WebM&M: Case Studies

This pair of cases describes patients misdiagnosed and treated for migraines before being diagnosed with life-threatening conditions: encephalitis and cancer. The commentary discusses the challenges involved when diagnosing patients presenting with headache and a framework consisting of three key factors (diagnostic pitfalls, red flags, and “don’t miss” diagnoses) to consider in diagnostically challenging situations.

A man with a history of prior umbilical hernia repair presented to the emergency department (ED) with abdominal pain and was initially diagnosed with cholelithiasis before being discharged home. However, the next day he returned to another ED with similar symptoms and was diagnosed with a small bowel obstruction caused by adhesions from a ventral hernia. He underwent surgery but died three days later from multi-organ failure and sepsis caused by necrotic bowel and peritonitis. The commentary describes the appropriate evaluation for acute abdominal pain, the importance of imaging in patients with high-risk abdominal pain, and how to mitigate the influence of cognitive biases in the diagnostic process.

Following an uncomplicated urologic surgery for hypospadias repair, a previously healthy 2-year-old boy was discharged with a 5-day course of hydrocodone-acetaminophen 7.5-325 mg/15 mL solution. The child was brought to the emergency department due to inconsolable crying. The ED workup was unremarkable, and he was sent home with a 4.6 day supply of oxycodone 1 mg/mL. Four days later, he became apneic, cyanotic, and unresponsive at home. Emergency first responders were called to the scene and the patient’s cardiac rhythm was determined to be pulseless electrical activity. They began cardiopulmonary resuscitation and administered naloxone and two doses of epinephrine. Upon arrival at the ED, continued resuscitation was unsuccessful, and the child was declared deceased. Inadvertent dose stacking and opioid polypharmacy may have contributed to this patient’s death.

A 55-year-old woman with a history of panic attacks, obesity, and untreated hypertension, experienced syncope after feeling flushed and lightheaded. On arrival at the emergency department, she had severely elevated blood pressure and hypoxemia. Diagnostic tests revealed acute heart failure exacerbation with pulmonary edema, marked elevation of brain natriuretic peptide (BNP), and elevated troponin-I. Despite treatment with diuretics and antihypertensives, her condition deteriorated, leading to intubation due to respiratory failure and subsequent cardiac arrest; cardiopulmonary resuscitation resulted in with return of spontaneous circulation. However, she suffered from ischemic stroke and intracranial hemorrhages, ultimately leading to a transition to comfort care and subsequent death. The commentary discusses the contraindications for beta-blockers in the setting of acute decompensated heart failure and appropriate treatment for hypertensive emergencies in the emergency department and intensive care unit. 

A 54-year-old man with a history of tobacco use presented to the emergency department (ED) with acute chest pain. He was initially stable upon arrival, though with signs of fluid overload and electrolyte abnormalities including hyponatremia and hyperkalemia. Despite treatment including heparin, amiodarone, and metoprolol for atrial fibrillation, and interventions for hyperkalemia, the patient deteriorated rapidly into cardiac arrest characterized by Torsades de pointes, which was mistaken for ventricular fibrillation. Despite resuscitative efforts, he did not achieve return of spontaneous circulation and autopsy revealed sudden cardiac arrest without myocardial infarction as the cause of death. The commentary highlights how the misinterpretation of a common laboratory complication can lead to incorrect treatment and patient harm.

A patient in his mid-30s presented to the emergency department (ED) with three weeks of intermittent left-sided headaches, balance issues, and one brief episode of difficulty speaking and moving. On exam, the patient had normal vital signs, neurologic exam, and initial imaging; he was discharged from the ED without consultation from neurology. A few hours later, he suffered a stroke due to left posterior cerebral artery occlusion and vertebral artery dissection, leading to severe neurological deficits after delayed treatment. The commentary highlights the importance of thorough neurological investigation of patients presenting with dizziness and other simultaneous neurological symptoms, the challenges of diagnosing transient ischemic attack (TIA) – particularly in a young, healthy adult, and the limitations of non-contrast brain CT for identifying TIA or early ischemic strokes in patients presenting with dizziness. 

