Malpractice Case: How Did Physicians Miss This Dangerous Abscess?

Jacqueline Ross, PhD, RN; David L. Feldman, MD, MBA

Disclosures

December 22, 2021

Malpractice Case: How Did Docs Miss This Heart Attack?

While risk factors are often noted, they are frequently considered secondary to test results. This case highlights why risk factors and patient history are essential to prioritize, even when tests appear normal.

A 53-year-old man presented to the hospital with complaints of acute chest, epigastric, and back pain with nausea. He had no pain radiating to the arm or jaw. He gave a history of hypertension, diabetes mellitus, and being a smoker. A brother had died from a myocardial infarction (MI). An ECG showed no evidence of ischemia and no significant ST segment changes. Lab test results included lipase of 1455 U/L (normal, < 95 U/L), CK of 78 U/L (total CK normal for males, 235 U/L), and elevated triglycerides of 388 mg/dL (normal, < 250 mg/dL). He was admitted to the hospital by an internist and diagnosed with acute pancreatitis, probably due to alcohol abuse. His troponin result was mildly elevated at 0.08 ng/mL (normal, 0.03 ng/mL).

The day after admission, the patient complained of pain in the lower chest. His epigastric pain was decreased, and the following day he had no epigastric pain and was eating well. There was chest pain only on palpation, so the internist believed that it was not cardiac in origin. He was discharged with instructions to follow up with the internist in 2-3 days, but the patient did not schedule an appointment.

Two weeks later, the patient presented to the ED with complaints of substernal chest pain radiating to his neck and jaw. The ECG indicated that he had suffered an MI. An emergent cardiac catheterization revealed 100% occlusion of the right coronary artery and 95% occlusion of the left anterior descending artery. An angioplasty was successful.

A claim was filed alleging that the internist failed to diagnose and treat an impending MI. Physician reviewers opined that, even though the pain was atypical for angina and troponin levels were borderline, the patient's risk factors should have prompted a cardiac workup. This case settled.

How to Prevent Lawsuits Like the One Above: Dr Feldman's 3 Ps

  1. Prevent adverse events by engaging the patient in order to obtain an accurate history. This is especially important when developing a differential diagnosis. Take the time to explore patient complaints, especially when the patient makes similar complaints on return visits. If possible, employ the use of decision-support tools, which may prompt physicians to consider diagnoses even in the face of atypical symptoms.

  2. Preclude lawsuits by communicating with patients the importance of follow-up appointments and treatment plans. Have the patients state in their own words their understanding of their condition and plan of care.

  3. Prevail in lawsuits by documenting your clinical decision-making and discussions with the patient.

This case comes from Internal Medicine Closed Claims Study" published by The Doctors Company.

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