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A. Vasu
Discussion
Description of chest pain was not evaluated appropriately. Patients have their way
of expressing the pain and grading it over a scale. The patients should be encouraged to explain their pain, and every attempt should be made to refrain from jumping to a diagnosis [4]. The American College of Cardiology/American Heart
Association (ACC/AHA) guidelines on evaluation and diagnosis of chest pain recommend using the term noncardiac chest pain to describe pain in the region of the
chest that is irrelevant to the heart [5]. The onset and duration of chest pain should
never be missed as this can point toward the seriousness of the symptoms.
Precipitating factors, location, radiation of pain, and associated symptoms should
all be given equal importance and evaluated by guiding the patient’s attention to
these details [6]. Last but not least for non-native speakers of English, wherever and
whenever possible, translator services with appropriate attention to cultural background should be practiced. Chest pain is usually not a reliable indicator of myocardial origin in smokers, women, diabetics, as well as elderly [7]. In this patient, the
history of diabetes and smoking had masked the intensity of chest pain and could
have been a reason for misdiagnosis.
ECG: This is a very important tool in the diagnosis of heart diseases in the hands
of trained. ACC/AHA recommends an ECG in all patients presenting to ER with
chest pain or any pain in the region of the chest within 10min of arrival and repeats
as and when required in suspected cases [8]. ECG should be read by comparing with
a previous one whenever available, and if no such ECG is available, then repeat
ECG taken at least an hour apart in all suspected cases should be followed carefully
looking for any new ST-T changes. In patients with normal ECG but cardiac sounding chest pain, right-sided ECG [9] leads should be considered which can save
many a heartburn later. In this patient, if a right precordial chest ECG was done, the
diagnosis could have been made much earlier. In patients having left circumex or
right coronary artery occlusions or posterior wall ischemia, the ECG can be deceivingly normal like in this patient, and the right precordial lead ECG should have been
advised. ECG whenever is normal in patients with chest pain should always be
repeated at 1 h intervals and expert opinion sought if one is not very condent in
interpreting the ECG.
Biomarkers: these can come to the rescue when in ambiguity about the diagnosis
and should always be advised in all suspected cases of chest pain with normal ECG;
ACC/AHA recommends cardiac Troponin I or T because of their high sensitivity
and specicity [10]. Although certain other diseases of the heart muscle also cause
an elevation in troponins, proper interpretation of the results of biomarkers should
be done in correlation with all the clinical information. In our case biomarkers were
not advised to begin with, and that led to a considerable delay in making the diagnosis, which could have been easily avoided. There are many other diagnostic tools
that are available which will aid in the diagnosis of chest pain but are of limited
clinical relevance.
17 Acute Coronary Syndrome Misdiagnosed asAnxiety
115
Differential Diagnosis
1. Musculoskeletal chest pain– Pain usually in the region of the entire chest with
or without extension to the back of chest. History of preceding course of events
helps to differentiate.
2. Traumatic chest pain– Pain in the chest following any blunt injury to the chest
wall following a st ght or otherwise or may be due to an accidental fall. A
good clinical history will almost always establish the diagnosis.
3. Chest pain secondary to dissection of the aorta– Excruciating pain in the region
of chest, usually sudden in onset and mostly in the younger age group.
4. Acute gastritis– Unrelated to a specic age group, but history of alcohol abuse
and or irregular diet should raise the suspicion, more common in certain ethnic groups.
5. Angina pectoris– More prevalent in the fairer sex, usually accompanied with
prior history of similar chest pain that is precipitated on increased physical
activity.
6. Herpetic infections– A history of fever or a skin rash over the chest should raise
a suspicion.
7. Stress (loss of a close relative or nancial loss)– A common but almost always
neglected aspect of clinical medicine. Paying close attention to the physical
appearance and habitus of the patient should help in exclusion.
Conclusion
It is of prime importance that all patients coming to ER with chest pain should be
evaluated thoroughly, in the suspected few, additional evaluations should be considered, and wherever possible expert opinion should be sought to identify those
requiring hospitalization and further management. Patients visiting the ER with cardiac sounding chest pain should undergo a triage so as to identify the potential from
the confounding cases, and wherever possible patients should be offered ACC/AHA
guidelines-based treatments, sex of the patient or ethnicity should not be a deterrent.
The current guidelines recommend percutaneous coronary intervention or intravenous thrombolysis for all patients presenting within the golden hour unless otherwise contraindicated. All patients presenting within a reasonable period of time
with evidence of acute myocardial infarction should be offered treatment according
to the standard operating protocols of the treating hospital. Whenever the ER physician is presented with a challenging patient, the above algorithm should come in
handy (Fig.17.1).
