The diagnosis is not easy. Remember to take your mind step by step.
Author: Liu Yan Tsinghua University Yuquan Hospital
This article is published by the author’s authorization of the doctor. Do not reprint without authorization.
too difficult!Doctors must not only be busy with diagnosis, duty, scientific research, and teaching, but they must also beware of the post -day account.
On August 18, 2016, patient Xiao complained that "coughing for 1-2 years, the cough in the morning was obvious, and currently falling asleep is obvious, dry cough, sputum, occasionally yellow sputum, not fever"For cough.
On August 24, 2016, the affected party went to the medical side again. The outpatient medical records recorded that the history of the medical history was the same…. IMP: Cycles of lung, fibrosis in the lungs.September 8, 2016 Calendar: The same history.RX: Check the chest HRCT in 6 months.
In June 2017, the patient had a hoarse voice. When he went to many hospitals, he was diagnosed with differentiated glandular cancer.
From July 3rd to August 2, 2017, the patient went to a Beijing Specialist Hospital for hospitalization for treatment.
1. Left lung adenocarcinoma, T4N2M1C, IV stage, vicious tumor of pulmonary lymph nodes, complanitional secondary malignant tumors, secondary vicious tumors of pulmonary lungs, malignant tumors of hypotinomy, vast tumor, and brain secondary malignant tumorRadiation therapy, EGFR, ROS-1, Braf, KRAS, ALK negative.
2. Sound band paralysis.
3. Decreased vestibular function.
4. Thyroid nodules.
5. Lung infection.
Since then, patients have repeatedly received chemotherapy.
On April 17, 2018, the patient died of ineffective treatment. The cause of death: lung malignant tumor, bone marrow suppression, and respiratory failure.
After the patient’s death, the patient’s family would sue the first hospital to the court.The affected side believes that the three hospitals with a higher medical level have a high level of medical care. As the patient’s first consultation hospital, the hospital did not inform and propose the patient’s disease development risk.After a monthly development, it was not visited after obvious symptoms, and cancer metastasis had occurred.The affected party believes that the misdiagnosis of the medical party causes the patient to die after delaying treatment, and requires the court to determine that the medical party compensate for the loss of about 300,000 yuan.
The medical side believes that the consequences of the patient’s damage are not caused by the diagnosis and treatment of the medical prescription, but the natural transfer of their own diseases, and they do not agree with the request of the affected party.
In the lawsuit, the court applied for the appraisal center to identify whether there was a causal relationship or cause of the cause of the patient’s death in the diagnosis and treatment process of the patient’s diagnosis and treatment.
On October 19, 2019, the appraisal center issued an appraisal opinion, and the analysis was as follows:
1. Lung cancer is one of the malignant tumors with the highest incidence and mortality rate. Most of the early lung cancer has no obvious symptoms. Most patients have been diagnosed at the advanced stage, and the overall lung cancer has a low survival rate of 5 years.In this case, the cause of pathological death is unknown.According to the existing medical history, the patient’s left lung cancer has occurred multiple metastasis, bone marrow suppression, and lung infection and death. The ultimate death meets the development and return of his own disease.
2. Pulmonary nodules are a common clinical phenomenon, including benign nodules and malignant nodules. Early detection of malignant pulmonary nodules is relatively concealed. If it does not intervene in early intervention, its disease course is rapid, malignant, and poor prognosis.On August 18, 2016, the main treatment was 1-2 years due to cough for 1-2 years. On August 19, 2016, CT examination showed the left upper lung nodule, with a maximum diameter of 2.3cm, uniform density, leaflet, CT value of 32.4Hu, and lungs at the same time.The door is plump and multiple lymph nodes. The image diagnosis of the upper lobe of the left lung is clear. The imaging performance indicates that the malignant nodules may be possible.This patient was 53 years old, 10 smoke/day*40 years, has not quit smoking, and has high risk of lung cancer. The medical party has not recorded and preliminary diagnosis of the lung nodules found in the image in the outpatient record.Risk assessment and further examination are not in line with diagnosis and treatment specifications, which are deemed to be fault, which is related to the delay of diagnosis and treatment of lung cancer in patients.
