Jeffrey L. Susman, MD

A 64-YEAR-OLD MAN WAS REFERRED TO A PULMONARY SPECIALIST in January by his primary care physician after a computed tomography (CT) scan showed a spiculated density adjacent to the right main-stem bronchus, a prominent right hilar lymph node, and a noncalcified nodule in the right middle lobe.

Before examining the patient, the pulmonary specialist ordered a positron emission tomography (PET) scan, which he interpreted as showing no significant uptake. He attributed the prominent lymph node to bronchitis and ordered surveillance at 3-month intervals.

A CT scan ordered by the pulmonary specialist in May showed no change, but the radiologist noted that “the possibility of malignancy cannot be excluded.” When the patient saw the specialist in early June, the doctor recommended another CT scan in 3 months.

The patient didn’t return to the specialist until September of the following year. By that time, a CT scan taken a couple of months before (June) as part of preoperative clearance for knee surgery showed that the irregular mass had grown significantly since the CT scan in May of the previous year. A bronchoscopy done in September to evaluate the mass was negative. In November, a lymph node biopsy revealed that the patient had metastatic lung cancer. He died about a month later.

PLAINTIFF’S CLAIM Because the patient was a smoker and the CT scan showed a density, the suspicion for cancer should have been high. A specimen should have been obtained to rule out cancer.

DOCTORS’ DEFENSE The pulmonary specialist followed the correct protocol; failure to diagnose cancer at the September visit didn’t affect the outcome because the cancer was already metastatic and incurable. The patient didn’t quit smoking or follow up regularly with his primary care physician. Moreover, the cancer was at least stage IIA when the primary care physician referred the patient to the specialist.

VERDICT Pennsylvania defense verdict.

COMMENT Although a defense verdict was ultimately returned, wouldn’t a “tickler file” or a reminder to the patient (and documentation if the patient failed to follow-up as recommended) have been easier?

A 64-YEAR-OLD MAN WAS REFERRED TO A PULMONARY SPECIALIST in January by his primary care physician after a computed tomography (CT) scan showed a spiculated density adjacent to the right main-stem bronchus, a prominent right hilar lymph node, and a noncalcified nodule in the right middle lobe.

Before examining the patient, the pulmonary specialist ordered a positron emission tomography (PET) scan, which he interpreted as showing no significant uptake. He attributed the prominent lymph node to bronchitis and ordered surveillance at 3-month intervals.

A CT scan ordered by the pulmonary specialist in May showed no change, but the radiologist noted that “the possibility of malignancy cannot be excluded.” When the patient saw the specialist in early June, the doctor recommended another CT scan in 3 months.

The patient didn’t return to the specialist until September of the following year. By that time, a CT scan taken a couple of months before (June) as part of preoperative clearance for knee surgery showed that the irregular mass had grown significantly since the CT scan in May of the previous year. A bronchoscopy done in September to evaluate the mass was negative. In November, a lymph node biopsy revealed that the patient had metastatic lung cancer. He died about a month later.

PLAINTIFF’S CLAIM Because the patient was a smoker and the CT scan showed a density, the suspicion for cancer should have been high. A specimen should have been obtained to rule out cancer.

DOCTORS’ DEFENSE The pulmonary specialist followed the correct protocol; failure to diagnose cancer at the September visit didn’t affect the outcome because the cancer was already metastatic and incurable. The patient didn’t quit smoking or follow up regularly with his primary care physician. Moreover, the cancer was at least stage IIA when the primary care physician referred the patient to the specialist.

VERDICT Pennsylvania defense verdict.

COMMENT Although a defense verdict was ultimately returned, wouldn’t a “tickler file” or a reminder to the patient (and documentation if the patient failed to follow-up as recommended) have been easier?

A 64-YEAR-OLD MAN WAS REFERRED TO A PULMONARY SPECIALIST in January by his primary care physician after a computed tomography (CT) scan showed a spiculated density adjacent to the right main-stem bronchus, a prominent right hilar lymph node, and a noncalcified nodule in the right middle lobe.

Before examining the patient, the pulmonary specialist ordered a positron emission tomography (PET) scan, which he interpreted as showing no significant uptake. He attributed the prominent lymph node to bronchitis and ordered surveillance at 3-month intervals.

A CT scan ordered by the pulmonary specialist in May showed no change, but the radiologist noted that “the possibility of malignancy cannot be excluded.” When the patient saw the specialist in early June, the doctor recommended another CT scan in 3 months.

The patient didn’t return to the specialist until September of the following year. By that time, a CT scan taken a couple of months before (June) as part of preoperative clearance for knee surgery showed that the irregular mass had grown significantly since the CT scan in May of the previous year. A bronchoscopy done in September to evaluate the mass was negative. In November, a lymph node biopsy revealed that the patient had metastatic lung cancer. He died about a month later.

PLAINTIFF’S CLAIM Because the patient was a smoker and the CT scan showed a density, the suspicion for cancer should have been high. A specimen should have been obtained to rule out cancer.

DOCTORS’ DEFENSE The pulmonary specialist followed the correct protocol; failure to diagnose cancer at the September visit didn’t affect the outcome because the cancer was already metastatic and incurable. The patient didn’t quit smoking or follow up regularly with his primary care physician. Moreover, the cancer was at least stage IIA when the primary care physician referred the patient to the specialist.

VERDICT Pennsylvania defense verdict.

COMMENT Although a defense verdict was ultimately returned, wouldn’t a “tickler file” or a reminder to the patient (and documentation if the patient failed to follow-up as recommended) have been easier?

Discontinued anticoagulant blamed for stroke

A MAN ON WARFARIN 3 YEARS AFTER A MASSIVE PULMONARY EMBOLISM visited a doctor, who reviewed the 37-year-old patient’s records and noted that test results showed he no longer had hypercoagulation. The doctor discontinued the warfarin.

About 5 months later, the patient suffered an embolic stroke that caused brain damage. He has impaired cognitive function and executive decision-making skills, as well as residual emotional and psychiatric problems.

PLAINTIFF’S CLAIM The patient had a hereditary disposition to clots and had suffered a previous embolism, necessitating lifelong use of warfarin.

DOCTOR’S DEFENSE Hypercoagulation is treated with 6 to 12 months of warfarin; the patient hadn’t showed a recurrence of hypercoagulation. The doctor denied conclusive evidence of a hereditary predisposition to developing clots.

VERDICT $3.1 million New York verdict.

COMMENT Whatever the underlying factors in this case, documenting a careful discussion of benefits and harms and consulting with experts can sometimes avoid a date in court.

Filing misstep leads to missed diagnosis

A 76-YEAR-OLD MAN HAD A CHEST RADIOGRAPH before undergoing cardiac catheterization. The radiograph showed a 4-cm mass in the left lung, which the radiologist reported as bronchogenic carcinoma. A staff member in the office of the physician who ordered the radiograph filed the radiologist’s report in the patient’s chart in the mistaken belief that the physician had seen it. No one saw the report again until 6 months later, after the patient had been diagnosed with lung cancer that had metastasized to the liver, pelvis, hip, femur, spine, and shoulder. The patient died 18 days after the diagnosis.

PLAINTIFF’S CLAIM If the cancer had been diagnosed earlier, the patient could have been made comfortable while undergoing treatment and would have survived longer.

DOCTORS’ DEFENSE The physician admitted liability, but claimed that the reduction in the patient’s life expectancy was minimal because his cancer was advanced at the time of the radiograph. The net increase in pain and suffering also was minimal because the patient would have undergone chemotherapy and radiation if the cancer had been diagnosed earlier.

VERDICT $1 million Illinois verdict.

COMMENT Coordination of care is key. Never assume that another clinician on the team has taken responsibility for a high-stakes finding such as a mass on a chest X-ray.

Too much amiodarone led to respiratory failure

AMIODARONE WAS PRESCRIBED TO REGULATE THE HEARTBEAT of a patient who underwent surgery at a Veteran’s Administration medical center to replace a defective heart defibrillator. The plan was to decrease the dosage gradually from 600 to 200 mg a day. A second doctor subsequently saw the patient and prescribed amiodarone but with no reduction in dosage. Each of the 7 authorized refills directed the patient to take 3 pills a day. The patient refilled the prescription 6 times at the VA hospital.

A year after the surgery, the patient was admitted to another hospital with respiratory problems, which were attributed to the amiodarone. The patient died a few weeks later after several relapses. The cause of death was listed as pulmonary fibrosis and respiratory failure caused by the medication.

PLAINTIFF’S CLAIM No information about the plaintiff’s claim is available.

DOCTOR’S DEFENSE No information about the doctor’s defense is available.

VERDICT $400,000 Utah settlement.

COMMENT Prescribing limited refills of medications that can cause substantial harm will help assure appropriate monitoring and evaluation for side effects.

Rising PSA, but no follow-up

CHEST PAIN PROMPTED A 48-YEAR-OLD MAN to visit his primary care physician. Blood work, including a prostate-specific antigen (PSA) test, revealed a slightly elevated PSA of 5.08. Five months later, the patient returned to the doctor complaining of a burning sensation on urination. Urinalysis and a digital rectal examination were normal. Laboratory test results included a PSA of 8.29. Nine months later the patient visited the physician for nonurologic complaints. Six months after that, when the patient had a complete physical because of a change in his insurance, his PSA was 17.11.

Subsequent testing revealed prostate cancer, and the patient underwent a non-nerve-sparing prostatectomy. A positron emission tomography scan done after the surgery showed an enlarged internal iliac lymph node, which indicated metastatic disease.

PLAINTIFF’S CLAIM The primary care physician was negligent in failing to follow up on the rising PSA values. The patient wasn’t informed of the PSA results.

THE DEFENSE The patient was informed of the abnormal test results (though it wasn’t charted). The patient would have had the same treatment, even with an earlier diagnosis, because he had a high Gleason score.

VERDICT $750,000 California settlement.

COMMENT Not charted = never happened. So many cases could be avoided if documentation was timely and complete!

Discontinued anticoagulant blamed for stroke

A MAN ON WARFARIN 3 YEARS AFTER A MASSIVE PULMONARY EMBOLISM visited a doctor, who reviewed the 37-year-old patient’s records and noted that test results showed he no longer had hypercoagulation. The doctor discontinued the warfarin.

About 5 months later, the patient suffered an embolic stroke that caused brain damage. He has impaired cognitive function and executive decision-making skills, as well as residual emotional and psychiatric problems.

PLAINTIFF’S CLAIM The patient had a hereditary disposition to clots and had suffered a previous embolism, necessitating lifelong use of warfarin.

DOCTOR’S DEFENSE Hypercoagulation is treated with 6 to 12 months of warfarin; the patient hadn’t showed a recurrence of hypercoagulation. The doctor denied conclusive evidence of a hereditary predisposition to developing clots.

VERDICT $3.1 million New York verdict.

COMMENT Whatever the underlying factors in this case, documenting a careful discussion of benefits and harms and consulting with experts can sometimes avoid a date in court.

Filing misstep leads to missed diagnosis

A 76-YEAR-OLD MAN HAD A CHEST RADIOGRAPH before undergoing cardiac catheterization. The radiograph showed a 4-cm mass in the left lung, which the radiologist reported as bronchogenic carcinoma. A staff member in the office of the physician who ordered the radiograph filed the radiologist’s report in the patient’s chart in the mistaken belief that the physician had seen it. No one saw the report again until 6 months later, after the patient had been diagnosed with lung cancer that had metastasized to the liver, pelvis, hip, femur, spine, and shoulder. The patient died 18 days after the diagnosis.

PLAINTIFF’S CLAIM If the cancer had been diagnosed earlier, the patient could have been made comfortable while undergoing treatment and would have survived longer.