116
Fig. 17.1 Diagnostic algorithm for evaluation of chest pain
References
A. Vasu
1. Rui P, Kang K.National Hospital Ambulatory Medical Care Survey: 2017 emergency department summary tables. National Center for Health Statistics. https://www.cdc.gov/nchs/data/
nhamcs/web_tables/2017_ed_web_tables- 508.pdf.
2. Ruigomez A, Rodriguez LA, Wallander MA, etal. Chest pain in general practice: incidence,
comorbidity, and mortality. Fam Pract. 2006;23:167–74.
3. Hsia RY, Hale Z, Tabas JA.A national study of the prevalence of life-threatening diagnoses in
patients with chest pain. JAMA Intern Med. 2016;176:1029–32.
4. King-Shier K, Quan H, Kapral MK, et al. Acute coronary syndromes presentations and
care outcomes in white, South Asian and Chinese patients: a cohort study. BMJ Open.
2019;9:e022479.
5. Gulati M, Levy PD, Mukherjee D, Amsterdam E, Bhatt DL, Birtcher KK, Blankstein R, Boyd
J, Bullock-Palmer RP, Conejo T, Diercks DB, Gentile F, Greenwood JP, Hess EP, Hollenberg
SM, Jaber WA, Jneid H, Joglar JA, Morrow DA, O’Connor RE, Ross MA, Shaw LJ. 2021
AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR guideline for the evaluation and diagnosis of
chest pain: a report of the American College of Cardiology/American Heart Association Joint
Committee on Clinical Practice Guidelines. J Am Coll Cardiol. 2021;78(22):e187–285.
6. Fanaroff AC, Rymer JA, Goldstein SA, et al. Does this patient with chest pain have
an acute coronary syndrome?: the rational clinical examination systematic review.
JAMA. 2015;314:1955–65.
7. Leifheit-Limson EC, D’Onofrio G, Daneshvar M, etal. Sex differences in cardiac risk factors, perceived risk, and health care provider discussion of risk and risk modication among
young patients with acute myocardial infarction: the VIRGO Study. J Am Coll Cardiol.
2015;66:1949–57.
17 Acute Coronary Syndrome Misdiagnosed asAnxiety
8. Turnipseed SD, Trythall WS, Diercks DB, et al. Frequency of acute coronary syndrome in
patients with normal electrocardiogram performed during presence or absence of chest pain.
Acad Emerg Med. 2009;16:495–9.
9. Neumann JT, Twerenbold R, Ojeda F, et al. Application of high-sensitivity troponin in suspected myocardial infarction. N Engl J Med. 2019;380:2529–40.
10. Vogiatzis I, Koulouris E, Ioannidis A, etal. The importance of the 15-lead versus 12-lead ECG
recordings in the diagnosis and treatment of right ventricle and left ventricle posterior and
lateral wall acute myocardial infarctions. Acta Inform Med. 2019;27:35–9.
117
Chapter 18
Diabetic Neuropathy Misdiagnosed
asRight Lower Limb Injury
AlluriVasu
Learning Objectives
By the end of this presentation, the clinician will be able to:
1. Discuss why diabetic neuropathy may be a complication of poorly controlled
diabetes.
2. Discuss the signicance of appropriately enquiring about the comorbidities that
a patient might be having.
3. Enumerate the complications and refer patients for expert management.
4. Restate the importance of tight glycemic control to prevent the complications of
diabetes.
5. Rationalize and select drug therapy that should be dictated by the blood glucose
levels augmented by a diet as well as exercise regimen.
Introduction
In the modern world, there is an alarming desire to outwit each other, and that
applies to the occurrences of disease as well. The current COVID-19 pandemic has
forced the young as well as the old to stay indoors, which has greatly restricted
outdoor activities and has almost resulted in no physical activity. Now, as the world
slowly but steadily is moving toward the new normal, the medical fraternity is going
to be overwhelmed with an increase in lifestyle/metabolic diseases. We are going to
see an increase in the number of new as well as uncontrolled diabetic patients.
Diabetes has since long been known as a lifestyle disease. Modern-day lifestyle as
A. Vasu (*)
St. Martinus University Faculty of Medicine, Willemstad, Curacao
e-mail: alluri.vasu@martinus.edu
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
H. Tohid et al. (eds.), The Misdiagnosis Casebook in Clinical Medicine,
https://doi.org/10.1007/978-3-031-28296-6_18
119
120
A. Vasu
well as the increased availability of energy-dense foods has contributed signicantly
to diabetes. Stress, an often-overlooked factor is not given the importance it deserves.
This pandemic that we are in now has increased the stress levels of one and all. The
fear of diseases such as COVID-19 as well as loss of employment and a decrease in
family time have worsened the incidence of several diseases, diabetes in particular.
