Missed It

In this case, a middle-aged male presents in the early hours of the morning to the emergency department (ED) of a teaching hospital. His chief complaint is shortness of breath. His history is significant for chronic obstructive pulmonary disease (COPD), and he is diagnosed as having exacerbation of COPD. The ED physician calls a medical intern to do the admission, and the patient is taken to the floor. The patient does not settle, and the intern is called back to the floor twice. The second time the intern is called back, the patient deteriorates further and has a cardiac arrest from which he cannot be resuscitated. His true diagnosis is revealed at an autopsy later that day.