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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

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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

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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

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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.1993.

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Infectious Mononucleosis

Ball AP. Infectious Diseases 1993. Forbes CD. Color Atlas Medicine. 1993.

Infectious Mononucleosis

Highest incidence in 15-24 years of age

Posterior cervical lymphadenopathy, fatigue

Lymphocytosis with atypical lymphocytes

Monospot test:

1st week of illness with high false-neg rate

Most splenic ruptures occur in 1st 3 wks of illness

Instruct to avoid contact sports for 3-4 weeks

N Engl J Med. 2010;362:1993-2000 [Infectious mononucleosis].

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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

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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…..

136

3.1 19

105

0.9

18108

11.56.8

36.4289

Non-contrast head CT:No mass or bleed

Lymphocyte: 10%

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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

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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;50:291-322 [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

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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

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Case # 3: ED Course

IVF 2 liters NS

Ceftriaxone 1 gram IV

Labs:

CMP, CBC, Lipase

Blood cultures x 2

UA & culture

138

4.0

95

1.8

32425

12.222.3

36.4109

PMNs 89%Bands 15%Toxic vacuolization

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Nitrite: PositiveLeukocyte esterase: PositiveWBC: 158; RBC: NoneBacteria: Many

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 …..

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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

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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;160:797-805 [Emphysematous pyelo; prognosis].Urol Int. 2005;75:123-28 [Emphysematous pyelo; management].

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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