"The Diagnosis Was Correct But the Patient Died"

We have all heard this remark but what does it mean? Perhaps more people die of "half" a diagnosis than none at all because the "killer" factor was missed. A case in point happened recently. My patient, a 65 year old male, was hospitalized with acute bacterial pneumonia. Onset symptoms were the same as Jim Henson's, the muppeteer, with mild to moderate fever soon followed by bed shaking chills. Other symptoms were mild to minimal. X-rays showed heavy infiltration opacity in the left lower lung. White blood count was elevated with an expected shift to the right (high polys) suggesting acute bacterial rather than viral type infection. Spectum cultures and smears revealed hemophilus bacillus gram positive rods, a particularly nasty type of infection fulminating and often called "galloping pneumonia" because it rapidly enters the blood stream and spreads to other organs. In this case, within 36 hours of insidious onset it spread to cause sinusitis, conjuntivitis, encephalitis, pneumonitis, and hepatitis. In Henson's case it included nephritis and kidney failure.

Geriatrics refers to pneumonia as "friend of the aged" because it ushers in death with relatively less suffering than most terminal diseases. But when an aging person otherwise has a lot of potential for living a longer life, he can be saved by making a "whole diagnosis." The word diagnosis literally means "to see through and through" -- to understand etiology, mechanism of symptoms, course of disease, experience of effective treatment and prognosis. If all of these components are not understood, the diagnosis is not whole. Physicians make mistakes as do all humans, but I again remind you that an incomplete diagnosis is the most common cause of iatrogenic disease and/or death.

Now our patient shows an expected positive response to intravenous ceftin (antibiotic). The fever abated and symptoms improved except for an incredible amount of weakness. There was no cough, no dyspnea and none of the other expected respiratory symptoms. X-rays were clearing very slowly and a mid-afternoon recurrent fever around 100 degrees F. persisted. After ten days in the hospital he was discharged to recover at home. After five days the weakness worsened but he was reassured by all four specialists that this was expected from bacterial pneumonia, and it would probably take six to eight weeks to regain strength.

Repeated tests for bacteremia were negative and radiographs showed little improvement. The doctors grew obviously puzzled and concerned. I called for a conference to discuss other possibilities and suggested suppression of cortico steroid production, but I was again reassured the cortisol level was within normal and eosinophils were four percent (normal one to five percent). The specialists increased their effort to find bacterial complication while I was concerned with an immune system hypersensitivity reaction. Again, we continued to investigate this line of thinking by repeating lab and x-rays for the fifth time and then, suddenly, at 11 p.m., on the seventeenth day of the illness the second diagnosis appeared. Eosinophils went from 4 percent normal to 69 percent and lung x-rays revealed new large areas of infiltration in the mid-lung sections, both left and right sides -- eosinophilic pneumonia! Bronchoscopy with biopsies, cultures and more blood work established the definitive condition -- patient was critical. Intravenous cortisone and antibiotics were ordered and the patient rehospitalized. Within 48 hours eosinophils were normal at 2 percent, the lungs were 50 percent more clear, and the patient progressed dramatically in a week. After two more weeks he was fully recovered, and then returned to work following another two weeks.

I cite this case as an example of a mental process involved in case management where there was persistent investigation into other areas of consideration which are seldom thought of. In this case the patient lived. Jim Henson was not so disposed. He and my patient had their onset the same day, Friday. My patient hospitalized himself by calling Rescue 911 on Saturday by 11:54 p.m. Henson waited until Tuesday morning. He diagnosed himself as having a "touch of the flu" and would be all right.

As chiropractors, I hope I can persuade you that as doctors of disease prevention and health maintenance, we learn to administer lifetime care to our patients. Not merely by relieving backaches, and other pains and symptoms, but by proper case management in knowing when and how to refer and guide our patients when they have other medical needs than physical medicine, chiropractic, and natural health care. I see case management as the great challenge ahead for our profession.