DOCTORS’ DEFENSE The physician admitted liability, but claimed that the reduction in the patient’s life expectancy was minimal because his cancer was advanced at the time of the radiograph. The net increase in pain and suffering also was minimal because the patient would have undergone chemotherapy and radiation if the cancer had been diagnosed earlier.

VERDICT $1 million Illinois verdict.

COMMENT Coordination of care is key. Never assume that another clinician on the team has taken responsibility for a high-stakes finding such as a mass on a chest X-ray.

Too much amiodarone led to respiratory failure

AMIODARONE WAS PRESCRIBED TO REGULATE THE HEARTBEAT of a patient who underwent surgery at a Veteran’s Administration medical center to replace a defective heart defibrillator. The plan was to decrease the dosage gradually from 600 to 200 mg a day. A second doctor subsequently saw the patient and prescribed amiodarone but with no reduction in dosage. Each of the 7 authorized refills directed the patient to take 3 pills a day. The patient refilled the prescription 6 times at the VA hospital.

A year after the surgery, the patient was admitted to another hospital with respiratory problems, which were attributed to the amiodarone. The patient died a few weeks later after several relapses. The cause of death was listed as pulmonary fibrosis and respiratory failure caused by the medication.

PLAINTIFF’S CLAIM No information about the plaintiff’s claim is available.

DOCTOR’S DEFENSE No information about the doctor’s defense is available.

VERDICT $400,000 Utah settlement.

COMMENT Prescribing limited refills of medications that can cause substantial harm will help assure appropriate monitoring and evaluation for side effects.

Rising PSA, but no follow-up

CHEST PAIN PROMPTED A 48-YEAR-OLD MAN to visit his primary care physician. Blood work, including a prostate-specific antigen (PSA) test, revealed a slightly elevated PSA of 5.08. Five months later, the patient returned to the doctor complaining of a burning sensation on urination. Urinalysis and a digital rectal examination were normal. Laboratory test results included a PSA of 8.29. Nine months later the patient visited the physician for nonurologic complaints. Six months after that, when the patient had a complete physical because of a change in his insurance, his PSA was 17.11.

Subsequent testing revealed prostate cancer, and the patient underwent a non-nerve-sparing prostatectomy. A positron emission tomography scan done after the surgery showed an enlarged internal iliac lymph node, which indicated metastatic disease.

PLAINTIFF’S CLAIM The primary care physician was negligent in failing to follow up on the rising PSA values. The patient wasn’t informed of the PSA results.

THE DEFENSE The patient was informed of the abnormal test results (though it wasn’t charted). The patient would have had the same treatment, even with an earlier diagnosis, because he had a high Gleason score.

VERDICT $750,000 California settlement.

COMMENT Not charted = never happened. So many cases could be avoided if documentation was timely and complete!

Discontinued anticoagulant blamed for stroke

A MAN ON WARFARIN 3 YEARS AFTER A MASSIVE PULMONARY EMBOLISM visited a doctor, who reviewed the 37-year-old patient’s records and noted that test results showed he no longer had hypercoagulation. The doctor discontinued the warfarin.

About 5 months later, the patient suffered an embolic stroke that caused brain damage. He has impaired cognitive function and executive decision-making skills, as well as residual emotional and psychiatric problems.

PLAINTIFF’S CLAIM The patient had a hereditary disposition to clots and had suffered a previous embolism, necessitating lifelong use of warfarin.

DOCTOR’S DEFENSE Hypercoagulation is treated with 6 to 12 months of warfarin; the patient hadn’t showed a recurrence of hypercoagulation. The doctor denied conclusive evidence of a hereditary predisposition to developing clots.

VERDICT $3.1 million New York verdict.

COMMENT Whatever the underlying factors in this case, documenting a careful discussion of benefits and harms and consulting with experts can sometimes avoid a date in court.

Filing misstep leads to missed diagnosis

A 76-YEAR-OLD MAN HAD A CHEST RADIOGRAPH before undergoing cardiac catheterization. The radiograph showed a 4-cm mass in the left lung, which the radiologist reported as bronchogenic carcinoma. A staff member in the office of the physician who ordered the radiograph filed the radiologist’s report in the patient’s chart in the mistaken belief that the physician had seen it. No one saw the report again until 6 months later, after the patient had been diagnosed with lung cancer that had metastasized to the liver, pelvis, hip, femur, spine, and shoulder. The patient died 18 days after the diagnosis.

PLAINTIFF’S CLAIM If the cancer had been diagnosed earlier, the patient could have been made comfortable while undergoing treatment and would have survived longer.

DOCTORS’ DEFENSE The physician admitted liability, but claimed that the reduction in the patient’s life expectancy was minimal because his cancer was advanced at the time of the radiograph. The net increase in pain and suffering also was minimal because the patient would have undergone chemotherapy and radiation if the cancer had been diagnosed earlier.

VERDICT $1 million Illinois verdict.

COMMENT Coordination of care is key. Never assume that another clinician on the team has taken responsibility for a high-stakes finding such as a mass on a chest X-ray.

Too much amiodarone led to respiratory failure

AMIODARONE WAS PRESCRIBED TO REGULATE THE HEARTBEAT of a patient who underwent surgery at a Veteran’s Administration medical center to replace a defective heart defibrillator. The plan was to decrease the dosage gradually from 600 to 200 mg a day. A second doctor subsequently saw the patient and prescribed amiodarone but with no reduction in dosage. Each of the 7 authorized refills directed the patient to take 3 pills a day. The patient refilled the prescription 6 times at the VA hospital.

A year after the surgery, the patient was admitted to another hospital with respiratory problems, which were attributed to the amiodarone. The patient died a few weeks later after several relapses. The cause of death was listed as pulmonary fibrosis and respiratory failure caused by the medication.

PLAINTIFF’S CLAIM No information about the plaintiff’s claim is available.

DOCTOR’S DEFENSE No information about the doctor’s defense is available.

VERDICT $400,000 Utah settlement.

COMMENT Prescribing limited refills of medications that can cause substantial harm will help assure appropriate monitoring and evaluation for side effects.

Rising PSA, but no follow-up

CHEST PAIN PROMPTED A 48-YEAR-OLD MAN to visit his primary care physician. Blood work, including a prostate-specific antigen (PSA) test, revealed a slightly elevated PSA of 5.08. Five months later, the patient returned to the doctor complaining of a burning sensation on urination. Urinalysis and a digital rectal examination were normal. Laboratory test results included a PSA of 8.29. Nine months later the patient visited the physician for nonurologic complaints. Six months after that, when the patient had a complete physical because of a change in his insurance, his PSA was 17.11.

Subsequent testing revealed prostate cancer, and the patient underwent a non-nerve-sparing prostatectomy. A positron emission tomography scan done after the surgery showed an enlarged internal iliac lymph node, which indicated metastatic disease.

PLAINTIFF’S CLAIM The primary care physician was negligent in failing to follow up on the rising PSA values. The patient wasn’t informed of the PSA results.

THE DEFENSE The patient was informed of the abnormal test results (though it wasn’t charted). The patient would have had the same treatment, even with an earlier diagnosis, because he had a high Gleason score.

VERDICT $750,000 California settlement.

COMMENT Not charted = never happened. So many cases could be avoided if documentation was timely and complete!

Lack of CT follow-up delays cancer diagnosis

SEVERAL WEEKS OF ABDOMINAL PAIN in the lower left quadrant prompted a 58-year-old woman to visit her doctor in March. A colonoscopy performed in July showed 2 small polyps, which were removed. The woman returned in August complaining of feeling weak and again in early September with pain and rectal bleeding. An abdominal computed tomography (CT) scan performed 11 days later revealed a 4 × 3-inch left pelvic mass.

Believing that the CT results suggested an inflammatory process, the doctor prescribed antibiotics. The patient subsequently developed anemia, but didn’t undergo small bowel follow through and barium enema because of equipment failure and scheduling difficulties. She was told to diet and exercise and follow up in 3 months. She returned in a few days with the same complaints and was started on Levaquin and Flagyl.

The patient was seen again the following May, 8 months after the CT scan. A barium enema and small bowel follow through performed in July were negative.

In November, the patient went to a hospital complaining of abdominal pain. A CT scan showed a diffuse abdominal and pelvic mass; a needle biopsy diagnosed a gastrointestinal stromal tumor. Disease was widespread; the patient’s chance of survival was estimated at <50%.

PLAINTIFF’S CLAIM A diagnosis should have been made at the time of the first abdominal CT scan.

DOCTOR’S DEFENSE No information about the doctor’s defense is available.

VERDICT $700,000 Virginia settlement.

COMMENT Whenever a mass—potentially cancer—is involved, effective follow-up is key. Even when the risk is deemed small, repeat imaging is usually the prudent path.

PE recognized too late

TWO MONTHS AFTER UNDERGOING KNEE SURGERY, a 35-year-old man was hospitalized for diverticulitis. A week and a half later, he went to an emergency room complaining of chest pain, shortness of breath, and heart palpitations. The ER physician performed an electrocardiogram (EKG), which he read as normal. He diagnosed a panic attack, prescribed lorazepam, and discharged the patient.

Two days later, the patient visited a psychiatrist complaining of panic attacks. Believing that the man had a medical condition, the psychiatrist told him to see his personal doctor or go to an ER. The patient went to his primary care physician, who suspected angina and admitted him to a local medical center.

In the 12 hours before he was seen, the patient’s pain and breathing problems increased and his calf swelled. By the time his doctor and a cardiologist noted the swelling and diagnosed pulmonary embolism (PE), a clot had traveled to his heart. He was airlifted to another hospital, where he died within 8 hours.

PLAINTIFF’S CLAIM The doctors were negligent in failing to promptly diagnose and treat PE. The ER physician failed to read the EKG correctly and take a detailed history; he diagnosed a panic attack without ruling out PE. The patient’s increased heart rate, shortness of breath, and abnormal EKG should have raised suspicion of an embolism.

DOCTORS’ DEFENSE The diagnosis was reasonable.

VERDICT $1.26 million Pennsylvania verdict.

COMMENT PE should be in the differential diagnosis of any patient with chest pain or shortness of breath.

“GERD” turns out to be heart disease

INDIGESTION AND PAIN IN HIS ARMS FOR 2 MONTHS led a 38-year-old man to consult his primary care physician, who diagnosed gastroesophageal reflux disease (GERD) and prescribed medication. The patient called the doctor to express satisfaction with the reflux medication and symptom relief, but the doctor doubled the dosage and told the patient he would refer him to a gastroenterologist. (The plaintiff later claimed that the medication never worked, and other medical records appeared to support that claim.)

About 6 weeks after the initial visit, the primary care physician referred the patient to a gastroenterologist, who also diagnosed GERD and scheduled an endoscopy. The gastroenterologist noted that a cardiac stress test should be considered if the symptoms worsened or the endoscopy was negative.

Six days later, before the endoscopy, the patient died after complaining of chest pain and temporary loss of vision. An autopsy attributed death to a fatal arrhythmia caused by idiopathic cardiomyopathy. The pathologist who performed the autopsy testified that the patient had dilated cardiomyopathy with a noncontributing component of ischemic change.

PLAINTIFF’S CLAIM The doctors failed to diagnose and treat the patient’s cardiac condition. The patient should have been referred for an EKG or other cardiac evaluation when he was first seen; doing so would have revealed the cardiomyopathy, which could then have been treated.

DOCTORS’ DEFENSE The patient’s symptoms were consistent with GERD and didn’t require cardiac testing. The autopsy report and evidence from the tissue slides were inconsistent with heart disease.

Additionally, the gastroenterologist claimed that cardiac disease could not have been diagnosed and treated in 6 days even if he’d referred the patient for evaluation. He also claimed that the patient died of a stroke.

VERDICT $2.3 million Virginia verdict against the primary care physician only.

COMMENT The misdiagnosis of cardiac disease is common; remember coronary artery disease when confronted with unresponsive GERD.

Lack of CT follow-up delays cancer diagnosis

SEVERAL WEEKS OF ABDOMINAL PAIN in the lower left quadrant prompted a 58-year-old woman to visit her doctor in March. A colonoscopy performed in July showed 2 small polyps, which were removed. The woman returned in August complaining of feeling weak and again in early September with pain and rectal bleeding. An abdominal computed tomography (CT) scan performed 11 days later revealed a 4 × 3-inch left pelvic mass.

Believing that the CT results suggested an inflammatory process, the doctor prescribed antibiotics. The patient subsequently developed anemia, but didn’t undergo small bowel follow through and barium enema because of equipment failure and scheduling difficulties. She was told to diet and exercise and follow up in 3 months. She returned in a few days with the same complaints and was started on Levaquin and Flagyl.

The patient was seen again the following May, 8 months after the CT scan. A barium enema and small bowel follow through performed in July were negative.

In November, the patient went to a hospital complaining of abdominal pain. A CT scan showed a diffuse abdominal and pelvic mass; a needle biopsy diagnosed a gastrointestinal stromal tumor. Disease was widespread; the patient’s chance of survival was estimated at <50%.

PLAINTIFF’S CLAIM A diagnosis should have been made at the time of the first abdominal CT scan.

DOCTOR’S DEFENSE No information about the doctor’s defense is available.

VERDICT $700,000 Virginia settlement.

COMMENT Whenever a mass—potentially cancer—is involved, effective follow-up is key. Even when the risk is deemed small, repeat imaging is usually the prudent path.

PE recognized too late

TWO MONTHS AFTER UNDERGOING KNEE SURGERY, a 35-year-old man was hospitalized for diverticulitis. A week and a half later, he went to an emergency room complaining of chest pain, shortness of breath, and heart palpitations. The ER physician performed an electrocardiogram (EKG), which he read as normal. He diagnosed a panic attack, prescribed lorazepam, and discharged the patient.

Two days later, the patient visited a psychiatrist complaining of panic attacks. Believing that the man had a medical condition, the psychiatrist told him to see his personal doctor or go to an ER. The patient went to his primary care physician, who suspected angina and admitted him to a local medical center.

In the 12 hours before he was seen, the patient’s pain and breathing problems increased and his calf swelled. By the time his doctor and a cardiologist noted the swelling and diagnosed pulmonary embolism (PE), a clot had traveled to his heart. He was airlifted to another hospital, where he died within 8 hours.

PLAINTIFF’S CLAIM The doctors were negligent in failing to promptly diagnose and treat PE. The ER physician failed to read the EKG correctly and take a detailed history; he diagnosed a panic attack without ruling out PE. The patient’s increased heart rate, shortness of breath, and abnormal EKG should have raised suspicion of an embolism.

DOCTORS’ DEFENSE The diagnosis was reasonable.

VERDICT $1.26 million Pennsylvania verdict.

COMMENT PE should be in the differential diagnosis of any patient with chest pain or shortness of breath.

“GERD” turns out to be heart disease

INDIGESTION AND PAIN IN HIS ARMS FOR 2 MONTHS led a 38-year-old man to consult his primary care physician, who diagnosed gastroesophageal reflux disease (GERD) and prescribed medication. The patient called the doctor to express satisfaction with the reflux medication and symptom relief, but the doctor doubled the dosage and told the patient he would refer him to a gastroenterologist. (The plaintiff later claimed that the medication never worked, and other medical records appeared to support that claim.)

About 6 weeks after the initial visit, the primary care physician referred the patient to a gastroenterologist, who also diagnosed GERD and scheduled an endoscopy. The gastroenterologist noted that a cardiac stress test should be considered if the symptoms worsened or the endoscopy was negative.

Six days later, before the endoscopy, the patient died after complaining of chest pain and temporary loss of vision. An autopsy attributed death to a fatal arrhythmia caused by idiopathic cardiomyopathy. The pathologist who performed the autopsy testified that the patient had dilated cardiomyopathy with a noncontributing component of ischemic change.

PLAINTIFF’S CLAIM The doctors failed to diagnose and treat the patient’s cardiac condition. The patient should have been referred for an EKG or other cardiac evaluation when he was first seen; doing so would have revealed the cardiomyopathy, which could then have been treated.

DOCTORS’ DEFENSE The patient’s symptoms were consistent with GERD and didn’t require cardiac testing. The autopsy report and evidence from the tissue slides were inconsistent with heart disease.

Additionally, the gastroenterologist claimed that cardiac disease could not have been diagnosed and treated in 6 days even if he’d referred the patient for evaluation. He also claimed that the patient died of a stroke.

VERDICT $2.3 million Virginia verdict against the primary care physician only.

COMMENT The misdiagnosis of cardiac disease is common; remember coronary artery disease when confronted with unresponsive GERD.

Lack of CT follow-up delays cancer diagnosis

SEVERAL WEEKS OF ABDOMINAL PAIN in the lower left quadrant prompted a 58-year-old woman to visit her doctor in March. A colonoscopy performed in July showed 2 small polyps, which were removed. The woman returned in August complaining of feeling weak and again in early September with pain and rectal bleeding. An abdominal computed tomography (CT) scan performed 11 days later revealed a 4 × 3-inch left pelvic mass.

Believing that the CT results suggested an inflammatory process, the doctor prescribed antibiotics. The patient subsequently developed anemia, but didn’t undergo small bowel follow through and barium enema because of equipment failure and scheduling difficulties. She was told to diet and exercise and follow up in 3 months. She returned in a few days with the same complaints and was started on Levaquin and Flagyl.

The patient was seen again the following May, 8 months after the CT scan. A barium enema and small bowel follow through performed in July were negative.

In November, the patient went to a hospital complaining of abdominal pain. A CT scan showed a diffuse abdominal and pelvic mass; a needle biopsy diagnosed a gastrointestinal stromal tumor. Disease was widespread; the patient’s chance of survival was estimated at <50%.

PLAINTIFF’S CLAIM A diagnosis should have been made at the time of the first abdominal CT scan.

DOCTOR’S DEFENSE No information about the doctor’s defense is available.

VERDICT $700,000 Virginia settlement.

COMMENT Whenever a mass—potentially cancer—is involved, effective follow-up is key. Even when the risk is deemed small, repeat imaging is usually the prudent path.

PE recognized too late

TWO MONTHS AFTER UNDERGOING KNEE SURGERY, a 35-year-old man was hospitalized for diverticulitis. A week and a half later, he went to an emergency room complaining of chest pain, shortness of breath, and heart palpitations. The ER physician performed an electrocardiogram (EKG), which he read as normal. He diagnosed a panic attack, prescribed lorazepam, and discharged the patient.

Two days later, the patient visited a psychiatrist complaining of panic attacks. Believing that the man had a medical condition, the psychiatrist told him to see his personal doctor or go to an ER. The patient went to his primary care physician, who suspected angina and admitted him to a local medical center.

In the 12 hours before he was seen, the patient’s pain and breathing problems increased and his calf swelled. By the time his doctor and a cardiologist noted the swelling and diagnosed pulmonary embolism (PE), a clot had traveled to his heart. He was airlifted to another hospital, where he died within 8 hours.

PLAINTIFF’S CLAIM The doctors were negligent in failing to promptly diagnose and treat PE. The ER physician failed to read the EKG correctly and take a detailed history; he diagnosed a panic attack without ruling out PE. The patient’s increased heart rate, shortness of breath, and abnormal EKG should have raised suspicion of an embolism.

DOCTORS’ DEFENSE The diagnosis was reasonable.

VERDICT $1.26 million Pennsylvania verdict.

COMMENT PE should be in the differential diagnosis of any patient with chest pain or shortness of breath.

“GERD” turns out to be heart disease

INDIGESTION AND PAIN IN HIS ARMS FOR 2 MONTHS led a 38-year-old man to consult his primary care physician, who diagnosed gastroesophageal reflux disease (GERD) and prescribed medication. The patient called the doctor to express satisfaction with the reflux medication and symptom relief, but the doctor doubled the dosage and told the patient he would refer him to a gastroenterologist. (The plaintiff later claimed that the medication never worked, and other medical records appeared to support that claim.)

About 6 weeks after the initial visit, the primary care physician referred the patient to a gastroenterologist, who also diagnosed GERD and scheduled an endoscopy. The gastroenterologist noted that a cardiac stress test should be considered if the symptoms worsened or the endoscopy was negative.

Six days later, before the endoscopy, the patient died after complaining of chest pain and temporary loss of vision. An autopsy attributed death to a fatal arrhythmia caused by idiopathic cardiomyopathy. The pathologist who performed the autopsy testified that the patient had dilated cardiomyopathy with a noncontributing component of ischemic change.

PLAINTIFF’S CLAIM The doctors failed to diagnose and treat the patient’s cardiac condition. The patient should have been referred for an EKG or other cardiac evaluation when he was first seen; doing so would have revealed the cardiomyopathy, which could then have been treated.

DOCTORS’ DEFENSE The patient’s symptoms were consistent with GERD and didn’t require cardiac testing. The autopsy report and evidence from the tissue slides were inconsistent with heart disease.

Additionally, the gastroenterologist claimed that cardiac disease could not have been diagnosed and treated in 6 days even if he’d referred the patient for evaluation. He also claimed that the patient died of a stroke.

VERDICT $2.3 million Virginia verdict against the primary care physician only.

COMMENT The misdiagnosis of cardiac disease is common; remember coronary artery disease when confronted with unresponsive GERD.

Disabling stroke follows failure to treat stenosis

NUMBNESS AND WEAKNESS IN HIS LEFT ARM brought a 52-year-old man to his internist. A magnetic resonance imaging scan revealed that the patient had suffered a minor, nondisabling stroke within the previous few weeks caused by an embolism arising from stenosis of the right internal carotid artery. The internist referred the patient to a neurologist but didn’t inform the neurologist that the man’s symptoms were becoming worse.

The neurologist saw the patient about a week later. She was unaware of the unstable symptoms and didn’t communicate with the internist, whose office was 1 floor below hers. The neurologist put the patient on low-dose aspirin and sent him for a nonurgent ultrasound to determine the extent of the stenosis.

The ultrasound report, which the neurologist read 8 days after the patient visit, indicated an 80% to 90% stenosis of the right internal carotid artery. The neurologist claimed she tried to reach the patient 4 times over 2 days. She left one message, but did not reach him.

Two days after the neurologist obtained the ultrasound report, the patient had a major stroke caused by a clot that had broken off from his right internal carotid artery. The stroke left him mostly paralyzed on his left side, confined to a wheelchair, and unable to work or drive.

PLAINTIFF’S CLAIM The internist failed to convey all medically significant information to the neurologist; he had a duty to intervene when he received worrisome clinical information. The neurologist should have ordered an urgent carotid endarterectomy, which would have prevented a major stroke. She also should have contacted the internist; communication would have brought to light the need for urgent treatment.

DOCTORS’ DEFENSE The internist claimed that the neurology referral was all that was required of him. The neurologist maintained that the risk of another embolic stroke within 90 days of the minor stroke was low and that nonurgent evaluation was appropriate. Both doctors claimed that the major stroke was an unfortunate and unpredictable occurrence and that, in any event, vascular surgery wouldn’t have been performed for at least 4 to 6 weeks after the small stroke because of concern over severe cerebral hemorrhage.

VERDICT $1.75 million Massachusetts settlement.

COMMENT Communicate, communicate, communicate. Without appropriate coordination of care, such unfortunate stories are likely to be repeated. Never assume that another colleague is going to follow up on that markedly abnormal finding—take matters into your own hands!

