Diagnostic Excellence 03: 16- year-old female with pelvic pain

Author(s):Author(s): Michaela Voss, MD and Emily Ruedinger, MD

! CASE INTRODUCTION HISTORY “

Dr. Roberts, Kayla, you, and nurse.Dr. Roberts, Kayla, you, and nurse.

!”

Aquifer Diagnostic Excellence

Diagnostic Excellence 03: 16-year-old female with pelvic painDiagnostic Excellence 03: 16-year-old female with pelvic pain

# DIAGNOSES

$ FINDINGS

% NOTES

& BOOKMARKS

# LAB VALUES

MENUMENU

It is the first day of your Emergency Medicine elective rotation and it is a very busy evening. The attending, Dr. Roberts, suggests that you shadow for the first few hours to become oriented to how the emergency department works. She is about to see a patient and is speaking with the nurse outside of the door. The nurse says, “Kayla is a 16-year-old female who was seen just a couple days ago. Looks like she was diagnosed with pelvic inflammatory disease (PID). Her abdominal pain isn’t getting better, and now she’s vomiting.”

Dr. Roberts says, “I’ve seen lots of cases like this before – the doxycycline can cause a lot of stomach upset, and they can’t keep it down. I’m guessing she’s still in pain because she’s not been adequately treated. Teenagers can be so tough to treat, even for simple things.”

You and Dr. Roberts walk into the room together and introduce yourselves.

! MEETING KAYLA HISTORY “

View a transcript of the video

‘ “Hi Kayla, I’m Dr. Roberts. I have a medical student with me today, is it ok if they listen while we’re talking?” (Kayla continues moaning uncomfortably)

(while moaning) “Yeah, whatever.”

‘ “Wow, it looks like you’re not feeling any better at all …” “uh-uh”

‘ “Can you tell me what’s been going on?” “Oh, the pain, it’s just worse … It’s a lot worse. Whatever they did before didn’t work.”

‘ “So tell me what’s been going on over the past day or so?” “Oh, the pain, it’s just, uuuuhhh! I can’t stand it anymore!”

‘ “Where is the pain?” “Ugh, down here.” (points to L pelvic area)

‘ “OK, so still on that left side?” “Mmm-hmmm.”

‘ “So the way it feels, does it feel any diYerent or just worse?” (As Kayla is answering, Dr. Roberts’ pager goes oY. She pulls it out and looks at it, then puts it back on her waist while Kayla is answering). “Just worse… Ugh, it comes and goes, but it’s so much worse!”

‘ (a little distracted, getting back into the moment). “So it’s really bad huh?” “Yeah, it gets really, really, really bad and I have to throw up.”

‘ “OK. How much have you been throwing up today?” “uuuuh, probably, um … a couple times.”

‘ “Anything bloody in there, or dark green? (Kayla shaking head, saying uh-uh, while Dr. Roberts is talking) OK. So the pain, on a scale of 1 to 10, how bad is it?” “When it’s really bad? A ten!!! OH, GOSH!”

‘ “Does anything make it worse?” (kind of irritated) “When I move! It’s just … it’s so bad I can’t even think straight!”

‘ “OK, have you taken any medicines for it?”

“Um, I think my mom gave me something, like ibuprofen, I don’t know, but it didn’t work.”

(nurse pops head in)

Nurse: “Just a reminder, you still need to put an order in for Room 3 before I can give the Medications.”

‘ (turns to nurse) OK, yes, sorry I’ll be right there. (turns back to Kayla, getting more terse and direct in her questions, though still has empathetic body language, seems somewhat distracted) “Ah, when you left the hospital last time they gave you a prescription for some antibiotics. Have you gotten those?” “Um, I think so, yeah. But I’ve been throwing up so I missed my dose today.”

‘ “OK. Just a couple more questions. Any fevers?” “No, I don’t know. We don’t have a thermometer.”

‘ “Peeing and pooping ok?” “Yes.”

‘ “And then just a couple questions I ask everyone your age. Are you sexually active?” “Yes, but my boyfriend said he’s been tested.”

