Ref. # 655201
In 1996 a 28-year-old woman with a recorded history of bulimia and anorexia suffered a seizure-like episode. She had given birth for the first time three weeks prior. EMT's took her to the ER of a medical center. A nurse referred her to the medical center's eating disorders program. There is no record of the patient's course there, although the records of the woman's primary care physician refer to participation in the program. One year and ten months later the woman gave birth to a second child. The delivery was uneventful. One month later, according to her husband, the woman suffered an identical seizure at home. EMT's took her to a local hospital, not the initial medical center. The ER physician noted the woman had been dieting and had lost 30 pounds since childbirth. The triage assessment recorded chronic diarrhea and nausea since childhood. The diagnosis was seizure secondary to hypokalemia. The woman was seen in the ER by her primary care physician, who ordered a neurology consult. Records from that visit note classic migraine with visual aura, anorexia and bulimia. There was a brief note about a significant weight loss but nothing further about the woman's recent eating habits or use of laxatives. An EEG and MRI were ordered and subsequently interpreted as normal. Lab reports from the hospital showed potassium of 3.2, CO2 of 36.1, and severely depressed albumin. There was no diagnosis recorded; the woman was told to call in the event of another seizure. One month later the woman did suffer another seizure, which included cardiac arrest. EMT's arrived and performed emergency resuscitation measures and CPR. The woman was unresponsive at the ER of another clinic, where the admitting notes included ventricular fibrillation arrest secondary to hypokalemia, as well as uncertainty about previous laxative abuse. Her serum potassium was 2.2. The woman remained in a coma for 27 days, after which she expired. A medQuest weight management expert noted there were multiple references to the woman's history of bulimia, yet no actual documentation of the condition. Despite the woman's two seizures and documented potassium deficit, there was a negligent failure to further investigate the cause of the hypokalemia. The woman should have been placed on potassium supplementation with careful monitoring. With accurate diagnosis and timely treatment, the woman could have avoided the third seizure and resultant death.