Table 3.
Common pitfalls and missed diagnoses in the elderly
| Condition | Index of suspicion | Tips |
|---|---|---|
| Ruptured AAA | May be confused for cardiac event (collapse, hypotension), renal colic (first presentation with renal calculi is uncommon in patients >60 years of age); pulsatile mass may be difficult to feel in the hypotensive or obese patient | Back pain ± collapse + hypotension should prompt FAST or CT scan to assess abdominal aorta |
| Acute groin hernia | 70% Patients >70 years old, increasing age means increasing risk of obstruction and strangulation | Careful and thorough examination of femoral and inguinal canals must be performed |
| Ischemic bowel | Nonspecific features, sudden onset abdominal pain out of proportion to clinical signs; patients have a soft abdomen in the early stages of the disease | Raised lactate and acidosis levels are late features Low threshold for CT imaging White cell count is typically high Peritonism and rigidity usually indicate infarcted intestine |
| Appendicitis | Still common in elderly patients but not as common as in young patients | Consider cecal malignancy or diverticulitis as cause and consider CT to exclude |
| Gastric volvulus | Nonbilious vomiting; more common in the elderly; associated with chest pain and retching; patient may have a history of a hiatus hernia or signs of a hiatus hernia on plain chest X-ray; often misdiagnosed as a upper GI bleed with “coffee ground” type vomiting | Chest X-ray reveals a hiatus hernia with a distended stomach, typically visible in the chest and the upper abdomen |
| Ischemic lower limb | Common cause for “off-legs”, consider in AF/cancer patients | Always examine unwell patients’ feet |
| Hip fracture | Easily missed, particularly if bedbound; the severity of the fall can be fairly minor; contractures may make external rotation difficult to assess | Maintain a high index of suspicion and consider routine hip X-ray after fall in high-risk patients |
Abbreviations: AAA, abdominal aortic aneurysm; AF, atrial fibrillation; CT, computed tomography; FAST, Focused Assessment with Sonography in Trauma; GI, gastrointestinal.