I had a thought the other day when I was walking out of the hospital, although I am most of the way through my 3rd year I have almost never seen a pt who was a "classic presentation." If you read Cope you would be left with the impression that the qualities of pain, locations of referred pain, timing of onset etc will give you the correct dx. But I consistently read journal articles that describe the wild variation in presentation of even simple cases, there was that recent paper in AEM about appendicitis is peds that basically concluded that there was no "classic picture." So the question for the higher-ups here is do you ever trust the story? I mean, a 55y/o obese dude complaining of RUQ pain that sounds clearly biliary with a +Murphy's aren't you always going to get the amylase/lipase and ROMI? Is this a) the philosophy of EM, b) the fault of the attorneys, or c) the result of "getting fooled" by pts presenting in variable ways?