How Could Anyone Have Missed this Diagnosis of Near-Fatal Hypothyroidism?

To the Editor:

Desai et al (1) describe a tragic case of panhypopituitarism diagnosed only when the patient developed cardiogenic shock and required two weeks of mechanical and pharmacological inotropic support, plus an implanted defibrillator.

Because they focus chiefly on the final outcome, the authors consider the patient’s management as a success. Instead, they should have used techniques of aviation mishap investigation to question how this patient’s close, 21st-century medical care over the preceding year could have allowed an eminently treatable disease to reach Dickensian severity.

Why did the review of systems upon admission not disclose the patient’s symptoms of hypothyroidism? Why did the admission physical miss the obvious hair and skin signs? Why was the neurological examination deemed “unremarkable” when this patient very likely had markedly delayed relaxation of tendon reflexes (2,3,4)? Evaluating such suspicious findings could have advanced hormone replacement and averted complications.

Aviators live and die by their checklists – literally. Thorough patient histories and physical exams are medicine’s ultimate checklist. We shortcut them at our peril, and at the peril of our patients.