EDs have gone for quantity over quality and use standardized discharge instructions for back pain or belly pain or headache that may go on for 12 pages. We need to compress our discharge instructions dramatically so people understand what’s important and what’s not.
A lot of discharge instructions say, “See your doctor in two days.” That may have been true 25 years ago, but I’m a physician, and I can’t see my doctor in two months. If you think somebody needs to follow up in two days, you can say: “If you are unable to do that, come back to the ED.”
What we really need to do for every discharge is say to the patient: “If you get worse, come back.” If it’s a mild cough and they’re not short of breath, and they’re young and healthy, maybe they don’t need to come to the ED if the cough gets worse. But certainly for vague, potentially serious symptoms, the single most important discharge instruction is: Come back for any new or worsening symptoms. Come back immediately.
If all of that’s clear and well-documented, and the patient waited a week and something bad happens? Then from a legal standpoint, it becomes contributory negligence. The ED defense can be: Not everything can be diagnosed on the first visit, but we could have diagnosed you on the second visit.
REFERENCE
1. Newman-Toker DE, Peterson SM, Badihian S, et al. Diagnostic errors in the emergency department: A systematic review. Dec. 15, 2022.
An emergency medicine professor explains how providers can reduce risks for ED patients who present with unusual symptoms.
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