Outpatient Pneumonia Misdiagnosis [Cardiac Arrest in ED]
Case #144
A 65-year-old man had been seeing his primary care provider, an NP, for several years.
Comorbidities included smoking, COPD, hypertension, and hyperlipidemia.
On January 9, he was seen for a sick visit, and reported shortness of breath.
She was suspicious that he was developing pneumonia, and started him on antibiotics.
On January 29, he called the office and left a message stating that he was still short of breath.
She called in a prescription for a new antibiotic.
The patient still did not improve, so he went to an urgent care on February 9.
He was seen by a PA.
He had unilateral leg swelling, so a DVT ultrasound was ordered.
The results were negative, and he was discharged.
On February 14, he had another appointment with his NP.
Vitals included a heart rate of 148bpm.
He noted severe shortness of breath when lying flat.
Both of his legs were now edematous.
He vomited frothy fluid during the visit.
The NP ordered outpatient labs (CBC and CMP) and he was released from the clinic.
The next day she checked the labs, which reportedly showing a significant leukocytosis.
Based on this, the patient was called and told to go to the nearest ED.
On arrival to the ED, the patient and his wife stated to the triage nurse that he had been sent in for treatment of pneumonia.
The patient was assigned an ESI 3 and was in the waiting room for 3 hours.
He was roomed around 12:30pm, then seen by a board-certified EM physician.
The patient and his wife told the physician that he was suffering from chronic pneumonia.
Lung exam noted bibasilar crackles but no lower extremity edema was documented.
The patient’s NP and the ED physician spoke on the phone about his lingering pneumonia and 2 rounds of antibiotics.
The ED physician ordered basic labs and a CT of his chest.
A differential was documented that included pneumonia, CHF, and possible lung mass.
He told the patient that he would be admitted.
No EKG, BNP, or troponins were ordered.
The patient’s wife would later claim that the ED doctor never came back after the initial history and exam.
IV antibiotics were started and the patient was admitted to the hospitalist.
Around 4:45pm the hospital NP came to see the patient in the ED.
She immediately realized he was cyanotic and in severe respiratory distress.
The hospital NP ordered an EKG and consulted cardiology.
According to the cardiologist, the EKG showed a “late presentation of an inferolateral infarction”.
Shortly thereafter, the patient went into cardiac arrest and could not be resuscitated.
An excerpt from the cardiologist’s note is shown here: