Lost in Transcription

A CLINICAL PROBLEM-SOLVING article by Robert Kalus from University of Washington, Seattle.
Urinary urgency and fever developed in a 55-year-old, bedridden woman with multiple sclerosis, a long-term indwelling Foley catheter, and multiple prior urinary tract infections. The patient had recently been transferred from an assisted-living facility to a skilled-nursing facility because of progressive disability. On the day of presentation, she reported urinary urgency and dysuria, despite a normally functioning urethral catheter; her temperature was 38.5°C.
Her long-term medications included ranitidine for reflux symptoms, rofecoxib for pain control, baclofen for spasticity, gabapentin for neuropathic pain, and weekly methotrexate as corticosteroid-sparing therapy for her progressive multiple sclerosis. She had also mouth pain and fatigue for several days before presentation.
On examination at the emergency department, the patient was thin, somnolent, diaphoretic, and ill-appearing. She had notable dry oral mucosa, with desquamation of her tongue, palate, and buccal surfaces.
Laboratory testing revealed a white-cell count of 330 per cubic millimeter, with an absolute neutrophil count of 50; the platelet count was 7000, and the hematocrit was 34%; serum creatinine, 1.0 mg per deciliter, increased from 0.5 mg 10 weeks earlier.
In this case, after initially considering a broad differential diagnosis, the discussant quickly focused on the possibility of medical error.

メソトレキセート処方の転記(transcription)ミスによる骨髄抑制のケース。この薬剤は、「白質脳症」にも気をつける必要がある。