Stacey (a Frequent Visitor to the Emergency Department) Stacey is a 28-year-old patient who presents to the emergency department (ED) with lower abdominal pain. She has had numerous visits to the ED...

Stacey (a Frequent Visitor to the Emergency Department)

Stacey is a 28-year-old patient who presents to the emergency department (ED) with lower abdominal pain. She has had numerous visits to the ED over the past few years with similar complaints and is known to have visited all four EDs in the city in the same evening. She is described as a ‘frequent flyer’. She has been extensively investigated by gynaecology, urology, gastroenterology and psychiatry. Despite numerous investigations including ultrasound, abdominal CT and hysterosalpingogram, no somatic cause has been found for her discomfort. The ED is extremely busy with 30 people in the waiting room. The EP who assesses her has seen her several times in the past. Her abdominal discomfort is mostly on the left side. Her vital signs are stable. She has a soft abdomen with good bowel sounds and vague tenderness in the left lower quadrant. Her urinalysis is normal. The EP reassures her that she doesn't have a urinary tract infection and does not appear to have any serious condition. He comments on the extensive workups she has had in the past for similar symptoms. She tells him that she feels different this time, but he reminds her that she has said that numerous times before. She responds well to further reassurance, and he discharges her from the ED. The next afternoon, she is brought back to the same ED having collapsed at the local mall. She is pale and hypotensive. Bloodwork shows a haemoglobin of 6 and a positive pregnancy test. Pelvic ultrasound revealed a complex adnexal mass on the left side with a large amount of free fluid. She is diagnosed with a ruptured ectopic pregnancy and taken immediately to the operating room. Comment. The EP was aware of the patient's label as a ‘frequent flyer’ and her diagnosis of somatoform disorder and well aware of the perils of making assumptions about such patients. However, he saw her in the closing hours of an 8-hour shift in a very busy ED and was fatigued. Had he simply allowed the patient the benefit of the doubt and performed a pregnancy test on the first visit, he may well have made the correct diagnosis.