Not Everything Has a Single Diagnosis: A Case of Hematemesis, Pneumothorax, and Acute Pancreatitis Mimicking Boerhaave Syndrome

Patients presenting with multiple unrelated complaints are a common occurrence in the emergency department and one that poses significant difficulty.While we as physicians are trained to look for a unifying diagnosis, we must never forget "Hickam's dictum," stating that a patient may have multiple simultaneous diagnoses.A 48-year-old man presented to the emergency department with a history of hematemesis, acute shortness of breath, epigastric pain, and right-sided chest pain, after a bout of alcohol binge.On examination, the patient had reduced air entry on the right side, raising suspicion for pneumothorax, which was subsequently confirmed on imaging.The presentation immediately raised suspicion of Boerhaave syndrome given the combination of hematemesis, chest pain, and respiratory distress.However, further clinical assessment and investigation revealed three concurrent pathologies: an upper gastrointestinal bleed, pneumothorax, and acute pancreatitis.The patient was subsequently evaluated and treated for each complaint separately and was discharged from the hospital.This case highlights the need for us to always be aware of cognitive biases like anchoring bias and premature closure when evaluating patients with complex emergency presentations.Although a unifying diagnosis may provide a seemingly elegant explanation for multiple findings, clinicians should remain alert to the possibility of coexisting diseases.