If I had to pick one case from intern year that truly taught me the importance of keeping a wide differential diagnosis, it would be my final Room 9 of the year. The buzzer went off, and as I made my way to the trauma bays, I was able to get a brief rundown from the attending. “Seizure, 40-sish male, no known history”. OK, this was something I could do. I began running everything I’d need to do through my head as I prepared for the patient. “ABC’s. Vitals. Fingerstick glucose. Ativan… Could be trauma, hypoglycemia, benzo or alcohol withdrawal…” As I was refining my differential, the patient came in. The patient was non-rhythmically jerking, was not responsive to voice or sternal rub. I noticed he was wearing dress pants and a collared shirt. He was breathing spontaneously and maintaining sats in the mid 90’s. Palpable pulses and good heart sounds. Glucose was in the 100’s. EMS said he had been found like this approximately fifteen minutes prior, and his clinical status hadn’t changed since then. No known medical history or medicines.  I called out for the nurse to draw up Ativan, as I said this I noticed the patient had urinated on himself. Everything in my mind pointed towards a seizure. I grabbed the otoscope to perform the secondary survey and pried open his eyes. That’s when I felt the rug come out from under me.

The patient had pinpoint pupils, one millimeter bilaterally. The attending and I immediately had the same thought, and as I opened my mouth I heard him say, “let’s get some narcan for this guy!” The narcan got administered quickly, and soon after the patient woke up agitated, but responsive. His family had driven to the ED soon after he arrived, so questioning him was difficult. We ended up taking him to privacy in an empty x-ray room, where he admitted to using heroin earlier in the day. Sure enough, his toxicology screen was positive for opiates. We counseled him, observed him in the ED to ensure he didn’t need another dose, and then discharged him home.

What struck me about this case was that while I had formulated a differential, I had done so after anchoring to a faulty premise. It taught me a valuable lesson in keeping my differential broad, and it’s a lesson I’ll carry to every patient encounter from here on out.