Detailed Treatment Process
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Male, 54 years old. On October 31, he presented to the emergency department with chest tightness and chest pain. Laboratory report Department: Emergency Department Specimen type: Blood Collection time: October 31, 10:28 1 Urea 4.8 (2.5-6.5 mmol/L) 2 Sodium 140 (135-148 mmol/L) 3 Potassium 3.8 (3.5-5.5 mmol/L) 4 Chloride 101 (96-106 mmol/L) 5 Glucose 6.1 (3.6-6.1 mmol/L) 6 Creatinine 82 (50-110 umol/L) 7 Troponin <0.01 (<0.1 ug/L) Received date: October 31, 10:28 Report date: October 31, 11:18
Laboratory report Department: Cardiology Submission date: November 1 Report date: November 1 Creatine kinase MB: 14.0 (<25 u/L) Troponin: <0.01 (<0.1 ug/L) Myoglobin: 135 (10-46 ug/L)
Discharge summary Admission date: November 1 Discharge date: November 11 Length of stay: 10 days Admission diagnosis: 1. Aortic dissection aneurysm; 2. Grade III hypertension (very high risk) Discharge diagnosis: 1. Acute ascending aortic dissection (intramural hematoma type); 2. Grade III hypertension (very high risk) Admission status: Main symptoms and signs: The patient was admitted on November 1 with a suspected “aortic dissection aneurysm” after presenting to the outpatient clinic with “sudden persistent tearing pain in the sternum, accompanied by profuse sweating and fever for 1 day.” Admission physical examination: Not documented. Major examination findings during hospitalization: Electrocardiogram (November 1, this hospital) showed sinus rhythm with frequent premature atrial contractions. CTA (November 1, this hospital) showed aortic dissection aneurysm (thoracic-abdominal aorta). Treatment course: After admission, blood pressure control and sedation were administered. On November 4, aortic angiography was performed under general anesthesia. Intraoperatively, the aortic entry tear was found to have completely closed. Discharge status: The patient was in generally stable condition. Blood pressure was stable on medication, and the condition was satisfactory. Discharge was approved by the attending physician. Discharge instructions: 1. Discharge medications: Metoprolol tartrate tablets (50.0 mg); 2/day; oral; Amlodipine besylate tablets (5 mg); 1/day; oral; Valsartan capsules (80 mg); 1/day; oral. 2. Rehabilitation advice: Maintain stable blood pressure, keep bowel movements regular, and avoid emotional stress. 3. Follow-up: Repeat CTA in 3 months.
CT report Examination site: Thoracic aorta Department: Cardiology Report date: November 2 Scanning protocol: Thoracic aorta multi-slice spiral CT volume scan and three-dimensional reconstruction. CT findings: Circumferential low-density shadows were visible around the ascending aorta, aortic arch, descending aorta, and proximal abdominal aorta, with no contrast entering the lumen and no definite rupture site identified. The aortic arch and its three supra-aortic branches were clearly visualized without stenosis or dissection. Bilateral renal arteries, superior mesenteric artery, and celiac trunk showed normal courses without obvious abnormalities. Major branch vessels showed no significant stenosis. CT impression: Circumferential low-density shadow around the aorta, suggestive of intramural aortic hematoma.
Department: Vascular Surgery Surgical record Surgery date: November 4 Preoperative diagnosis: 1. Aortic dissection aneurysm; 2. Grade III hypertension (very high risk) Intraoperative diagnosis: 1. Aortic dissection: intramural hematoma; 2. Grade III hypertension (very high risk) Procedure: Thoracic aortic angiography Anesthesia: General anesthesia Surgical procedure: After successful anesthesia, the patient was placed in supine position. The lower abdomen was routinely disinfected and draped. The right brachial artery was punctured, and a pigtail catheter and guidewire were advanced to the innominate artery origin but could not proceed further. A right inguinal incision was made, skin and subcutaneous tissue were opened, and the right femoral artery was isolated. After puncture, a 0.035 soft guidewire was introduced. Angiography via the pigtail catheter showed that the aortic entry tear had completely closed. The catheters and guidewire were withdrawn. The arterial puncture site was sutured, the vessel wall incision was closed layer by layer, and the right brachial artery puncture site was compressed locally. The procedure was uneventful, with approximately 10 ml blood loss and no transfusion. The patient recovered smoothly and returned to the ward.