An older man underwent L4-5 decompressive lumbar laminectomy and discectomy, which was complicated by intraoperative durotomy. At a follow-up visit, he reported clear drainage from the surgical site and the surgeon suspected a cerebrospinal fluid (CSF) leak. Despite conservative management at home, his condition worsened over several weeks before being readmitted with discitis, osteomyelitis and sepsis, resulting in his death 50 days after the operation. The commentary provides an overview of the clinical manifestations of intraoperative durotomy, intra- and postoperative management strategies to address intraoperative durotomy and CSF leaks, and approaches to ensuring patient safety during spine surgery.

After drowning in a pool, a 19-month-old child arrived at the ED in respiratory distress, requiring intubation and mechanical ventilation. The patient’s SpO2 did not improve after the first intubation attempt; after a second attempt, it was discovered that the mechanical ventilator had not been connected to an oxygen source. The commentary discusses approaches to improving safety during emergency intubation, such as capnography confirmation, standardized algorithms to assess post-intubation hypoxia, and simulation training to improve intubation skills.

Infant feeding presents an opportunity for hospital and community staff to review safety processes around feeding of expressed breast milk or the provision of infant formula. This commentary describes safe infant feeding practices and strategies to avoid breast milk feeding errors or the provision of expired feeding products.

A 38-year-old man sustained multiple injuries in a motorcycle crash, including head trauma, chest injuries, and spinal fractures. Attempts to intubate him to manage his respiratory distress were unsuccessful and he underwent emergency cricothyroidotomy. Despite initial neurological evaluations indicating normal extremity movements, he developed progressive paralysis of his lower extremities over the hospital course. A delayed MRI revealed a significant epidural hematoma compressing his spinal cord from C3 to C7, prompting emergency surgery. Despite decompression, he suffered permanent paralysis. The commentary highlights the cognitive pitfalls associated with managing and processing large volumes of clinical information and the importance of effective communication and active engagement among all clinical team members.

A man in his mid-50s presented to the hospital with a persistent headache after a sledding injury. A head CT scan was read as normal and he was diagnosed with a minor head injury and discharged without any specific treatment. Three weeks later, he presented with ongoing symptoms including worsening cognition and increased headache and was diagnosed with post-concussive syndrome and discharged without specific treatment. He was later diagnosed with a large frontal subdural hematoma requiring urgent surgery. The commentary discusses risk factors for delayed acute subdural hematoma and the importance of repeat brain imaging in patients with risk factors and persistent symptoms.

These cases involve two elderly patients presenting to the emergency department (ED) who suffered falls during their care, despite recognition of risk factors including previous ground-level falls. The commentary summarizes risk factors for fall injuries among high-risk populations (such as older adults), appropriate use of fall assessment and prevention strategies, and strategies to improve communication between healthcare team members to reduce the risk of patient falls.

A man presented at the emergency department (ED) after a motorcycle crash. He had superficial lacerations on his left elbow, where wood chips were noted on exam and x-ray but were not fully removed before discharge. He was discharged with antibiotic prescriptions, but returned three days later with worsening symptoms, including pain, swelling, and pus, leading to additional foreign material being removed and further antibiotic treatment, but without repeat x-rays. Ultimately, he developed osteomyelitis, requiring multiple surgeries and a long hospital stay due to the retained foreign bodies. The commentary highlights the importance of evaluating patient risk of wound infection and poor wound healing, the role of imaging modalities to help identify foreign material in wounds, and diligent follow-up to prevent complications.

An 8-year-old boy undergoing a neck mass aspiration experienced a sudden drop in oxygen saturation and heart rate, requiring CPR and intubation, due to being administered nitrous oxide instead of oxygen following a maintenance error by an inadequately trained employee. The patient was transferred to the intensive care unit (ICU) on a ventilator but remained unresponsive and died. The commentary discusses several approaches to improving patient safety during anesthesia administration in the surgical suite, such as use of oxygen analyzers and considering hypoxic gas mixture as the cause for sudden deterioration.

