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psnet.ahrq.gov/web-mm/mismanagement-delirium
February 13, 2014 - Case An 85-year-old man with early stage vascular dementia fell on the sidewalk and fractured his leg … He was given crutches and instructions for no weight-bearing on the injured leg. … The patient continued to have constipation, mild dehydration, increased leg pain, and ingrown toenail … If soon after the patient was admitted with the leg fracture it was also known he had LBD, the clinical … Similarly, he had leg and toenail pain, and it is not clear if his pain was adequately managed.
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psnet.ahrq.gov/node/49760/psn-pdf
May 01, 2016 - Case
An 85-year-old man with early stage vascular dementia fell on the sidewalk and fractured his leg … He was given
crutches and instructions for no weight-bearing on the injured leg. … The patient continued to have constipation, mild
dehydration, increased leg pain, and ingrown toenail … If soon after the patient was admitted with the leg fracture it was also known he had LBD, the clinical … Similarly, he had leg and toenail pain, and it is not clear if his pain was adequately managed.
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psnet.ahrq.gov/web-mm/spinal-epidural-abscess
November 13, 2019 - She described the pain as moderate-to-severe, radiating down the left leg and buttock. … She only partially recovered function of her legs and was mainly using a wheelchair. … of fever in a patient with new back pain is very concerning.( 8 ) Focal neurologic complaints (e.g., leg … Certainly, a focal neurologic finding (e.g., left leg weakness on examination) may be evidence of a SEA … WebM&M Cases
Under Pressure: Delayed Diagnosis of Compartment Syndrome after Lower Leg
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psnet.ahrq.gov/glossary/active-error-or-active-failure
September 13, 2021 - This person may literally be holding a scalpel (e.g., an orthopedist operating on the wrong leg) or figuratively
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psnet.ahrq.gov/web-mm/superficial-report-leads-deep-problem
July 01, 2012 - The patient denied any recent trauma to her leg and had no fever or respiratory symptoms. … physical examination was significant for moderate pitting edema, mild erythema, and tenderness of the left leg … The patient was able to bear weight on the affected leg but had an antalgic gait (a limp adopted to avoid … thrombophlebitis and prescribed oral antibiotics along with elevation and warm compresses to the affected leg
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.350_slideshow.ppt
June 01, 2015 - On examination his left lower leg was dusky in color, extremely tender to palpation, and his pulses could … disease.
5
Case: Anchoring Bias (3)
The patient required emergent bypass surgery of the left leg … Unfortunately, due to ischemia (lack of blood flow from the arterial disease) of his leg, he developed … computerized decision-support system: pain left foot, numbness left foot, foot drop, loss of sensation left leg
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.320_slideshow.ppt
January 01, 2020 - likely due to the delay in making the diagnosis and surgery, the patient still has some weakness in his legs … no atrophy More profound atrophy
Weakness in pyramidal pattern
Arms: Extensors weaker than flexors
Legs … States are diabetes and alcohol use
Peripheral neuropathy usually presents with length-dependent (i.e., legs … Motor
Assess bulk and tone
Pronator drift
Finger and foot taps
Extensors in the arms and flexors in the legs
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psnet.ahrq.gov/node/865531/psn-pdf
April 10, 2024 - with a case involving an 18-month-old African American child with a spiral fracture of the left lower leg
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psnet.ahrq.gov/node/49872/psn-pdf
August 08, 2019 - She described the pain as moderate-to-severe, radiating down the left leg and
buttock. … She only
partially recovered function of her legs and was mainly using a wheelchair. … of fever in a patient with new back pain is very concerning.(8)
Focal neurologic complaints (e.g., leg … Certainly, a focal neurologic finding (e.g., left leg weakness
on examination) may be evidence of a
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psnet.ahrq.gov/node/612828/psn-pdf
February 23, 2022 - discharged home on
POD 4, but on POD 9, during a clinic visit, the patient reported increasing left leg … His left leg was cool with absent pulses. … strong EIA pulse after nephrectomy, there was an additional delay in
diagnosis of his symptomatic leg
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psnet.ahrq.gov/node/37514/psn-pdf
February 04, 2015 - J Empirical Leg Stud.
