Cases studied by PRIDE:

Delayed colon cancer diagnosis results in death

37-year-old male with family history of colon cancer seeks care after weeks of poor appetite and jaundice. CT scan showed large mass suggesting sigmoid colon cancer and finally a colonoscopy found a fungating, ulcerated, partially obstructing mass. The diagnostic delay was linked in part to lack of insurance and primary care relationship. Patient underwent treatment but ultimately died at age 41.

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Repeated missed diagnosis of testicular torsion

16-year-old male went to the ED and two urgent care visits within a week for lower abdominal pain, vomiting and testicular discomfort. At the second urgent care visit, provider ordered stat urology consult and testicular ultrasound. The ultrasound findings were consistent with right testicular torsion and patient underwent a right orchiectomy.

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Delayed diagnosis of myasthenia gravis

71-year-old female in urgent care clinic with one year history of fatigue, anorexia, and weight loss; clinician made no definitive diagnosis. Patient experienced worsening symptoms and was seen by several specialists over the next three months. Ultimately, a definitive diagnosis of myasthenia gravis resulted in urgent therapy.

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Delayed testicular torsion diagnosis results in orchiectomy

16-year-old male seen in emergency center after waking to lower abdominal pain radiating to testicles. CT suggested inflammation of lymph nodes but no ultrasound was ordered. Patient was discharged with advice to return if symptoms recurred. Nine days later he presented with continuing pain where a urologist diagnosed torsion and performed left orchiectomy and right scrotal orchiopexy.

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Testicular torsion in a 19-year-old patient

9-year-old male sought urgent care with right testicular pain. Clinician ruled out testicular torsion based on the patient’s apparent level of pain and gradual onset. Ultrasound was not available at the clinic. Despite no recent sexual activity discharged with epididymitis diagnosis. Patient presented to the emergency department a few days later with persistent right testicular pain. He was sent to the operating room immediately for right orchiectomy due to testicular torsion.

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Cases studied by PRIDE published on AHRQ’s PSNet WebM&M:

Anemia and Delayed Colon Cancer Diagnosis

An elderly man had iron deficiency anemia with progressively falling hemoglobin levels for nearly 2 years. Although during that time he underwent an upper endoscopy, capsule endoscopy, and repeat upper endoscopy and received multiple infusions of iron and blood, his primary physician maintained that he didn't need a repeat colonoscopy despite his anemia because his previous colonoscopy was negative. The patient ultimately presented to the emergency department with a bowel obstruction, was diagnosed with colon cancer, and underwent surgery to resect the mass.

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Delayed Breast Cancer Diagnosis: A False Sense of Security

Elderly iron deficient man had progressively falling hemoglobin levels for nearly 2 years. During that time he underwent multiple endoscopies and iron and blood infusions. Primary physician maintained that he didn't need a repeat colonoscopy. Patient ultimately presented to the emergency department with bowel obstruction, was diagnosed with colon cancer, and underwent surgery to resect the mass.

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Endometriosis: A Common and Commonly Missed and Delayed Diagnosis

15-year-old girl developed disabling menstrual cramps and heavy bleeding at onset of first menstrual period. Over the next 12 years she sought care from multiple clinicians and received a variety of misdiagnoses. Emergency appendectomy found that endometriosis lesions close to the appendix caused infection; later diagnostic laparoscopy confirmed endometriosis.

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Paroxysmal Supraventricular Tachycardia Masquerading as Panic Attacks

From age 16, this female patient experienced 5- to 15-minute episodes of “feeling woozy” with a racing and pounding heart. Symptoms reoccurred periodically, leading to emergency department and PCP visits, as well as ECGs and a 24-hour Holter monitor test. A potential diagnoses of stress reaction and panic attacks was made by ED and PCP. After a particularly acute episode at age 40, she was diagnosed with paroxysmal supraventricular tachycardia.

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Postpartum Woman with Erroneous SARS-CoV-2 Test

Patient developed a fever and required oxygen supplementation during scheduled cesarean delivery. Because a PCR test processed at the hospital lab returned as positive for SARS-CoV-2, the patient isolated at home for 14 days and chose to bottle-feed rather than breastfeed. Two days after discharge, two additional PCR tests taken during her stay and processed at other labs both reported negative. The positive test result was due to cross-contamination from a neighboring positive sample.

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Renal Failure Due to Benign Prostatic Hyperplasia

Elderly man with history of urinary difficulties was referred to urology but was reluctant to seek care. A physician assistant ordered several tests and urged patient to self-catheterize. Patient elected not to follow up. Ten weeks later, he sought care with his PCP where his blood pressure and creatinine levels were found to be markedly elevated, 2L of urine were drained via catheter, and he was admitted to the hospital for renal failure.

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Spinal Epidural Abscess

Young woman with history of spine surgery in emergency department with progressive low back pain. MRI scan showed lumbar degenerative joint disease and small disc herniation. Patient referred to PT and prescribed medication. Ten days later, she presented to community hospital with fever, inability to walk, and numbness from waist down. Lab tests showed she was in acute renal and liver failure. She was transferred to neurosurgery where a thoracic MRI revealed epidural abscess.

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