** The patient died on January 14 of the following year. The family filed a complaint with the hospital, which provided a written response, as follows. The patient, a 54-year-old male, presented to the cardiology outpatient clinic with “sudden persistent tearing pain in the sternum, accompanied by profuse sweating and fever for 1 day.” He was admitted to the cardiology department on November 1 with a diagnosis of “chest pain to be investigated, hypertension, aortic dissection, and coronary heart disease.” After admission, he had elevated blood pressure, chest and back pain, and a mildly elevated temperature around 38°C. On November 1, blood tests showed WBC 16.37 × 10⁹/L and GRAN% 86.1%. Electrocardiogram showed sinus rhythm with frequent premature atrial contractions. CTA indicated aortic dissection aneurysm (thoracic-abdominal aorta). Cardiology provided blood pressure reduction, coronary vasodilation, bed rest, physical cooling, and oral antipyretics. Vascular surgery was consulted. After consultation, the patient was transferred to vascular surgery on November 3 with “acute Stanford type A aortic dissection.” Preoperative evaluation was completed, and thoracic aortic angiography was performed on November 4. Intraoperatively, a pigtail catheter was introduced via the right femoral artery. Angiography showed that the aortic entry tear had completely closed. The ascending aortic dissection with intramural hematoma was considered to have undergone spontaneous thrombosis. The guidewire and catheter were withdrawn and the incision closed. After intraoperative discussion, it was determined that the false lumen had thrombosed and endovascular repair was not required at that time, although disease progression could not be ruled out. The family was informed of the condition. The patient returned to the ward. Moxifloxacin was used prophylactically before angiography. Postoperatively, the patient received ECG monitoring, intravenous moxifloxacin, omeprazole, ulinastatin to suppress inflammation, and sodium nitroprusside for blood pressure control. The patient’s general condition was good and blood pressure remained stable on medication, so he was discharged on November 11 with instructions to control blood pressure and return if symptoms occurred. The patient returned to the outpatient clinic on November 22 with fever outside the hospital. The attending physician considered that the false lumen thrombosis made inflammation-related persistent high fever unlikely and recommended evaluation at a specialized hospital to rule out tuberculosis or other specific infections before returning to this clinic. The patient did not follow up as advised. After internal discussion, our department concluded (as stated in the original text): 1. The treatment plan in our vascular surgery department was correct, the procedure was performed smoothly, intraoperative findings clearly showed spontaneous resolution of the dissection, and postoperative low-grade fever was a normal response after vascular surgery that was appropriately managed, with no violation of standard medical or nursing protocols. 2. When the patient returned for follow-up on November 22, the physician informed him that fever due to inflammation of the thrombosed false lumen was unlikely and that the symptoms suggested possible tuberculosis. The patient was advised to visit a specialized hospital to rule out pulmonary tuberculosis. He did not do so. The department determined that the physician’s management complied with diagnostic standards and differential diagnosis principles. We express deep regret regarding the patient’s subsequent course in thoracic surgery. The patient visited our outpatient clinic multiple times, but no signs of bacteremia were identified. His afternoon low-grade fever was typical of tuberculosis. Our physician clearly advised the need to rule out tuberculosis and offered return visits for any other issues, but the patient did not return. In summary, our hospital maintains that the entire diagnostic and treatment process complied with medical standards. February 23
The family subsequently requested a medical malpractice assessment. The appraisal committee issued a report (describing the treatment process) as follows: On October 31, the patient presented to the defendant hospital’s emergency department with “chest tightness and chest pain for 1 hour with radiation to the shoulder and back.” Examination: Alert, blood pressure 140/90 