3. The death of patients for malignant tumors belongs to the development and return of their own diseases, and has no direct causality with the diagnosis and treatment behavior of the medical side.The purpose of the clinical diagnosis and treatment of malignant tumors is to extend the survival period and improve the quality of life. The treatment of lung cancer is currently mainly adopted comprehensive treatment of surgery, which affects the survival of patients with malignant tumors.Proper diagnosis and treatment can be obtained, but early diagnosis and early treatment can improve the treatment effect of lung cancer.In this example, the patient found that the lung nodule to the malignant tumor from the doctor’s consultation on the medical prescription was clearly diagnosed for 9 months. At the same time, the imaging data confirmed that the disease had obvious progress or deterioration.Opportunities for effect.
In summary, the appraisal opinion believes that the patient’s left lung cancer is repeated multiple places to metastasize multiple places, that is, bone marrow suppression, lung infection and death, and its ultimate death is in line with the development and return of their own diseases.There is a fault in the diagnosis and treatment behavior of the medical party. Although there is no direct causal relationship with the death, it has caused the patient to lose the treatment of early treatment and get better treatment results.Cause and effect, comprehensively considering the severity of the patient’s condition and the degree of fault of the medical party, it is recommended that the medical fault the cause of the cause of the patient’s death is mild.
Based on the appraisal opinion, the court determined that there was a fault in the diagnosis and treatment behavior of the medical prescription. Although there was no direct causal relationship with the patient’s death, there was a minor responsibility with the acceleration of the patient’s extension or death of the patient.However, the judgment also pointed out that because my country’s laws have not provided compensation for survival, and the costs claimed by the affected party are produced by the primary disease of patients.
During the trial process, the medical party agreed to compensate the affected party’s reasonable losses at a rate of 5%.; Medical prescriptions bear half of the case acceptance and appraisal fee.
Is it responsible for misdiagnosis?
The misdiagnosis, that is, the medical personnel are not carefully observed and not carefully observed.The purpose of diagnosis is to determine the essence of the disease, and to choose a targeted and timely treatment, so that the disease can be brought back to good aspects.Therefore, it is wrong to treat incorrect diagnosis as errors, and the diagnosis that is not timely and incomplete is also wrong.
Mistakes lack strict classification in textbooks or clinical.In combination with the current clinical classification, we are divided into the following five types by misdiagnosis according to the different nature and degree of misdiagnosis:
Diagnosis errors, delay diagnosis, misalignment diagnosis, cause judgment errors, and disease nature judgment errors.
There have been many misdiagnosed cases before. For example, the chest was diagnosed with lung cancer in the center of the medical examination center. The diagnosis of lung cancer was leaked before cardiac surgery.This type of misunderstanding of misdiagnosis is often clear, especially some cases with imaging materials, and responsibilities are also easily identified.
According to the law, when the patient is checked and treated in the hospital, a medical service contract relationship has formed between the patient and the hospital.Inspection and treatment, if the hospital did not conduct a comprehensive examination of the patient during the diagnosis and treatment process, the patient’s severe disease was missed, and the best treatment period was deteriorated.Responsibility, that is, losses related to the missed diagnosis shall be liable for compensation.
What are the specific manifestations of misdiagnosis in the wrong diagnosis and treatment?
The misdiagnosis is regarded as a medical negligence, and all doctors are trying to avoid misdiagnosis.But in fact, every doctor will have misdiagnosis, even if the clever doctor can not be spared.However, the misdiagnosis may not be negligence. Because all kinds of diseases have a complex development process. When the typical symptoms and signs have not yet been showed, doctors are often difficult to confirm.Only to gradually become clear, and then the correct diagnosis can be established.The previous error diagnosis did not constitute a fault.
When judging whether there is a fault in the misdiagnosis process, the following aspects will be considered:
1 Whether the doctor meets the diagnosis and treatment routine during the diagnosis
The routine of diagnosis and treatment is an important norm to measure whether the doctor’s practice process is fault. Any operation that violates the routine diagnosis and treatment may be identified as fault.
