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Each question has 5 possible answers from which to choose. Only one choice is the most correct answer. Each choice may be accompanied by an explanation.

A pediatrician refers a 5-year-old child with developmental delay, attention deficit disorder (ADD) and sleep disorder to a physician who is a behavioral specialist.

The consultant starts a newly marketed sedative medication qhs (before bed). The consultant's letter containing dosage and monitoring recommendations is not received or is misfiled. Unable to reach the consultant, the parents ask the pediatrician if it is permissible to increase the dosage of the drug as it seems only partially effective. Although unfamiliar with the medication, the pediatrician increases the dose.

Several days later the parents cannot rouse the child and hospital monitoring is required until the child becomes better.

The consultant subsequently indicated that, given the child's neurological condition, a smaller increment in dosage would have been prudent.

Which one of the following likely contributed most to what happened?

A 42-year-old woman has multiple health problems including poorly controlled type II diabetes mellitus, and is sometimes non-compliant with her many medications. She sees her physician frequently with relatively minor complaints. At a recent visit, she complains of feeling generally unwell and fatigue, and has a new rash. Her HgA1C is high and her platelet count is slightly low. Her physician is slow to follow up on these results but at the next visit — two months later — stops the acetylsalicylic acid medication she is taking. A repeat platelet count is not ordered.

Three months later the patient presents with abdominal pain, confusion, and slurred speech. She has a very low platelet count and is diagnosed with thrombotic thrombocytopenic purpura (TTP).

The diagnostic delay in this case is best explained by which one of the following:

A family physician sees a previously healthy 4-month-old girl with a 2-day history of fever. She is discharged with a diagnosis of viral illness. The next day the child is seen in an emergency department for continued fever, nasal congestion, and cough. Overall the child appears well and is sent home with a diagnosis of viral upper respiratory infection (URI). The following day, the worried parents bring the child back to the family physician as she is no better, although still drinking fluids. Her temperature is 38.5 C, and the physical examination is normal. There is no nuchal rigidity or rash.

Before sending the patient home again, what might help most at this point?

A middle-aged patient presents with a non-healing, scaling, and erosive patch on his scalp. Thinking it is some form of dermatitis or fungal infection, over the next year his family physician prescribes a number of topical steroid treatments and topical antifungals. Several of these treatments are recommended over the telephone without assessing the patient directly. The patient requests a consultation with a dermatologist, however this will take months. The frustrated family physician agrees to discuss the problem with a dermatologist without making an actual consult. Another stronger broad-spectrum topical cream is tried.

About one year later, the patient changes physicians and obtains a dermatology consultation. A biopsy of the lesion indicates squamous cell cancer.

The main problem that delayed diagnosis in this case appears to be:

A 38-year-old female presents to her gynecologist stating she feels a breast lump and is concerned about cancer. A family history is not taken. The physical examination of the breast detects no abnormalities. A screening mammogram is ordered. The patient is reassured by the physician and told she will be contacted if there are any abnormalities on the mammogram. The mammogram report notes a very dense stromal pattern of the breast but no other findings. No malignancy is identified. The results of the mammogram are not discussed with the patient.

The patient visits the gynecologist many months later thinking she is pregnant. No enquires about the breast are made. One year after this visit, the patient is diagnosed with an advanced ductile breast cancer. Her clinical course is difficult and she eventually dies.

A lawsuit was subsequently launched. Supportive peer expert opinion could not be obtained, and her family received compensation.

[Ref: Case example adapted, with permission, from CRICO, the patient safety and medical professional liability provider for the Harvard medical community. Retrieved from http://www.rmf.harvard.edu/case-studies/index.aspx.]


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