Patients presenting to the emergency department with multiple vague and nonspecific symptoms pose a particular diagnostic challenge. Generally, these presentations do not result in discovery of any severe issues, but periodically, they herald the onset of a sinister and hidden emergency disease. Multiple return visits give the emergency physician an opportunity to rethink the situation with the benefit of further information.
Explore This IssueACEP Now: Vol 38 – No 12 – December 2019
The below medical malpractice lawsuit highlights a patient presenting with vague complaints over multiple visits, leading to a bad outcome from a diagnosis that is a well-known medicolegal risk.
A 36-year-old man presented to an urgent care with a dry cough, body aches, and general malaise. He was seen by a physician, who did not order any testing and discharged him with generic instructions to take Tylenol and ibuprofen.
Two days later, the patient’s symptoms persisted, and he presented to a local emergency department. The documentation from this visit notes he was also complaining of back pain and neck stiffness. An aggressive workup was ordered, including a complete blood count, a comprehensive metabolic panel, mononucleosis testing, urinalysis, an ECG, and a chest X-ray.
The results showed thrombocytopenia of 61,000 and a glucose of 245. Given the patient’s neck stiffness, a lumbar puncture was recommended. The cerebrospinal fluid results did not show any abnormal findings. The patient was ultimately discharged with a diagnosis of viral meningitis, thrombocytopenia, and hyperglycemia (see Figure 1).
Over the next few days, the patient continued to feel worse. His malaise progressed, and his back pain also worsened. He presented back to the emergency department. His platelet count had improved to 120,000. A lactate was in the normal range. He was prescribed Percocet and Soma, then discharged again.
Following his third discharge, he began to experience weakness and numbness in his legs. He returned to the emergency department for a fourth time. The emergency physician reviewed his case and appropriately recognized the patient was showing signs of a spinal cord syndrome. Therefore, an MRI of his lumbar spine was ordered.
The results of the lumbar spine MRI did not show any acute abnormalities. Given the patient’s objective neurological deficits, he was admitted to the hospital. Eventually, a thoracic MRI was ordered as well. The results showed a spinal epidural abscess (SEA) at T9/T10 (see Figure 2).