Common faults include: do not collect medical history in detail, ignore key medical history; do not comprehensively check, ignore the important signs of patients; do not carefully analyze the cause, fail to conduct necessary auxiliary examinations for patients in accordance with the diagnosis and treatment routine;, Resulting in important positive results that have not been paid in time; do not pay attention to the abnormal results of the auxiliary inspection, and fail to further improve the inspection; when the diagnosis is clearly diagnosed, the superiors do not ask for instructions in time, ask for instructions or refer to the superior medical institution;Explain the condition in detail.
2 Whether the doctor is irresponsible during the diagnosis
Some misdiagnosis is not caused by the routine of diagnosis and treatment, but caused by doctors who are engaged in, negligible, and irresponsible to work.For example, ignore the changes in the symptoms and the progress of the patient’s symptoms, leading to delay diagnosis; the test form or auxiliary examination report of the patient’s test; neglect the lesion of the lesion when issuing a imaging report;Timely tracking the pathological diagnosis report and notifying the patient.
The misdiagnosis that appears under such "low -level errors" is often a responsible misdiagnosis.Although it is some "low -level errors", if you can’t concentrate your energy in busy clinical work, maintain a high sense of responsibility, and conscientiously and responsible to check and check it, this error is actually easy to occur.
3 The level of diagnosis and treatment in the area where the medical institution is located
The clear diagnosis of disease depends on the hardware and software levels of medical institutions. The hardware level is mainly various inspection and inspection equipment instruments, and the software level is the theoretical level and experience of the doctor.level.However, in terms of judgment to fault, the level, conditions and doctors of medical institutions are factors that need to be considered, but they often focus on the diagnosis and treatment level of the area where the medical structure is located.In other words, if a disease has a high diagnosis rate in this area, it is often necessary to take a lot of responsibility for misdiagnosis.Because consulting and referrals in the same area are relatively easy to achieve. If grassroots hospitals think that the diagnosis is difficult, it should be referred in time, otherwise it will be considered a fault.
How to cross the pit of the lung nodule?
The lung nodule is a common lesion in clinical practice. As people attach more importance to physical examination, many asymptomatic lung nodules are detected.The diameter of the lung nodule is generally less than 3 cm, which may be the early stage of certain malignant lesions, or it may be a benign lesion.For the diagnosis of lung nodules, pathological diagnosis is definitely a gold standard.Although the imaging examination will have some clinical prompts for the nature of the nodule, such as whether the boundary is clear, whether there are separatist leaves, burrs, whether the density is uniform, the range of the CT value, etc.But if you want to check the nature of the nodule through the image, the risk of misdiagnosis is too great.
In the practice of litigation, some imaging examinations indicate malignant lesions. Surgical resection of the pathological results of post -pulmonary field shows chronic inflammation and causes the medical party to lose the case; some imaging examination prompts benign lesions to observe the rapid progress of the lesion in the middle of the lesion.After the biopsy was diagnosed with malignant tumors, but because the tumor metastasis occurred after complications or puncture caused by the puncture, it was considered to be claimed by the fault of diagnosis and treatment; some doctors informed the patient’s lung nodule.In order to be benign, the doctor claims the medical expenses, misunderstanding and mental loss (the reason may not only spend money and waste time to do a "meaningless" inspection, but also seriously "scare").More cases were encountered in this case. The doctor was considered to be malignant for the lung nodule prompting in the imaging examination. After all, patients had a history of chronic pulmonary disease in the past.In the end, it is recommended to observe and regularly review the chest CT.The patient failed to review regularly in accordance with the doctor’s instructions, and the lesions had increased significantly when severe symptoms occurred.
If the lung nodules are too positive, not only waste medical resources, but also may cause patients to over -be inspected, cost huge, and cause unnecessary anxiety.However, if it is not very positive, it may often cause the disease to be diagnosed early and delayed treatment.How to grasp the score and how to communicate with the patient is also the knowledge.
The 2016 "Classification, Diagnosis and Treatment Guide (2016 Edition)" was released, and the 2018 "Consensus of the Chinese Experts (2018 Edition)" was released.Detailed recommendations.Following the guide, although it may not be able to avoid clinical misdiagnosis, the diagnosis and treatment process has a basis, and the clinical risk is greatly reduced.
The diagnosis is not easy. Remember to take your mind step by step.
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