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Teachable Moment
August 2015

When Medical Care Leads to Harm—Difficulty Finding WordsA Teachable Moment

Author Affiliations
  • 1Department of Medicine, Oregon Health and Science University, Portland
  • 2Veterans Affairs Portland Health Care System, Portland, Oregon
JAMA Intern Med. 2015;175(8):1271-1272. doi:10.1001/jamainternmed.2015.2334

A 66-year-old man with diabetes, hypertension, and peripheral vascular disease presented with complaint of fevers, rigors, and malaise along with a mild frontal headache of 7 days’ duration. He was febrile and hypotensive though alert and oriented. Examination findings were consistent with cellulitis in his right lower extremity. Blood cultures grew group G Streptococcus, with cellulitis as the presumed source for sepsis. Infectious disease specialists were consulted.

Given the indolent time course of symptoms, and a grade I/VI diastolic murmur not auscultated at presentation, endocarditis was considered, and a transthoracic echocardiogram was recommended. Despite a lack of documented abnormalities on neurologic examination, a computed tomographic (CT) angiogram of his head and neck was also recommended to evaluate for mycotic aneurysm out of concern for the history of headache. Findings of the echocardiogram were negative for valvular regurgitation or vegetation. The CT angiogram revealed stenosis of various segments of the intracerebral arteries and a 4-mm aneurysm of the left posterior cerebral artery without evidence of infectious cause.

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