This case involves a 16-year-old female, Kayla, who presented to the emergency department twice with severe pelvic pain. The first attending physician diagnosed her with pelvic inflammatory disease (PID) based on her symptoms and sexual history. However, her pain continued to worsen despite antibiotics. When consulted, the gynecology team discovered she actually had ovarian torsion requiring surgical removal of her ovary. This case highlights how diagnostic errors can occur from cognitive biases, lack of thorough history and exam, and failure to consider alternatives to the initial diagnosis. It is important for physicians to reflect on errors to improve care and prevent future mistakes.

1. Diagnostic Excellence 03: 16-year-old female with pelvic
pain
User: Daniela Fernandez
Email: [email protected]
Date: February 17, 2021 4:35PM
Learning Objectives
The student should be able to:
Define analytic and nonanalytic decision-making processes.
Discuss how both analytic and nonanalytic decision-making
processes may lead to diagnostic error.
Describe three different systems factors that contribute to
diagnostic error.
Communicate safely and accurately with team members or
health care providers about diagnostic errors discovered during
handovers.
Discuss the role of metacognition in preventing error.
Clinical Reasoning
Prioritized Differential Diagnosis with Evidence—A Marriage
of System 1 and 2
A helpful practice when approaching a clinical problem is to
create a prioritized differential diagnosis (from most likely to
least
likely) and providing evidence for and against each item on the
differential. Previously developed illness scripts (system 1
pattern
recognition) help inform the differential, and meticulous

2. weighing of evidence (system 2 analytics) explain what is more
likely or
less likely to be occurring.
Learning From Error—Reflection
Reflecting on the causes of a diagnostic error can help
clinicians process and debrief from the emotional aftermath of
an error (if
unaddressed it can lead to the "second victim effect" and impact
providers' wellbeing ) and also allows the opportunity to
identify
personal and systems-level cognitive bias mitigation strategies
and quality improvement opportunities.
Heuristics—Being a Cognitive Load
Over time, we develop mental shortcuts or heuristics which help
us more quickly and easily make sense of information.
Heuristics
can be helpful and ease our cognitive burden, but they can also
be prone to biases.
Error Disclosure
After an error has occurred, it is best to disclose the error to the
patient (and family if applicable) as soon as possible.
After an error has occurred, report the error through your
institution's reporting system.
References
Graber ML, Franklin N, Gordon R. Diagnostic error in internal
medicine. Arch Intern Med. 2005 Jul 11;165(13):1493-9.
Hayward RA. Counting deaths due to medical errors. JAMA.

3. 2002 Nov 20;288(19):2404-5;
Singh H, Meyer AN, Thomas EJ. The frequency of diagnostic
errors in outpatient care: estimations from three large
observational
studies involving US adult populations. BMJ Qual Saf. 2014
Sep;23(9):727-31.
© 2021 Aquifer 1/1
https://pubmed.ncbi.nlm.nih.gov/16009864/
https://pubmed.ncbi.nlm.nih.gov/12435247/
https://pubmed.ncbi.nlm.nih.gov/24742777/Diagnostic
Excellence 03: 16-year-old female with pelvic painLearning
ObjectivesClinical ReasoningPrioritized Differential Diagnosis
with Evidence—A Marriage of System 1 and 2Learning From
Error—ReflectionHeuristics—Being a Cognitive LoadError
DisclosureReferences
It is the first day of your emergency medicine elective rotation
and it is a very busy evening. The attending, Dr. Roberts,
suggests that you shadow for the first few hours to become
oriented to how the emergency department works. She is about
to see a patient and is speaking with the nurse outside of the
door. The nurse says, "Kayla is a 16-year-old female who was
seen just a couple days ago. Looks like she was diagnosed with
pelvic inflammatory disease (PID). Her abdominal pain isn't
getting better, and now she's vomiting."
Dr. Roberts says, "I've seen lots of cases like this before—the
doxycycline can cause a lot of stomach upset, and they can't
keep it down. I'm guessing she's still in pain because she's not
been adequately treated. Teenagers can be so tough to treat,
even for simple things."
You and Dr. Roberts walk into the room together and introduce
yourselves.

