In this episode, we unpack the case of a 40-year-old woman who came to the Emergency Department with right upper quadrant abdominal pain—an atypical presentation that led her care team away from considering appendicitis. Without the “classic” symptoms, the diagnosis was missed, and she was discharged home—only to return two days later with a ruptured appendix.

We explore how cognitive biases, atypical presentation, and time pressures in the ED can impact clinical decision-making. More importantly, we discuss practical strategies to reduce diagnostic error: broadening differentials, recognizing atypical presentations, improving team communication, and strengthening safety-netting at discharge. This episode is a powerful reminder that uncommon presentations of common conditions can test even experienced clinicians—and that small shifts in thinking can make a life-saving difference.