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DECEMBER 2012
A Real Heartache
with commentary by Steven K. Polevoi, MD
Following an emergency department (ED) evaluation for chest pain, a patient was discharged with a presumptive diagnosis of gastroesophageal reflux disease. Two days later, he returned to the ED in severe distress, now with an acute myocardial infarction and a large pericardial effusion.
DECEMBER 2012
The Lung Nodule That Refused To Grow
with commentary by Alex A. Balekian, MD, MSHS, and Michael K. Gould, MD, MS
At his first visit with a new physician, a man with a "spot" on his lung reported being followed with CT scans every 6–12 months for 8 years. In total, the patient had more than 20 CT scans.
NOVEMBER 2012
Missed Pneumonia
with commentary by Jeffrey M. Rohde, MD, and Scott A. Flanders, MD
A 32-year-old man went to the emergency department with fever and pleuritic chest pain. Following an extensive work-up, he was discharged with "fever, pleural effusion, and chest wall pain", but no clear diagnosis. He returned to the ED 3 days later with worsening pain, continued fever, a new cough, and dyspnea. The patient was started on antibiotics and admitted for pneumonia with effusion.
JULY 2012
Misleading Complaint
with commentary by Krishan Soni, MD, MBA, and Gurpreet Dhaliwal, MD
A man presented to the emergency department (ED) complaining of knee problems, and the triage nurse wrote down the chief complaint as "bilateral knee pain." The ED physician diagnosed a musculoskeletal injury and prepared to discharge him, but the patient was noticeably unsteady. Further examination and imaging revealed a subdural hematoma requiring urgent neurosurgical intervention.
MARCH 2012
Cultural Dimensions of Depression
with commentary by J. David Kinzie, MD
Admitted to the hospital complaining of difficulty breathing and swallowing, a Vietnamese man was diagnosed with reflux disease and an outpouching of the esophagus. The patient was anxious and repeatedly stated that he was "dying" from his physical ailments. During a gastroenterology consultation, the patient ran to the restroom and jumped out the window, killing himself.
DECEMBER 2011
Missing the Point—Eye Injury
with commentary by Rahul Sharma, MD, MBA; and Douglas Brunette, MD, MPH
A woman presented to the emergency department with an eyelid laceration, which was sutured without complication. Her visual acuity was not formally tested and ophthalmology was not consulted. Ten days later, she presented with eye pain and poor vision. Ophthalmologist evaluation revealed a ruptured globe requiring surgical repair.
NOVEMBER 2011
Liver Failure After Chemotherapy: Did We Forget Something?
with commentary by John Lubel, MD
A woman undergoing chemotherapy for breast cancer developed fulminant liver failure after clinicians failed to check whether she had a history of hepatitis.
OCTOBER 2011
The Dropped "No"
with commentary by Annette J. Johnson, MD, MS
When a hospitalized man developed an arrhythmia, the night float resident checked a radiology report that stated the patient had a DVT. Intervention was started based on that assumption. However, the radiology report had been transcribed incorrectly.
MAY 2011
Duty to Disclose Someone Else’s Error?
with commentary by Thomas H. Gallagher, MD
Transferred to a tertiary hospital, a child with severe swelling of the brain is found to have venous sinus thromboses and little chance of survival. Further review revealed that the referring hospital had missed subtle signs of cerebral edema on the initial CT scan days earlier, raising the question of whether to disclose the errors of other facilities or caregivers.
FEBRUARY 2011
Paradoxical Pulse
with commentary by Christopher Roy, MD
A week after successful pacemaker placement, an elderly man developed chest pain and was admitted to the hospital without having an urgent echocardiogram. Although providers felt that he "looked fine," the patient became acutely hypotensive, developed ventricular tachycardia and pulseless electrical activity, and required emergent resuscitative measures for cardiac tamponade.
OCTOBER 2010
"Recurrent" Appendicitis
with commentary by Caprice C. Greenberg, MD, MPH
Following an appendectomy, an elderly man continued to have right lower quadrant pain. Reviewing the specimen removed during the surgery, the pathologist found no appendiceal tissue. The patient was emergently taken back to the OR, and the appendix was located and removed.
JUNE 2010
Acute Respiratory Arrest in Pregnancy
with commentary by Baha Sibai, MD
A woman with chronic hypertension developed undiagnosed preeclampsia during pregnancy with twins. At 38 weeks, she experienced respiratory and cardiac arrest. Although she eventually recovered, the infants were stillborn.
FEBRUARY 2010
Defensive Medicine: "Glowing" with Pain
with commentary by Manish K. Sethi, MD
Over the course of 2 years, a patient who frequently came to the emergency department complaining of abdominal pain underwent 12 CT scans of the abdomen and pelvis. All of them were completely normal.
FEBRUARY 2010
Adolescent Diabetes: A Routine Visit?
with commentary by Gail B. Slap, MD, MSc
An overweight teenaged girl came to the pediatrics clinic for routine follow-up of her type 2 diabetes, complaining of nonspecific, intermittent abdominal pain and worsening acne. The physician prescribed topical acne cream and increased her diabetes medications. The next day, an obstetrician notified the pediatrician that this patient had delivered a healthy infant via Caesarian section overnight.
DECEMBER 2009
"Superficial" Report Leads to "Deep" Problem
with commentary by Gurpreet Dhaliwal, MD
Physicians confuse the terminology on a preliminary radiology report and diagnose a woman with foot and ankle pain as having a low-risk case of superficial vein thrombosis, rather than the more dangerous deep vein thrombosis she actually had.
AUGUST2009
Hiding in Plain Sight
with commentary by Jeffrey M. Weinberg, MD
One day after being discharged from the ED, a woman with severe back pain returns and is admitted for observation and analgesics. The next morning, the hospitalist notes a vesicular rash in the exact distribution of the patient's pain symptoms and diagnoses a herpes zoster infection (shingles).
MAY 2009
Missing Trauma
with commentary by Gregory J. Jurkovich, MD
After an hour of failed resuscitative efforts, a woman who collapsed in a market is pronounced dead in the emergency department (ED). Only later do the paramedics and physician discover a small bullet in the patient's chest.
MAY 2009
Delirium or Dementia?
with commentary by James L. Rudolph, MD, SM
An elderly woman hospitalized for pneumonia becomes disoriented during hospitalization. Even though the patient was never confused at baseline, doctors attribute it to "senile dementia" and place her in restraints.
FEBRUARY/MARCH 2009
All in the History
with commentary by Christopher Fee, MD
Interrupted during a telephone handoff, an ED physician, despite limited information, must treat a patient in respiratory arrest. The patient is stabilized and transferred to the ICU with a presumed diagnosis of aspiration pneumonia and septic shock. Later, ICU physicians obtain further history that leads to the correct diagnosis: pulmonary embolism.
OCTOBER 2008
Coming Up Short
with commentary by Ze'ev Hochberg, MD, PhD
Well-child checks failed to determine that the growth of a young immigrant girl was severely behind the curve. At the age of 12, routine lab tests showed a TSH of 834—indicating severe hypothyroidism.
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