Case report
EFIM Summer School 2016
Sara Lindberg
SWEDEN
56 year old male
● Married, works full time
● Longtime smoker 1 pack/day
● Previously healthy, no medication
● July 4:th slowly progressing headache
● July 5:th some dizziness, throws up once
July 6 - ER● Comes to the ER in the evening
– No current dizziness or nausea
– Alert, no visible signs of pain
– No fever or signs of infection
● Physical examination– Neurological examination normal
– Cardiopulmonary examination, ECG and standard blood tests normal
– Tender muscles of neck and head – palpation reproduces same pain
● Diagnosis? Actions?
Actions
● Patient is sent home
● Probably tension headache
– Naproxen 500 mg x 2
– Diazepam 5 mg at bedtime for three days
– Advice about physical therapy
– ”Come back or contact your primary care facility if your headache gets worse, if you vomit again or if you get neurological symptoms”
July 11
● Comes back to the ER– Headache better
– Still some dizziness (”was told to come back if symoms didn't go away”)
● Full work up (physical + neurological examination and blood tests normal)– Some dizzyness provoked by Dix Hallpike – BPPV?
– Gets 1 week of sick leave and advice about physical exercise/therapy
July 13● Still dizzy● Primary Care facility:
– Discrete neurological deficiency– Referal to the ER: intracranial bleeding?
● ER:– Points finger slightly beside nose– Walks slightly unsteady– Intern contacts an attending within Stroke/Neurological
disorders that recommends more analgetics
July 19
● Primary care center– Feels better, but still unable to work
– Neurological examination now normal
– Sick leave extended 1 month
– ”Three doctors in the hospital said nothing is wrong”
– Start of physiotherapy
August 28● No improvement
– Impossible to work
– Nausea and vomits in the morning
– Sometimes blurred vision
● Primary Care Center– Neurological examination normal but lively reflexes
– Impaired balance
– Tender muscles in the neck
● Referal to MRI of the brain – prioritized by radiologist in 6-8 weeks
Still not better...
● Sept 4: Comes to the ER because of nausea– ”Unchanged condition, ongoing investigation at PCC”– ”Alert and vital”– Neurological examination normal– Prescription Metoklopramid
● Sept 14: Primary Care Center– Condition worsened– More vomiting in the morning– Referal to hasten the MRI
Sept 19
● ER
– Headache, nausea, dizziness
– Vomits every day
– Can’t keep food and drink down
– Neurological examination: unsteady walk otherwise normal
Sept 20
CT scan
Sept 20● Patient is given Betametason 16 mg iv
● Condition worsens fast
● Neurosurgery not possible
● Patient goes ad mortem in a few hours
Errors● What went wrong?
● When did it start?
● Who/what is responsible?
Errors● Initial diagnosis?
● First return to the ER?
● First neurological symptoms?
● Waiting time for / prioritization of MRI?
● Trusting others / ongoing investigations?
● Lack of time / resources?
● Patient not being able to advocate for himself?
● Other?
Errors
Will happenWe have to learn from them
Trust your instinctReevaluate
Questions or comments?
Thank you!