4. "Hi Kayla, I’m Dr. Roberts. I have a medical student with me
today, is it okay if they listen while we’re talking?" (Kayla
continues moaning uncomfortably)
(While moaning) "Yeah, whatever."
"Wow, it looks like you’re not feeling any better at all."
"Uh-uh"
"Can you tell me what’s been going on?"
"Oh, the pain, it’s just worse… It’s a lot worse. Whatever they
did before didn’t work."
"So tell me what’s been going on over the past day or so?"
"Oh, the pain, it’s just, uuuuhhh! I can’t stand it anymore!"
"Where is the pain?"
"Ugh, down here." (points to L pelvic area)
"Okay, so still on that left side?"
"Mmm-hmmm."
"So the way it feels, does it feel any different or just worse?"
(As Kayla is answering, Dr. Roberts’ pager goes off. She pulls
it out and looks at it, then puts it back on her waist while Kayla
is answering).
"Just worse… Ugh, it comes and goes, but it’s so much worse!"
(A little distracted, getting back into the moment). "So it’s
really bad huh?"
"Yeah, it gets really, really, really bad and I have to throw up."
"Okay. How much have you been throwing up today?"
"Uuuuh, probably, um … a couple times."
"Anything bloody in there, or dark green? (Kayla shaking head,
saying 'uh-uh,' while Dr. Roberts is talking) Okay. So the pain,
on a scale of 1 to 10, how bad is it?"
"When it’s really bad? A ten!!! OH, GOSH!"
"Does anything make it worse?"
(kind of irritated) "When I move! It’s just … it’s so bad I can’t
even think straight!"
"Okay, have you taken any medicines for it?"
"Um, I think my mom gave me something, like ibuprofen, I
don’t know, but it didn’t work."
(The nurse pops her head in.)

5. Nurse: "Just a reminder, you still need to put an order in for
room 3 before I can give the medications."
(Turns to nurse) "Okay, yes, sorry I’ll be right there" (turns
back to Kayla, getting more terse and direct in her questions,
though still has empathetic body language, seems somewhat
distracted). "Ah, when you left the hospital last time they gave
you a prescription for some antibiotics. Have you gotten those?"
"Um, I think so, yeah. But I’ve been throwing up so I missed
my dose today."
"Okay. Just a couple more questions. Any fevers?"
"No, I don’t know. We don’t have a thermometer."
"Peeing and pooping okay?"
"Yes."
"And then just a couple questions I ask everyone your age. Are
you sexually active?"
"Yes, but my boyfriend said he’s been tested."
"Do you use condoms?"
"Sometimes…" (moaning)
"Having any vaginal discharge?"
(Frustrated) "The same as before! I already told you guys this
… Can I please have something for this pain."
It can be helpful to think about the decision-making processes
we use to make medical decisions.
You log in and pull up Kayla's electronic medical record
(EMR). You see that her gonorrhea and chlamydia tests are still
pending, and then navigate to the note from her ED visit two
days ago, when she was seen by Dr. Santos, to gather more
information.
HISTORY
Chief Concern:
Pelvic pain
History of Present Illness:
16 y/o F with left lower and mid pelvic pain, moderate, started
this a.m. Came on suddenly, sharp, some intermittent relief but

6. no clear relieving or exacerbating factors. Tried ibuprofen and
heat packs, no change. Non-bilious non-bloody vomiting x 2.
+Vaginal discharge, white, no pruritis. No prior episodes. No
known prior sexually transmitted infections. No sick contacts.
Review of Systems:
Negative except as per HPI. Reports no dysuria, hematuria,
flank pain, fevers/chills, diarrhea, constipation. LMP: periods
irregular since Nexplanon placed 6 mos ago.
Past Medical History:
Asthma
Medications:
Albuterol PRN, Nexplanon
Allergies:
NKDA
Family History:
Non-contributory
Social History:
Sexually active, 4 lifetime partners male and female, last
intercourse 5 d ago with male partner, consensual, no condom,
positive occasional EtOH and marijuana use, no other illicit
drugs, no history of sexual abuse, no history of depressive
symptoms. Lives w/ both parents and sister, 10th grade, does
well in school.
PHYSICAL EXAM
Vitals:
T 37.9 C, P 85 bpm, BP 110/72 mmHg, RR 14 bpm, POx
99%RA, Wt 62kg.
General:
A&O, NAD, appears mildly uncomfortable, lying in bed
HEENT:
NC/AT, MMM
Cardiovascular:
RRR, no M/R/G, nl S1/S2
Respiratory:
CTAB

