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!