Child’s hearing loss blamed on missed meningitis Dx

A 1-YEAR-OLD GIRL WITH A PERSISTENT FEVER was seen by her pediatrician, who diagnosed tonsillitis. During the hours after her visit to the pediatrician, the child’s fever reached 104°F and she began to vomit. She was brought to an emergency room, where a radiograph revealed a potentially abnormal density of the lungs. Developing pneumonia was suspected, and she was admitted to the hospital. Doctors also suspected meningitis, but didn’t detect any abnormalities of the meninges. An antibiotic was given.

On the third day of hospitalization, a nurse observed nuchal rigidity. The child remained in the hospital for 2 weeks, during which time her body temperature remained at 100°F or higher. Two days after discharge, the girl experienced a total loss of hearing. A computed tomography scan revealed damage to the cochleae.

PLAINTIFF’S CLAIM The damage to the patient’s cochleae was caused by untreated meningitis. Nuchal rigidity should have prompted an immediate spinal tap or other test for meningitis.

DOCTOR’S DEFENSE Proper care was given; the child’s symptoms didn’t warrant additional treatment. The cochlear damage was congenital.

VERDICT $3 million New York settlement.

COMMENT Meningitis may occur less often nowadays, but it should never be forgotten. When in doubt, order (or perform) a lumbar puncture, which can lead to a life-saving diagnosis. Early initiation of presumptive antibiotic treatment is critical.

Untreated high blood sugar ends in coma and disability

A 65-YEAR-OLD MAN sought treatment from an endocrinologist for previously diagnosed diabetes. An in-office pin prick test showed a blood sugar level exceeding the instrument’s limit. The endocrinologist ordered blood work at an outside lab. The tests indicated dangerous blood sugar levels, which were reported to the endocrinologist and his staff. The doctor allegedly didn’t act on the results.

About a week after seeing the endocrinologist, the patient collapsed; he was rushed to a hospital and placed in a protective coma. He emerged from the coma with significant injuries, including blindness in 1 eye and bilateral foot drop.

PLAINTIFF’S CLAIM The in-office test results should have alerted the doctor to a serious problem. The doctor should have sent the patient to the hospital for an immediate blood test.

DOCTOR’S DEFENSE The doctor denied any negligence.

VERDICT $1.5 million Connecticut settlement.

COMMENT Delayed or inappropriate follow up of in-office lab work remains a preventable cause of liability. If you order a test, make sure you have a protocol in place to assure timely adjudication of test results.

Disabling stroke follows failure to treat stenosis

NUMBNESS AND WEAKNESS IN HIS LEFT ARM brought a 52-year-old man to his internist. A magnetic resonance imaging scan revealed that the patient had suffered a minor, nondisabling stroke within the previous few weeks caused by an embolism arising from stenosis of the right internal carotid artery. The internist referred the patient to a neurologist but didn’t inform the neurologist that the man’s symptoms were becoming worse.

The neurologist saw the patient about a week later. She was unaware of the unstable symptoms and didn’t communicate with the internist, whose office was 1 floor below hers. The neurologist put the patient on low-dose aspirin and sent him for a nonurgent ultrasound to determine the extent of the stenosis.

The ultrasound report, which the neurologist read 8 days after the patient visit, indicated an 80% to 90% stenosis of the right internal carotid artery. The neurologist claimed she tried to reach the patient 4 times over 2 days. She left one message, but did not reach him.

Two days after the neurologist obtained the ultrasound report, the patient had a major stroke caused by a clot that had broken off from his right internal carotid artery. The stroke left him mostly paralyzed on his left side, confined to a wheelchair, and unable to work or drive.

PLAINTIFF’S CLAIM The internist failed to convey all medically significant information to the neurologist; he had a duty to intervene when he received worrisome clinical information. The neurologist should have ordered an urgent carotid endarterectomy, which would have prevented a major stroke. She also should have contacted the internist; communication would have brought to light the need for urgent treatment.

DOCTORS’ DEFENSE The internist claimed that the neurology referral was all that was required of him. The neurologist maintained that the risk of another embolic stroke within 90 days of the minor stroke was low and that nonurgent evaluation was appropriate. Both doctors claimed that the major stroke was an unfortunate and unpredictable occurrence and that, in any event, vascular surgery wouldn’t have been performed for at least 4 to 6 weeks after the small stroke because of concern over severe cerebral hemorrhage.

VERDICT $1.75 million Massachusetts settlement.

COMMENT Communicate, communicate, communicate. Without appropriate coordination of care, such unfortunate stories are likely to be repeated. Never assume that another colleague is going to follow up on that markedly abnormal finding—take matters into your own hands!

Child’s hearing loss blamed on missed meningitis Dx

A 1-YEAR-OLD GIRL WITH A PERSISTENT FEVER was seen by her pediatrician, who diagnosed tonsillitis. During the hours after her visit to the pediatrician, the child’s fever reached 104°F and she began to vomit. She was brought to an emergency room, where a radiograph revealed a potentially abnormal density of the lungs. Developing pneumonia was suspected, and she was admitted to the hospital. Doctors also suspected meningitis, but didn’t detect any abnormalities of the meninges. An antibiotic was given.

On the third day of hospitalization, a nurse observed nuchal rigidity. The child remained in the hospital for 2 weeks, during which time her body temperature remained at 100°F or higher. Two days after discharge, the girl experienced a total loss of hearing. A computed tomography scan revealed damage to the cochleae.

PLAINTIFF’S CLAIM The damage to the patient’s cochleae was caused by untreated meningitis. Nuchal rigidity should have prompted an immediate spinal tap or other test for meningitis.

DOCTOR’S DEFENSE Proper care was given; the child’s symptoms didn’t warrant additional treatment. The cochlear damage was congenital.

VERDICT $3 million New York settlement.

COMMENT Meningitis may occur less often nowadays, but it should never be forgotten. When in doubt, order (or perform) a lumbar puncture, which can lead to a life-saving diagnosis. Early initiation of presumptive antibiotic treatment is critical.

Untreated high blood sugar ends in coma and disability

A 65-YEAR-OLD MAN sought treatment from an endocrinologist for previously diagnosed diabetes. An in-office pin prick test showed a blood sugar level exceeding the instrument’s limit. The endocrinologist ordered blood work at an outside lab. The tests indicated dangerous blood sugar levels, which were reported to the endocrinologist and his staff. The doctor allegedly didn’t act on the results.

About a week after seeing the endocrinologist, the patient collapsed; he was rushed to a hospital and placed in a protective coma. He emerged from the coma with significant injuries, including blindness in 1 eye and bilateral foot drop.

PLAINTIFF’S CLAIM The in-office test results should have alerted the doctor to a serious problem. The doctor should have sent the patient to the hospital for an immediate blood test.

DOCTOR’S DEFENSE The doctor denied any negligence.

VERDICT $1.5 million Connecticut settlement.

COMMENT Delayed or inappropriate follow up of in-office lab work remains a preventable cause of liability. If you order a test, make sure you have a protocol in place to assure timely adjudication of test results.

Disabling stroke follows failure to treat stenosis

NUMBNESS AND WEAKNESS IN HIS LEFT ARM brought a 52-year-old man to his internist. A magnetic resonance imaging scan revealed that the patient had suffered a minor, nondisabling stroke within the previous few weeks caused by an embolism arising from stenosis of the right internal carotid artery. The internist referred the patient to a neurologist but didn’t inform the neurologist that the man’s symptoms were becoming worse.

The neurologist saw the patient about a week later. She was unaware of the unstable symptoms and didn’t communicate with the internist, whose office was 1 floor below hers. The neurologist put the patient on low-dose aspirin and sent him for a nonurgent ultrasound to determine the extent of the stenosis.

The ultrasound report, which the neurologist read 8 days after the patient visit, indicated an 80% to 90% stenosis of the right internal carotid artery. The neurologist claimed she tried to reach the patient 4 times over 2 days. She left one message, but did not reach him.

Two days after the neurologist obtained the ultrasound report, the patient had a major stroke caused by a clot that had broken off from his right internal carotid artery. The stroke left him mostly paralyzed on his left side, confined to a wheelchair, and unable to work or drive.

PLAINTIFF’S CLAIM The internist failed to convey all medically significant information to the neurologist; he had a duty to intervene when he received worrisome clinical information. The neurologist should have ordered an urgent carotid endarterectomy, which would have prevented a major stroke. She also should have contacted the internist; communication would have brought to light the need for urgent treatment.

DOCTORS’ DEFENSE The internist claimed that the neurology referral was all that was required of him. The neurologist maintained that the risk of another embolic stroke within 90 days of the minor stroke was low and that nonurgent evaluation was appropriate. Both doctors claimed that the major stroke was an unfortunate and unpredictable occurrence and that, in any event, vascular surgery wouldn’t have been performed for at least 4 to 6 weeks after the small stroke because of concern over severe cerebral hemorrhage.

VERDICT $1.75 million Massachusetts settlement.

COMMENT Communicate, communicate, communicate. Without appropriate coordination of care, such unfortunate stories are likely to be repeated. Never assume that another colleague is going to follow up on that markedly abnormal finding—take matters into your own hands!

Child’s hearing loss blamed on missed meningitis Dx

A 1-YEAR-OLD GIRL WITH A PERSISTENT FEVER was seen by her pediatrician, who diagnosed tonsillitis. During the hours after her visit to the pediatrician, the child’s fever reached 104°F and she began to vomit. She was brought to an emergency room, where a radiograph revealed a potentially abnormal density of the lungs. Developing pneumonia was suspected, and she was admitted to the hospital. Doctors also suspected meningitis, but didn’t detect any abnormalities of the meninges. An antibiotic was given.

On the third day of hospitalization, a nurse observed nuchal rigidity. The child remained in the hospital for 2 weeks, during which time her body temperature remained at 100°F or higher. Two days after discharge, the girl experienced a total loss of hearing. A computed tomography scan revealed damage to the cochleae.

PLAINTIFF’S CLAIM The damage to the patient’s cochleae was caused by untreated meningitis. Nuchal rigidity should have prompted an immediate spinal tap or other test for meningitis.

DOCTOR’S DEFENSE Proper care was given; the child’s symptoms didn’t warrant additional treatment. The cochlear damage was congenital.

VERDICT $3 million New York settlement.

COMMENT Meningitis may occur less often nowadays, but it should never be forgotten. When in doubt, order (or perform) a lumbar puncture, which can lead to a life-saving diagnosis. Early initiation of presumptive antibiotic treatment is critical.

Untreated high blood sugar ends in coma and disability

A 65-YEAR-OLD MAN sought treatment from an endocrinologist for previously diagnosed diabetes. An in-office pin prick test showed a blood sugar level exceeding the instrument’s limit. The endocrinologist ordered blood work at an outside lab. The tests indicated dangerous blood sugar levels, which were reported to the endocrinologist and his staff. The doctor allegedly didn’t act on the results.

About a week after seeing the endocrinologist, the patient collapsed; he was rushed to a hospital and placed in a protective coma. He emerged from the coma with significant injuries, including blindness in 1 eye and bilateral foot drop.

PLAINTIFF’S CLAIM The in-office test results should have alerted the doctor to a serious problem. The doctor should have sent the patient to the hospital for an immediate blood test.

DOCTOR’S DEFENSE The doctor denied any negligence.

VERDICT $1.5 million Connecticut settlement.

COMMENT Delayed or inappropriate follow up of in-office lab work remains a preventable cause of liability. If you order a test, make sure you have a protocol in place to assure timely adjudication of test results.

Complaint of arm pain ends in death

TWO WEEKS OF SEVERE PAIN IN HER LEFT ARM, along with severe chest pain and a sensation of “elephants” on her chest, prompted a 49-year-old woman to visit her primary care physician. The patient had gone to the emergency room 3 months earlier with chest pain. A stress test done at that time was negative, and an electrocardiogram was normal. The woman had a history of hypercholesterolemia and a family history of heart disease. She had recently quit smoking after 25 years.