‘ “Do you use condoms?” “Sometimes…” (moaning)

‘ “Having any vaginal discharge?” (frustrated) “The same as before! I already told you guys this … Can I please have something for this pain.”

It can be helpful to think about the decision-making processes we use to make medical decisions.

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! FAST VERSUS SLOW THINKING TEACHING ( System 1 versus System 2 Decision-MakingSystem 1 versus System 2 Decision-Making

Sometimes health care providers utilize “fast” decision-making, which is also called “System 1” or “non-analytical” decision-making. This can include relying on instincts, pattern recognition, and experience to guide decision-making. This occurs subconsciously and without much effort. An example would be making a quick diagnosis in a patient whose presentation is the same as what one has seen in many previous patients.

There is also a “System 2” approach, which refers to “analytical” decision-making. This decision-making is slower, deliberate, and effortful. This is the kind of decision-making you see in Morning Report or when working through a case in class.

) Question Dr. Roberts thinks that Kayla has pelvic inflammatory disease. What characteristics describe the decision-making process she used to arrive at this diagnosis? Choose the single best answer.

A. Slow and deliberate

* B. Fast and nearly automatic

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Answer Comment The correct answer is B.The correct answer is B.

Here, it appears Dr. Roberts is primarily using the System 1 approach with Kayla as she manages a busy ED. Kayla fits a superficial pattern for PID: a sexually active teen with pelvic pain. Dr. Roberts’ experiences with other female adolescents with pelvic pain is playing into her decision-making, perhaps without her even realizing it. Dr. Roberts seems to be using a relatively superficial illness script, likely in part

because she is rushed.

Illness scriptsIllness scripts are structures that clinicians use to categorize complicated information and make it accessible and useful. As we go through training, we go from thinking about diseases in only abstract or pathophysiologic terms; instead, we begin to associate clinical patterns with certain diseases, thus developing patterns that allow us to recognize diseases quickly and accurately.

System 1 decision makingSystem 1 decision making can be an effective way of making decisions, especially when a robust illness script is used. Experienced physicians who have built nuanced illness scripts over time often do this frequently and effectively. For less experienced physicians, illness scripts and patterns are not as well developed – they will be refined with experience. Use of pattern recognition can sometimes seem like magic to a less experienced provider – and because System 1 processes are subconscious, even the more experienced provider may not even realize how they came to a conclusion so quickly, either. However, even experienced physicians can get tripped up by using mental shortcuts (heuristics).

! REVIEWING KAYLA’S CHART HISTORY ” You log in and pull up Kayla’s electronic medical record (EMR). You see that her gonorrhea and chlamydia tests are still pending, and then navigate to the note from her ED visit two days agotwo days ago, when she was seen by Dr. Santos, to gather more information.

HISTORYHISTORY

Chief Concern: Pelvic pain

History of Present Illness:

16 y/o F with left lower and mid pelvic pain, moderate, started this AM. Came on suddenly, sharp, some intermittent relief but no clear relieving or exacerbating factors. Tried ibuprofen and heat packs, no change. Non- bilious non-bloody vomiting x 2. +Vaginal discharge, white, no pruritis. No prior episodes. No known prior sexually

transmitted infections. No sick contacts.

Review of Systems:

Negative except as per HPI. Reports no dysuria, hematuria, flank pain, fevers/chills, diarrhea, constipation. LMP: periods irregular since Nexplanon placed 6 mos ago.

Past Medical History:

Asthma

Medications: Albuterol PRN, Nexplanon

Allergies: NKDA

Family History: Non-contributory

Social History:

Sexually active, 4 lifetime partners male and female, last intercourse 5 d ago with male partner, consensual, no condom, positive occasional EtOH and marijuana use, no other illicit drugs, no history of sexual abuse, no history of depressive symptoms. Lives w/ both parents and sister, 10th grade, does well in school.

PHYSICALPHYSICAL EXAMEXAM

Vitals: T 37.9 C, P 85 bpm, BP 110/72 mmHg, RR 14 bpm, POx 99%RA, Wt 62kg.

