At a December 2003 visit, the patient again complained of lightheadedness. Her blood pressure was measured at 164/84 mm Hg when she lay down, 146/80 mm Hg while she was seated, and 90/50 when she stood up. The primary care provider noted significant orthostasis and autonomic dysfunction. Fludrocortisone was prescribed, as were thigh-high compression stockings. Results of blood work (which did not include an amitriptyline level) were essentially normal.
The patient was seen by her provider in April 2004 for nausea and vomiting. She had significant orthostasis and blood pressure as low as 72/50 mm Hg; she was too weak to walk. She was hospitalized, with admission orders indicating that she was still taking amitriptyline at bedtime. During her week-long hospitalization, the patient continued to experience significant orthostasis, with complaints of dizziness on standing. She was seen by a neurologist, who ordered blood work (again, with no amitriptyline level).
On discharge, the patient was feeling better and able to ambulate without dizziness. Subsequently, however, she continued to report significant orthostasis and dizziness at every visit with her primary care provider. In May 2004, she reported worsening anorexia, nausea, vomiting, watery diarrhea, and episodes of syncope. She had fallen several times and was bruised all over her body.
She was hospitalized once again. On admission, the patient was pale and cachectic, with blood pressure as low as 60/40 mm Hg when she stood; she was also noted to have tremors. She was given a diagnosis of profound orthostatic hypotension with syncope/autonomic dysfunction and a question of Shy-Drager syndrome.
During this hospitalization, she was examined by another neurologist, who believed the woman had multiple systems atrophy with Shy-Drager syndrome, Parkinson's disease, and dementia, as well as spells suggestive of seizures. A covering physician ordered blood work to check the woman's amitriptyline level, which was found to be abnormally elevated. Amitriptyline was discontinued and the level returned to normal therapeutic range, then fell to zero.
The woman developed severe respiratory compromise with probable adult respiratory distress syndrome and was transferred to intensive care. She died three weeks later as a result of respiratory failure.
The primary care provider claimed that amitriptyline toxicity is extraordinarily rare and is almost always associated with intentional overdose; thus, it was acceptable not to consider this explanation for the decedent's illness, especially with regard to the broad differential diagnosis available. The defendant also suggested that the decedent had been taking amitriptyline more often than prescribed without telling the primary care provider.
A $1 million settlement was reached.