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.

FAST TRACK
The physician said that he’d ruled out cardiac disease and prescribed Darvocet for arm pain. Two days later, the patient was dead.

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.

FAST TRACK
The patient’s health care team never suspected bacterial endocarditis, despite her fever, constitutional symptoms, and heart murmur.

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.