mmHg, clear breath sounds in both lungs without rales or wheezes. Electrocardiogram showed sinus bradycardia, left ventricular hypertrophy, and T-wave changes. The next day, chest pain became paroxysmal and stabbing. Cardiology consultation: General condition fair, blood pressure 170/120 mmHg, electrocardiogram showed sinus tachycardia. Outpatient diagnosis: Chest pain to be investigated; possible aortic dissection aneurysm; coronary heart disease. At 12:06, the patient was admitted to the cardiology ward with sudden persistent tearing sternal pain, profuse sweating, and fever for 1 day. Examination: Temperature 37.8°C; pulse 76 beats/min; respirations 20 breaths/min; blood pressure 180/110 mmHg. Alert, spontaneous position. On November 1, auxiliary examinations: Electrocardiogram showed “sinus rhythm with frequent premature atrial contractions”; CTA showed “aortic dissection aneurysm (thoracic-abdominal aorta).” Admission diagnosis: 1. Aortic dissection aneurysm; 2. Grade III hypertension (very high risk). The family was informed of critical condition. On November 2, CT showed circumferential low-density shadow around the aorta, suggestive of intramural aortic hematoma. On November 3, the patient was transferred to vascular surgery. The following day, after informed consent, thoracic aortic angiography was performed under general anesthesia. The right brachial artery was punctured and a pigtail catheter advanced to the innominate artery, but advancement was not possible. A right inguinal incision was made for femoral access. Angiography showed that the aortic entry tear had completely closed. The patient was discharged on November 9. The record stated that the patient was in generally stable condition with blood pressure well controlled on medication. On November 16, outpatient record: Fever for 2 days, maximum 39.2°C. White blood cell count: 18.17 × 10⁹/L; ESR: 88 mm/h. Diagnosis: Acute bronchitis? Intravenous mezlocillin sodium was given for 3 days. The patient returned for fever on November 17 and 19. On November 22, temperature 39.5°C; blood pressure 90/50 mmHg; pulse 86 beats/min. The hospital’s opinion was that fever might be related to the angiography. Blood culture showed Staphylococcus aureus and Acinetobacter baumannii. Pericardial fluid culture also showed Staphylococcus aureus. On November 23, temperature 39.1°C; blood pressure 112/70 mmHg. The family was informed of the condition, and the patient was admitted to the thoracic surgery ICU. Admission diagnosis: Subacute aortic dissection with closed entry tear and false lumen thrombosis; bilateral pleural effusion and pericardial effusion; Grade III hypertension (very high risk); fever to be investigated; possible bacteremia? On December 2, ultrasound showed aortic dissection (type A) and infective endocarditis. On December 6, ultrasound showed left pleural and pericardial effusion. On December 31, ultrasound showed aortic dissection (type A), infective endocarditis, and left pleural and pericardial effusion. On January 3 at 0:45, the patient suddenly lost consciousness while using the toilet, with unmeasurable heart rate and blood pressure. Intubation was performed, and the family was informed of critical condition. Possibility of acute intracranial embolism from vegetation detachment could not be excluded. On January 4 at 10:46, heart rate and blood pressure dropped again, followed by decreased peripheral oxygen saturation. Cardiopulmonary resuscitation was initiated. At 17:35, cardiac arrest occurred with flatline ECG, falling blood pressure and oxygen saturation. The patient was pronounced dead at 18:05. Appraisal conclusion: This case constitutes medical harm to the patient. The hospital committed medical fault in that on November 16, during outpatient follow-up, the patient had already had fever for 2 days with a maximum of 39.2°C and WBC 18.17 × 10⁹/L, yet active diagnostic and therapeutic measures were not taken. This fault bears a certain causal relationship to the patient’s death. According to information provided by the family to the author, the discharge summary did not mention fever on the day of discharge. The family noted that ward temperature measurements were taken axillary, and on several occasions the thermometer fell into the bedding while the patient was reading. As a result, recorded temperatures were often inaccurate. The family emphasized that the patient’s temperature had never returned to normal after the surgery.