On 12/10/2014, a patient, a resident of an inpatient psychiatric facility, fell on his face during a fire drill.  Per ward staff, it appeared the patient had experienced a seizure.  An on-the-scene physician ordered labs for the next morning, checked the patient’s vital signs, performed a dental consult, and provided a dose of antibiotic and some Gatorade.

On 12/11/2014, the same physician examined the patient and noted his pulse to be 90-100, after an initial measurement of 113, and his blood pressure stable.  Soon after, a second physician performed an examination on the patient and noted that he was “feeling generally unwell, had a low grade temperature and some muscle pain.”  It appeared to the physician the patient had an upper respiratory infection.  Albuterol and a complete blood count were ordered.

On the afternoon of 12/11/2014, a third physician examined the patient.  The physician’s records showed the patient presented with a probable upper respiratory virus with asthmatic bronchitis.  The patient’s heart rate was 120.  The physician documented that the patient’s tachycardia was probably due to mild dehydration and medications.  The treatment plan for the patient included a chest x-ray and evaluation of creatine phosphokinase (CPK) levels.  It was reported that the patient’s chest x-ray “seemed negative.”  The patient denied having any chest pain.  The physician opined that the increased CPK level may have been caused by medications or a possible recent seizure.  The physician’s treatment plan included an electrocardiogram (ECG), rechecking labs, and oral hydration.

On 12/12/2014, an internist entered the patient’s medical room.  She ordered fluid monitoring every shift, continuation with vital signs every four hours, and repeat lab testing in the morning.  The ECG reported “probably abnormal ECG.”  The internist was notified of this reporting and informed an assisting physician.

The internist failed to review the patient’s previous medical records, which included chest x-rays and perpetuated the diagnosis of dehydration despite adequate hydration.  The internist failed to respond to abnormal vital signs and properly diagnose and treat the patient’s medical condition.  The internist also failed to transfer the patient to a higher level of care for additional work-up.

On 12/13/2014,  the patient’s treating psychiatrist received a call from the nursing staff informing her the patient was suffering from an elevated heart rate, and had an elevated, though declining, CPK level.  The patient continued to receive treatment from various physicians who noted the patient’s decline, which included symptoms of tachycardia and weakness.

On 12/14/2014, the patient was transported to a hospital by ambulance where diagnostic tests revealed “extensive bilateral pulmonary emboli and probably thrombus in the right atrium.” The patient was transported to a second hospital.  While in interventional radiology, the patient became pulseless and was later pronounced dead.

The Commission stipulated the internist reimburse costs to the Commission and write and submit a paper of at least 1000 words on how to appropriately evaluate patients with shortness of breath and tachycardia.  The paper should also discuss the proper review of ECG findings consistent with pulmonary embolisms.

State: Washington

Date: March 2016

Specialty: Internal Medicine

Symptom: Palpitations, Shortness of Breath, Weakness/Fatigue

Diagnosis: Pulmonary Embolism

Medical Error: Diagnostic error

Significant Outcome: Death

Case Rating: 5

Link to Original Case File: Download PDF