The physician’s nurse practitioner noted bilateral arm pain and diagnosed arthralgia. The doctor and nurse claimed that the doctor performed an impromptu physical examination as the patient was leaving the office (the patient claimed, in disallowed testimony, that she had seen the doctor only in the parking lot, and he didn’t examine her). The doctor said that the patient denied chest pain when he examined her and reported bilateral rather than left arm pain. He also said he found a neck spasm and prescribed Darvocet for the arm pain. The doctor didn’t record the findings of the exam.

The patient died in her bathroom 2 days later. The cause was an arrhythmia resulting from decreased blood flow to the heart from atherosclerotic disease.

PLAINTIFF’S CLAIM Cardiac ischemia should have been ruled out at the office visit.

DOCTOR’S DEFENSE An adequate examination was performed to rule out cardiac disease, and reliance on the previous stress test results was proper.

VERDICT $1.215 million Florida verdict.

COMMENT Appropriate documentation might have averted a $1.2 million plaintiff verdict!

Delayed diagnosis leads to quadriplegia

A 60-YEAR-OLD WOMAN WAS TREATED FOR NECK PAIN at a hospital and released. The next day, she went to a medical center because of pain running down her arm. Nine hours later, she lost sensation in her legs.

Magnetic resonance imaging performed the following day revealed an epidural abscess. The woman underwent surgery at another hospital that night.

PLAINTIFF’S CLAIM The delay in diagnosis and surgery caused the plaintiff to become quadriplegic.

THE DEFENSE No information about the nature of the defense is available.

VERDICT $1.9 million New Jersey settlement.

COMMENT While most radiculopathy (whether cervical or lumbar) can be treated conservatively, cauda equina or symptoms of myelopathy indicate a neurosurgical emergency. A delay in definitive diagnosis and treatment will undoubtedly play out in court.

“Classic” endocarditis is missed again, and again

AFTER 5 OR 6 WEEKS OF SYMPTOMS, including fever, chills, myalgia, weight loss, fatigue, light-headedness, weakness, non-productive cough, and intermittent fever that peaked at 102.3°F, a 24-year-old woman sought treatment at her family physician’s office. She had a documented grade III heart murmur, interpreted by her physician as a long-standing benign systolic murmur.

Although she didn’t report dysuria, urgency, frequency, flank pain, or other urinary symptoms, the physician assistant who saw the patient at this visit diagnosed a urinary tract infection. The PA prescribed antibiotics and instructed the patient to follow up in several weeks.

The woman returned twice during the month after her initial visit; she was seen by a physician on both occasions. She reported a syncopal episode and was diagnosed with ongoing anemia attributable to normal iron deficiency. No diagnostic tests were ordered.

During follow-up visits over the next 2 months, the patient complained of increasing fatigue, shortness of breath, tremors, and loss of appetite. She was given a diagnosis of depression and a prescription for Zoloft. When she continued to deteriorate, she was given an additional diagnosis of possible bronchitis or pneumonia.

Early one evening 3 months after her initial visit, on a day when she had been seen at the practice, the patient collapsed at home. She was taken by ambulance to a hospital, where she died of cardiopulmonary arrest. An autopsy revealed bacterial endocarditis of the mitral valve.

PLAINTIFF’S CLAIM The patient had a classic presentation of endocarditis; a proper workup would have led to diagnosis and treatment.

THE DEFENSE No information about the nature of the defense is available.

VERDICT $1.2 million Virginia settlement.

COMMENT Although horses are common, when a patient fails to improve, we need to think of zebras, too. In this case, the combination of fever, constitutional symptoms, and a heart murmur should have at least raised the suspicion of bacterial endocarditis.

Malignant mole never made it to pathology

A WOMAN NOTICED A NEW MOLE ON HER LEFT FOOT, which didn’t concern her until 4 years later, when it began to grow, itch, and turn red. She went to her family physician, who decided to remove the mole. After doing so, the doctor told the patient that he’d send it for pathologic inspection and handed it to the assisting nurse, expecting her to prepare it properly for the laboratory.

When the time came to remove the stitches, the patient asked her family physician if a doctor in the medical practice where she worked could take them out. The family physician agreed. The patient didn’t return to her family physician afterward; she transferred to a primary care physician in the office where she worked.

The mole then returned to the patient’s foot, and she requested transfer of her records to the new physician. When the records arrived, they didn’t include a pathology report; it appeared that the mole hadn’t been sent to the pathology lab.

The patient’s physician sent her to a podiatrist, who removed the recurrent mole a little over a year after she first consulted her family physician. The pathology report indicated it was a malignant melanoma.

PLAINTIFF’S CLAIM It was negligent to fail to send the mole to a pathology lab and to fail to notice that a pathology report had not come back. The delay in diagnosis and treatment of the cancer increased the risk of recurrence and other complications.

THE DEFENSE The family physician blamed the procedures of the group, and the group blamed the family doctor.

VERDICT $3.25 million Kentucky verdict.

COMMENT I recently participated as an expert witness (for the defense) in a similar malpractice case in which the defendant did send the mole to pathology. In today’s litigious society, how can we not send every “mole” for pathologic examination?

Complaint of arm pain ends in death

TWO WEEKS OF SEVERE PAIN IN HER LEFT ARM, along with severe chest pain and a sensation of “elephants” on her chest, prompted a 49-year-old woman to visit her primary care physician. The patient had gone to the emergency room 3 months earlier with chest pain. A stress test done at that time was negative, and an electrocardiogram was normal. The woman had a history of hypercholesterolemia and a family history of heart disease. She had recently quit smoking after 25 years.

The physician’s nurse practitioner noted bilateral arm pain and diagnosed arthralgia. The doctor and nurse claimed that the doctor performed an impromptu physical examination as the patient was leaving the office (the patient claimed, in disallowed testimony, that she had seen the doctor only in the parking lot, and he didn’t examine her). The doctor said that the patient denied chest pain when he examined her and reported bilateral rather than left arm pain. He also said he found a neck spasm and prescribed Darvocet for the arm pain. The doctor didn’t record the findings of the exam.

The patient died in her bathroom 2 days later. The cause was an arrhythmia resulting from decreased blood flow to the heart from atherosclerotic disease.

PLAINTIFF’S CLAIM Cardiac ischemia should have been ruled out at the office visit.

DOCTOR’S DEFENSE An adequate examination was performed to rule out cardiac disease, and reliance on the previous stress test results was proper.

VERDICT $1.215 million Florida verdict.

COMMENT Appropriate documentation might have averted a $1.2 million plaintiff verdict!

Delayed diagnosis leads to quadriplegia

A 60-YEAR-OLD WOMAN WAS TREATED FOR NECK PAIN at a hospital and released. The next day, she went to a medical center because of pain running down her arm. Nine hours later, she lost sensation in her legs.

Magnetic resonance imaging performed the following day revealed an epidural abscess. The woman underwent surgery at another hospital that night.

PLAINTIFF’S CLAIM The delay in diagnosis and surgery caused the plaintiff to become quadriplegic.

THE DEFENSE No information about the nature of the defense is available.

VERDICT $1.9 million New Jersey settlement.

COMMENT While most radiculopathy (whether cervical or lumbar) can be treated conservatively, cauda equina or symptoms of myelopathy indicate a neurosurgical emergency. A delay in definitive diagnosis and treatment will undoubtedly play out in court.

“Classic” endocarditis is missed again, and again

AFTER 5 OR 6 WEEKS OF SYMPTOMS, including fever, chills, myalgia, weight loss, fatigue, light-headedness, weakness, non-productive cough, and intermittent fever that peaked at 102.3°F, a 24-year-old woman sought treatment at her family physician’s office. She had a documented grade III heart murmur, interpreted by her physician as a long-standing benign systolic murmur.

Although she didn’t report dysuria, urgency, frequency, flank pain, or other urinary symptoms, the physician assistant who saw the patient at this visit diagnosed a urinary tract infection. The PA prescribed antibiotics and instructed the patient to follow up in several weeks.

The woman returned twice during the month after her initial visit; she was seen by a physician on both occasions. She reported a syncopal episode and was diagnosed with ongoing anemia attributable to normal iron deficiency. No diagnostic tests were ordered.

During follow-up visits over the next 2 months, the patient complained of increasing fatigue, shortness of breath, tremors, and loss of appetite. She was given a diagnosis of depression and a prescription for Zoloft. When she continued to deteriorate, she was given an additional diagnosis of possible bronchitis or pneumonia.

Early one evening 3 months after her initial visit, on a day when she had been seen at the practice, the patient collapsed at home. She was taken by ambulance to a hospital, where she died of cardiopulmonary arrest. An autopsy revealed bacterial endocarditis of the mitral valve.

PLAINTIFF’S CLAIM The patient had a classic presentation of endocarditis; a proper workup would have led to diagnosis and treatment.

THE DEFENSE No information about the nature of the defense is available.

VERDICT $1.2 million Virginia settlement.

COMMENT Although horses are common, when a patient fails to improve, we need to think of zebras, too. In this case, the combination of fever, constitutional symptoms, and a heart murmur should have at least raised the suspicion of bacterial endocarditis.

Malignant mole never made it to pathology

A WOMAN NOTICED A NEW MOLE ON HER LEFT FOOT, which didn’t concern her until 4 years later, when it began to grow, itch, and turn red. She went to her family physician, who decided to remove the mole. After doing so, the doctor told the patient that he’d send it for pathologic inspection and handed it to the assisting nurse, expecting her to prepare it properly for the laboratory.

When the time came to remove the stitches, the patient asked her family physician if a doctor in the medical practice where she worked could take them out. The family physician agreed. The patient didn’t return to her family physician afterward; she transferred to a primary care physician in the office where she worked.

The mole then returned to the patient’s foot, and she requested transfer of her records to the new physician. When the records arrived, they didn’t include a pathology report; it appeared that the mole hadn’t been sent to the pathology lab.

The patient’s physician sent her to a podiatrist, who removed the recurrent mole a little over a year after she first consulted her family physician. The pathology report indicated it was a malignant melanoma.

PLAINTIFF’S CLAIM It was negligent to fail to send the mole to a pathology lab and to fail to notice that a pathology report had not come back. The delay in diagnosis and treatment of the cancer increased the risk of recurrence and other complications.

THE DEFENSE The family physician blamed the procedures of the group, and the group blamed the family doctor.

VERDICT $3.25 million Kentucky verdict.

COMMENT I recently participated as an expert witness (for the defense) in a similar malpractice case in which the defendant did send the mole to pathology. In today’s litigious society, how can we not send every “mole” for pathologic examination?

Complaint of arm pain ends in death

TWO WEEKS OF SEVERE PAIN IN HER LEFT ARM, along with severe chest pain and a sensation of “elephants” on her chest, prompted a 49-year-old woman to visit her primary care physician. The patient had gone to the emergency room 3 months earlier with chest pain. A stress test done at that time was negative, and an electrocardiogram was normal. The woman had a history of hypercholesterolemia and a family history of heart disease. She had recently quit smoking after 25 years.

The physician’s nurse practitioner noted bilateral arm pain and diagnosed arthralgia. The doctor and nurse claimed that the doctor performed an impromptu physical examination as the patient was leaving the office (the patient claimed, in disallowed testimony, that she had seen the doctor only in the parking lot, and he didn’t examine her). The doctor said that the patient denied chest pain when he examined her and reported bilateral rather than left arm pain. He also said he found a neck spasm and prescribed Darvocet for the arm pain. The doctor didn’t record the findings of the exam.

The patient died in her bathroom 2 days later. The cause was an arrhythmia resulting from decreased blood flow to the heart from atherosclerotic disease.

PLAINTIFF’S CLAIM Cardiac ischemia should have been ruled out at the office visit.

