Online Symptom checker: 48 year old male with severe abdominal pain

The real story used for testing online symptom checker

Mr. W had abdominal pain since last night. It started as a mild discomfort in his mid abdominal area. It started shortly after he had his normal dinner at home. It slowly got worse and seemed to spread sideways and went all the way across his mid abdomen. It was a sharp pain but also had some burning quality to it. He took some antacids but that did not help much. He then took some ibuprofen. It helped a little bit. He went to bed early, took some sleeping pills and finally fell asleep despite the pain. At around 4 am, he woke up with severe pain. It was similar to the pain from the night but was significantly worse in intensity. It had also spread out much wider and it was also going all the way across to his back. He felt very sick and tried to drink some ice water. It made his pain worse. He sat up, woke up his wife. She was very concerned and gave him another Ibuprofen. He took the pill but it did not help his pain at all. He tried his antacid one more time but that only made him sicker. His wife made some green tea to see if that would help. It did not. He became severely nauseated and he threw up a few times.  They waited a little more to see if it would go away. It was almost 8 am and his pain was getting worse instead of getting better. Finally, they decided to get some medical help.

There was an urgent care center in the neighborhood that opened at 8 am. His wife drove him there.

Before we continue this story any further, let’s see what the five symptom checkers would have suggested them if they had used those. As a standard process in all our online symptom checker review, we will use these five websites:

1. Online symptom checker by WebMD
2. Isabel online symptom checker
3. Online symptom checker by Mayo Clinic
4. Everyday Health online symptom checker
5. Online symptom checker from familymedicine.org

 

Online symptom checker by WebMd:

The online symptom checker by WebMd first lets you choose a body part to locate your symptom. Unlike our previous case, we do have a body part we can check this time. We moved our mouse around the front abdominal area on the anatomical diagram of the online symptom checker. It had the abdomen divided into the upper abdomen and lower abdomen. We noticed that the middle part of the abdomen was included in the diagram for the upper abdomen. We checked that area. It gave us a list of symptoms labelled “upper abdominal symptoms”. We found “pain or discomfort” on the list. It was the closest option that we could use as the starting symptom on the online symptom checker. After we selected that option, the online symptom checker asked us a series of questions. The first question was “does it wake you up at night” and we answered “yes” because our patient did wake up that morning because of the pain. The next question asked us to pick the words that would describe the pain. We had two choices that represented our patient’s symptom. We selected “sharp” and “burning”. It then asked us about the severity of the pain and we checked the option that said “severe”.

When we selected severe, the online symptom checker stopped us and told us to get prompt medical attention if our patient had severe abdominal pain. We were unable proceed any further with this online symptom checker as long as the “severe” option was checked. Since our patient did have severe abdominal pain, we did not want to change that option to get the list of diagnoses. We stopped and proceeded to the next online symptom checker on the list.

Isabel online symptom checker:

This online symptom checker is simple and easy to use. We just had to enter the patient’ s age, gender and region. We could then simply type the symptoms. First we typed “abdominal pain” and it did had that option. We typed “nausea and vomiting” and it did have that option too. So, we checked those two symptoms and clicked the “search” button. This online symptom checker directly gave us the list of top 10 diagnoses we were looking for. Here is the list from Isabel online symptom checker:

1. Acute Appendicitis
2. Pancreatitis
3. Peritonitis
4. Biliary Colic
5. Aortic Aneurysm
6. Liver Cancer
7. Cirrhosis
8. Gallstones
9. Hepatitis C
10. Urinary Infection

Mayo Clinic online symptom checker

The online symptom checker from Mayo clinic starts with a list of symptoms to choose from. It was relatively easy to find the symptom we were looking for as “abdominal pain” was the first symptom on the list for adults. We clicked on the symptom and it asked us a set of questions to further analyze the symptom. When it asked what kind of pain it was, we checked “acute or began suddenly”, “sharp”, “burning” and “worsening or progressing”. We checked “mid abdomen” for the question asking where the pain was located. Under “triggered or worsened by” we checked “eating certain food” as that was the closest answer on the list. The more appropriate answer would have been “eating any food” but we did not have this option on the online symptom checker. The next question was “relieved by” and none of the answer choices came close to what our patient had and we left that blank. The next question on the online symptom checker was “accompanied by” and we checked “nausea or vomiting”. That was the last question on the online symptom checker and we just had to click “find causes.” It gave us the list of diagnoses we were looking for. However, it was a long list and had 22 possible diagnoses listed. We picked the following top 10 diagnoses from the list of diagnoses given by this online symptom checker:

