Detailed Treatment Process
Male, 54 years old, presented to the emergency department on October 31 due to chest tightness and chest pain. Laboratory report Department: Emergency Department Specimen type: Blood Sampling: 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 Item: Creatine kinase MB Result: 14.0 (<25 u/L) Item: Troponin Result: <0.01 (<0.1 ug/L) Item: Myoglobin Result: 135 (10-46 ug/L)
Discharge summary Admission date: November 1 Discharge date: November 11 Hospital stay: 10 days Admission diagnosis: 1. Aortic dissecting 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: Admitted to hospital on November 1 with a preliminary outpatient diagnosis of “aortic dissecting aneurysm” due to “sudden persistent tearing pain in the sternum, accompanied by profuse sweating and fever for 1 day.” Admission physical examination: None Main examination results during hospitalization: Electrocardiogram (November 1, our hospital) showed: Sinus rhythm, frequent premature atrial contractions; CTA examination (November 1, our hospital) showed: Aortic dissecting aneurysm (thoracic aorta-abdominal aorta) Treatment process: After admission, blood pressure control and sedation were given. Treatment details: On November 4 after admission, aortic angiography was performed under general anesthesia, during which the aortic tear was found to have completely closed. Discharge status: The patient is currently in fair general condition, with blood pressure maintained stable under medication, and the condition is stable. Discharge is approved by the attending physician. Discharge orders: 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: Keep blood pressure stable, maintain smooth bowel movements, avoid emotional agitation 3. Outpatient follow-up: CTA review in 3 months
CT report Examination site: Thoracic aorta Department: Cardiology Report date: November 2 Scanning sequence: Thoracic aorta multi-slice spiral CT volume scan and three-dimensional reconstruction imaging CT findings: Circular low-density shadows are visible around the ascending aorta, aortic arch, descending aorta, and proximal abdominal aorta, with no contrast entering and no clear rupture identified. The aortic arch and its three supra-aortic branches are clearly displayed without stenosis or dissection; the bilateral renal arteries, superior mesenteric artery, and celiac trunk show natural courses without obvious abnormalities; no obvious stenosis in the main branch vessels. CT diagnosis: The circular low-density shadow around the aorta is considered to be intramural hematoma of the aortic wall.
Department: Vascular Surgery Surgical record Surgery date: November 4 Preoperative diagnosis: 1. Aortic dissecting aneurysm; 2. Grade III hypertension (very high risk) Intraoperative diagnosis: 1. Aortic dissection: intramural hematoma; 2. Grade III hypertension (very high risk) Procedure name: Thoracic aortic angiography Anesthesia method: General anesthesia Surgical procedure: After successful anesthesia, the patient was placed in supine position, the lower abdomen was routinely disinfected, and sterile drapes were applied. The right brachial artery was punctured, and a pigtail catheter and guidewire were introduced to the brachiocephalic trunk opening, but could not advance further. A right inguinal incision was made, skin and subcutaneous tissue were incised sequentially, the right femoral artery was isolated, punctured, and a 0.035 soft guidewire was introduced. Angiography via the pigtail catheter showed: the aortic tear had completely closed. The catheter and guidewire were then withdrawn. The arterial puncture site was sutured, the vessel wall incision was closed layer by layer, and the right brachial artery puncture site was locally compressed and bandaged. The operation went smoothly, with approximately 10 ml blood loss and no transfusion. The patient returned to the ward awake.
** The patient died on January 14 of the following year. The family filed a complaint with the hospital, and the hospital provided a written response to the family, as follows, The patient, a 54-year-old male, presented to the cardiology outpatient clinic of our hospital with “sudden persistent tearing pain in the sternum, accompanied by profuse sweating and fever for 1 day.” The cardiology clinic admitted him to the cardiology department on November 1 with a diagnosis of “chest pain to be investigated, hypertension, aortic dissection, coronary heart disease.” After admission, he had high blood pressure, chest pain, back pain, and a slightly elevated temperature around 38 degrees Celsius. On November 1, blood routine showed WBC 16.37 × 10⁹/L, GRAN% 86.1%. Electrocardiogram showed sinus rhythm with frequent premature atrial contractions. CTA suggested aortic dissecting aneurysm (thoracic-abdominal aorta). The cardiology department administered blood pressure lowering, coronary dilation, bed rest, physical cooling, and oral antipyretics for symptomatic treatment, and requested a vascular surgery consultation. After consultation, our department transferred the patient on November 3 with “acute aortic dissection Stanford type A” and performed aortic angiography on November 4 after completing preoperative examinations. During the procedure, a pigtail catheter was introduced via the right femoral artery approach for angiography, which showed that the aortic tear had completely closed. Considering that the ascending aortic dissection and intramural hematoma had spontaneously thrombosed, the guidewire and catheter were withdrawn and the incision closed. After intraoperative discussion, the physicians determined that the false lumen of the aortic dissection had thrombosed and endovascular repair was not required at that time, though the possibility of disease progression could not be ruled out. The condition was communicated to the family. The patient then returned to the ward safely. Moxifloxacin was used for infection prevention before angiography. Postoperatively, electrocardiographic monitoring, intravenous moxifloxacin, omeprazole, ulinastatin to suppress inflammatory response, and urapidil for blood pressure control were administered. Subsequently, the patient’s general condition was good and stable, with blood pressure controlled stably by medication, so he was discharged on November 11. He was advised to control blood pressure and seek follow-up if unwell. The patient presented to our hospital’s specialist outpatient clinic on November 22 due to “fever” outside the hospital. The attending doctor considered that the false lumen of the aortic dissection had thrombosed, making an inflammatory response from the false lumen thrombosis unlikely to cause “persistent high fever,” and recommended that the patient visit a relevant specialist hospital to rule out tuberculosis or other specific infections before returning to our specialist clinic. However, the patient did not go. After internal hospital discussion, our department believes (as per the original text): 1. The treatment plan for the patient in our vascular surgery department was correct, the surgical procedure went smoothly, intraoperative findings clearly showed spontaneous healing of the dissection, and postoperative low-grade fever was a normal phenomenon after surgery and had been managed symptomatically, with no violation of standard medical or nursing protocols. 