Can Be Done Better for the Diagnosis of Non-Differentiated Diseases in Community Hospital?

General Practice is a comprehensive subject with a wide spectrum of diseases. It is challenging to make a more correct diagnosis timely and reasonable treatment with the least instrument examination for the diagnosis of medically unexplained physical symptoms (MUPS). This article reviews the case report of a patient who presented to a community hospital with a one-month history of constant diffuse abdominal pain and underwent eight weeks of examinations, finally experienced deterioration of their condition. Based on this case, this article discusses the problems in the diagnosis of abdominal pain in a community hospital, and according to the clinical thinking mode and checklist of abdominal pain, the diagnostic process of abdominal pain can be improved, and the diagnosis of non-differentiated diseases can be done better, the harm caused by delayed diagnosis may be reduced.


Introduction
General practitioners often get a more appropriate diagnosis with the least instrument examination for the diagnosis of medically unexplained physical symptoms (MUPS), which may also produce inertial thinking and get into confusion.
With the development of general medicine, the discussion of thinking mode of general medicine is increasing day by day [1] [2]. How to make an effective diagnosis has always been an issue. The recent article entitled "Led Astray" re-counts a meaningful and complete case of abdominal pain [3]. In this case, the patient presented to a community hospital with a one-month history of constant diffuse abdominal pain. After eight weeks of examinations and deterioration of their condition, and diagnosis was delayed to threaten the patient's life. Whether a more effective mode of thinking can be used to solve this problem is worth considering. This article reviews this case, and discusses a clinical symptom-oriented modular diagnosis scheme to improve the diagnostic process of abdominal pain [4].

Simple Review of the Case Report [3]
A 34-year-old man presented to a community hospital in Vancouver, Canada, with a 1-month history of constant diffuse abdominal pain, fatigue, and anorexia associated with a weight loss of 2.7 kg but no fevers or night sweats. He reported constipation but no diarrhea, melena, or hematochezia. His medical history and travel history were unremarkable. He worked at a family-run business and lived with his wife and his parents. He did not use medications leading to his recent paint.
In this case, anemia and liver dysfunction were identified as prominent manifestations after the relevant laboratory examination. At the same time, computed tomography (CT) of the abdomen revealed thickening of the rectum and sigmoid colon near the hepatic flexure. This prompted an upper and lower endoscopy and endoscopic pathological examinations, but no positive findings were found. The initial diagnosis was thalassemia, but thalassemia could not explain the abdominal pain. During the next six weeks, the patient visited the emergency department for ongoing abdominal pain three times, confirming that a clear diagnosis was not achieved. During the seventh week, the patient developed a headache and fever in addition to the abdominal pain that had not been alleviated. Further tests and examinations were performed, including serologic testing, lumbar puncture, blood and urine cultures, chest radiography, magnetic resonance imaging of the head and spine, and capsule endoscopy, but no unifying diagnosis was identified. The patient developed epilepsy in the eighth week and was transferred to the intensive care unit with tracheal intubation. Finally, it was found that the serum-free protoporphyrin level was increased, and blood lead level was significantly elevated. Consequently, the correct diagnosis of lead poisoning was identified. On this basis, the patient was again asked about his history, and it was clear that the patient had been using lead-containing opium, which was the cause of poisoning.
As the authors described, the differential diagnosis of subacute, diffuse abdominal pain in a young man is broad [5]. Practitioners need to inquire further to obtain a thorough medical history, physical examinations, and laboratory examination for these clinical problems.

Earlier Diagnosis Using a Clinical Thinking Checklist
There are many potential causes of abdominal pain, including external abdominal injuries, chest, and systemic disease. These may involve a range of medical  [3]. We propose that a clinical thinking checklist may have improved the diagnostic process in the present case. This scheme (Table 1)

Discussion
General practitioners often get a more appropriate diagnosis with the least instrument examination for the diagnosis of MUPS. It is challenging to make a more correct diagnosis timely and reasonable treatment with the least instrument examination in a short time. Abdominal pain is a common undifferentiated disease among general practitioners.
There are many potential causes of abdominal pain, many of which fall under X. R. Li et al.
the purview of a range of medical disciplines. The differential diagnosis of abdominal pain presents hundreds of possible causes, making it easy to miss a diagnosis or even misdiagnose, and a delayed diagnosis can threaten the life of a patient. Abdominal pain is difficult to diagnose and has a high misdiagnosis and missed diagnosis rate. Birgisdottir et al. also reported abdominal pain caused by acute porphyria [6]. Two cases of abdominal Henoch-Schonlein purpura with abdominal pain were reported, and surgical treatment was performed. One patient died due to a postoperative intestinal fistula [7]. Lead poisoning is a diagnosis that is often overlooked. A case of abdominal pain caused by lead poisoning was misdiagnosed as nonspecific abdominal pain and acute porphyria [8]. In During differential diagnosis for abdominal pain, physicians are required to be aware of hundreds of potential causes. "I don't know" is perhaps the most important three-word sentence in medicine [9]. Physicians deal with uncertainty in medicine, and "I don't know" contributes to the uncertainty in the clinical thinking process, which guides physicians' actions in clinical practice [10]. It is Case Reports in Clinical Medicine challenging for doctors to make the correct diagnosis with a low number of examinations, so a checklist can ensure medical safety. The checklist is not just the direction of diagnosis we need to pay attention to, but also to develop a mode of thinking.
In conclusion, abdominal pain masks atypical diseases or rare diseases that are more prone to misdiagnosis and missed diagnosis [11]. If the current diagnosis cannot be explained, screening cause of disease one by one according to the checklist should consider poisoning earlier in the clinical course. Then, the availability, accuracy, and relatively low cost of serum testing should be performed promptly, which could get the diagnosis to be faster for MUPS in Community medical institutions.