General: A&O, NAD, appears mildly uncomfortable, lying in bed

HEENT: NC/AT, MMM

Cardiovascular: RRR, no M/R/G, nl S1/S2

Respiratory: CTAB

Abdomen: Soft, TTP in suprapubic and left pelvic region otherwise NT elsewhere, +BS, non-distended, no hepatosplenomegaly, neg psoas, no guarding/rebound, neg Murphy’s.

Normal external Tanner 5 female, moderate thin

Pelvic: white/yellow discharge in vaginal vault, no cervical discharge. There is discomfort with movement of cervix and during left bimanual adnexal exam, no pain on right during bimanual examination.

Extremities: WWP, CR < 2 sec

Neurological: Grossly normal

Skin: No rashes

LABSLABS Negative HCG, negative wet mount, GC/chlamydia sent and pending, UA pH 5, SG 1.020, neg nitrites, neg LE, trace heme, trace protein, neg ketones, neg bili, neg glucose.

IMAGINGIMAGING Abdominal radiograph read as normal loops of bowel, no air fluid levels, scant stool throughout colon, overall unremarkable.

ASSESSMENTASSESSMENT PLANPLAN

16y/o F with 12hrs left pelvic pain and vomiting, sexually active, with cervical motion tenderness and Left adnexal tenderness. Most likely PID. Negative UA rules out pyelo, negative HCG rules out ectopic pregnancy. Pain in LLQ, not RLQ, appendicitis unlikely. Pt expresses concern for severe pain but exam does not seem consistent with surgical process such as appy or torsion. KUB not consistent with constipation or with obstruction. Appears non-toxic and tolerating small amounts of oral fluids in the ER. Given 250mg ceftriaxone x1 in ER, Rx doxycycline 100mg PO BID x14d, advise f/u with PMD in 2-3 days or sooner if worsens or not tolerating PO. Call pt at 999-999-9999 confidential cell for f/u GC/chlam results.

Normal abdominal x-ray radiograph. Image Credit: Jeffrey Hogg, MDNormal abdominal x-ray radiograph. Image Credit: Jeffrey Hogg, MD

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) Question Although it’s hard to know exactly what Dr. Santos was thinking, how would you contrast his apparent thought process with Dr. Roberts’ thought process?

The suggested answer is shown below.

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Answer Comment Dr. Santos clearly considered a number of other items on his differential diagnosis besides PID, and considered why each diagnosis may or may not fit with Kayla’s presentation. He has “rank ordered” his differential diagnosis to come to the conclusion that she likely has PID. This is an example of System 2 thinking: Dr. Santos consciously weighs multiple factors in making a decision; at the same time, however, his illness scripts for each of these diagnoses are influenced by his previous experiences.

For more information about pelvic inflammatory disease, click here

System 2 ThinkingSystem 2 Thinking

Creating a differential diagnosis is one example of slowing down your thinking. This type of thinking is deliberate and requires effort and time. This “slowed down” thinking is also called “System 2” or “Analytical” thinking. Another example would be thinking through the pathophysiology of your proposed diagnosis to make sure it explains all of the patient’s signs and symptoms. System 2 processes are deliberate and require mental effort. This type of thinking is often used by clinicians when a case is unfamiliar or complicated.

System 1 and System 2 processesSystem 1 and System 2 processes

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! PHYSICAL EXAMINATION PHYSICAL EXAM +

You and Dr. RobertsYou and Dr. Roberts

!”

You have never seen a patient with PID before and you decide that you want to create your own differential diagnosis using a very deliberate approach. Considering a number of alternatives, you feel like you need more information

from the patient. You go in and examine Kayla and find that she has significant tenderness in her abdomen. As you’re walking out of the room, Dr. Roberts approaches.

“Phew, what a night!” she says. “Back to Kayla… it sounds like she’s going to need to get admitted for IV antibiotics since she can’t tolerate the oral treatment for her PID. I already wrote the order to get her a bed. Let’s go in and I’ll do Kayla’s exam before she goes up.” Your history and physical examination have made you wonder if this might be something other than PID. But before you’re able to get in a word, Dr. Roberts opens Kayla’s door.