A woman underwent surgery for carpal tunnel syndrome without complications and was discharged with instructions to avoid soaking her hand in water (to reduce infection risk) and return for suture removal in 10 days. Despite reporting symptoms such as warmth, redness, and pain in her wrist shortly after surgery, her concerns were not adequately addressed by the surgeon's office. The patient returned for suture removal and visit notes stated that the wound was not infected or swollen. However, the patient continued to report pain, swelling, redness and oozing at the incision site after suture removal. Two weeks later, she presented to the emergency department (ED) and diagnosed with a severe infection, leading to multiple hospitalizations and permanent impairment of her right hand. The commentary discusses the importance of preoperative discussions about post-operative care, including sterile practices, and the use of protocol-based management strategies for medical office personnel to ensure that patient interactions and communication are appropriately documented and acted upon

An adolescent with type 1 diabetes presented to the emergency department (ED) with dizziness, fatigue, and a “high” reading on her home blood glucose monitor. She was diagnosed with diabetic ketoacidosis (DKA) likely due to insulin pump malfunction. Despite initial treatment, her condition did not improve as expected. Later, it was discovered that an incorrect weight was used to calculate her insulin drip rate, based on a guessed weight provided by the patient upon admission. Once her actual weight was used to adjust treatment, her DKA resolved rapidly within 12 hours. The commentary discusses how human factors engineering and electronic health record (EHR) functionalities can optimize weight measurement during patient encounters and the role of clinical pharmacists in the ED to improve medication safety.

During elective rhinoplasty, a patient became aware that she was awake. She heard the conversation among the surgical team members and felt that the breathing tube was pushed up against the inside of her throat, impeding her ability to breathe. She was unable to move but recalls making a “monumental effort” to utter a small groaning noise, which alerted the surgeon to the fact that she was awake. She heard the surgeon verbally acknowledge her condition and offer reassurance that the operation was almost over. During the first follow-up visit, the surgeon did not address the situation, so the patient brought it up at the end of the visit. The surgeon seemed surprised and embarrassed that the patient remembered waking up during the operation but could not explain what happened. The commentary discusses the risk factors for intraoperative awareness, approaches to prevent awareness, and the importance of validating and addressing the patient’s experience, including addressing symptoms of post-traumatic stress syndrome. 

A 19-month-old boy was being transferred to a tertiary medical center from another emergency department after undergoing comprehensive resuscitation efforts due to cardiopulmonary arrest. The transport clinician intended to administer rocuronium (a neuromuscular blocking agent) to treat ventilator desynchrony, but instead unintentionally administered flumazenil (a benzodiazepine antagonist). The clinician promptly corrected the error by administering the appropriate dose of rocuronium. The commentary highlights the importance of “double checks” during medication administration and how both technologic approaches and human factors engineering principles can support safe medication administration practices.

A 67-year-old man with severe low back pain was admitted to the hospital for anterior lumbar interbody fusion (ALIF) with bone autograft from the iliac crest. The surgical team had difficulty controlling bleeding and the patient left the operating room (OR) with the bone graft donor site open and oozing blood. In the postanesthesia care unit (PACU), the nurse called the attending physician three times to report hypotension and ongoing bleeding. Each time, the surgeon ordered hetastarch for volume expansion. Over the next 14 hours, the patient’s blood pressure remained at or below 90/60 with continued complaints of back and pelvic pain. The next morning, the patient was unresponsive and in severe hypovolemic shock. Electrocardiography confirmed a non-ST segment elevation myocardial infarction (NSTEMI). The patient was transferred to an intensive care unit and resuscitative efforts were initiated, but the patient expired from multiorgan failure resulting from hypovolemic shock. The commentary discusses appropriate management of ongoing intraoperative and postoperative bleeding and how a culture of safety can enable care team members to voice concerns about patient safety. 

A 36-year-old woman with class 2 obesity underwent a difficult laparoscopic hysterectomy, performed in the lithotomy position with a steep head down (Trendelenburg) position. Intermittent pneumatic compression devices were placed on both calves to prevent venous thrombosis (DVT), but on awakening from general anesthesia, the patient complained of severe pain in the right leg. The gynecologist made a presumptive diagnosis of DVT and put her on subcutaneous dalteparin at therapeutic dosing and acetaminophen and oral morphine for pain relief. The patient continued to complain of severe pain and paresthesias in her right calf and doppler ultrasound scan was negative for DVT. The next day the orthopedic on-call team was consulted and diagnosed compartment syndrome of the right leg. The patient required fasciectomy of the right leg and excision of necrotic muscle tissue, with a prolonged hospital stay. The commentary discusses how patient positioning during surgery can increase the risk for surgical complications, the role of interdisciplinary teamwork to achieve optimal positioning, and the importance of early identification of compartment syndrome to prevent permanent injury.