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In this slideshow, Alan M. Fein, MD, a clinical professor of medicine at New York University School of Medicine's Department of Pulmonary, Sleep & Critical Care; and Jaoquin E. Morante, MD, and Aashir M. Shah, MBBS, both fellows in the department of pulmonary medicine at Jamaica Hospital Medical Center in Queens, New York, describe five cases of diagnostic errors in patients presenting with signs and symptoms suggestive of pulmonary disease.
See if you recognize some of these scenarios.
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Diagnostic Errors in Patients With Pulmonary Symptoms
Alan Fein, MD; Jaoquin E. Morante, MD; Aashir M. Shah, MBBS | June 15, 2017 | Contributor Information
Leg Pain and Shortness of Breath
A 63-year-old woman with a history of obesity and ovarian cancer (treated with chemotherapy and surgery 2 years earlier) presents to her primary care provider (PCP). Three weeks earlier, she experienced a pathologic fracture of the right femur, which required casting. At the PCP's office, she reports cough, mild shortness of breath on exertion, and lower leg pain lasting 2 days. A chest x-ray was negative for pulmonary pathology. The patient is prescribed a course of antibiotics and an antitussive and sent home. Two days later she presents to the emergency department with worsening shortness of breath. She is found to be tachycardic, tachypneic, and hypoxic on an arterial blood gas. CT pulmonary angiography confirms bilateral pulmonary embolism.
What medical diagnostic error was made?
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Diagnostic Errors in Patients With Pulmonary Symptoms
Alan Fein, MD; Jaoquin E. Morante, MD; Aashir M. Shah, MBBS | June 15, 2017 | Contributor Information
Pulmonary Embolism and Deep Vein Thrombosis
In a patient with a recent pathologic fracture requiring immobilization of the bone, who has a clinical history of cancer in conjunction with signs and symptoms worrisome for pulmonary embolism, CT pulmonary angiography should have been considered at her initial presentation. The Wells criteria for pulmonary embolism and deep vein thrombosis have been formulated to stratify the probability that a patient's signs and symptoms point to one of these diagnoses.
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Diagnostic Errors in Patients With Pulmonary Symptoms
Alan Fein, MD; Jaoquin E. Morante, MD; Aashir M. Shah, MBBS | June 15, 2017 | Contributor Information
A Mysterious Cough
A 60-year-old woman with hypertension and well-controlled diabetes mellitus presents to her PCP with a 3-week history of a nonproductive bothersome cough associated with occasional wheezing. She denies shortness of breath, fevers, or allergic symptoms. Her current medications include metformin, hydrochlorothiazide, ramipril, and lovastatin. The PCP orders a chest x-ray which is clear and starts her on a short-acting beta agonist for cough-variant asthma. She is also given a referral to a pulmonologist.
Why is this a medical diagnostic error?
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Diagnostic Errors in Patients With Pulmonary Symptoms
Alan Fein, MD; Jaoquin E. Morante, MD; Aashir M. Shah, MBBS | June 15, 2017 | Contributor Information
Drug-Related Cough
Common reasons for cough should be investigated. Cough occurs as a side effect in 9.9% of patients treated with angiotensin-converting enzyme (ACE) inhibitors. American College of Chest Physicians guidelines present an algorithmic approach for use in patients who present with cough. In this case, the PCP did not suspect that ramipril (started 2 weeks earlier) was the cause of the cough. The ACE inhibitor was discontinued, and the patient's cough gradually abated. Cough related to ACE inhibitors typically begins within 2 weeks (and rarely up to 6 months) after treatment initiation. Angiotensin receptor blockers, which are not associated with bradykinin-induced cough, are an alternative treatment.
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Diagnostic Errors in Patients With Pulmonary Symptoms
Alan Fein, MD; Jaoquin E. Morante, MD; Aashir M. Shah, MBBS | June 15, 2017 | Contributor Information
Wheeze
A 66-year-old woman with anxiety disorder presents for follow-up with a complaint of intermittent wheezing and shortness of breath that began 3 months ago. She reports that at times, she feels like her breathing is restricted. She has been smoking a half pack of cigarettes each day for 50 years. A chest x-ray was obtained which showed clear lung fields. She was prescribed an albuterol inhaler but returned 10 days later reporting that her wheezing and shortness of breath did not improve. She has been using albuterol twice a day almost daily, so an inhaled corticosteroid was added for worsening asthma. Pulmonary function testing reveals normal lung volumes, and methacholine challenge and fractional exhaled nitric oxide are both within normal limits. On physical examination she has inspiratory and expiratory wheeze.
What medical diagnostic error was made?