“Hi, Kayla, sorry for the interruption,” Dr. Roberts says as she washes her hands. “We think you need to come in to the hospital so that we can give your antibiotics through an IV. Before they come move you to your room, we just need to do a quick exam.” Dr. Roberts briefly listens to her heart and lungs. Dr. Roberts begins to reach for her abdomen and Kayla curls up her legs and retracts.

Dr. Roberts tells Kayla to relax, but Kayla keeps pulling up her knees and wailing when Dr. Roberts tries to touch her lower belly. You see the frustration in Dr. Roberts’ eyes as she just tries to get through a cursory abdominal exam. She tells Kayla that the nurse will be in soon to place an IV and says kindly, “I’m sure you’ll start feeling better once the IV antibiotics are started. I’ll ask the nurse to give you some medicine to help with your pain, too,” and leaves the room.

As you leave the room, Dr. Roberts says, almost to herself, “The abdominal exam was so tough, I’m sure she won’t tolerate a pelvic exam…we’d have to move her to a different bed. Besides, she just had one a couple of days ago, I don’t think I’d find anything new.”

You start to discuss what you found in the chart and some of the thoughts you had, but Dr. Roberts interrupts, “I have to get back to the trauma bay. Let’s try to talk about Kayla later when things slow down.” But things never slow down and the shift ends without further discussion.

) Question A fundamental factor in avoiding diagnostic error is speaking up when something doesn’t feel right or seem to fit. This can be hard especially when you are dealing with supervisors in busy situations. What would you have liked to tell Dr. Roberts about Kayla’s case if you had the time?

The suggested answer is shown below.

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Answer Comment It is very important to pay attention to findings that don’t fit with the working explanation for a patient’s health problem. In this case, although Kayla has risk factors for PID there are a number of findings that “don’t quite fit.” First, her pain was sudden in onset and is intermittent, both of which would be atypical for PID. Second, she doesn’t have a fever and it seems like her abdomen is more tender than one would expect.

Although none of these would definitively rule out PID, when taken together they should prompt the clinician to broaden the differential diagnosis.

! DISCOVERING A DIAGNOSTIC ERROR HISTORY ” As you walk towards the ED three days later for your next shift, you think about Kayla and wonder how she did. Your rotation requires that you review charts of the patients you’ve cared for and you start with Kayla. You learn that Kayla was started on IV antibiotics, and two days later when her severe pain and vomiting continued, the gynecologists were consulted.

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After seeing Kayla, the gynecology team discussed with the pediatrics team that maybe PID wasn’t the correct diagnosis after all. They thought that ovarian torsion was possible and decided to take Kayla to the operating room for a laparoscopy. During the operation, they found that her ovary was necrotic and could not be salvaged and needed to be removed.

When you have a little break and go to grab a coffee with Dr. Matthews, the pediatric emergency medicine fellow you’re working with, he asks you how the rotation is going. You tell him about the case and say, “I don’t know how we could have missed that! It seems so obvious now. I just wonder what we could have done differently.”

Dr. Matthews responds, “These things are always easier to see in hindsight. The important thing is to learn from them so that we don’t make the same kind of mistake again. What do you think went wrong?”

) Question As you respond to Dr. Matthews, you think about what factors led to this diagnostic error. Which of the following responses accurately describes factors that contributed to this error? Select all that apply.

* A. Dr. Roberts was too busy. She barely got to take a history,

we glossed over the physical exam and I never got to tell her what I

found.

* B. No one was listening to Kayla when she was talking about

the severity of her pain.

* C. I feel like our care was sub-optimal. We didn’t even do a

pelvic exam.

* D. I knew there was something going on! I didn’t speak up

because Dr. Roberts is the attending… I’m just a med student, and I

was only shadowing. I should have said something.

SUBMITSUBMIT

Answer Comment

The correct answers are A, B, C, D.The correct answers are A, B, C, D.

