What is the most commonly missed dangerous diagnosis?

[NYYk9005]

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I was curious.

We are supposedly experts in being able to catch the lethal killer on people. Is there a specific diagnosis that is lethal or very dangerous but we tend to miss?

I'd say myocarditis in young chest pain people without ekg changes.

 

[RustedFox]

Myocardial infarction leads the list of missed diagnoses and med-mal suits last I checked.

 

[NYYk9005]

Myocardial infarction leads the list of missed diagnoses and med-mal suits last I checked.

Yes of course!

 

[camaronal15]

Posterior MI

 

[NYYk9005]

Cholinergic crisis
Carbon monoxide poisoning

Are anoyher two.

 

[RustedFox]

Epidural abscess.
Subarachnoid hemorrhage.

 

[namethatsmell]

dilaudidopenia. as the crackdown on this medication progresses patient's are forced to try medications they've had allergies to in the past. including motrin causing convulsions and tylenol causing renal failure. it's a minefield out there.

 

[Arcan57]

Cholinergic crisis
Carbon monoxide poisoning

Are anoyher two.

Both of those are vanishingly rare. Is question "dangerous diagnosis with highest miss rate" or "most commonly missed diagnosis". Prevalence or rate?

 

[Zebra Hunter]

Sepsis. Sepsis is usually the diagnosis I see "missed" most frequently, as it often subtle. Sometimes it's really hard to figure out why a patient is persistently tachycardic and having generalized weakness, and then they come back 2 days later dying from pneumonia or pyelonephritis. I've also seen cauda equina missed more than once (a lesson to get post void residuals on your higher risk back pain patients).

 

[WilcoWorld]

Myocardial infarction leads the list of missed diagnoses and med-mal suits last I checked.

I checked with my Cardiology department. They said muscoloskeletal chest pain was the #1 missed diagnosis in the ER, trailed closely by the dreaded "GI related".

 

[alpinism]

Both of those are vanishingly rare. Is question "dangerous diagnosis with highest miss rate" or "most commonly missed diagnosis". Prevalence or rate?

Define vanishingly rare.

We see a handful of CO poisonings every year during the winter from things like faulty space heaters and indoor campfires.

When I worked in Guatemala we'd see it on almost a daily basis from people living in tin shacks with indoor stoves and no ventilation ducts.

 

[sum dude]

MI...though I've heard epidural abscess is catching up, given increased IVDA
http://edus.ucsf.edu/sites/edus.ucsf.edu/files/wysiwyg/Epi of ED Lawsuits. 2010 Acad EM.pdf

 

[DocEspana]

It seriously has to be aortic dissection. If you read the literature on predictive markers for it you see that the problem we have witg designing a marker is that 70% of people have classic symptoms (when do you ever have classic being that high) and if you have classic symptoms you have a comically high chance of having it. The markers are perfect on them, but so is "just take a history and physical"

And 30% of them have a ADD score of 1 or 0. (Aka non-typical chest pain with absolutely no other symptoms, or completely asymtomatic except for impending cardiovascular collapse and possible some big htn beforehand). So 30% of these people drop dead with zero symptoms to suggest this impending death diagnosis (and vague chest pain with no other symptoms is not gonna trigger anyone to CT angio someone. So that counts as zero symptoms). The markers are also perfect on them but there is a massive false positive rate, so how do you tell everyday musculoskeletal chest pain from a low-symptom dissection? Angio everyone?

 

[CliveStaples]

I've heard from a coroner that pulmonary embolism continues to be a "common" undiagnosed cause of death in patients - though I think this also includes hospitalized patients who don't come into contact with the ED.

 

[WilcoWorld]

It seriously has to be aortic dissection. If you read the literature on predictive markers for it you see that the problem we have witg designing a marker is that 70% of people have classic symptoms (when do you ever have classic being that high) and if you have classic symptoms you have a comically high chance of having it. The markers are perfect on them, but so is "just take a history and physical"

And 30% of them have a ADD score of 1 or 0. (Aka non-typical chest pain with absolutely no other symptoms, or completely asymtomatic except for impending cardiovascular collapse and possible some big htn beforehand). So 30% of these people drop dead with zero symptoms to suggest this impending death diagnosis (and vague chest pain with no other symptoms is not gonna trigger anyone to CT angio someone. So that counts as zero symptoms). The markers are also perfect on them but there is a massive false positive rate, so how do you tell everyday musculoskeletal chest pain from a low-symptom dissection? Angio everyone?

