Real Cases: Bad Outcomes

Transcription

1 Real Cases: Bad Outcomes Fredrick M. Abrahamian, D.O., FACEP, FIDSA Clinical Professor of Medicine UCLA School of Medicine Director of Education Department of Emergency Medicine Olive View-UCLA Medical Center Sylmar, California Case # 1: History 17 y/o male Chief complaint: Throat pain for 4 days In addition, complains of: Difficulty swallowing Weakness Abdominal pain Intermittent fevers No vomiting, CP, or SOB 1

2 Case # 1: History PMHx: None Meds: None Allergies: None Denies smoking, alcohol or drug use ROS: Unremarkable Case # 1: Physical Examination Vitals on arrival: BP 145/85 P 125 R 22 T 38.5 ºC (101.3 ºF) General: In no acute resp. distress but looks ill Neck: Supple but complains of severe pain; Very large lymph nodes Throat: Large exudates over tonsils; no PTA Resp: CTA; non-labored Heart: Tachycardic but no murmurs GI: Diffusely tender but no rebound or guarding 2

3 Case # 1: ED Course Orders: IVF 1 liter NS Tylenol 650 mg PO Labs: Rapid strep test negative Diagnosis: Viral pharyngitis Plan: D/C home; F/U with PMD as needed Nursing D/C notes: Patient looks really tired Vitals on discharge: BP 132/82 P 115 R 22 T 37.8 ºC (100.0 ºF) Case # 1: Follow up 2 weeks later collapses while playing football Pale, diaphoretic Complains of severe abdominal pain Taken by ambulance to hospital Dx: Splenomegaly & splenic laceration Underwent splenectomy EBV serology consistent with acute infection 3

4 Case # 1: Litigation Claims Claims: Failure to consider mononucleosis in DDx Failure to send diagnostic tests Failure to provide proper D/C instructions Defense: Diagnostic testing may not have been helpful Splenic rupture would have occurred Infectious Mononucleosis Ball AP, et al. Infectious Diseases

5 Infectious Mononucleosis Ball AP. Infectious Diseases Forbes CD. Color Atlas Medicine Infectious Mononucleosis Highest incidence in years of age Posterior cervical lymphadenopathy, fatigue Lymphocytosis with atypical lymphocytes Monospot test: 1 st week of illness with high false-neg rate Most splenic ruptures occur in 1 st 3 wks of illness Instruct to avoid contact sports for 3-4 weeks N Engl J Med. 2010;362: [Infectious mononucleosis]. 5

6 Case # 2: History 48 y/o male c/o headache x 2 weeks Arrives with wife by ambulance Gradual onset of pain, severe & constant Multiple episodes of non-bloody vomiting Reports chills & subjective fever Complains of photophobia No CP, SOB, or abdominal pain Case # 2: History PMHx: HIV, hypertension Unknown if has AIDS-defining illness Unknown last CD4 count Meds: Multiple meds (unaware of names) Allergies: None Denies smoking, alcohol or drug use ROS: Unremarkable 6

7 Case # 2: Physical Examination Vitals on arrival: BP 198/118 P 98 R 24 T 37.6 ºC (99.7 ºF) General: In severe distress from headache HEENT: PERRLA; erythematous oropharynx Neck: Supple; no lymphadenopathy Resp: CTA; no wheezing Heart: Normal rate & rhythm, no murmurs Abdomen: Normal bowel sounds; non-tender Neuro: A&O x4; non-focal neuro exam Case # 2: ED Course Orders: IVF 1 liter NS BMP, CBC, UA Blood cultures Head CT Rocephin 1 gram IV Vicodin 1 PO Refused LP risks.inability to Dx infection or bleed Lymphocyte: 10% 289 Non-contrast head CT: No mass or bleed 7

8 Case # 2: Hospital Course Admitted to non-monitored floor Dx: 1) Severe headache; 2) HIV Complains of visual changes Became confused & lethargic.. apneic Unable to resuscitate Autopsy: Cerebral edema, herniation Final Dx: Cryptococcal meningitis Case # 2: Litigation Claims Claims: Inadequate physical examination Failure to consider cryptococcal meningitis Failure to properly warn of all risks Defense: Patient refused diagnostic procedure Outcome would not have changed 8

9 AIDS & Cryptococcal Meningitis Majority with no meningismus or fever Often normal head CT scan & CSF findings A critical clue is elevated CSF pressure Antifungal drugs & relief of elevated ICP are mainstays of therapy Pressure may be relieved with serial LPs, ventricular or lumbar drains, CSF shunts Clin Infect Dis. 2010;50: [IDSA Practice guidelines]. Case # 3: History 62 y/o female c/o left flank & back pain Gradual onset of pain 2 weeks ago Pain described as severe & constant Admits to chills, subjective fevers, Complains of dysuria & urinary hesitancy Pain radiates to abdomen & chest Multiple episodes of non-bloody vomiting 9

10 Case # 3: History PMHx: DM, hypertension, bipolar disease Hx. of multiple prior UTIs Meds: Metformin, Glipizide, Benazepril Allergies: None Admits to smoking; occasional alcohol use Denies drug use ROS: Unremarkable Case # 3: Physical Examination Vitals on arrival: BP 98/50 P 130 R 22 T 38.9 ºC (102 ºF) General: In severe distress from pain HEENT: PERRLA; EOMI; normal TMs Neck: Supple; no lymphadenopathy Resp: CTA; no wheezing Heart: Tachycardia, no murmurs Abdomen: Mild tenderness over LLQ, left CVAT Neuro: Moves all extremities; normal sensation 10

11 Case # 3: ED Course IVF 2 liters NS Ceftriaxone 1 gram IV Labs: CMP, CBC, Lipase Blood cultures x 2 UA & culture Nitrite: Positive Leukocyte esterase: Positive WBC: 158; RBC: None Bacteria: Many PMNs 89% Bands 15% Toxic vacuolization Case # 3: ED Course ED: IVF; insulin drip Dx: DKA; UTI; possible urosepsis Admitted to ICU In ED, complains of increasing pain Reassessment note:... not sure if she is truly in pain. part of it may be due to underlying psychiatric disorder.. 11

12 Case # 3: Hospital Course Complains of more back pain & dizziness Progressively becomes more hypotensive Requires intubation arrests. Unable to resuscitate Autopsy: Emphysematous pyelonephritis Case # 3: Litigation Claims Claims: Failure to consider emphysematous pyelo Failure to initiate proper antibiotics Failure to initiate timely interventions Defense: Rare condition Presentation consistent with urosepsis Outcome would not have changed 12

13 Emphysematous Pyelonephritis Life-threatening, suppurative, necrotizing infection E. coli most common cause CT scan imaging modality of choice Differentiate emphysematous pyelonephritis: Emphysematous pyelitis Emphysematous cystitis Broad-spectrum antibiotics Immediate surgical consultation Arch Intern Med. 2000;160: [Emphysematous pyelo; prognosis]. Urol Int. 2005;75: [Emphysematous pyelo; management]. 13

14 Medical Take Home Points Mononucleosis Monospot test: 1st week with high false-neg rate Avoid contact sports for 3-4 weeks Cryptococcal meningitis Normal CSF values Critical clue is increased CSF pressure Emphysematous pyelonephritis CT scan imaging modality of choice Immediate surgical consultation Legal Take Home Points Documentation: It is the quality ( key words ), not the quantity Re-evaluation: Improved, unchanged, worsened Repeat vitals Address abnormal labs; know limitations; avoid bias Beware of the non-fit Diagnosis doesn t match S/Sxs & tests Document refusal of care with all the risks Avoid attributing physical findings to psychiatric illness 14