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Cases & Commentaries
- Web M&M
Robert Chang, MD, and Scott Flanders, MD; February 2019
A woman was admitted to a hospital's telemetry floor for management of uncontrolled hypertension and palpitations. On the first hospital day, she complained of right arm numbness and weakness and had new difficulty answering questions. The nurse called the hospitalist and relayed the arm symptoms, but not the word-finding difficulty. The hospitalist asked the nurse to call for a neurology consultation. Four hours later, the patient's weakness had progressed; she was now completely unable to move her right arm. At that point, neither the hospitalist nor the neurology consultant had evaluated the patient in person. A stat head CT revealed a large ischemic stroke.
Journal Article > Commentary
Graber ML, Berg D, Jerde W, Kibort P, Olson APJ, Parkash V. Diagnosis (Berl). 2018;5:257-266.
This commentary provides a clinical review of a missed diagnosis of Epstein-Barr virus infection that was identified via autopsy and summarizes contributing factors to the incident with an emphasis on the role of cognitive bias. The piece includes the perspectives of the patient's family and from the organization regarding what happened and what could have been done to prevent this outcome. This discussion is the first in a series of diagnostic error case presentations to be published in this journal.