I enjoy Dr. Jennifer Wiler's Quick Consult column, and often find it very informative. Her article, “Symptoms: Left Upper Quadrant Pain,” left me with a question. (EMN 2013;35:15; http://bit.ly/14uWk9v.)
The 63-year-old man with a huge abdominal tumor that filled his abdomen and pelvis was discharged the week before being diagnosed with that tumor, with a diagnosis on the previous admission of “hypertensive urgency,” which is a diagnosis in search of a disease.
Did anybody ever examine this patient? I think that anyone who examined the abdomen would have felt a large firm mass. Dr. Wiler doesn't mention the physical examination findings. I know that physical examination is becoming a lost art, but we still should examine our patients occasionally. There's no telling what we might find.
The other take-home point from this article is that the patient was complaining of abdominal pain for three weeks, which means he already had abdominal pain on his previous admission. Emergency physicians should have a low threshold for obtaining a CT scan on patients over 60 with abdominal pain because CT has a very high yield in such patients.
Ken Zafren, MD
Dr. Wiler responds: Thank you for your note. Indeed, there were many opportunities to meaningfully evaluate this patient's abdomen during his previous visits. He was a stoic patient who did not express abdominal pain during his previous admission, which made it less a focus for the teams that cared for him. But, no doubt, the physical exam is an art that requires our vigilant reverence.