Ten days later, the woman went to the county emergency department with numbness and tingling. A lumbar puncture revealed a protein level of 531 mg/dL (normal, 15-40 mg/dL). After an MRI, the patient was diagnosed with Guillain-Barré syndrome and underwent intravenous treatment and rehabilitation.
The woman later sued Dr N for failing to order proper tests for Guillain-Barré syndrome. The parties resolved the dispute informally.
In this case, better charting could have possibly helped the treating physicians to come to an accurate diagnosis more quickly. Physician charting is not only for the benefit of a patient's other healthcare providers. A discipline of charting why a certain differential diagnosis is doubtful while also writing down what developing conditions would change that outlook can help the physician avoid the need to rely on just memory when considering what steps to take next.
In this case, the physician noted several times that he doubted Guillain-Barré syndrome, but he did not expand on his reasons in the chart nor explain what might change this assessment. Such detailed charting may have changed his course of testing when the patient's condition did not improve. At the very least, a more thorough explanation in the chart for doubting Guillain-Barré syndrome could have provided a stronger defense when his care came under scrutiny.
This case comes from the "Case of the Month" column featured in the member newsletter published by the Cooperative of American Physicians, Inc. The article was originally titled "When Ruling Out Disease, Chart Your Findings Carefully."
© 2021 Cooperative of American Physicians, Inc.
This case comes from Medicine on Trial, originally published by Cooperative of American Physicians, Inc., to provide risk management lessons from litigated case histories.