Diagnostic Errors in Patients With Pulmonary Symptoms
Alan Fein, MD; Jaoquin E. Morante, MD; Aashir M. Shah, MBBS | June 15, 2017 | Contributor Information
Flow Volume Loops
An evaluation of wheeze can be expanded to include the upper airway. After an evaluation of flow volume loops, a bronchoscopy was performed in this patient which confirmed a tracheal chondroma. In these cases, patients can be misdiagnosed as having asthma owing to the intermittent nature of the symptoms. Patients often complain of cough and restricted breathing. Inhaled beta agonists and steroids are not helpful. Other causes of upper airway wheeze should also be ruled out. Flow volume loops are helpful in distinguishing intrathoracic from extrathoracic airway obstructions.
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Diagnostic Errors in Patients With Pulmonary Symptoms
Alan Fein, MD; Jaoquin E. Morante, MD; Aashir M. Shah, MBBS | June 15, 2017 | Contributor Information
Is It Cardiac?
A 59-year-old man, a past smoker (20 pack-year smoking history; quit 10 years ago) with a history of allergies, initially presents to his PCP with a 6-month history of gradually progressive exertional shortness of breath. His vital signs and physical examination are normal, and he is referred to a cardiologist for dyspnea on exertion. Over the next 6 months, the patient is worked up for dyspnea with an echocardiogram, stress test, and a cardiac angiogram. He then undergoes a coronary artery bypass graft for “multivessel obstructive coronary artery disease.” However, the patient's symptoms worsen. Pulmonary function tests are consistent with a restrictive ventilator defect. Chest imaging from the past 6 months is reviewed. A high-resolution CT of the lungs is consistent with interstitial lung disease.
What medical diagnostic error was made?
Image courtesy of Medscape
Diagnostic Errors in Patients With Pulmonary Symptoms
Alan Fein, MD; Jaoquin E. Morante, MD; Aashir M. Shah, MBBS | June 15, 2017 | Contributor Information
During workup for dyspnea on exertion, a cardiac evaluation may be appropriate. The differential should include respiratory as well as cardiac causes. While evaluating for interstitial lung disease, a careful evaluation of the chest x-ray is important because imaging may appear similar to that of congestive heart failure. The figure above illustrates the basic dyspnea workup.
To learn more about diffuse parenchymal lung diseases and interstitial (nonidiopathic) pulmonary fibrosis, click here.
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Diagnostic Errors in Patients With Pulmonary Symptoms
Alan Fein, MD; Jaoquin E. Morante, MD; Aashir M. Shah, MBBS | June 15, 2017 | Contributor Information
Insomnia
A 42-year-old woman with a history of well-controlled hypertension on medications presents to her PCP because she has not been sleeping well for 2 months. The patient's husband confirms that his wife has not been sleeping well and adds that she has also been moody. She states that she can't concentrate during the day because she doesn't sleep well at night. She feels that she may lose her job. Last month, she was prescribed a sleeping aid for insomnia. She still feels extremely tired during the day. A physical exam reveals a healthy patient with normal vital signs, a body mass index (BMI) of 24 kg/m2, and a crowded oral airway.
What is the correct next diagnostic step?
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Diagnostic Errors in Patients With Pulmonary Symptoms
Alan Fein, MD; Jaoquin E. Morante, MD; Aashir M. Shah, MBBS | June 15, 2017 | Contributor Information
Sleep Apnea
Obstructive sleep apnea (OSA) is an extremely common condition, affecting 20%-30% of men and 10%-15% of women in North America. Typical symptoms include fatigue, daytime somnolence, headache, dry mouth in the morning, snoring, emotional lability, and inability to concentrate. While more common in the obese, it is frequently seen in patients with a normal BMI, so suspicion should be high in patients presenting with typical symptoms. The diagnosis is made by a polysomnography study, and if positive, CPAP titration should be done. Treatment options include CPAP therapy. Benzodiazepines and other sedating agents should be avoided in patients with untreated OSA because they can worsen mood disorders and cause more weight gain. Other therapies include weight loss, tonsillectomy, and dental devices. Surgical therapy for OSA with hypoglossal nerve stimulation is a recently introduced modality that is undergoing study to assess its efficacy and indications for treatment of OSA.
According to the IOM, little progress has been made in reducing diagnostic errors in the 15 years since publication of their landmark report To Err Is Human. In a new series, Medscape has asked experts across the healthcare spectrum to provide their insights on the most common errors in their own fields.
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Contributor Information
Alan Fein, MD
Clinical Professor of Medicine, Department of Pulmonary Critical Care and Sleep
Hofstra Northwell School of Medicine, Hofstra University
Hempstead, New York;
Chief, Department of Pulmonary Critical Care
ProHEALTHCare Associates
Lake Success, New York
Disclosure: Alan Fein, MD, has disclosed no relevant financial relationships.
Jaoquin E. Morante, MD
Fellow, Department of Pulmonary Medicine
Jamaica Hospital Medical Center
Queens, New York
Disclosure: Jaoquin E. Morante, MD, has disclosed no relevant financial relationships.
Aashir M. Shah, MBBS
Fellow, Department of Pulmonary Medicine
Jamaica Hospital Medical Center
Queens, New York
Disclosure: Aashir M. Shah, MBBS, has disclosed no relevant financial relationships.
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