Friday, August 17, 2018

Be Aware of the Stoic Man

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Author: Taylor Brittan, MSIV
University of Queensland-Ochsner Clinic
AAEM/RSA Education Committee

There are several patient populations to which we are attentive so as not to miss a diagnosis in the context of an atypical presentation. Typical cases include the elderly, female, diabetics, or those with HIV.[1,2,3] I contend that there is another group which we should assess with even more caution—the stoic man.

A 45-year-old man presents to the emergency department (ED) with abdominal pain. It has been going on for a couple days but became acutely worse last night with associated nausea. He also notes some intermittent episodes of abdominal pain over the past year. On examination, his general appearance gives off little indication of any severe pain or disease process. When asked, he describes mild discomfort, 5-6/10 pain, and some chills. On exam he is tachycardic and febrile, but normotensive with normal oxygen saturation on room air. His abdomen is diffusely tender, greatest in the right upper quadrant, without guarding or rebound. Murphy’s sign and obturator sign are negative and McBurney’s point is nontender.

As I am evaluating the patient, the resident I’m working with comes in. There is a vague sign of concern on her face, and she politely asks me to catch her up. My first assumption was I had been taking too long. She leaves, then my attending walks in. At this point I’m concerned that there is something I’m missing and that this patient could be sick. My attending kindly asks me to catch her up as well, and then leaves, telling the patient we are going to get a computed tomography (CT) scan of the abdomen.

I finish the examination and step out to look at his labs. Complete blood count (CBC) revealed leukocytosis. Alkaline phosphatase and lipase are also mildly elevated. Abdominal CT reveals a fluid-filled, dilated appendix with mural enhancement and mild free fluid, concerning for acute perforated appendicitis. There is also diffuse gallbladder wall edema without biliary duct dilation but with periportal free fluid, concerning for acute cholecystitis.

In an observational study of 2623 patients presenting to the ED, 9.1% had a presenting complaint of acute abdominal pain.[6] A retrospective study of 1000 consecutive cases of abdominal pain identified the following factors to help identify the high-risk patient with abdominal pain: (1) pain for less than 48 hours; (2) pain followed by vomiting; (3) guarding and rebound tenderness on physical examination; (4) advanced age; (5) a prior surgical procedure.[4] However, elderly and diabetic patients often have atypical presentations of potentially severe conditions, sometimes with vague, nonspecific complaints.[2-5] Sometimes these atypical presentations are seemingly benign or less severe. This leads to a noteworthy aspect of this case, the ostensibly “not sick” initial presentation.

On general appearance, the above patient gave away minimal clues as to his degree of illness. Although generally underwhelming, during the interview, he used surreptitious phrases such as, “I don’t like to complain about pain,” and “I usually just try to suck it up.” These types of statements that are subconsciously or consciously meant to underplay the situation may indicate you are dealing with a stoic patient. As a student or a new resident, it is important to remember that gestalt is not always reliable. The stoic man is another patient population we need to consider as an “atypical” presentation.


1. Powers RD, Guertler AT. Abdominal pain in the ED: stability and change over 20 years. Am J Emerg Med 1995; 13:301.

2. Bugliosi TF, Meloy TD, Vukov LF. Acute abdominal pain in the elderly. Ann Emerg Med 1990; 19:1383.

3. Kamin RA, Nowicki TA, Courtney DS, Powers RD. Pearls and pitfalls in the emergency department evaluation of abdominal pain. Emerg Med Clin North Am 2003; 21:61.

4. Brewer BJ, Golden GT, Hitch DC, et al. Abdominal pain. An analysis of 1,000 consecutive cases in a University Hospital emergency room. Am J Surg 1976; 131:219.

5. Sanson TG, O'Keefe KP. Evaluation of abdominal pain in the elderly. Emerg Med Clin North Am 1996; 14:615.

6. Caporale N, Morselli-Labate AM, Nardi E, Cogliandro R, Cavazza M, Stanghellini V. Acute abdominal pain in the emergency department of a university hospital in Italy. United European Gastroenterol J. 2016 Apr;4(2):297-304.

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