“Please Come Back to the Hospital: Your Test Results Show You May Have…“

1Division of Hospital Medicine, St. Josephs Mercy Health Center, Hot Springs, AR

Meeting: Hospital Medicine 2008, April 3-5, San Diego, Calif.

Abstract number: 135

Case Presentation:

A 61‐year‐old nonsmoker presented with right‐sided weakness and an unstable gait for 2 days. Exam showed an obvious right‐sided weakness and dysarthria. He was admitted for inpatient care. PE revealed an edentulous, frail male with stable vitals. Pertinent positives included a left facial droop and right‐sided motor weakness. Lung exam revealed coarse crackles and rhonchii in the right lower zone with egophony. An initial head CT showed multiple enhancing lesions suspicious for metastases. The patient was started on IV steroids, antibiotics, and prophylactic antiepileptic drug therapy. Further workup revealed localized bronchiectasis of the right lower lobe with a 3 × 4 cm mass in the right lower lung field on CT. A CT‐guided biopsy of this lesion was performed, and the patient was rapidly discharged awaiting test results. The lung biopsy revealed an intense inflammatory infiltrate of an acute nature with necrotic debris. No malignant cells were seen on multiple slide preparations. The patient was called back for admission and reevaluation.

Figure 1. Left, CT with contrast showing multiple enhancing lesions in the cortex; middle, CT‐guided lung biopsy of right lung mass; right, MRI showing multiple lesions with vasogenic edema and enhancement on FLAIR sequences.

Discussion:

Clinically, this patient had stage IV lung cancer with brain metastases. His workup was rapid, and he was safely discharged awaiting biopsy results. The findings of an acute inflammatory infiltrate changed not only the diagnosis but also the prognosis and further management of this patient. Failure to follow up on these findings may have resulted in inappropriate treatment (brain radiation) or a catastrophic delay in antimicrobial treatment. This underscores the responsibility hospitalists bear for follow‐up of in‐patient testing at discharge. The case also highlights the need for hospitalists to always remain vigilant for “zebras” in clinical practice. The patient ultimately underwent stereotactic brain biopsy, where cultures confirmed the diagnoses of bacterial abscess caused by Streptococcus. He was started on long‐term IV antibiotics and continues to improve clinically.

Conclusions:

The lack of direct clinical contact after discharge mandates hospitalists to employ reliable mechanisms to follow up inpatient test results. Failure to have such systems in place can have disastrous consequences. Finally, remembering that “diseases do not read textbooks,” would serve the hospitalist well, as illustrated in this case.

Author Disclosure:

V. Chopra, none.

To cite this abstract:

Chopra V. “Please Come Back to the Hospital: Your Test Results Show You May Have…“. Abstract published at Hospital Medicine 2008, April 3-5, San Diego, Calif. Abstract 135. Journal of Hospital Medicine. 2008; 3 (suppl 1). https://www.shmabstracts.com/abstract/please-come-back-to-the-hospital-your-test-results-show-you-may-have/. Accessed November 13, 2019.

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