1/ #UncleBob thought a lot about diagnostic error this week #5goodminutes
2 important podcasts: Hoofbeats: A 39M on Inpatient Psychiatry with a Fever coreimpodcast.com/2020/01/22/hoo…
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Episode 63 - Human Dx unknown with Reza & Pitt residents - blurry vision and headache clinicalproblemsolving.com/2020/01/26/epi… via @CPSolvers
3/
These remind me of a patient I saw around 10 years ago. The team had missed the diagnosis for 9 days before I joined the team. I too missed the diagnosis for 1 day.
Here is the story:
4/
41-year-old Hispanic man (left Mexico 7 yrs ago) presents with 4 day h/o progressive dyspnea and fevers
No previous illness
Clear sputum with occasional blood streaks
Feels well other than dyspnea
Denies orthopnea or PND
5/
T 101 P 140 BP 140/85 RR 22 O2 sat 91%
Decreased breath sounds on the right
Heart exam – tachycardia, no murmurs, rubs or gallops
No peripheral edema
6/
Routine labs
WBC 13K, 84a%N, 10&L
Hgb 10.4
Plt 325
135/4.1/97/27/12/0.8/128
7/
Images
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Over the next 9 days the patient had antibiotics changed twice with continued fever. I joined the team on a Monday.
When I examined him he had decreased breath sounds at both bases. He was coughing up blood.
9/
I did not pay enough attention to his exam. I was picking up 18 new patients that day.
He had a bronchoscopy that day that showed pulmonary hemorrhage. Repeat CXR - original on the left.
10/
Paid much attention - Hgb had decreased from 10.4 to less than 8 and he had documented iron deficiency
Checked his BMP - creatinine had increased from 0.8 to 1.2
No U/A on admission - U/A on day 10 - 180 RBC (no casts noted)
11/
I have obsessed about this patient for years. I should have gotten to the diagnosis a day earlier. I might have saved him an ICU stay (he was transferred on day 10).
Labs and renal biopsy made the GPA diagnosis.
12/
The good news - I learned a great deal about the problem of picking up new patients. We sometimes do not focus when we are seemingly overwhelmed. We cannot allow ourselves to lose that focus - our patients deserve our full attention.
The patient did respond to rituximab.
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