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Obtaining a diagnosis in the Emergency Department

This blog is written by Dr. Victor Ge, a medical intern at Peninsula Health.

As junior doctors in the Emergency Department (ED) we frequently find ourselves speaking to patients about their symptoms. Sometimes the main reason patients come to ED is for the relief of symptoms such as severe pain. More often it is the concern that a symptom is a sign of a more serious medical condition – such as an infection, appendicitis or heart disease.

In the ED we would like nothing more than to diagnose every symptom and treat every patient that we see. In this post I hope to address what happens when the cause of a patient’s symptoms cannot be found.

We see an incredible variety of patients in the ED, many with serious and urgent conditions. Patients often present with undifferentiated symptoms – that is non-specific symptoms that could be explained by a number of causes, some urgent and others relatively non-urgent.

For example, headaches are a common reason for presentation to the ED and can be a sign of a serious condition such as head injury, bleed within the skull, vision-endangering vascular inflammation or even a tumor. It can also be due to non-emergency causes – including stress, eye strain, sinus infection, or migraines.

When it comes to these undifferentiated presentations, we do our best to give our patients an explanation for their symptoms. However, it is more important that we investigate, identify and rule out any serious condition though the process of asking questions, examining and performing any necessary tests. If there is no urgent and serious pathology found, and no obvious cause for the patient’s complaints are identified, it doesn’t mean the symptoms aren’t real.

Let’s take abdominal pain as an example. Like headaches, many conditions can cause abdominal pain. Some of the tools we use to identify abdominal conditions may include blood tests, Ultra-Sounds, X-rays, CT scans and even endoscopy. Many acute and serious causes of abdominal pain can be identified with these tests, but other pathologies can be more elusive. Some say that up to half of the patients who present to EDs do not have an identifiable cause of abdominal pain despite having thorough examination and investigation.

In these instances, we ask patients to arrange follow-up with their local doctor or specialist in a non-emergency setting to further clarify their diagnosis and management.

You might wonder why EDs do this. Don’t we have the ability to investigate, diagnose and treat every known medical condition? Isn’t the ED the last port of call if patients have chronic symptoms that are difficult to manage or would like a second opinion?

It’s true that the ED has a vast array of resources and services at its disposal. However, we see a large number of patients, many whom are very sick. Our main efforts are directed towards diagnosing and treating acute, serious illness and this is why we ‘triage’ our patients into urgency categories. Our time is unfortunately limited, and if a patient has a chronic, non-urgent medical illness we are sometimes unable to provide the time and attention they deserve to adequately address their concerns.

In these situations, our colleagues – the local doctor or outpatient specialist – are better placed to provide ongoing non-urgent investigation, management and follow-up.

Upon discharge we always advise patients that their condition may change. If symptoms return, become worse, or there are any concerns, we encourage patients to return to ED or seek medical attention for re-evaluation of their medical condition.

Dr. Victor Ge