Patients often present to the emergency department with multiple symptoms that do not fit clearly into one specific chief complaint or diagnostic pathway. In these atypical situations that defy simple description, policies and algorithms are difficult to apply. But when patients suffer unexpectedly bad outcomes, plaintiff’s lawyers are quick to point out any deviation from hospital protocols. This medical malpractice case highlights these issues.

The Case

A 61-year-old man presented to the emergency department with several complaints. The triage note (see Figure 1) mentioned a sudden onset of feeling like his abdomen was “going to explode” and a vibrating sensation in his legs. Initial triage vitals showed a blood pressure of 169/84, pulse of 66 beats per minute, 18 respirations per minute, and a temperature of 96.1°F. The triage nurse listed the chief complaint as “chest pain” but later documented “pt denies chest pain.” His allergies listed an anaphylactic reaction to iodinated contrast.

Figure 1: Triage note

The physician’s note described the pain as starting suddenly while loading a car. He had an “abrupt onset of the sensation that he had a lid of a paint can that began in his epigastrium and slammed up into his jaw and then came down and continues to compress upon his abdomen.” The patient described feeling diaphoretic, a sense of his legs shaking, and a small amount of diarrhea. He denied chest pain to the physician. His past medical history was remarkable for history of aortic valve replacement, but he denied history of coronary artery disease or abdominal aortic aneurysm or other aortic syndrome.

The physician’s examination noted a “very kind and cooperative” patient. His large abdomen made the exam difficult, but an aortic pulsation was detected and noted to be “concerning given this gentleman’s proportions.” The vascular exam in his lower extremities was “symmetrically diminished.” The cardiac exam noted a systolic click.

After taking a full history and exam, the physician documented a differential diagnosis that included a concern for abdominal aortic aneurysm, acute coronary syndrome, and renal colic. An ECG showed no acute signs of ischemia. An initial troponin level was negative. The patient medication list included warfarin, and his International Normalized Ratio was 2.8 in the emergency department. The complete blood count and metabolic panels were unremarkable. Given the history of anaphylaxis to contrast, a noncontrast CT scan of the patient’s abdomen was ordered. No abdominal aortic aneurysm or evidence of dissection was seen on CT (see Figure 2).