2010;4(4):835-860. doi:10.1111/j.1740-1461.2007.00108.x.
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psnet.ahrq.gov/node/49716/psn-pdf
August 21, 2014 - Three hours after the IO line was placed, a nurse notified the primary team that the left leg was a dusky … purple, and on examination the leg was bluish and tensely edematous with sluggish distal pulses. … Left leg with intraosseous device placed in proximal tibia. (Illustration © 2014 Chris
Gralapp.)
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psnet.ahrq.gov/node/49578/psn-pdf
January 01, 2009 - hospital-admission-due-high-dose-methotrexate-drug-interaction
The Case
A 40-year-old woman with osteosarcoma in her left leg … received neoadjuvant high-dose methotrexate,
doxorubicin, and cisplatin (MAP) prior to left leg resection … Four months after leg reconstruction, the patient
developed left lower extremity erythema and was admitted
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psnet.ahrq.gov/node/41698/psn-pdf
November 27, 2012 - duplication-surgical-site-marking
Describing a case of duplicate surgical site markings on a patient's legs
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psnet.ahrq.gov/web-mm/anchoring-bias-critical-implications
June 15, 2022 - On exam his left lower leg was dusky in color with extreme tenderness to palpation and his pulses could … The patient required emergent bypass surgery of the left leg by vascular surgery. … Unfortunately, due to ischemia (lack of blood flow from the arterial disease) of his leg, he developed … computer–assisted diagnosis program : "pain left foot, numbness left foot, foot drop, loss of sensation left leg
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psnet.ahrq.gov/web-mm/hospital-admission-due-high-dose-methotrexate-drug-interaction
October 01, 2003 - The Case A 40-year-old woman with osteosarcoma in her left leg received neoadjuvant high-dose methotrexate … , doxorubicin, and cisplatin (MAP) prior to left leg resection and reconstruction. … Four months after leg reconstruction, the patient developed left lower extremity erythema and was admitted
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psnet.ahrq.gov/web-mm/benefits-vs-risks-intraosseous-vascular-access
September 01, 2005 - Three hours after the IO line was placed, a nurse notified the primary team that the left leg was a dusky … purple, and on examination the leg was bluish and tensely edematous with sluggish distal pulses. … Left leg with intraosseous device placed in proximal tibia.
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psnet.ahrq.gov/web-mm/delayed-diagnosis-kidney-transplant-complications
January 29, 2020 - discharged home on POD 4, but on POD 9, during a clinic visit, the patient reported increasing left leg … His left leg was cool with absent pulses. … a strong EIA pulse after nephrectomy, there was an additional delay in diagnosis of his symptomatic leg
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psnet.ahrq.gov/node/49735/psn-pdf
June 01, 2015 - On exam his left lower leg was dusky in color with
extreme tenderness to palpation and his pulses could … The patient required emergent bypass surgery of the left leg by vascular surgery. … Unfortunately, due to ischemia (lack of blood flow from the arterial disease) of his leg, he developed … computer–assisted diagnosis program: "pain left foot, numbness left foot, foot drop, loss of sensation left
leg
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psnet.ahrq.gov/sites/default/files/2022-02/final_cme_reviewed_spotlight_loss_of_trust_and_a_missed_diagnosis_02.14.20221_-_clean_-_revised.pdf
January 01, 2022 - video twice for progressive pain—now 9 out of 10 in
severity and limiting her ability to walk due to leg … She
began experiencing balance problems and leg spasms such that she
required use of a walker to ambulate … As her symptoms progressed to involve
radicular symptoms with leg spasms, magnetic resonance imaging … and additional evaluation as the patient’s pain worsened and she
developed new symptoms, including leg