Alleged improper performance of general exam
Clinical presentation
A 25-year-old female was involved in a motor vehicle accident and was apparently wearing a seat belt. She received an impact to the upper abdomen and left upper quadrant of the abdomen. She was worked up in the emergency room. Everything, including x-rays, was "negative" at the time. Four days later she presented to a family physician as a new patient. She complained of muscle soreness and pain in the left ribs.
Physician action
The physician’s examination revealed "tender on the left rib cage and left shoulder and abdomen. Neck is painful to flexion and extension." There is no specific documented abdominal exam. Blood pressure was 110/68. The physician diagnosed contusion of the left ribs and the shoulder with muscle soreness in the neck and the back. He prescribed Flexoril 10 mg t.i.d.; and Lasix, at the patient’s request for "fluid retention." He asked her to return if not better in two days. The patient did reasonably well until four days later when she experienced pain the lower sternum while in a swimming pool and fainted.
She was taken to the emergency room where she was noted to be very anemic and in "pre-shock" according to the admitting physician. A sonogram performed in the emergency room demonstrated fluid in the abdomen and an irregularity at the top of the spleen. In addition, she had an abnormal abdominal x-ray which showed an irregularity along the anterior splenic surface and some fluid present in the peritoneal cavity as well as left pleural effusion. Rib details were normal. Plain abdominal x-rays also showed "splenic elargement with loss of the left psoas margin, possible splenic hematoma with rupture suggested." Her physical examination at the time of presentation to the emergency room showed her to be pale, conscious and coherent with a rapid pulse rate. Her chest x-ray at the time of the emergency room admission also showed a large amount of fluid in the left chest. A thoracentesis was obtained which showed a large quantity of serosanguineous fluid.
The patient underwent a exploratory laparotomy which revealed an enlarged, swollen and ruptured spleen with a large quantity of blood in the free peritoneal space. The spleen was removed without incidient, a chest tube was inserted on the left side and placed to water seal drainage. Intraoperatively, the patient was administered an undocumented number of units of blood. The hemoglobin increased from its preoperative H&H level of 6.8 and 20.1 to a postoperative H&H of 10.9 and 32.3.
The patient had a fairly unremarkable hospital course. She experienced some atelectasis but responded well to respiratory therapy. The chest tube and NG tube were removed on day two postoperatively and the patient tolerated this well. She was dismissed home on postoperative day six suffering no complications.
Allegations
• Improper performance of the general examination
• Failure to adequately monitor the patient’s condition
• Failure to diagnose and timely treat the patient’s condition
Failure to perform necessary diagnostic studies to determine and advise the patient of her condition.
Legal principle
Standard of care is reasonable and generally accepted medical practice and treatment based on that used by other reasonable health care providers in the community and/or throughout the United States, when faced with the same or similar circumstances.
Risk management issues
This case was successfully defended in the courtroom; however, the suit may not have been necessary had the medical records reflected better documentation.
• In patients complaining of rib pain, record a respiratory rate to demonstrate the patient is not suffering any respiratory compromise.
• Document the hematocrit to demonstrate that the patient’s blood count has not dropped significantly.
• Document objective examination findings correlating to the patient’s complaints.
• Document in detail an abdominal exam on patient’s complaining of "tenderness in rib cage, left shoulder and abdomen."
• Document appropriate testing, such as sonograms, when indicated.
• Utilize a broad definitive diagnosis.