Diabetes is a multifactorial, multiorgan, and often accepted as a naïve disease when
treated adequately with strict control of blood glucose to the normal therapeutic
range. The glucose metabolism is hampered in all patients suffering from diabetes,
and as the blood glucose increases, so do the complications that are associated with
it. The degree of blood glucose, as well as the duration of diabetes [1], plays an
important role in the prevalence of associated complications and are equally prevalent in all irrespective of gender and age. A recent review of literature has shown the
presence of both microvascular and macrovascular complications of diabetes and
the steady decline of macrovascular complications the world over due to improvement in approach to diabetes, but the microvascular complication remains a cause
of concern, and peripheral neuropathy is more prevalent in these patients with type
II diabetes [2]. It is now a known fact that by the time of diagnosis of diabetes,
patients already have one or more complications of the disease. The reason for the
high prevalence of complications of diabetes even before the diagnosis of the disease is attributed to the prevalence and degree of hyperglycemia apart from other
coexisting comorbidities. Between the microvascular and macrovascular, microvascular complications develop early in the course of the disease. There has been a
steady increase in the number of drugs that are better than the previous ones in
managing blood glucose on one hand and greatly decreasing the complication on
the other hand. With these modications in treatment options, patients with diabetes
are now able to slow not only the development but also the progression of both
micro- and macrovascular complications. Patients are now being increasingly
trained and encouraged for home monitoring of blood glucose. The practicing doctors have recognized the importance of patient education as well as participation in
managing diabetes and often actively engage with patients in titrating their medication. Patients now monitor their blood glucose using point-of-care devices and
update their doctor through various digital apps. This way adequate monitoring of
out-of-hospital blood glucose in the real world has enabled the treatment of diabetes
adequately with a visible difference in the quality of life of the affected patients.
Despite this, diabetes happens to be the Achilles heel of medical science, and with
our expanding knowledge, we learn more about this syndrome. There is no organ
left untouched by diabetes if blood glucose is not under control. The practicing doctor should always remember to manage blood glucose not with medications but also
with diet and exercise. All three (diet, drugs, and exercise) contribute equally and
should always be emphasized on each visit to the clinic by a patient suffering from
this disease. Despite the several advances in the diagnosis and management, diabetes happens to be a challenge, and frequently patients present with complications
that affect the eyes, kidneys, and nervous tissue. If managed inadequately this syndrome can always end with unpleasant consequences.
18 Diabetic Neuropathy Misdiagnosed asRight Lower Limb Injury
121
Clinical Case Presentation
A 40-year-old male “Mr. X” was seen in the emergency room (ER) for a bleeding
injury to his right great toe, which he sustained while getting off the bus. He was
attended to immediately, the bleeding was arrested, the right greater toe was dressed
adequately, and he was discharged home. Neither the patient “Mr. X” nor the doctor
gave any thought to a follow-up visit or further evaluation. A week later the patient
revisited the ER with pain and swelling of the right foot. “Mr. X” was quick to recognize the young and attractive doctor, who had attended to him and reminded her
of his last visit. It came as a surprise to the doctor that “Mr. X” did not get his
checkup or went to see any other doctor for his wound care. On further questioning
“Mr. X” gave a history of diabetes of 10years’ duration and use of insulin for effective control of his blood sugars, although he did not remember the type of insulin
and other medication he was on for his diabetes care. He conrmed that he has
missed his last few appointments with his physician who was managing his diabetes
as he was stressed out about meeting his targets for his sales job and did not remember when he last got tested for his blood sugars. On examination, the right greater
toe was badly infected and foul-smelling as the dressing was opened. There was a
considerable spread of the infection up to the lower third of the foot. He was referred
to a surgeon for further management. Mr. X was seen by the surgeon the next day
and was advised of a battery of investigations. The reports of which pointed toward
uncontrolled blood sugars, peripheral diabetic neuropathy, and early signs of renal
insufciency. The wound on the right greater toe was severely infected and had
spread considerably, and he was advised below-knee amputation of the right lower
limb to prevent any further spread of infection and salvage the kidney. “Mr. X” was
operated on and had undergone a right lower limb below-knee amputation. He was
discharged the following week with strict advice to follow up with his physician for
postoperative care as well as diabetes.
Differential Diagnosis
1. Diabetic neuropathy when suspected should be differentiated from peripheral
neuropathy– Vascular causes of neuropathy should be excluded.
2. Sensorimotor polyneuropathy– Diabetic neuropathy usually develops a decade
after the onset of symptoms in type I, but in those with type II may present at
diagnosis. It is usually bilateral and diffuse.
3. Diabetic neuropathy when diagnosed is usually present along with the involvement of other organs gastrointestinal neuropathy, bladder dysfunction, and erectile dysfunction.
4. Mononeuropathy and focal neuropathy can occur with the involvement of either
the ulnar, radial, or peroneal nerves.