7. Abdomen:
Soft, TTP in suprapubic and left pelvic region otherwise NT
elsewhere, +BS, non-distended, no hepatosplenomegaly, neg
psoas, no guarding/rebound, neg Murphy's.
Pelvic:
Normal external Tanner 5 female, moderate thin white/yellow
discharge in vaginal vault, no cervical discharge. There is
discomfort with movement of cervix and during left bimanual
adnexal exam, no pain on right during bimanual examination.
Extremities:
WWP, CR < 2 sec
Neurological:
Grossly normal
Skin:
No rashes
LABS
Negative HCG, negative wet mount, GC/chlamydia sent and
pending, UA pH 5, SG 1.020, neg nitrites, neg LE, trace heme,
trace protein, neg ketones, neg bili, neg glucose.
IMAGING
Abdominal radiograph read as normal loops of bowel, no air
fluid levels, scant stool throughout colon, overall unremarkable.
ASSESSMENT PLAN
16y/o F with 12hrs left pelvic pain and vomiting, sexually
active, with cervical motion tenderness and Left adnexal
tenderness. Most likely PID. Negative UA rules out pyelo,
negative HCG rules out ectopic pregnancy. Pain in LLQ, not
RLQ, appendicitis unlikely. Pt expresses concern for severe
pain but exam does not seem consistent with surgical process
such as appy or torsion. KUB not consistent with constipation
or with obstruction. Appears non-toxic and tolerating small
amounts of oral fluids in the ER. Given 250mg ceftriaxone x1 in
ER, Rx doxycycline 100mg PO BID x14d, advise f/u with PMD
in 2–3 days or sooner if worsens or not tolerating PO. Call pt at
999-999-9999 confidential cell for f/u GC/chlam results.

8. Dr. Santos clearly considered a number of other items on his
differential diagnosis besides PID, and considered why each
diagnosis may or may not fit with Kayla's presentation. He has
"rank ordered" his differential diagnosis to come to the
conclusion that she likely has PID. This is an example of system
2 thinking: Dr. Santos consciously weighs multiple factors in
making a decision; at the same time, however, his illness scripts
for each of these diagnoses are influenced by his previous
experiences.
You have never seen a patient with PID before and you decide
that you want to create your own differential diagnosis using a
very deliberate approach. Considering a number of alternatives,
you feel like you need more information from the patient. You
go in and examine Kayla and find that she has significant
tenderness in her abdomen. As you're walking out of the room,
Dr. Roberts approaches.
"Phew, what a night!" she says. "Back to Kayla... it sounds like
she's going to need to get admitted for IV antibiotics since she
can't tolerate the oral treatment for her PID. I already wrote the
order to get her a bed. Let's go in and I'll do Kayla's exam
before she goes up." Your history and physical examination
have made you wonder if this might be something other than
PID. But before you're able to get in a word, Dr. Roberts opens
Kayla's door.
"Hi, Kayla, sorry for the interruption," Dr. Roberts says as she
washes her hands. "We think you need to come in to the hospital
so that we can give your antibiotics through an IV. Before they
come move you to your room, we just need to do a quick exam."
Dr. Roberts briefly listens to her heart and lungs. Dr. Roberts
begins to reach for her abdomen and Kayla curls up her legs and
retracts.
Dr. Roberts tells Kayla to relax, but Kayla keeps pulling up her
knees and wailing when Dr. Roberts tries to touch her lower
belly. You see the frustration in Dr. Roberts' eyes as she just
tries to get through a cursory abdominal exam. She tells Kayla

