Dec 27, 2022·edited Dec 27, 2022Liked by Med Mal Reviewer
The first platelet count of 32,000 would have given me pause regarding LP without CT, but I would CT pretty much all heads prior to LP. The prednisone given on first visit could have caused the increased platelet count and steered clinical concern away from spontaneous bleed if one did not know the previous lower count.
Although 78,000 would not worry me as much for risk of bleeding post-LP, I wonder if the ED doc was trying to talk him-/herself into not doing the LP. Unlike hospital records, I don't routinely call for prior urgent care records, but perhaps I will going forward, or at least document they weren't available if after 'business hours'.
Hooray for indiscriminate steroid prescribing. I'm surprised there wasn't a Z-pak in the mix somewhere.
My facility has a rule for platelets of 50k (or ongoing transfusion correction) which seems reasonable given how catastrophic a subdural hematoma could be. I would not have performed this LP myself without a head CT first.
The platelets of 32 should have been addressed, especially in a young woman without family history of coagulopathy. Documenting that as normal was really damning for that first NP. The ER doctor absolutely had rationale to order a CT at his first encounter with her given her neuro symptoms and the duration of her headache. The somnolence should have also been a big red flag in an otherwise healthy 27 year old (IMO). Always easy to see in hindsight though. Thank you so much for these cases, I've shared with multiple colleagues.
I thought of Dr. Greg Henry's pearl of wisdom while reading this case. If someone comes back a third time admit them, even if its the pizza man. Good case.
ery intriguing case, I am surprised the thrombocytopenia was not worked up further in the outpt or inpt settings, so many differentials besides ITP, secondary causes etc DITP, infective, SLE/ APLS , Liver, MDS, TTP, HUS, **infection,
I would appreciate more polls under the future cases,
being a resident in major metropolitan area sometimes our attending supervise 4-5 NP's at once and there is also an NP 'fellowship', sounds like recipe for disaster. I will be sure to explicitly not supervise NP's until I have a good decade of post residency experience under my belt.
A few questions - if plts < 50 x 10^9 without bleeding diathesis - I realize mos transfusion guidelines recommend < 30 or <20 but if she had petechiae in itself would consider transfusing here as well?
Interesting case. Does Lyme igG not suggest historic exposure? It’s not endemic where I am so don’t come across it much.
A differential would be a first presentation of ITP… this would explain why the platelet count increased after a course of steroids and why the patient bled despite an ok count. I think ITP would explain the blood findings too.
Personally I would put more blame on the ED dr than the NPs… no CT for a headache presenting for the third time with possible AMS and low plts is a tough one to jusitfy.
Not doing the LP with plts >50 (or at least ringing haem for advice) is also a rookie error.
Yes, agree that Lyme IgG not necessarily diagnostic. I ran out of room to do an explainer on Lyme diagnosis and its probably out of my league anyway.
ITP is a good theory, although neither the plaintiff nor the defendant mentioned it. I'm assuming if they had diagnosed ITP the defense would have pointed it out.
What an interesting case, so much to learn and make sure that we don’t fall into diagnostic anchoring. Curious question, do you have a poll under each case or just that interesting ones?
Mostly just when I remember the poll feature exists. Do you like the polls? I wanted to add another one halfway down where I had people guess the final diagnosis but the email got too long and I had to delete something.
I'm often surprised by the results.... for example I'd say NP#2 was much closer to negligence than NP#1, but the poll says the opposite right now. I'll try to add more polls in the future!
One negligent in failing to obtain proper hpi, documentation and follow up on results and the other in failing to identify warning signs and worsening clinical picture. I still can’t believe how she didnt get a ct head during her 1st ED visit!! I feel bad for the patient and for the providers to be honest with you. This is not as clear of a case as one would think retroactively.
The first platelet count of 32,000 would have given me pause regarding LP without CT, but I would CT pretty much all heads prior to LP. The prednisone given on first visit could have caused the increased platelet count and steered clinical concern away from spontaneous bleed if one did not know the previous lower count.
