This claim illustrates the importance of differential diagnoses and the unfortunate turn a case can take when a differential diagnosis is not considered.
A 47-year-old patient presented to his primary care physician with complaints of back pain that had started the prior week. The patient had a history of Mallory-Weiss tear (a tear of tissue in the lower esophagus) and type 1 thoracic ascending and descending aortic dissection (a tear in the inner layer of the aorta), which had occurred 5 years earlier.
The ascending dissection was repaired; however, the residual descending aortic dissection was left unrepaired due to potential surgical complications that could include paralysis of the legs and lower body. The patient was seeing a cardiologist, who monitored his blood pressure and conducted annual echocardiograms.
During the primary care visit, the patient reported no trauma or nausea. He also reported that the back pain had resolved at one point but then returned below his shoulder blade. Later the pain wrapped around his abdomen and up into his neck and throat. It lasted for an hour. Pain medication helped reduce the pain.
During the examination, the patient's back was not tender upon palpation. He experienced no pain when bending or twisting at the waist. His lungs were clear. He appeared anxious.
The primary care provider thought that the patient's pain could be a sign of shingles. However, the physician ordered a chest x-ray that was performed later that day.
At home the next day, the patient retrieved an ice pack from the refrigerator to relieve his increased back pain. A short time later, he cried out and collapsed. He was transported to the hospital emergency room, where he was pronounced dead. The previous day's x-ray, read after the patient died, showed a massive enlargement of descending thoracic aorta. The patient died of a ruptured dissecting aortic aneurysm.
A claim was filed against the primary care provider, cardiologist, and cardiac surgeon.
What Did the Experts Say?
Considering the patient's history, medical experts testified that the primary care provider should have included dissecting aortic aneurysm on the differential and sent the patient to the emergency department immediately. The experts stated that the patient's symptoms were classic for dissecting aortic aneurysm.
The cardiologist and cardiac surgeon were also criticized by experts in the case, who said the cardiac surgeon should have communicated a plan for regular follow-up to the cardiologist and primary care provider.
In addition, the cardiologist should have consulted with the cardiac surgeon on periodic monitoring. The annual echocardiograms performed by the cardiologist were not the appropriate tests for tracking the patient's condition, they said. He should have ordered annual CT scans to monitor the aorta.
Experts agreed that had there been a good plan for monitoring and early diagnosis of the new dissection, the patient would have had a reasonable chance of survival. All parties agreed to settle the case.
Tips for Malpractice Risk Reduction: Dr Feldman's 3 P's
1. Prevent adverse events by considering differential diagnoses, especially in patients with significant health history and a preexisting condition like this one. Ruling out life-threatening conditions first is critical and would have necessitated sending this patient, who had a residual aneurysm, to an emergency department immediately. Open communication and collaboration might have allowed the primary care physician to contact the cardiac surgeon when the patient was first seen, resulting in immediate referral and an opportunity to prevent this death.
2. Preclude malpractice claims by assuring that the patient is aware of the signs and symptoms of their preexisting condition, such as this patient's dissecting aneurysm, and what to do in the event that these symptoms occur and/or worsen. Had the patient gone to an emergency room when he experienced the back pain, the imaging would have shown the expanding aneurysm.
3. Prevail in lawsuits by documenting your rationale for diagnosis and plan of care. This patient was at high risk for descending aortic dissection and rupture. Documenting how the follow-up plan would adequately address these risks would have been critical in service of the defense. In a case like this, where the care was substandard, it would have been difficult to defend regardless, but when care teams meet the standard of care, documentation can make all the difference.
This case comes from "Cardiology Closed Claims Study," published by The Doctors Company.
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Any views expressed above are the author's own and do not necessarily reflect the views of WebMD or Medscape.
Cite this: Jacqueline Ross, David L. Feldman. Malpractice Case: Would Focus on History Have Saved Patient? - Medscape - Mar 02, 2022.