My First Missed Diagnosis

Starting off in the medical profession is full of "firsts:" my first dead body, my first patient, my first dead patient, etc. I can now add "my first missed diagnosis" to the list. It all began on Wednesday morning when Dad came down to breakfast and told me he was having pain in his right inguinal (groin) area. He said it woke him up at 3:00 AM and it was really hurting. He wanted to know if I thought he had appendicitis. I was honored to show off all that I had learned about the appendix. I know that in kids, the appendix has an immune function. It is surrounded by lymphatic nodules that help survey the body for intruding bacteria and infection. Thus, any kind of infection in kids has the potential to concentrate itself in the appendix, leading to the classic childhood appendicitis. However, the lymphatic nodules gradually disappear with age, a process know as hyalinization. In adults, the appendix sticks off the ascending colon like a little twig and has no real purpose. However, bits of fecal matter can become lodged in the tiny appendicular lumen. This so-called "fecolith" can become a bastion of injection, leading to an inflammed appendix and the classic adult onset of appendicitis. I had also learned that an infected appendix would present with acute pain in the lower right abdominal quadrant. It would not hurt to push inward at that area of the abdomen, but quickly pulling one's fingers off the abdomen would cause the patient to jump off the exam table (so-called "rebound tenderness").

Well, Dad's pain was on the right side but it was rather low. Also, it hurt him to push in at that area, but there was no pain on rebound. Based on the location of the pain, I feared that he had an inguinal hernia. He had brought in a load of firewood a few days previously, and maybe he sprung a hernia. He didn't appear to be in pain outwardly, he denied any fevers, and I joked, "I don't think you have appendicitis. But if you do, we'll know in a few hours!" Dad went off to work.

The phone rang at 11:00 AM. Dad was calling to let me know that he called his doctor and was heading off to an emergency appointment. I knew that Dad's pain must be considerable if he was willing to schedule an emergency appointment in the middle of the workday. His doctor examined him and declared, "I'm pretty sure you have appendicitis. You better go to the emergency room for a CAT scan." Sure enough, 9 hours of waiting and 1 CAT scan later, Dad was diagnosed with acute appendicitis. By now it was well past 9:00 PM, and it was unsure whether surgery could be done immediately. He wound up spending the night in the hospital, during which time his pain became more diffuse and rose a bit higher than the groin. He had surgery around noon yesterday. His appendix was infected and inflammed and was easily removed. I visited him yesterday afternoon and he's doing super! Today we picked him up and he's recovering nicely at home. He's up and about, running errands, and looking back to normal (with the exception of having to wear sweat pants -- his incision is right on the belt line of his pants). We expect a rapid and complete recovery, with very little compromise to our Christmas agenda. Dad now can joke that the doctor has ordered him to "take it easy, don't do any heavy lifting for a few days, and absolutely no Christmas shopping!"

And that is the tale of my first missed diagnosis as a doctor-in-training. I'm now heading off to dinner at a friend's house, where we will be seeing a Chinese friend of ours and her parents, who are visiting from Shanghai!