Emergency Medicine Physician Opines on Delayed Diagnosis of Brain Tumor

    Emergency Medicine Expert WitnessThis case involves a child in Virginia who was seen by  pediatrician with complaints of vomiting and sore throat. The child was treated with antibiotics, as well as additional medication for pain and vomiting, and sent home. A few days later, the child was taken to the emergency room with complaints of incessant vomiting. No neurological exam or imaging was done, and the patient was discharged again. Within the week, the child was back in the emergency room, where he was taken for an MRI that discovered a cranial hemorrhage. Further examination revealed the source of the hemorrhage to be a previously undiscovered brain tumor.

    Question(s) For Expert Witness

    • 1. Have you diagnosed a cerebellar mass?
    • 2. Do you have extensive experience treating patient who present with similar symptoms?
    • 3. What tests should be conducted soon after patient presents complaining of symptoms?

    Expert Witness Response E-005591

    I have diagnosed many brain tumors within the past 5 years. Given my practice environment in the pediatric ED, we often are the ones to make this diagnosis – based mostly on history, clinical suspicion, and physical examination. Imaging typically confirms what we fear and suspect if we feel a scan is clinically warranted. A child with early am headaches, especially if accompanied by emesis, change in gait, speech, personality, school performance, visual changes, or new onset afebrile seizure, can all be indications of a potential brain tumor. At the point of suspicion a CT will be ordered, typically without contrast. However, if there is a concern for cerebellar lesions, an MRI often needs to be done. An MRI is often better for fine details of the brain, grading tumors, and is helpful for neurosurgery’s development of their management plan. Often, physical findings like head tilt, papilledema, facial droop, and cerebellar signs may be present – though not always. Vital signs are also important – especially pulse and blood pressure – as increased intracranial pressure may be manifested as bradycardia, altered respiratory pattern and hypertension. If symptoms are acute, doctors must consider cva, atypical migraine, seizure, infectious causes like an abscess or meningitis, in addition to a potential tumor or mass.

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