DOCTOR’S DEFENSE An adequate examination was performed to rule out cardiac disease, and reliance on the previous stress test results was proper.

VERDICT $1.215 million Florida verdict.

COMMENT Appropriate documentation might have averted a $1.2 million plaintiff verdict!

Delayed diagnosis leads to quadriplegia

A 60-YEAR-OLD WOMAN WAS TREATED FOR NECK PAIN at a hospital and released. The next day, she went to a medical center because of pain running down her arm. Nine hours later, she lost sensation in her legs.

Magnetic resonance imaging performed the following day revealed an epidural abscess. The woman underwent surgery at another hospital that night.

PLAINTIFF’S CLAIM The delay in diagnosis and surgery caused the plaintiff to become quadriplegic.

THE DEFENSE No information about the nature of the defense is available.

VERDICT $1.9 million New Jersey settlement.

COMMENT While most radiculopathy (whether cervical or lumbar) can be treated conservatively, cauda equina or symptoms of myelopathy indicate a neurosurgical emergency. A delay in definitive diagnosis and treatment will undoubtedly play out in court.

“Classic” endocarditis is missed again, and again

AFTER 5 OR 6 WEEKS OF SYMPTOMS, including fever, chills, myalgia, weight loss, fatigue, light-headedness, weakness, non-productive cough, and intermittent fever that peaked at 102.3°F, a 24-year-old woman sought treatment at her family physician’s office. She had a documented grade III heart murmur, interpreted by her physician as a long-standing benign systolic murmur.

Although she didn’t report dysuria, urgency, frequency, flank pain, or other urinary symptoms, the physician assistant who saw the patient at this visit diagnosed a urinary tract infection. The PA prescribed antibiotics and instructed the patient to follow up in several weeks.

The woman returned twice during the month after her initial visit; she was seen by a physician on both occasions. She reported a syncopal episode and was diagnosed with ongoing anemia attributable to normal iron deficiency. No diagnostic tests were ordered.

During follow-up visits over the next 2 months, the patient complained of increasing fatigue, shortness of breath, tremors, and loss of appetite. She was given a diagnosis of depression and a prescription for Zoloft. When she continued to deteriorate, she was given an additional diagnosis of possible bronchitis or pneumonia.

Early one evening 3 months after her initial visit, on a day when she had been seen at the practice, the patient collapsed at home. She was taken by ambulance to a hospital, where she died of cardiopulmonary arrest. An autopsy revealed bacterial endocarditis of the mitral valve.

PLAINTIFF’S CLAIM The patient had a classic presentation of endocarditis; a proper workup would have led to diagnosis and treatment.

THE DEFENSE No information about the nature of the defense is available.

VERDICT $1.2 million Virginia settlement.

COMMENT Although horses are common, when a patient fails to improve, we need to think of zebras, too. In this case, the combination of fever, constitutional symptoms, and a heart murmur should have at least raised the suspicion of bacterial endocarditis.

Malignant mole never made it to pathology

A WOMAN NOTICED A NEW MOLE ON HER LEFT FOOT, which didn’t concern her until 4 years later, when it began to grow, itch, and turn red. She went to her family physician, who decided to remove the mole. After doing so, the doctor told the patient that he’d send it for pathologic inspection and handed it to the assisting nurse, expecting her to prepare it properly for the laboratory.

When the time came to remove the stitches, the patient asked her family physician if a doctor in the medical practice where she worked could take them out. The family physician agreed. The patient didn’t return to her family physician afterward; she transferred to a primary care physician in the office where she worked.

The mole then returned to the patient’s foot, and she requested transfer of her records to the new physician. When the records arrived, they didn’t include a pathology report; it appeared that the mole hadn’t been sent to the pathology lab.

The patient’s physician sent her to a podiatrist, who removed the recurrent mole a little over a year after she first consulted her family physician. The pathology report indicated it was a malignant melanoma.

PLAINTIFF’S CLAIM It was negligent to fail to send the mole to a pathology lab and to fail to notice that a pathology report had not come back. The delay in diagnosis and treatment of the cancer increased the risk of recurrence and other complications.

THE DEFENSE The family physician blamed the procedures of the group, and the group blamed the family doctor.

VERDICT $3.25 million Kentucky verdict.

COMMENT I recently participated as an expert witness (for the defense) in a similar malpractice case in which the defendant did send the mole to pathology. In today’s litigious society, how can we not send every “mole” for pathologic examination?

Birth control change proves fatal

THE WORST HEADACHE SHE EVER HAD brought a 21-year-old woman to the emergency room. She had suffered severe headaches the previous month after switching from Depo-Provera shots to Nordette 28 birth control pills; the headaches went away, then returned.

A month after the ER visit, she visited a family medicine clinic, complaining of headaches, nausea, diarrhea, possible fever, and slight dizziness. A physician assistant prescribed Bactrim DS, Phenergan for the nausea, and Phrenilin for the headache.

Two days later, the patient was taken by ambulance to an ER because of numbness all over, nausea, vomiting, and dizziness. She was discharged, but brought back 4 hours later somnolent, difficult to arouse, and unable to obey commands. A computed tomography (CT) scan and magnetic resonance imaging performed the next morning showed blood clots in the brain, with complete occlusion of the superior sagittal sinus vein, and cerebral herniation.

A few days later, the patient was removed from life support. An autopsy indicated that the cause of death was a recent thrombus of the superior sagittal sinus with bilateral acute cerebral infarcts associated with secondary thrombi of tributary veins.

PLAINTIFF’S CLAIM The defendants were negligent in failing to pay attention to the change in the patient’s birth control regimen and test for cerebral thrombosis, a recognized adverse reaction when switching from shots to pills for birth control.

THE DEFENSE No information about the nature of the defense is available.

VERDICT $7 million North Carolina verdict.

COMMENT If you want to avoid malpractice, make sure you obtain urgent imaging for the patient with the worst headache of his or her life.

“Bronchitis” turns out to be lung cancer

UPPER RESPIRATORY TRACT SYMPTOMS prompted the patient to visit his primary care physician, who diagnosed asthma. Six months later, the patient returned with difficulty breathing and discolored mucus. The doctor diagnosed acute bronchitis and ordered a chest radiograph, which showed a growth in the lung. A subsequent CT scan confirmed the finding and identified a swollen right paratracheal lymph node. The radiologist’s report noted that “neoplasm cannot be entirely excluded.”

A series of radiographs and CT scans over the next several months continued to show the growth, which appeared unchanged. Radiologists’ reports advised that cancer couldn’t be ruled out and recommended further evaluation.

More than a year after the initial radiograph, the patient began to complain of persistent back pain along with the respiratory problems. A pain specialist ordered magnetic resonance imaging of the thoracic spine, which showed that the growth had enlarged. The report noted that the mass “must be considered highly worrisome for metastatic or other tumor unless proven otherwise.” A subsequent biopsy revealed stage IV lung cancer.

PLAINTIFF’S CLAIM If the defendant had investigated the growth at the time of the first radiograph, the cancer might have been curable.

DOCTOR’S DEFENSE The lung cancer was caused by the patient’s smoking, and the physician had tried unsuccessfully to get the patient to quit. The doctor did what the radiologists recommended after each CT scan and radiograph. The cancer wasn’t diagnosed earlier because a second scan failed to note that the right lymph node was still enlarged.

VERDICT $3 million Pennsylvania verdict.

COMMENT Failure to aggressively follow up—and diagnose—lung masses is a common malpractice pitfall.

Undiagnosed diabetes leads to death

A 27-YEAR-OLD MAN went to his primary care physician complaining of dry mouth unrelieved by increased fluid intake and occasional soreness while swallowing. He’d lost 11 pounds in the last 5 months. Although the patient had a family history of diabetes and symptoms consistent with diabetes, the physician didn’t check his glucose levels.

Almost a month later, the young man returned with blurred vision and severe headaches. He also complained of bilateral calf cramps at night and had lost another 13 pounds. The physician referred him for an eye exam, but didn’t test for diabetes.

A few weeks later, the patient went to the hospital with the “worst headache ever.” He also reported blurred vision and seeing white dots. Immediately after giving the history, he suffered 2 generalized seizures. A brain scan showed edema; initial urine testing revealed a glucose level of 500, proteinuria 2+, blood, and positive ketones.

The patient was intubated and transferred to another hospital, where he was diagnosed with diabetic ketoacidosis and an elevated intracranial pressure of 57. He didn’t respond to treatment and was pronounced dead 3 days later. An autopsy revealed cerebral edema with herniation of the cerebellar tonsils and brain stem compression and hypoxic encephalopathy associated with diabetic ketoacidosis.

PLAINTIFF’S CLAIM The patient had diabetes when he first saw the doctor; the doctor was negligent in failing to perform a diabetes workup.

DOCTOR’S DEFENSE The patient had a virus when he was first seen, and the headaches were caused by eye strain. The patient died not from undiagnosed diabetes, but from an underlying virus, which couldn’t have been detected until an autopsy was performed.

VERDICT $1 million Massachusetts settlement.

COMMENT Be alert for common but potentially serious medical problems, such as diabetes, when faced with a patient with multiple nonspecific symptoms.

Birth control change proves fatal

THE WORST HEADACHE SHE EVER HAD brought a 21-year-old woman to the emergency room. She had suffered severe headaches the previous month after switching from Depo-Provera shots to Nordette 28 birth control pills; the headaches went away, then returned.

A month after the ER visit, she visited a family medicine clinic, complaining of headaches, nausea, diarrhea, possible fever, and slight dizziness. A physician assistant prescribed Bactrim DS, Phenergan for the nausea, and Phrenilin for the headache.

Two days later, the patient was taken by ambulance to an ER because of numbness all over, nausea, vomiting, and dizziness. She was discharged, but brought back 4 hours later somnolent, difficult to arouse, and unable to obey commands. A computed tomography (CT) scan and magnetic resonance imaging performed the next morning showed blood clots in the brain, with complete occlusion of the superior sagittal sinus vein, and cerebral herniation.

A few days later, the patient was removed from life support. An autopsy indicated that the cause of death was a recent thrombus of the superior sagittal sinus with bilateral acute cerebral infarcts associated with secondary thrombi of tributary veins.

PLAINTIFF’S CLAIM The defendants were negligent in failing to pay attention to the change in the patient’s birth control regimen and test for cerebral thrombosis, a recognized adverse reaction when switching from shots to pills for birth control.

THE DEFENSE No information about the nature of the defense is available.

VERDICT $7 million North Carolina verdict.

COMMENT If you want to avoid malpractice, make sure you obtain urgent imaging for the patient with the worst headache of his or her life.

“Bronchitis” turns out to be lung cancer

UPPER RESPIRATORY TRACT SYMPTOMS prompted the patient to visit his primary care physician, who diagnosed asthma. Six months later, the patient returned with difficulty breathing and discolored mucus. The doctor diagnosed acute bronchitis and ordered a chest radiograph, which showed a growth in the lung. A subsequent CT scan confirmed the finding and identified a swollen right paratracheal lymph node. The radiologist’s report noted that “neoplasm cannot be entirely excluded.”

A series of radiographs and CT scans over the next several months continued to show the growth, which appeared unchanged. Radiologists’ reports advised that cancer couldn’t be ruled out and recommended further evaluation.

More than a year after the initial radiograph, the patient began to complain of persistent back pain along with the respiratory problems. A pain specialist ordered magnetic resonance imaging of the thoracic spine, which showed that the growth had enlarged. The report noted that the mass “must be considered highly worrisome for metastatic or other tumor unless proven otherwise.” A subsequent biopsy revealed stage IV lung cancer.

PLAINTIFF’S CLAIM If the defendant had investigated the growth at the time of the first radiograph, the cancer might have been curable.

