A 16-year-old football player presented to the pediatric ED with a severe headache. The attending physician was a first-year pediatric emergency physician.
The patient reported a constant, severe headache that he attributed to a hard collision in practice the day before. He had not lost consciousness, and his vital signs were normal.
A head CT was normal, and he was discharged with a diagnosis of post-concussion syndrome and given appropriate instructions.
The patient returned to the ED two days later (day three of symptoms), still alert and ambulatory. His headache had worsened, and was now severe. He presented with normal vital signs and was afebrile. He did report malaise and subjective fever.
He had taken ibuprofen an hour before ED arrival, and was still attributing his symptoms to the football collision. He said, however, that his headache had not started immediately after the collision but approximately 15 hours later. The collision itself didn't involve his head.
He had subjective posterior neck pain with flexion, but his neck was supple. Neurologic and skin exams were normal. I reviewed the initial head CT, and agreed that it appeared normal. I felt the presentation was more consistent with meningitis than a TBI, and after discussing my thoughts with the patient and his mother, they consented to a lumbar puncture.
An examination of cerebrospinal fluid revealed aseptic meningitis, and he was admitted for observation. Antibiotics were withheld because nothing suggested bacterial meningitis (afebrile, normal peripheral WBC count).
The "consider the worst first" rule was broken. Anchoring on a TBI occurred when the physician followed the patient down the wrong path and didn't take a detailed history about symptom onset or consider alternative and potentially more dangerous explanations.
Although listening to patients and considering their ideas is good, it can lead to error if we take the path of least resistance and accept an incorrect self-diagnosis. In a case like this, thinking for ourselves and disagreeing with them is essential.
Absence of fever due to antipyretic administration can also lead to error. This patient endorsed subjective fever, but didn't have a fever in triage. A history of fever should be treated the same as an objective fever recorded in the ED.