Case Report: The Value of Vigilance and Iterative Evaluations with an Uncooperative Patient in the Emergency Department

A patient in the sixth decade of life presented to the Emergency Department (ED) with an apparent suicide attempt as well as with abdominal pain. The patient appeared to be inebriated. The prehospital emergency medicine service (EMS) providers suggested that the presentation may have been due to diabetic ketoacidosis. A chest x-ray finding showed possible pneumoperitoneum, but was read by radiology has having been seen on a chest x-ray from a year prior. Repeat physical examination continued to show abdominal tenderness, leading to a CT scan of the abdomen that demonstrated a large pneumo-peritoneum with a mild ileus and chronic surgical findings. The patient was transferred to a tertiary level of care for exploratory laparotomy after broad spectrum antibiotics and additional pain medication given. A bowel perforation was identified and was repaired. He had an uncomplicated clinical course and was discharged from the hospital 8 days later. The critical thinking skill of iterative reconsideration of a diagnosis along with iterative testing can avoid the pitfalls that can attend to such biases of cognition as anchoring and premature closure of thinking.