Although 78,000 would not worry me as much for risk of bleeding post-LP, I wonder if the ED doc was trying to talk him-/herself into not doing the LP. Unlike hospital records, I don't routinely call for prior urgent care records, but perhaps I will going forward, or at least document they weren't available if after 'business hours'.
Hooray for indiscriminate steroid prescribing. I'm surprised there wasn't a Z-pak in the mix somewhere.
My facility has a rule for platelets of 50k (or ongoing transfusion correction) which seems reasonable given how catastrophic a subdural hematoma could be. I would not have performed this LP myself without a head CT first.
The platelets of 32 should have been addressed, especially in a young woman without family history of coagulopathy. Documenting that as normal was really damning for that first NP. The ER doctor absolutely had rationale to order a CT at his first encounter with her given her neuro symptoms and the duration of her headache. The somnolence should have also been a big red flag in an otherwise healthy 27 year old (IMO). Always easy to see in hindsight though. Thank you so much for these cases, I've shared with multiple colleagues.
I thought of Dr. Greg Henry's pearl of wisdom while reading this case. If someone comes back a third time admit them, even if its the pizza man. Good case.
ery intriguing case, I am surprised the thrombocytopenia was not worked up further in the outpt or inpt settings, so many differentials besides ITP, secondary causes etc DITP, infective, SLE/ APLS , Liver, MDS, TTP, HUS, **infection,
I would appreciate more polls under the future cases,
being a resident in major metropolitan area sometimes our attending supervise 4-5 NP's at once and there is also an NP 'fellowship', sounds like recipe for disaster. I will be sure to explicitly not supervise NP's until I have a good decade of post residency experience under my belt.
A few questions - if plts < 50 x 10^9 without bleeding diathesis - I realize mos transfusion guidelines recommend < 30 or <20 but if she had petechiae in itself would consider transfusing here as well?
"There were 3 noteworthy findings:
Her platelets were 32,000
Mildly elevated AST and ALT (exact levels not given in court records)
A positive Lyme IgG immunoassay"
These all seem consistent with Lyme or classically coinfection with Ehrlichia.
Interesting case. Does Lyme igG not suggest historic exposure? It’s not endemic where I am so don’t come across it much.
A differential would be a first presentation of ITP… this would explain why the platelet count increased after a course of steroids and why the patient bled despite an ok count. I think ITP would explain the blood findings too.
Personally I would put more blame on the ED dr than the NPs… no CT for a headache presenting for the third time with possible AMS and low plts is a tough one to jusitfy.
Not doing the LP with plts >50 (or at least ringing haem for advice) is also a rookie error.
Always easy to criticise in retrospect.
I'm sure the toradol didn't help with the bleeding either.
Yes, agree that Lyme IgG not necessarily diagnostic. I ran out of room to do an explainer on Lyme diagnosis and its probably out of my league anyway.
ITP is a good theory, although neither the plaintiff nor the defendant mentioned it. I'm assuming if they had diagnosed ITP the defense would have pointed it out.
What an interesting case, so much to learn and make sure that we don’t fall into diagnostic anchoring. Curious question, do you have a poll under each case or just that interesting ones?
Thank you for all the work that you do.
Mostly just when I remember the poll feature exists. Do you like the polls? I wanted to add another one halfway down where I had people guess the final diagnosis but the email got too long and I had to delete something.
I actually do, its good to see where the global opinion in certain cases. I think it’s validating some how.
I'm often surprised by the results.... for example I'd say NP#2 was much closer to negligence than NP#1, but the poll says the opposite right now. I'll try to add more polls in the future!
One negligent in failing to obtain proper hpi, documentation and follow up on results and the other in failing to identify warning signs and worsening clinical picture. I still can’t believe how she didnt get a ct head during her 1st ED visit!! I feel bad for the patient and for the providers to be honest with you. This is not as clear of a case as one would think retroactively.