5. Vitamin deciencies (vitamin B1 and B12) should be excluded before conrming the diagnosis of diabetic neuropathy.
122
A. Vasu
Discussion
The case in discussion is a good learning example of how important history is, a
simple but very effective part of the management of patients and almost always
prevents pitfalls. A few words with the patients during their visit prevent volumes of
papers from defending oneself. During the initial visit of this patient, a very brief
history irrespective of the cause of the injury could have saved his limb. The duration of diabetes greatly determines the degree and extent of diabetic neuropathy [3]
patients often do not feel any pain when injured, and it’s the bleeding from the
injured site that brings them to medical attention. Apart from attending to the obvious, every attempt should be made to know more about other comorbid conditions
[4] the patient might be having at the time of presentation. In all patients with diabetes, diabetic triopathy should be suspected and evaluated thoroughly whenever
possible. Some simple tests like pinprick test, temperature test, and vibration tuning
fork test [5] can be done at the point of care to detect diabetic neuropathy and
require no additional training. These can be completed in a very short time. If only
doctors could spend that additional few minutes of time with patients, many complications can be avoided and go a long way in restoring the condence of our
patients. Aggressive management of blood glucose prevents the onset and spread of
neuropathy irrespective of the type of diabetes [6]. When recognized early and
treated adequately, complications of diabetes can be prevented. Foot ulceration and
loss of limbs are the disastrous complication of ineffective management of diabetes
and are often associated with psychologically traumatic experiences and loss of
productive years of life, in addition to healthcare costs [7].
Conclusion
The management of a patient should not be limited to attending to the primary complaint but also guiding the patient for follow-up visits to primary care physicians.
All diabetic patients should be appropriately trained in foot care and ambulatory
blood sugar monitoring. Patients should be encouraged to follow diet, exercise, and
effective pharmacologic therapy to reach their target glycated hemoglobin (HbA1C)
goals to prevent complications of diabetes.
References
1. Ang L, Jaiswal M, Martin C, et al. Glucose control and diabetic neuropathy: lessons from
recent large clinical trials. Curr Diab Rep. 2014;14:1–15.
2. An J, Nichols GA, Qian L, et al. Prevalence and incidence of microvascular and macrovascular
complications over 15 years among patients with incident type 2 diabetes. BMJ Open Diab Res
Care. 2021;9:e001847. https://doi.org/10.1136/bmjdrc-2020-001847.
18 Diabetic Neuropathy Misdiagnosed asRight Lower Limb Injury
3. Martin CL, Albers JW, Pop-Busui R, et al. Neuropathy and related ndings in the diabetes con-
trol and complications trial/epidemiology of diabetes interventions and complications study.
Diabetes Care. 2014;37:31–8.
4. Tesfaye S, Chaturvedi N, Eaton SE, etal. Vascular risk factors and diabetic neuropathy. N Engl
J Med. 2005;352:341–50.
5. Perkins BA, Olaleye D, Zinman B, etal. Simple screening tests for peripheral neuropathy in the
diabetes clinic. Diabetes Care. 2001;24:250–6.
6. daCosta DiBonaventura M, Cappelleri JC, Joshi AV.A longitudinal assessment of painful dia-
betic peripheral neuropathy on health status, productivity, and health care utilization and cost.
Pain Med. 2011;12:118–26.
7. UK Prospective Diabetes Study (UKPDS) Group. Intensive blood-glucose control with sulpho-
nylureas or insulin compared with conventional treatment and risk of complications in patients
with type 2 diabetes (UKPDS 33). Lancet. 1998;352:837–53.
123
Chapter 19
Multiple Sclerosis Is Misdiagnosed
asMigraine
AlluriVasu
Learning Objectives
By the end of this presentation, the clinician will be able to:
1. Discuss the progression of multiple sclerosis as relapsing-remitting, primary
progressive, or secondary progressive.
2. Appreciate that women in the reproductive age group and overall women outnumber men for this disease.
3. List the symptoms along with supportive investigations (MRI brain) to help
diagnose the diseases.
4. Enumerate the treatment regimen when the patient presents symptomatically
and the disease-modifying immunomodulators for long-term benet.
Introduction
Reaching the diagnosis within a short time frame is a challenge the doctors working
in ER are constantly experiencing. The doctors in ER are trained to look for early
signs and symptoms when attending to a patient, and they then come to a reasonable
working diagnosis to treat the patient. Many times because of several reasons, diagnosis is missed, which gets amplied as the patients reach the wrong ward or get
mistreated. Misdiagnosis is a costly mistake that often ends up with doctors being
sued. Physicians who just joined medical practice should not hesitate in seeking
help from seniors while dealing with unfamiliar cases. When faced with a
A. Vasu (*)
St. Martinus University Faculty of Medicine, Willemstad, Curacao
e-mail: alluri.vasu@martinus.edu
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
H. Tohid et al. (eds.), The Misdiagnosis Casebook in Clinical Medicine,
https://doi.org/10.1007/978-3-031-28296-6_19
125