A 54-year-old homeless man with a history of alcoholism presented to the emergency department (ED) with complaints of knee problems. The triage nurse documented the chief complaint as "bilateral knee pain" and left the chart for the ED physician. The patient had not experienced any trauma to the knees and had no other symptoms; a focused physical examination of the knees was unremarkable. The ED physician diagnosed the patient with a musculoskeletal injury and prepared to discharge him. After receiving his discharge instructions, the patient tried to get up and walk but was noted to be unsteady. A subsequent full neurologic examination raised additional concerns and a diagnostic head computed tomography (CT) showed a subdural hematoma. The patient was admitted for urgent neurosurgical intervention.
Given the near miss of an unsafe discharge and the initial diagnostic error, the hospital's quality committee formally reviewed the case. The triage nurse reported that the patient used a number of vague and varied complaints about his knees, such as: "giving out," "couldn't walk on them," and "feeling wobbly." The nurse simply summarized the descriptions with the term "bilateral knee pain." The ED physician relied heavily on this documented triage complaint, leading to an overly focused history and examination.
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