Case reprinted with permission from Medical Malpractice Verdicts, Settlements and Experts, Lewis Laska, Editor, (800) 298-6288.
A 54-year-old Utah man awoke in late February 2002 with a “gurgling” sensation and pain in his mid-abdomen. He felt sick all that day and into the next. He vomited three times the next day and noticed the pain move to the lower-right quadrant of the abdomen.
His sister took him to an urgent care clinic, where he was examined by a PA. The patient was diagnosed with flu, and antiviral medication, ibuprofen, and bed rest were prescribed. When asked about appendicitis, the PA responded, “I guarantee you do not have appendicitis.”
The patient initially felt better, but then his condition worsened. Calls to the clinic for more medication were not returned. The man was taken to another clinic 10 days later and then referred to a hospital, where he was diagnosed with a ruptured appendix.
An emergency appendectomy was performed. The patient was hospitalized for 12 days and required six months to fully recover. The plaintiff alleged negligence in the PA’s failure to diagnose appendicitis.
Outcome
According to a published report, a confidential settlement was reached in mediation.
Comment
The patient in this case presented with generalized mid-abdominal pain and vomiting, with pain moving to his right lower quadrant. Migrating pain is one of the more specific findings of appendicitis, so it is not entirely clear from the facts presented why appendicitis was not considered more fully. It seems that a more complete workup, including diagnostic imaging and laboratory analysis, was indicated.
Appendicitis is common; so are complaints of abdominal pain. Appendicitis must be considered in all cases of abdominal pain, as must meningitis in all cases of headache. Yet any abdominal pain could be appendicitis, and any headache could be meningitis. The trick is panning out the few with a serious illness from the many with mild disease—all potentially presenting with the same symptom complex early on.
We cannot observe all patients indefinitely. Often, a patient must be discharged with vague symptoms and nonspecific findings that could be the start of something more grave. In such cases, clinicians should document the negative findings that make further emergency evaluation unwarranted and enlist the patient to monitor for signs and symptoms warranting an immediate return. Document those instructions fully. This approach can be defended in court, because the clinician considered a grave diagnosis yet had no reason to act on it in the absence of more specific symptomatology, and informed the patient of changes requiring immediate return.
Patients often raise the specter of ominous diagnoses. Such concerns should be met with an acknowledgement that such concerns are a “good thought,” followed by what is hopefully a laundry list of signs and symptoms that the patient does not have. Discharging patients with specific instructions builds rapport with the patient and family. I’ve found that patients so informed will often return if symptoms change to fit a previously discussed pattern and will even credit the clinician for making the diagnosis.
Of course, squarely at odds with this approach are dogmatic pronouncements “guaranteeing” patients of a diagnosis or outcome. Such certitude should be reserved for actors practicing medicine on television or the truly clairvoyant. (Most of us are neither).
One thing is certain: If such pronouncements are wrong, a plaintiff’s attorney will hang them around the neck of a defending clinician as an albatross—and a jury will be invited to conclude that the clinician was arrogant and imprudent.
In sum, rarely speak in terms of absolutes. Always respect the chance of a changing clinical course. And document your concern and instructions clearly. —DML