This is actually a really complex question – all of these factors contributed. Some of these responses have a judgmental or blaming tone.

Thorough and Efficient Information GatheringThorough and Efficient Information Gathering

A key to avoiding error is gathering adequate and accurate information. This includes taking a good history, doing a physical exam, reviewing other information, empowering the patient to participate in their care, and discussing with other members of the care team. It’s not only important to ask questions, but also to listen to everyone that’s involved. This can be challenging in busy clinical settings. Finding a balance between being thorough and being efficient is a skill that is generally built over time, but even experienced clinicians find this difficult. Sometimes doctors take shortcuts; other times they may spend too much time on a single patient. Both of these can result in unnecessary tests, workup, or diagnostic errors.

Non-Judgmental Discussion of ErrorsNon-Judgmental Discussion of Errors

When an error occurs, it is normal to be upset. Trying to assign blame whether to yourself or to someone else, is a natural response but ultimately not helpful to preventing future errors or correcting the current one. It is important to remember that no one wakes up hoping to make an error, but it happens to all of us. Every physician will be involved in diagnostic errors – currently, nearly 1 out of 9 inpatient encounters and 1 out of 20 outpatient encounters involve a diagnostic error. If we are to change those statistics, we need to create a culture where people feel safe and comfortable discussing past errors in a productive, non-judgmental way.

! RESPONDING TO DIAGNOSTIC ERRORS TEACHING ( Dr. Matthews responds, “I totally get it. It can be hard to talk about these things without feeling like you’re assigning judgment or blame to the providers involved – especially when you’re a student talking to your residents and attendings. It is normal to feel guilty and frustrated after an error occurs. Many studies have

shown that providers suffer significant negative consequences when they are involved in an error.”

A constructive response to diagnostic error is fundamental. Here are examples of some potential responses as well as some modifications that could make the responses more constructive.

Original ResponseOriginal Response More Constructive ResponseMore Constructive Response

Dr. Roberts was too busy. She barely got to take a history, we glossed over the physical exam and I never got to tell her what I found.

It was busy, people were stressed, and a trauma had just arrived. The team had to be efficient. I don’t think we were aware of how many shortcuts we were taking, but looking back, we were not as thorough as we should have been.

No one was listening to Kayla when she talked about the severity of her pain.

Dr. Roberts has seen many sexually active female teenagers with pelvic pain before. This influenced her history taking, thought process and decision making. In the end, though, there were things that made her different from the other patients she’d seen in the past.

I feel like our care was sub-optimal. We didn’t even do a pelvic exam.

The ED is not designed to make pelvic exams easy to perform on any patient. This combined with a busy night and a recent pelvic exam influenced Dr. Roberts’ decision to defer the exam.

I knew there was something going on; I didn’t speak up because Dr. Roberts is the attending. I’m just a med student, and I was only shadowing. I should have said something.

It is intimidating to start a new rotation as a medical student. I need to remember this is a teaching hospital and attendings are used to interruptions and questions. Dr. Roberts was using System 1 thinking, which I have not developed yet. Everyone can play an important part in patient care and asking questions can be helpful.

! LEARNING ABOUT THE COGNITIVE MISER TEACHING ( Dr. Matthews continues, “You know, I have something that I think might help you as you think about this case and for approaching future ones. It was given to me by my mentor when I first started fellowship. I’ll make you a copy.

I know that as I reflect on my errors, I’ve missed diagnoses at times because another diagnosis was easier to make. For example, I missed a diagnosis of appendicitis once because the patient had a long-standing history of constipation.”

Cognitive MiserCognitive Miser

The Cognitive Miser is a concept that is frequently applied to medicine when discussing diagnostic error. It states that it is human nature to avoid effortful thought whenever possible because our mental processing is highly valued and needs to be reserved for when we really need it. We instinctively and automatically try to expend as little mental energy as possible. It is the brain’s default and cannot be turned off.

When evaluating a patient, the clinician’s brain will automatically turn to this type of thinking unless there is intentional, conscious overriding of the cognitive miser.

