Texas Medical Liability Trust

Failure to diagnose

Clinical presentation
A woman presented to her general practice physician with complaints of dizziness, blurred vision for 24 hours and that she was seeing spots. She also reported a cough, dull left ear pain and when she reached for something she “missed” it. (A year earlier, the patient was diagnosed by this physician with uncontrolled hypertension and hypercholesterolemia. She was prescribed Accupril.) She was obese and a heavy smoker.

Physician action
Examination indicated normal ears, sinus, nose, mouth, throat and neck. No neurological examination was performed. The physician believed the symptoms were the result of an inner ear infection and side effects from her medications (cough secondary to Accupril.) Her Accupril was changed to Ziac and she was prescribed Antivert.

The patient returned six days later and was seen by another physician in the practice association. The patient complained she saw “everything backward,” and she was unable to read. The second physician found fluid in the ear with inflammation and purulent drainage. A neurological exam showed “sensorimotor normal and mental status normal.” There is no indication the patient was checked for bruits. The second physician’s diagnosis was acute otitis media with vertigo. He prescribed antibiotics and recommended continuation of Antivert for vertigo.

The patient returned two days later and was seen by her original physician. She reported no improvement of her symptoms. The patient’s ears had cleared and the physician recommended continuation of Antivert.

The following day, the patient presented to the emergency room complaining of right hemiparesis and aphasia. Studies showed occlusion of the left internal carotid artery and she was diagnosed as having suffered an acute CVA causing aphasia and right-sided weakness. She was treated with anticoagulants and discharged a week later. An evaluation of the patient more than a year later revealed she had regained the use of her right side, but sensory loss prevents any functional use of her right upper extremity. She cannot drive an automobile and has severe non-fluent aphasia. She also suffers from depression.

Allegations
• Failure to perform a proper neurological examination

• Failure to diagnose and treat the impending CVA.

Legal principle
In this case, both negligence and proximate cause were issues to address. TMLT consultants were critical of the examinations performed by both physicians in failing to consider CVA in view of the patient’s risk factors. After three office visits, treatment should have been more aggressive, including an MRI and/or a CT scan and possibly a neurological referral. The stroke occurred 18 hours after her last visit to the general practice physician.

Regarding causation, the development of the stroke was partially attributed to an unfortunate family history of hypertension and the plaintiff’s non-compliance with medical treatment. She contributed to the disease process by continuing to smoke and failing to follow a low fat diet. The defense was able to locate experts to raise these causation issues.

The defense was compromised when the physician admitted he conducted a “chart review,” after learning of the patient’s CVA. He made numerous additions to chart dealing with the patient’s neurological and visual status.

Resolution
This case was settled on behalf of the physician for six figures.

Risk management considerations
The physician utilized history and physical exam forms for documentation. (See sample). Many physicians prefer forms for documentation as they provide cues and reminders for pertinent documentation. While forms are often a preferable method for documenting medical care and treatment, they must be consistently completed with all the blanks filled in. Medical record forms left blank or unanswered by you, your staff or the patient, may be open to conjecture by others reviewing records.

It is suggested that patient history forms left blank by the patient be reviewed and completed by staff or the physician. It is further suggested that the physician, acknowledging review of information, sign these forms. Likewise, physical examination forms should be signed and dated.

In this case, the physician did not complete all sections on the form at the visit the day prior to the patient’s CVA, leaving many sections unanswered and undocumented. Not only did he not complete the record, but upon learning of the patient’s CVA, performed a “chart review” where he added documentation including dates indicating “normal” examination in multiple areas. He added the later date to the documentation from the earlier visit. This greatly compromised defensibility in this case.

Following review of documentation of a patient encounter, it is appropriate for a physician to review entries and, if necessary, supplement that information with a “late entry.” Late entries should clearly be identified as such and include the reason for the lateness of the entry. It should reference the date and time of the actual encounter, but should clearly state the date and time of actual entry/documentation, and be signed by the person making the entry. Entries should be made at or near the time of the patient encounter. After the fact entries may be viewed as “alterations” to the medical record.

Altering the medical record seriously jeopardizes a physician’s credibility. Upon reviewing the medical record when served with a notice of claim or lawsuit, physicians may be tempted to add information they believe will assist in their defense. While the information itself may be accurate, the addition of such information after the event is frequently detrimental to the defense of the case. Plaintiff’s attorneys will use this information to discredit the physician. While there may have been no breach of the standard of care, situations such as this are difficult to defend at trial and frequently result in settlements out of court.