Ref. # 16128
A 40 year old Michigan man with a history of vallecular cyst presented to the ER complaining of difficulty in swallowing and breathing for 6-12 hours. The existing treatment plan was conservative, as the cyst had not been deemed threatening to the airway. The patient was evaluated in the ER by an experienced physician's assistant. X-rays showed swelling of the epiglottis. The physician's assistant diagnosed peritonsillar swelling and subglottic cyst with no airway threat. The patient was discharged and returned two hours later with increased difficulty in swallowing and breathing. He coded and died. A medQuest physician's assistant reported that the attending physician's assistant deviated from the standard of care by failing to secure the airway and admit the patient to the ICU.