DOCTOR’S DEFENSE The lung cancer was caused by the patient’s smoking, and the physician had tried unsuccessfully to get the patient to quit. The doctor did what the radiologists recommended after each CT scan and radiograph. The cancer wasn’t diagnosed earlier because a second scan failed to note that the right lymph node was still enlarged.

VERDICT $3 million Pennsylvania verdict.

COMMENT Failure to aggressively follow up—and diagnose—lung masses is a common malpractice pitfall.

Undiagnosed diabetes leads to death

A 27-YEAR-OLD MAN went to his primary care physician complaining of dry mouth unrelieved by increased fluid intake and occasional soreness while swallowing. He’d lost 11 pounds in the last 5 months. Although the patient had a family history of diabetes and symptoms consistent with diabetes, the physician didn’t check his glucose levels.

Almost a month later, the young man returned with blurred vision and severe headaches. He also complained of bilateral calf cramps at night and had lost another 13 pounds. The physician referred him for an eye exam, but didn’t test for diabetes.

A few weeks later, the patient went to the hospital with the “worst headache ever.” He also reported blurred vision and seeing white dots. Immediately after giving the history, he suffered 2 generalized seizures. A brain scan showed edema; initial urine testing revealed a glucose level of 500, proteinuria 2+, blood, and positive ketones.

The patient was intubated and transferred to another hospital, where he was diagnosed with diabetic ketoacidosis and an elevated intracranial pressure of 57. He didn’t respond to treatment and was pronounced dead 3 days later. An autopsy revealed cerebral edema with herniation of the cerebellar tonsils and brain stem compression and hypoxic encephalopathy associated with diabetic ketoacidosis.

PLAINTIFF’S CLAIM The patient had diabetes when he first saw the doctor; the doctor was negligent in failing to perform a diabetes workup.

DOCTOR’S DEFENSE The patient had a virus when he was first seen, and the headaches were caused by eye strain. The patient died not from undiagnosed diabetes, but from an underlying virus, which couldn’t have been detected until an autopsy was performed.

VERDICT $1 million Massachusetts settlement.

COMMENT Be alert for common but potentially serious medical problems, such as diabetes, when faced with a patient with multiple nonspecific symptoms.

Birth control change proves fatal

THE WORST HEADACHE SHE EVER HAD brought a 21-year-old woman to the emergency room. She had suffered severe headaches the previous month after switching from Depo-Provera shots to Nordette 28 birth control pills; the headaches went away, then returned.

A month after the ER visit, she visited a family medicine clinic, complaining of headaches, nausea, diarrhea, possible fever, and slight dizziness. A physician assistant prescribed Bactrim DS, Phenergan for the nausea, and Phrenilin for the headache.

Two days later, the patient was taken by ambulance to an ER because of numbness all over, nausea, vomiting, and dizziness. She was discharged, but brought back 4 hours later somnolent, difficult to arouse, and unable to obey commands. A computed tomography (CT) scan and magnetic resonance imaging performed the next morning showed blood clots in the brain, with complete occlusion of the superior sagittal sinus vein, and cerebral herniation.

A few days later, the patient was removed from life support. An autopsy indicated that the cause of death was a recent thrombus of the superior sagittal sinus with bilateral acute cerebral infarcts associated with secondary thrombi of tributary veins.

PLAINTIFF’S CLAIM The defendants were negligent in failing to pay attention to the change in the patient’s birth control regimen and test for cerebral thrombosis, a recognized adverse reaction when switching from shots to pills for birth control.

THE DEFENSE No information about the nature of the defense is available.

VERDICT $7 million North Carolina verdict.

COMMENT If you want to avoid malpractice, make sure you obtain urgent imaging for the patient with the worst headache of his or her life.

“Bronchitis” turns out to be lung cancer

UPPER RESPIRATORY TRACT SYMPTOMS prompted the patient to visit his primary care physician, who diagnosed asthma. Six months later, the patient returned with difficulty breathing and discolored mucus. The doctor diagnosed acute bronchitis and ordered a chest radiograph, which showed a growth in the lung. A subsequent CT scan confirmed the finding and identified a swollen right paratracheal lymph node. The radiologist’s report noted that “neoplasm cannot be entirely excluded.”

A series of radiographs and CT scans over the next several months continued to show the growth, which appeared unchanged. Radiologists’ reports advised that cancer couldn’t be ruled out and recommended further evaluation.

More than a year after the initial radiograph, the patient began to complain of persistent back pain along with the respiratory problems. A pain specialist ordered magnetic resonance imaging of the thoracic spine, which showed that the growth had enlarged. The report noted that the mass “must be considered highly worrisome for metastatic or other tumor unless proven otherwise.” A subsequent biopsy revealed stage IV lung cancer.

PLAINTIFF’S CLAIM If the defendant had investigated the growth at the time of the first radiograph, the cancer might have been curable.

DOCTOR’S DEFENSE The lung cancer was caused by the patient’s smoking, and the physician had tried unsuccessfully to get the patient to quit. The doctor did what the radiologists recommended after each CT scan and radiograph. The cancer wasn’t diagnosed earlier because a second scan failed to note that the right lymph node was still enlarged.

VERDICT $3 million Pennsylvania verdict.

COMMENT Failure to aggressively follow up—and diagnose—lung masses is a common malpractice pitfall.

Undiagnosed diabetes leads to death

A 27-YEAR-OLD MAN went to his primary care physician complaining of dry mouth unrelieved by increased fluid intake and occasional soreness while swallowing. He’d lost 11 pounds in the last 5 months. Although the patient had a family history of diabetes and symptoms consistent with diabetes, the physician didn’t check his glucose levels.

Almost a month later, the young man returned with blurred vision and severe headaches. He also complained of bilateral calf cramps at night and had lost another 13 pounds. The physician referred him for an eye exam, but didn’t test for diabetes.

A few weeks later, the patient went to the hospital with the “worst headache ever.” He also reported blurred vision and seeing white dots. Immediately after giving the history, he suffered 2 generalized seizures. A brain scan showed edema; initial urine testing revealed a glucose level of 500, proteinuria 2+, blood, and positive ketones.

The patient was intubated and transferred to another hospital, where he was diagnosed with diabetic ketoacidosis and an elevated intracranial pressure of 57. He didn’t respond to treatment and was pronounced dead 3 days later. An autopsy revealed cerebral edema with herniation of the cerebellar tonsils and brain stem compression and hypoxic encephalopathy associated with diabetic ketoacidosis.

PLAINTIFF’S CLAIM The patient had diabetes when he first saw the doctor; the doctor was negligent in failing to perform a diabetes workup.

DOCTOR’S DEFENSE The patient had a virus when he was first seen, and the headaches were caused by eye strain. The patient died not from undiagnosed diabetes, but from an underlying virus, which couldn’t have been detected until an autopsy was performed.

VERDICT $1 million Massachusetts settlement.

COMMENT Be alert for common but potentially serious medical problems, such as diabetes, when faced with a patient with multiple nonspecific symptoms.

Testing confusion delays breast cancer Dx

A WOMAN NOTICED A HARD SPOT IN HER LEFT BREAST in April and reported it to her physician in June. The doctor referred the 47-year-old patient to another physician, who performed a mammogram in early August. Four days later, the woman received a call directing her to return for imaging of her right breast. The patient claimed that when she told a radiology technician that she was concerned about her left breast, the technician replied that the order called for a right breast exam. Shortly thereafter, the patient received a letter informing her that everything was fine and instructing her to come back in a year.

She was still feeling the mass in her left breast when she returned for her annual exam the following August. A few weeks later, she was diagnosed with breast cancer. When the case went to trial, the patient had been told she had 2 years to live.

PLAINTIFF’S CLAIM: The plaintiff’s claim centered on the delay in her diagnosis, though the specifics were not detailed in the case summary.

DOCTORS’ DEFENSE: The defendants blamed each other for the delay; they also claimed that the patient should have kept complaining if she felt a mass. They further maintained that the required treatment would have been the same if the cancer had been diagnosed the previous year.

VERDICT: $4.5 million Missouri verdict (second physician, 85% at fault; radiology technician, 15% at fault).

COMMENT: What can go wrong does go wrong: A slip in communication and follow-up led to this $4.5 million verdict. Failure to make a timely diagnosis of breast cancer remains one of the most litigious areas in medicine.

Pulmonary disease masks lung cancer

A WOMAN WITH IDIOPATHIC PULMONARY FIBROSIS had been monitored by her physician for 7 years with physical exams, pulmonary function tests, and radiographic studies, including CT scans of the chest. During an office visit in October, the 57-year-old patient complained of increased difficulty breathing. A pulmonary function test and CT scan showed progression of the pulmonary fibrosis.

The following July, a pulmonary function test showed further deterioration of the patient’s condition, and the physician quadrupled her corticosteroid dosage. When the patient reported breathing problems again in December, a pulmonary function test showed continued decrease in breathing function.

Five months after that, the patient developed a malignant thigh lesion. A chest CT scan later that month revealed a lobular mass in the lower right lung, which had not appeared on the scan done a year and a half before. A biopsy revealed stage 4 adenocarcinoma. The woman died less than a month later of metastatic lung cancer.

PLAINTIFF’S CLAIM: The physician failed to follow up properly on the worsening fibrosis, allowing the cancer to grow un-detected. The physician should have ordered a CT scan in July or December.

DOCTOR’S DEFENSE: No negligence occurred; the patient didn’t complain much about her symptoms, and no signs or symptoms during her visits suggested that more tests should have been ordered. An earlier diagnosis wouldn’t have made a difference because the patient would not have been a candidate for surgery.

VERDICT: New York defense verdict.

COMMENT: Although a defense verdict was returned, we have to be careful not to overlook a serious new problem in the midst of a chronic disease—in this case, lung cancer against a background of pulmonary fibrosis.

Undiagnosed infection has disastrous results

WHILE HOSPITALIZED FOR ROUTINE POST-PARTUM CARE after the uneventful birth of her second child, a 37-year-old woman developed tachycardia and hypotension along with an expanding, excoriating wound on her labia. She claimed that the wound was treated only by applying ice and monitoring blood counts. The patient’s condition deteriorated until, on the third postpartum day, her blood pressure dropped and she coded. She was revived, and necrotizing fasciitis was diagnosed.

The woman spent 4 months in the ICU, during which time she underwent many surgeries to debride the wound as well as a nephrectomy and a permanent colostomy. The surgeries caused extensive scarring in the groin area. For 6 months after discharge from the ICU, the patient couldn’t walk without a cane or walker.

PLAINTIFF’S CLAIM: The specifics of the claim—which likely focused on the wound care she received and the delay in her diagnosis—were not detailed in the case summary.

DOCTOR’S DEFENSE: No negligence occurred. Necrotizing fasciitis is rare, and none of the health care providers should have been expected to diagnose it.

VERDICT: Confidential Nebraska settlement.

COMMENT: This case serves as a potent reminder of the serious nature of this dreaded infection.

Misdiagnosed chest pain leads to fatal MI

A 43-YEAR-OLD MAN, who smoked cigarettes and had a strong family history of coronary artery disease, had been under the care of a primary care physician for 3 years. The patient’s history also included at least 1 episode of chest pain.

The patient visited his physician complaining of intermittent chest pain for several days. He described 2 episodes of nausea, vomiting, and pain in his back teeth, followed by pain radiating down his right chest to the right costal margin. He had no symptoms during the office visit. The physician ordered an in-office EKG, which he interpreted as normal.

The physician diagnosed the chest pain as gastrointestinal in origin and prescribed an antacid. Because of the patient’s cardiac risk factors, the doctor scheduled a stress test and EKG for 2 days later.

On the morning of the stress test, the patient’s wife found him unresponsive. Resuscitation failed, and he was pronounced dead. An autopsy revealed severe proximal coronary artery disease of the left main coronary artery, left anterior descending coronary artery, and right coronary artery, as well as evidence of “remote and recent myocardial infarction.”