1. Appendicitis
2. Gastritis
3. Pancreatitis
4. Peptic ulcer
5. Diverticulitis
6. Food poisoning
7. Gallstones
8. Gas and gas pains
9. Viral gastroenteritis (stomach flu)
10. Intestinal obstruction

 Everyday Health Online Symptom Checker:

The online symptom checker by everyday health has an easy search function to start the process but we did not even have to use the search function in this case. “Abdominal pain” was the first option in its list of pre-selected symptoms. We just clicked on it and it started asking questions. The first 2 questions were about the age and gender of the patient and we answered those. The next question asked us if the patient had abdominal aortic aneurysm. We answered no. The next question was if our pain was in the upper part of the abdomen. We answered no because it was more in the middle. It then asked us if the patient had severe abdominal pain. We answered that in the affirmative. The next question was “Have you had severe abdominal pain for more than 1 hour?” We answered “yes”. It then asked, “Did you faint, pass out or lose consciousness with your abdominal pain?” We answered in the negative. It then asked us if we have measured the blood pressure. We answered no. It then asked if we measured the patient’s heart rate. We again answered “no”. It then asked us if the patient had the appendix removed. We answered in the negative. It then asked us if the pain was mainly in the right lower abdomen. We again answered “no”. It asked us if the patient had kidney stone in the past. We denied that. Finally, it asked us if the patient had been vomiting and we clicked “yes”. It asked us if the patient had swelling of the abdomen and we answered “no”. That seemed to be the last question. It gave us the list of possible diagnoses:

1.   Acute Appendicitis
2.   Acute Pancreatitis
3.   Kidney Stone
4.   Gallbladder Disease
5.   Intestinal Obstruction

It also gave its recommendation that the patient should see a doctor right away.

Online symptom checker from familymedicine.org:

This time we were able to use the online symptom checker from familymedicine.org because it did have the symptom listed. We had two choices for abdominal pain: long term and short term. We clicked on the “abdominal pain, short-term” option. The next step gave us an algorithm to help us guide toward the possible diagnosis. Before the start of the algorithm, it gave us a warning that sudden severe abdominal pain should not be ignored. The first question on the algorithm was “Do you have abdominal pain that is severe, constant and dull, severe and knife-like, or severe cramping?” It did have some of the features of the pain our patient had. We answered yes and went down to the next question. It asked us about possibility of pregnancy and we answered “no”. That led us down the path with the next question . It was actually a series of questions.

“Is your stomach very tender to touch?”

“Do you have bloody diarrhea or stools that are black or tarry?”

“Are you vomiting blood ?”

“Do you have a fever?”

We felt like some of the questions were half true but it would not be accurate to answer them as definite “yes”. Since we couldn’t explain our answers, we simply choose “no” and went down the path to next question. The next question was, “Does the pain start in your upper middle or upper right abdomen and shift to your back, and does it occur or worsen when you eat fatty or greasy food?” Our patient did have one out of the three things described in the question but it was “AND” question and not a “OR” question. We could not answer it as “yes” unless all the conditions were met. We therefore answered “no” and moved on to the next question which was, “Do you have a sudden sharp pain that starts in the back near the ribs and moves down toward the groin?” We simply answered “no”. The next question was “Is your pain in the lower right abdomen, and do you have blood or mucus in your stools?” We again answered “no” and moved down the path and encountered the next question “Do you have a mild ache or burning pain in the upper abdomen, or cramping pain that comes and goes?” We denied that and looked at the next question “Do you have watery diarrhea, fever, muscle aches, chills, nausea or vomiting?” This question was particularly difficult to answer. Technically, it was an “OR” question. We just had to have one of the conditions true for a “yes” answer. Our patient did have vomiting. We had to select “yes” knowing that it may not have been the true intent of the question. It lead us to our diagnosis: GASTROENTERITIS, commonly called the stomach flu. We only had one diagnosis and we were unable to get our top 10 or top 5 list.

What actually happened to our patient:

The urgent care was not busy that morning. He was the first patient and was able to see the doctor in less than 5 minutes. The doctor appeared very concerned about his symptoms and ordered some blood tests STAT. He advised the patient to wait there until the test results were back. It took about 45 minutes for the results. He waited in pain. He was getting sicker and felt very weak and tired. The doctor came back and said that things did not look well. There were multiple abnormalities in the lab results. He suggested that patient be admitted to the hospital. He offered to call the ambulance to get the patient to the hospital but his wife wanted to drive him there herself instead of waiting for the ambulance. It was only a ten minutes drive but he was very uncomfortable. Every bump in the road seemed to worsen his pain. His wife parked outside the emergency department and went inside to ask for help. They sent a volunteer out with a wheelchair so that they could get him inside with relative ease. She explained to the triage nurse that he was told to be there by the urgent care doctor. The nurse checked his name and date of birth and informed the wife that they had received information about him. They already had a bed reserved for him on the medical floor. The nurse still checked his vitals and made sure he was OK to be transferred to the floor. His temperature was 97.8, his pulse was 108, his blood pressure was 100/50 and his respiratory rate was 20. The nurse cleared him for medical floor and they took him to the room. He had an ultrasound of his abdomen performed at the bedside. The admitting doctor came in reviewed the chart, asked some questions and gave his diagnosis and treatment plan.