2. When the patient returned for follow-up on November 22, the attending doctor informed him that the likelihood of recurrent low fever due to inflammatory response from false lumen thrombosis was low, that his symptoms suggested a high possibility of tuberculosis, and recommended visiting a relevant specialist hospital to rule out pulmonary tuberculosis. The patient did not go. After discussion, our department believes that the attending doctor’s management complied with diagnostic and treatment standards and met the criteria for differential diagnosis. Regarding the patient’s subsequent condition in the thoracic surgery department, we express deep regret. The patient visited our department’s outpatient clinic multiple times, but no signs of bacteremia were found. His afternoon low-grade fever is a typical manifestation of tuberculosis. Our attending doctor clearly advised the need to rule out tuberculosis and stated that the patient could return to our department for follow-up if there were other issues. The patient did not come. In summary, our hospital believes that there was no violation of any medical standards in the patient’s diagnosis and treatment process. February 23
Subsequently, the family applied for medical damage assessment. After review, the appraisal committee issued an appraisal report (description of the treatment process) as follows: On October 31, the patient went to the defendant’s emergency department due to “chest tightness and chest pain for 1 hour with radiating pain to the shoulder and back.” Physical examination: Alert, blood pressure 140/90 mmHg, clear breath sounds in both lungs, no dry or wet rales. Electrocardiogram: Sinus bradycardia, left ventricular hypertrophy, T-wave changes. The next day, chest pain became paroxysmal and needle-like. Cardiology consultation: General condition fair, blood pressure 170/120 mmHg. Electrocardiogram suggested: Sinus tachycardia. Outpatient diagnosis: Chest pain to be investigated; aortic dissecting aneurysm? Coronary heart disease. At 12:06, the patient was admitted to the medical party’s cardiology ward due to sudden persistent tearing pain in the sternum, accompanied by profuse sweating and fever for 1 day. Physical examination: Temperature 37.8°C; pulse 76 beats/min; respiration 20 breaths/min; blood pressure 180/110 mmHg. Alert, active position. On November 1, the medical party’s auxiliary examinations: Electrocardiogram showed “sinus rhythm, frequent premature atrial contractions”; CTA showed “aortic dissecting aneurysm (thoracic-abdominal aorta)”. Admission diagnosis: 1. Aortic dissecting aneurysm; 2. Grade III hypertension (very high risk). The medical party informed of critical condition. On November 2, the medical party’s CT diagnosis: Circular low-density shadow around the aorta, considered intramural aortic hematoma. On November 3, the patient was transferred to the vascular surgery ward. The next day, after informed consent, thoracic aortic angiography was performed under general anesthesia. During the procedure, the right brachial artery was punctured, and a pigtail catheter and guidewire were introduced to the brachiocephalic trunk opening but could not advance further. A right inguinal incision was made for puncture and introduction. Angiography showed: The aortic tear had completely closed. The patient was discharged on November 9. The medical record noted: The patient is currently in fair general condition, with blood pressure maintained stable under medication, and the condition is stable. On November 16, the outpatient record noted: Fever for 2 days, maximum 39.2°C. Physical examination: White blood cell count 18.17 × 10⁹ /L; ESR 88 mm/H. Diagnosis: Acute bronchitis? The medical party administered intravenous mezlocillin sodium for 3 days. On November 17 and 19, the patient returned for follow-up due to fever and discomfort. On November 22, patient temperature: 39.5°C; blood pressure: 90/50 mmHg, pulse: 86 beats/min. The medical party’s opinion: Fever possibly related to angiography. Blood culture showed: Staphylococcus aureus infection, Acinetobacter baumannii infection; pericardial effusion culture showed: Staphylococcus aureus infection. On November 23, patient temperature: 39.1°C; blood pressure: 112/70 mmHg. The medical party informed of the condition, and the patient was admitted to the thoracic surgery ICU. Admission diagnosis: Subacute aortic dissection, closed dissection entry with false lumen thrombosis; bilateral pleural effusion, pericardial effusion; Grade III hypertension (very high risk); fever to be investigated; bacteremia? On December 2, ultrasound suggested: Aortic dissection (type A), infective endocarditis. On December 6, ultrasound suggested: Left pleural and pericardial effusion. On December 31, ultrasound suggested: Aortic dissection (type A), infective endocarditis; left pleural and pericardial effusion. At 0:45 on January 3, the patient suddenly fainted and fell while going to the toilet, lost consciousness, and heart rate and blood pressure could not be measured. The medical party performed endotracheal intubation and informed of critical condition, not ruling out acute intracranial embolism caused by dislodged valvular vegetation. At 10:46 on January 4, the patient again experienced sudden drop in heart rate and blood pressure, followed by decreased peripheral oxygen saturation. The medical party immediately initiated chest compressions and other resuscitation measures. At 17:35, the patient suffered sudden cardiac arrest with flatline ECG, dropping blood pressure and oxygen saturation. At 18:05, the patient was pronounced clinically dead. Appraisal conclusion: This case constitutes medical damage to the patient’s person. The hospital had the following fault in medical activities: On November 16 during the outpatient visit, the patient had already had fever for 2 days with a maximum of 39.2°C and white blood cell count of 18.17 × 10⁹ /L, yet the medical party did not provide active diagnosis and treatment during outpatient follow-up. This medical fault has a certain causal relationship with the patient’s death outcome.