PLAINTIFF’S CLAIM: The EKG demonstrated significant changes compared with an EKG performed 3 years earlier and indicated that the patient was suffering an acute coronary episode. The doctor was negligent in failing to diagnose the episode and transfer the patient for proper cardiac care.

DOCTOR’S DEFENSE: The patient’s presentation indicated gastrointestinal distress; the EKG was normal.

VERDICT: $1.5 million Massachusetts settlement.

COMMENT: It’s imperative to compare EKGs, chest radiographs, and other tests with baseline results. How many times do you see an EKG that shows subtle but important changes that influence management?

Testing confusion delays breast cancer Dx

A WOMAN NOTICED A HARD SPOT IN HER LEFT BREAST in April and reported it to her physician in June. The doctor referred the 47-year-old patient to another physician, who performed a mammogram in early August. Four days later, the woman received a call directing her to return for imaging of her right breast. The patient claimed that when she told a radiology technician that she was concerned about her left breast, the technician replied that the order called for a right breast exam. Shortly thereafter, the patient received a letter informing her that everything was fine and instructing her to come back in a year.

She was still feeling the mass in her left breast when she returned for her annual exam the following August. A few weeks later, she was diagnosed with breast cancer. When the case went to trial, the patient had been told she had 2 years to live.

PLAINTIFF’S CLAIM: The plaintiff’s claim centered on the delay in her diagnosis, though the specifics were not detailed in the case summary.

DOCTORS’ DEFENSE: The defendants blamed each other for the delay; they also claimed that the patient should have kept complaining if she felt a mass. They further maintained that the required treatment would have been the same if the cancer had been diagnosed the previous year.

VERDICT: $4.5 million Missouri verdict (second physician, 85% at fault; radiology technician, 15% at fault).

COMMENT: What can go wrong does go wrong: A slip in communication and follow-up led to this $4.5 million verdict. Failure to make a timely diagnosis of breast cancer remains one of the most litigious areas in medicine.

Pulmonary disease masks lung cancer

A WOMAN WITH IDIOPATHIC PULMONARY FIBROSIS had been monitored by her physician for 7 years with physical exams, pulmonary function tests, and radiographic studies, including CT scans of the chest. During an office visit in October, the 57-year-old patient complained of increased difficulty breathing. A pulmonary function test and CT scan showed progression of the pulmonary fibrosis.

The following July, a pulmonary function test showed further deterioration of the patient’s condition, and the physician quadrupled her corticosteroid dosage. When the patient reported breathing problems again in December, a pulmonary function test showed continued decrease in breathing function.

Five months after that, the patient developed a malignant thigh lesion. A chest CT scan later that month revealed a lobular mass in the lower right lung, which had not appeared on the scan done a year and a half before. A biopsy revealed stage 4 adenocarcinoma. The woman died less than a month later of metastatic lung cancer.

PLAINTIFF’S CLAIM: The physician failed to follow up properly on the worsening fibrosis, allowing the cancer to grow un-detected. The physician should have ordered a CT scan in July or December.

DOCTOR’S DEFENSE: No negligence occurred; the patient didn’t complain much about her symptoms, and no signs or symptoms during her visits suggested that more tests should have been ordered. An earlier diagnosis wouldn’t have made a difference because the patient would not have been a candidate for surgery.

VERDICT: New York defense verdict.

COMMENT: Although a defense verdict was returned, we have to be careful not to overlook a serious new problem in the midst of a chronic disease—in this case, lung cancer against a background of pulmonary fibrosis.

Undiagnosed infection has disastrous results

WHILE HOSPITALIZED FOR ROUTINE POST-PARTUM CARE after the uneventful birth of her second child, a 37-year-old woman developed tachycardia and hypotension along with an expanding, excoriating wound on her labia. She claimed that the wound was treated only by applying ice and monitoring blood counts. The patient’s condition deteriorated until, on the third postpartum day, her blood pressure dropped and she coded. She was revived, and necrotizing fasciitis was diagnosed.

The woman spent 4 months in the ICU, during which time she underwent many surgeries to debride the wound as well as a nephrectomy and a permanent colostomy. The surgeries caused extensive scarring in the groin area. For 6 months after discharge from the ICU, the patient couldn’t walk without a cane or walker.

PLAINTIFF’S CLAIM: The specifics of the claim—which likely focused on the wound care she received and the delay in her diagnosis—were not detailed in the case summary.

DOCTOR’S DEFENSE: No negligence occurred. Necrotizing fasciitis is rare, and none of the health care providers should have been expected to diagnose it.

VERDICT: Confidential Nebraska settlement.

COMMENT: This case serves as a potent reminder of the serious nature of this dreaded infection.

Misdiagnosed chest pain leads to fatal MI

A 43-YEAR-OLD MAN, who smoked cigarettes and had a strong family history of coronary artery disease, had been under the care of a primary care physician for 3 years. The patient’s history also included at least 1 episode of chest pain.

The patient visited his physician complaining of intermittent chest pain for several days. He described 2 episodes of nausea, vomiting, and pain in his back teeth, followed by pain radiating down his right chest to the right costal margin. He had no symptoms during the office visit. The physician ordered an in-office EKG, which he interpreted as normal.

The physician diagnosed the chest pain as gastrointestinal in origin and prescribed an antacid. Because of the patient’s cardiac risk factors, the doctor scheduled a stress test and EKG for 2 days later.

On the morning of the stress test, the patient’s wife found him unresponsive. Resuscitation failed, and he was pronounced dead. An autopsy revealed severe proximal coronary artery disease of the left main coronary artery, left anterior descending coronary artery, and right coronary artery, as well as evidence of “remote and recent myocardial infarction.”

PLAINTIFF’S CLAIM: The EKG demonstrated significant changes compared with an EKG performed 3 years earlier and indicated that the patient was suffering an acute coronary episode. The doctor was negligent in failing to diagnose the episode and transfer the patient for proper cardiac care.

DOCTOR’S DEFENSE: The patient’s presentation indicated gastrointestinal distress; the EKG was normal.

VERDICT: $1.5 million Massachusetts settlement.

COMMENT: It’s imperative to compare EKGs, chest radiographs, and other tests with baseline results. How many times do you see an EKG that shows subtle but important changes that influence management?

Testing confusion delays breast cancer Dx

A WOMAN NOTICED A HARD SPOT IN HER LEFT BREAST in April and reported it to her physician in June. The doctor referred the 47-year-old patient to another physician, who performed a mammogram in early August. Four days later, the woman received a call directing her to return for imaging of her right breast. The patient claimed that when she told a radiology technician that she was concerned about her left breast, the technician replied that the order called for a right breast exam. Shortly thereafter, the patient received a letter informing her that everything was fine and instructing her to come back in a year.

She was still feeling the mass in her left breast when she returned for her annual exam the following August. A few weeks later, she was diagnosed with breast cancer. When the case went to trial, the patient had been told she had 2 years to live.

PLAINTIFF’S CLAIM: The plaintiff’s claim centered on the delay in her diagnosis, though the specifics were not detailed in the case summary.

DOCTORS’ DEFENSE: The defendants blamed each other for the delay; they also claimed that the patient should have kept complaining if she felt a mass. They further maintained that the required treatment would have been the same if the cancer had been diagnosed the previous year.

VERDICT: $4.5 million Missouri verdict (second physician, 85% at fault; radiology technician, 15% at fault).

COMMENT: What can go wrong does go wrong: A slip in communication and follow-up led to this $4.5 million verdict. Failure to make a timely diagnosis of breast cancer remains one of the most litigious areas in medicine.

Pulmonary disease masks lung cancer

A WOMAN WITH IDIOPATHIC PULMONARY FIBROSIS had been monitored by her physician for 7 years with physical exams, pulmonary function tests, and radiographic studies, including CT scans of the chest. During an office visit in October, the 57-year-old patient complained of increased difficulty breathing. A pulmonary function test and CT scan showed progression of the pulmonary fibrosis.

The following July, a pulmonary function test showed further deterioration of the patient’s condition, and the physician quadrupled her corticosteroid dosage. When the patient reported breathing problems again in December, a pulmonary function test showed continued decrease in breathing function.

Five months after that, the patient developed a malignant thigh lesion. A chest CT scan later that month revealed a lobular mass in the lower right lung, which had not appeared on the scan done a year and a half before. A biopsy revealed stage 4 adenocarcinoma. The woman died less than a month later of metastatic lung cancer.

PLAINTIFF’S CLAIM: The physician failed to follow up properly on the worsening fibrosis, allowing the cancer to grow un-detected. The physician should have ordered a CT scan in July or December.

DOCTOR’S DEFENSE: No negligence occurred; the patient didn’t complain much about her symptoms, and no signs or symptoms during her visits suggested that more tests should have been ordered. An earlier diagnosis wouldn’t have made a difference because the patient would not have been a candidate for surgery.

VERDICT: New York defense verdict.

COMMENT: Although a defense verdict was returned, we have to be careful not to overlook a serious new problem in the midst of a chronic disease—in this case, lung cancer against a background of pulmonary fibrosis.

Undiagnosed infection has disastrous results

WHILE HOSPITALIZED FOR ROUTINE POST-PARTUM CARE after the uneventful birth of her second child, a 37-year-old woman developed tachycardia and hypotension along with an expanding, excoriating wound on her labia. She claimed that the wound was treated only by applying ice and monitoring blood counts. The patient’s condition deteriorated until, on the third postpartum day, her blood pressure dropped and she coded. She was revived, and necrotizing fasciitis was diagnosed.

The woman spent 4 months in the ICU, during which time she underwent many surgeries to debride the wound as well as a nephrectomy and a permanent colostomy. The surgeries caused extensive scarring in the groin area. For 6 months after discharge from the ICU, the patient couldn’t walk without a cane or walker.

PLAINTIFF’S CLAIM: The specifics of the claim—which likely focused on the wound care she received and the delay in her diagnosis—were not detailed in the case summary.

DOCTOR’S DEFENSE: No negligence occurred. Necrotizing fasciitis is rare, and none of the health care providers should have been expected to diagnose it.

VERDICT: Confidential Nebraska settlement.

COMMENT: This case serves as a potent reminder of the serious nature of this dreaded infection.

Misdiagnosed chest pain leads to fatal MI

A 43-YEAR-OLD MAN, who smoked cigarettes and had a strong family history of coronary artery disease, had been under the care of a primary care physician for 3 years. The patient’s history also included at least 1 episode of chest pain.

The patient visited his physician complaining of intermittent chest pain for several days. He described 2 episodes of nausea, vomiting, and pain in his back teeth, followed by pain radiating down his right chest to the right costal margin. He had no symptoms during the office visit. The physician ordered an in-office EKG, which he interpreted as normal.

The physician diagnosed the chest pain as gastrointestinal in origin and prescribed an antacid. Because of the patient’s cardiac risk factors, the doctor scheduled a stress test and EKG for 2 days later.

On the morning of the stress test, the patient’s wife found him unresponsive. Resuscitation failed, and he was pronounced dead. An autopsy revealed severe proximal coronary artery disease of the left main coronary artery, left anterior descending coronary artery, and right coronary artery, as well as evidence of “remote and recent myocardial infarction.”

PLAINTIFF’S CLAIM: The EKG demonstrated significant changes compared with an EKG performed 3 years earlier and indicated that the patient was suffering an acute coronary episode. The doctor was negligent in failing to diagnose the episode and transfer the patient for proper cardiac care.

DOCTOR’S DEFENSE: The patient’s presentation indicated gastrointestinal distress; the EKG was normal.

VERDICT: $1.5 million Massachusetts settlement.

COMMENT: It’s imperative to compare EKGs, chest radiographs, and other tests with baseline results. How many times do you see an EKG that shows subtle but important changes that influence management?