Our patient had acute pancreatitis. He also had inflammation of his gall bladder with small gallstones suggesting acute cholecystitis. He also had elevated bilirubin and had dilated common bile duct with possible acute cholangitis and choledocholithiasis.

At first, all these diagnoses seem overwhelming and confusing. However, once you know how these things are related and how they fit with the patient’s story, you will see that they follow a simple and logical explanation. Online symptom checkers are unable to process the complex information obtained from the story of a real patient and have trouble getting the correct diagnosis.

There are four organs involved in the disease process that happened in our patient. Once you know how they work together, his diagnoses will make sense. I will only describe those roles of these organs that apply to our patient’s disease. To read the details of how our organs function in health and illness, you can read the book once it gets published in the next few weeks.

Liver makes bile. Bile comes out of the liver and collects in a small sac called the gallbladder. Gallbladder releases the bile into the upper intestine through a small pipe like structure called the common bile duct. It is called common bile duct because it also gets the juice released by the pancreas. Pancreas makes digestive enzymes strong enough to digest protein and fat. The bile and the pancreatic juice flow through the common bile duct and reach the upper part of the intestine and help digest the food we eat.

The stones formed in the gallbladder. Gallbladder stones are very common and may not cause any problem at all. However, they can cause inflammation of the gall bladder and cause pain in the right upper part of the abdomen. That is called cholecystitis. Sometimes, the stones come out of the gall bladder and get lodged into the common bile duct. When that happens, it is called choledocholithiasis. It simply means “stones in the common bile duct”. The stone in the common bile duct can obstruct the flow of digestive juices and can cause severe inflammation. That is cholangitis, simply inflammation of the duct. This inflammation and obstruction can extent to the pancreas and acute pancreatitis happens. Acute pancreatitis can be very dangerous because the inflamed pancreas can release strong digestive juices that can burn and erode the internal structures in the abdomen. The resulting damage can be life threatening.

As you can see, the story of illness can give us the details of how a disease started, how it progressed and what happened at the organ level. The best way to analyze symptoms is not by picking some symptoms and running them through an algorithm: it is trying to put the whole story in the context of what could be happening in the internal organs. The individual symptoms matter but the story of how symptoms started and progressed in real time matter even more.


Our patient had gall stones that caused the inflammation of gallbladder but some of them also escaped it and got lodged in the common bile duct and obstructed the flow of digestive juices. It progressed into cholangitis and pancreatitis, and the pain became more severe.

Analysis of the online symptom checkers in this particular patient:

In this case, the winner among the online symptom checkers was the WebMD. We liked that WebMD did not give any diagnosis but urged the patient to seek medical help immediately. That way sound like a waste of time as you expect to get possible diagnoses from an online symptom checker. However, in this case, it was the right answer. When you have rapidly progressing severe abdominal pain, the best thing to do is to go to the nearest emergency department right away. The list of possible diagnosis in this particular scenario does not matter much because any of those diagnoses can be life threatening without rapid treatment.

Isabel online symptom checker did list some diagnoses that would be immediately life threatening without treatment but it also had a few relatively non-emergent diagnoses towards  the bottom of the list.

Everyday health online symptom checker also gave a list of possible diagnoses including the actual diagnosis of our patient. It was the second most helpful symptom checker because it also prompted you to seek medical help right away.

The list of diagnoses given by Mayo clinic online symptom checker was not very helpful because it listed almost anything that can cause abdominal pain. It did not seem to warn you about the urgency of the situation and included diagnoses that did not need immediate medical attention mixed with the diagnoses that required immediate attention. Also, the list was too long to be helpful.

The online symptom checker from familymedicine.org over-analyzed the symptoms and the algorithm failed to see the bigger picture. It squeezed us into a narrow, incorrect and potentially flawed path of diagnostic thinking and led to the diagnosis that did not require immediate medical attention. This kind of online symptom analysis may falsely reassure you and can be potentially harmful.