An example might be when you are considering two different conditions in a patient: one that is a common, simple disease and another that is more rare and more complicated. Your brain will likely automatically consider the common, simple disease before the other one due to the fact that it is easier to think about.

It is important to recognize this concept so you can learn ways to overcome it when diagnosing patients’ problems.

The cognitive miser is highly connected with heuristics, since heuristics are mental shortcuts our brains use to make decisions that require little energy.

! IMPACT OF DIAGNOSTIC ERRORS TEACHING ( Five months later, you are on your Ob-Gyn rotation in the Reproductive Endocrinology and Infertility Clinic. You are seeing a 30-year-old female and her

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husband. They have struggled for the past three years trying to get pregnant. You notice that this patient only has one ovary after surgical removal due to severe endometriosis. The resident mentions that having a single ovary does not usually lead to significant changes in fertility, and that this patient’s infertility is more likely related to scarring from her severe endometriosis. However, it gets you thinking about Kayla again. It sounds like having lost her ovary won’t likely impair her fertility, but you wonder if there will be other consequences for her because of that big misdiagnosis.

) Question Of the following statements, which are true? Choose the single best answer.

A. Patients rarely suffer harms from diagnostic errors.

* B. Studies show that patients and their families prefer to be

told as soon as possible when an error occurs.

C. Patients are not at risk for financial harm when a

diagnostic error occurs.

SUBMITSUBMIT

Answer Comment The correct answer is B.The correct answer is B.

Prevalence of Serious Diagnostic ErrorsPrevalence of Serious Diagnostic Errors

One study of 100 patient cases of diagnostic error showed that 90 cases involved some degree of harm, including 33 deaths (Graber, 2005). One study estimated that between 40,000 and 80,000 deaths occur each year as a result of diagnostic error (Haward, 2002).

Ely JW, Graber ML, Croskerry P. Checklists to reduce diagnostic errors. Acad Med. 2011 Mar;86(3):307-13..

Financial Impact of Medical Errors on PatientsFinancial Impact of Medical Errors on Patients

There are certain “errors” (for example, if a patient develops a pressure ulcer during hospitalization) for which most insurers will not pay, nor will the patient be charged. In these instances, the hospital bears the cost.

However, in many cases, the patient will still bear the financial burden of any additional health care costs associated with an error.

There are also other downstream costs associated with error — lost wages from work if recovery is prolonged, for example. Even if medical costs do not increase, these downstream effects can have a significant financial impact on patients and families.

Emotional Consequences of Medical Errors for PatientsEmotional Consequences of Medical Errors for Patients

Many patients suffer anxiety after an error occurs. Over the long term, this may impact their future interactions with the health care system. Some patients become over-utilizers of the health care system, always worried that doctors are “missing something”. Others can develop distrust in the health care system in general, and hesitate to seek care in the future even when it is needed. The response varies from patient to patient, and might also impact their family members and friends who hear about the error.

Still, it is best to tell a patient when an error occurs. Literature consistently supports that patients want to be told when an error occurs– and it is ethically the right thing to do. Patients should be given detailed information about the error, and given opportunities to ask questions. Information should not be glossed over or left out. During error disclosure, it is often helpful to have a non-involved person present to support the patient and facilitate communication. Many hospitals employ patient advocates, who can serve in this role.

It is also standard to report errors through a hospital reporting system, and to inform patients of steps that are being taken to ensure a similar error will not happen again to them or to someone else. If you are caring for someone who has encountered a medical error in the past, acknowledge the difficulty of being a victim of a medical error. Provide them with the opportunity to share how it has impacted their life.

As a provider, you may never know or see the long-term ramifications of an error on your patient. But it is important to keep in mind that there are social, financial, emotional and physical consequences that

can last long after the error is discovered, and that can reach beyond the individual patient.

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, LEARNING OBJECTIVES LEARNING OBJECTIVES Thank you for completing Diagnostic Excellence 03: 16-year-old female

with pelvic pain.