Both of those are vanishingly rare. Is question "dangerous diagnosis with highest miss rate" or "most commonly missed diagnosis". Prevalence or rate?

I want to combine these two posts to ask a slightly different question:

Which disease, when you multiply its (terribleness) x (the difficulty of testing for it) x (your uncertainty in ruling it out no matter what you do)*, yields the highest damaging miss rate product?

I agree, dissection gets a pretty high DMRP.



*Bayesians - please correct my math, and get my point.

 

[migm]

I really do wonder how many MI's are truly missed nowadays

 

[DocEspana]

I want to combine these two posts to ask a slightly different question:

Which disease, when you multiply its (terribleness) x (the difficulty of testing for it) x (your uncertainty in ruling it out no matter what you do)*, yields the highest damaging miss rate product?

I agree, dissection gets a pretty high DMRP.



*Bayesians - please correct my math, and get my point.

The only thing holding back dissection is that if you're willing to coat the aorta with contrast you've got an easy rule in or rule out. Of course there is that whole radiation thing

 

[Vandalia]

I want to combine these two posts to ask a slightly different question:

Which disease, when you multiply its (terribleness) x (the difficulty of testing for it) x (your uncertainty in ruling it out no matter what you do)*, yields the highest damaging miss rate product?

I agree, dissection gets a pretty high DMRP.

Good question, but I might add two additional factors: First, how frequently does this condition appear? Second, how likely can the ED physician (or medicine in general) do anything to treat it?

As an example, N. Fowleri (amoeba) infections - Primary Amebic Meningoencephalitis (PAM) - are very bad and difficult to diagnose in a living person. But they are also very rare ~8 cases in the US/year and even when it is diagnosed there isn't much that can be done about it.

 

[deleted109597]

I've heard from a coroner that pulmonary embolism continues to be a "common" undiagnosed cause of death in patients - though I think this also includes hospitalized patients who don't come into contact with the ED.

PE diagnosis has increased but mortality remains the same.

 

[deleted109597]

The only thing holding back dissection is that if you're willing to coat the aorta with contrast you've got an easy rule in or rule out. Of course there is that whole radiation thing

Or you get people arguing you can use D-dimer for this, which a) isn't true and b) yet another ****ty test

 

[DocEspana]

Or you get people arguing you can use D-dimer for this, which a) isn't true and b) yet another ****ty test

It's what I was referencing in the write up about dissection. It's basically 95 to 99% sensitive in all cases. But in high risk basically *everyone* is high risk and you don't need any test and in low risk patient the rate of dissection is so low that the positive predictive value is like 40%. So 2 out of every 3 positives is a pointless nuking because their D-dimer got tickled.

 

[res1cue]

I was curious.

We are supposedly experts in being able to catch the lethal killer on people. Is there a specific diagnosis that is lethal or very dangerous but we tend to miss?

I'd say myocarditis in young chest pain people without ekg changes.

Didnt see appy on this thread so far but i have been told it is frequently litigated

 

[Arcan57]

Rather than naming specific diagnoses (which will be by necessity an incomplete list of dangerous but subtle conditions), it's probably more helpful to think of what makes a dangerous diagnosis hard to detect.

1) Non-specific symptoms - especially if those symptoms mimic commonly seen benign diseases for which testing is not indicated
2) Variable time course
3) Lack of specific physical exam findings
4) Ubiquitous risk factors
5) High barriers to testing (PE or dissection before CTA) or obtaining definitive care (getting surgeon to buy into nec fasc, getting cards to work-up young patient with suspected ACS)

I'm sure I'm missing a couple there. Knowing these things are helpful because it makes you less likely to be dismissive when giving discharge instructions. Always be thinking, "This abdominal pain isn't appy, but it could be" or "this cellulitis isn't nec fasc, but if it were these are the signs". You're going to miss stuff (personal record would be seeing a young healthy woman s/p MVC with radicular leg pain and normal neuro exam other than subjective paresthesias 3 times over 2 weeks before she developed objective neuro findings and had an MRI of the spine that showed GBS), so try and miss small and make your decision making defensible.

 

[deleted109597]

Well, and the **** that results after the patient is discharged. Things like a normal CBC and no flags in the computer that bounces back and everyone says "why did you let someone with 40 bands go home?"
Bad QI systems can **** your world man.