Why do I miss the diagnosis? a personal experience

Time after time  all doctors miss a diagnosis. But this true is difficult to accept. Moreover, the training in medicine is still a world of information but not of improving based on clinical practice. Young doctors are now practical, they don´t want to waist time listing a complete differential diagnosis when the situation is so clear: fever, cough and sputum is always pneumonia; abdominal pain and vomiting in a patient with rectal cancer is a recurrence. But I would like to present a personal misdiagnosis to enhance the importance of a broad differential.

CLINICAL CASE: Marta was a 65 year-old patient who had a diagnosis of rectal cancer close to the sigmoid area. She had an abdominoperineal resection with a termino-terminal  union and a provisional ileostomy. She was treated with radiotherapy and chemotherapy. She received the last cycle of chemotherapy a week before admision. Three days before admision she started with abdominal pain, nausea and vomiting without fever. She was taking lorazepan and a low dose of oral morphine. She referred constipation in the last week.

Physical examination: Alert. No dyspnea. Abdomen: distension, tender, with some “metalic” intestinal sounds. The ileostomy bag was empty. No edemas.Her blood sample  showed moderate leukocytosis, normal amilasa. A plain abdominal X-ray showed a distended bowel.

After this first clinical data collection I have to suggest a possible diagnosis and to inform to the family about the situation. What is the first diagnosis for you?

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FINAL DIAGNOSIS: Hernia around the ileostomy area. She was treated in a conservative way with manual reduction and  a good evolution.

ANALYSIS: I didn´t think about this possibilityt. Why? First due to a lack of knowledge about surgical complications related with the ileostomy. Second because my  pattern of complications are more clinical complications in relation with the tumor or chemotherapy or radiotherapy.

I have had a second similar case: at this time I didn’t miss the diagnosis