9. that the nurse will be in soon to place an IV and says kindly,
"I'm sure you'll start feeling better once the IV antibiotics are
started. I'll ask the nurse to give you some medicine to help
with your pain, too," and leaves the room.
As you leave the room, Dr. Roberts says, almost to herself, "The
abdominal exam was so tough, I'm sure she won't tolerate a
pelvic exam. We'd have to move her to a different bed. Besides,
she just had one a couple of days ago, I don't think I'd find
anything new."
You start to discuss what you found in the chart and some of the
thoughts you had, but Dr. Roberts interrupts, "I have to get back
to the trauma bay. Let's try to talk about Kayla later when
things slow down." But things never slow down and the shift
ends without further discussion.
As you walk towards the ED three days later for your next shift,
you think about Kayla and wonder how she did. Your rotation
requires that you review charts of the patients you've cared for
and you start with Kayla. You learn that Kayla was started on
IV antibiotics, and two days later when her severe pain and
vomiting continued, the gynecologists were consulted.
After seeing Kayla, the Gynecology team discussed with the
Pediatrics team that maybe PID wasn't the correct diagnosis
after all. They thought that ovarian torsion was possible and
decided to take Kayla to the operating room for a laparoscopy.
During the operation, they found that her ovary was necrotic
and could not be salvaged and needed to be removed.
When you have a little break and go to grab a coffee with Dr.
Matthews, the Pediatric Emergency Medicine fellow you're
working with, he asks you how the rotation is going. You tell
him about the case and say, "I don't know how we could have
missed that! It seems so obvious now. I just wonder what we
could have done differently."
Dr. Matthews responds, "These things are always easier to see
in hindsight. The important thing is to learn from them so that
we don't make the same kind of mistake again. What do you

10. think went wrong?"
Dr. Matthews responds, "I totally get it. It can be hard to talk
about these things without feeling like you're assigning
judgment or blame to the providers involved—especially when
you're a student talking to your residents and attendings. It is
normal to feel guilty and frustrated after an error occurs. Many
studies have shown that providers suffer significant negative
consequences when they are involved in an error."
A constructive response to diagnostic error is fundamental. Here
are examples of some potential responses as well as some
modifications that could make the responses more constructive.
Original Response
More Constructive Response
Dr. Roberts was too busy. She barely got to take a history, we
glossed over the physical exam and I never got to tell her what I
found.
It was busy, people were stressed, and a trauma had just arrived.
The team had to be efficient. I don't think we were aware of
how many shortcuts we were taking, but looking back, we were
not as thorough as we should have been.
No one was listening to Kayla when she talked about the
severity of her pain.
Dr. Roberts has seen many sexually active female teenagers
with pelvic pain before. This influenced her history taking,
thought process and decision making. In the end, though, there
were things that made her different from the other patients she'd
seen in the past.
I feel like our care was sub-optimal. We didn't even do a pelvic
exam.
The ED is not designed to make pelvic exams easy to perform
on any patient. This combined with a busy night and a recent
pelvic exam influenced Dr. Roberts' decision to defer the exam.
I knew there was something going on; I didn't speak up because
Dr. Roberts is the attending. I'm just a med student, and I was
only shadowing. I should have said something.

11. It is intimidating to start a new rotation as a medical student. I
need to remember this is a teaching hospital and attendings are
used to interruptions and questions. Dr. Roberts was using
System 1 thinking, which I have not developed yet. Everyone
can play an important part in patient care and asking questions
can be helpful.
Dr. Matthews continues, "You know, I have something that I
think might help you as you think about this case and for
approaching future ones. It was given to me by my mentor when
I first started fellowship. I'll make you a copy. I know that as I
reflect on my errors, I've missed diagnoses at times because
another diagnosis was easier to make. For example, I missed a
diagnosis of appendicitis once because the patient had a long-
standing history of constipation."
Cognitive Load
Cognitive load is a concept that is frequently applied to
medicine when discussing diagnostic error. It is human nature
to minimize cognitive load when possible because mental
processing is labor intensive and also highly valuable, therefore
we automatically reserve processing power for when it is
needed most. This tendency is instinctive and cannot be turned
off. We rely on heuristics we have formed--mental shortcuts, or
pattern recognition--to ease the cognitive burden and conserve
energy. We automatically utilize heuristic-based processes
unless there is an intentional, conscious overriding of this
tendency.
An example might be when you are considering two different
conditions in a patient: one that is a common, simple disease
and another that is more rare and more complicated. Your brain
will likely automatically consider the common, simple disease
before the other one due to the fact that it is easier to think
about.
It is important to recognize this concept so you can learn ways
to overcome it when diagnosing patients' problems.
The cognitive load is highly connected with heuristics, since

12. heuristics are mental shortcuts our brains use to make decisions
that require little energy.