The Grand Rounds presentation that week was in the form of a Clinical Pathological Conference (CPC), a medical tradition where a case is presented to an expert or panel of experts in front of an audience of clinicians. The presentation is usually done in the order the information became available during the patient’s hospital course and the experts ask questions, discuss what they think is going on and why, are given more data based on the questions they ask, and ultimately try to come to the diagnosis that was proved at surgery or autopsy. The discussion often covers a wide range of diagnostic and therapeutic options that need to be considered - but end up as discarded dead ends. The educational value can be considerable and medical students, interns and residents are expected to attend.
The case presentation is often begun by reading the note from the first clinician to see the patient, often a very junior clinician, and this time a third year medical student. The note described a very complex elderly patient presenting to the emergency department with severe pain in the left upper quadrant (LUQ) of the abdomen. The third year student’s admission note suggested a ruptured artery in the spleen as the cause of his pain. Abdominal pain is the reason for 1 out of every 20 adult ED visits and is a common topic of conferences because the diagnostic possibilities are so varied in scope and outcomes. Splenic artery aneurysm is incredibly rare.
(It is also important to note that this occurred in the era before CT and MRI, when history and exam and the natural history of the process were key diagnostic tools even in the ED.)
During a very erudite discussion of the differential diagnosis many entities were mentioned: colon tumor, adnexal abscess, LLL pneumonia with empyema, porphyria, renal tumor, renal obstruction from ureteral tumor, adrenal tumor, metastatic disease, endometriosis, pancreatitis, appendicitis or cholecystitis with situs inversus, rib disease, polycystic kidney disease, ruptured ovarian cyst or abscess, leukemia or other malignant causes of splenomegaly, constipation, pyelonephritis, IBS, functional, perforated ulcer, pancreatic pseudocyst, splenic infarct with sickle crisis, gastric carcinoma, ischemic colitis, ectopic pregnancy, sub-phrenic abscess, Tietze’s syndrome, shingles, HSP, cardiac disease. For each of these, the experts explained the clues for and against and how to establish or exclude them as the diagnosis.
This particular patient was being presented because he died without a diagnosis. At autopsy he was found to have had a splenic artery aneurysm (from syphilis) that had ruptured, causing him to bleed to death. None of the expert discussants had felt that a splenic artery aneurysm had been his diagnosis.
Noting that the third year student had suggested the correct diagnosis, the moderator had him paged. “Let’s see what led him to suggest such a rare problem.” When he arrived, he was asked what the clue was.
His answer did nothing for his reputation as a clinician: “What else causes LUQ pain?”