Lost Vision After DX Delay

Description

A 72-year-old woman, who presented to her PCP with symptoms that he attributed to her leukemia, suffered a complete loss of vision in one eye following a delayed diagnosis of temporal arteritis.

Key Lessons

A pre-existing medical condition is a red flag for a potential narrow focus that can delay timely diagnosis.
Patients need to be told the results of diagnostic tests, without blanket statements like “unremarkable” in the presence of an elevated value.

Clinical Sequence

A 72-year-old woman with a complex medical history including asthma, chronic lymphocytic leukemia (CLL) and rheumatoid arthritis presented to her long-time PCP, with complaints of headache, left jaw pain, scalp tenderness and fatigue. An ESR was drawn with a result of 69 (normal value is below 20). The PCP attributed the elevated ESR to both the leukemia and the arthritis, suspected a reactivation or spread of the cancer. However, the patient had seen her oncologist during the prior month and was given a clean bill of health. It is unclear whether the PCP reviewed the oncology note, which was available in the medical record.

Three days later, the patient received a letter from her PCP that all tests results were “unremarkable.” Tests included TSH, HgAIC, electrolytes and the ESR.

Twelve days after seeing the PCP, the patient again called with complaints of a worsening headache. She was advised to see her oncologist for follow-up. The following day she sought care from her ophthalmologist instead, with complaints of visual symptoms that included reduction of her left visual field. The ophthalmologist evaluated the patient, sent her for blood work, and spoke to the PCP regarding a potential diagnosis of temporal arteritis. The PCP related his diagnosis of a reaction of the patient’s CLL. The ophthalmologist alerted the patient to the possibility of temporal arteritis and recommended steroids. He was unsure if the patient could take high dose steroids with CLL and referred her to the emergency department, as it was after 6:00 p.m. He also suggested she follow up with her rheumatologist. The patient declined to take any action, stating that she preferred to go home and consult her family and the internet.

The next day, laboratory results from the ophthalmology visit came back with an ESR of 80 and a high C-reactive protein, both indicative of temporal arteritis. The ophthalmologist left a message for the patient to call her PCP immediately and spoke to the PCP to alert him of the test results. The patient had independently contacted her oncologist, who confirmed she could take the steroids. The patient contacted her PCP, who referred her to her rheumatologist. The rheumatologist returned the patient’s call immediately, and, based on a review of the laboratory findings, diagnosed temporal arteritis. He prescribed prednisone and instructed the patient to go to the ED. She was admitted to the hospital and started on high dose steroids for temporal arteritis.

A biopsy confirmed giant cell temporal arteritis. The patient was discharged from the hospital after three days on a steroid taper, and she was followed by the rheumatologist.

The PCP was unable to speak to the patient until two weeks later, due to a death in her own family. When she called, the patient was very angry about her course of care and the fact that she had permanent vision loss in her left eye and was never visited by the PCP. The patient continued to follow up with the rheumatologist after discharge and during the period of steroid taper.

Allegation

The patient sued the PCP and the ophthalmologist, alleging negligent delay in diagnosis of temporal arteritis, leading to permanent vision loss.

Disposition

The case settled in the mid range for $450,000.

Analysis

Clinical Perspective

Incorporation of symptoms and diagnostic test results into a pre-existing condition resulted in a narrow focus and missed diagnosis.
Analysis of clinical presentation and diagnostic test results must be evaluated on their own merit in the creation of a differential diagnosis. Use of decision support tools may assist in this process.
The PCP remained “locked in” to the initial diagnosis when presented with an alternative diagnosis by a specialist.
When presented with a colleague’s alternative conclusions, it is important to reassess the initial diagnosis by weighing the pros and cons. Additional data, including a continued presentation of symptoms, additional diagnostic test results, and a “second set of eyes” with a different expertise, assists in expanding the differential. Discussion, rather than a reflexive re-entrenchment, are important components of the cognitive decision-making process.

Patient Perspective

The patient learned about the significance of her diagnosis and potential complications via the internet, and felt that her issues were minimized by both the PCP and the ophthalmologist.
Proactive patients are sometimes viewed as troublesome and non-compliant. Yet a patient is her best advocate, and her insistence on a visual examination, and subsequent research on the complications of a potential diagnosis can lead to a correct treatment. Providers need to remain alert to repeated complaints, and open to discussion of information obtained from other sources. This can help prevent patient feelings of being dismissed, and might also result in a better case outcome.
The patient felt abandoned by her PCP who was unavailable to communicate with her during the darkest moments of her illness and hospitalization.
Some personal developments are unavoidable for providers, the perception on the part of the patient may be lack of follow through. When arranging coverage in an emergency, a quick review of patients currently in crisis, using staff if necessary, can help bring needed attention and communication to patients most in need during an absence. A brief communication to the patient and clear designation of the primary care physician assuming care are strategies that may minimize the perception of abandonment by both the patient and a jury.

Risk Management Perspective

Notifying the patient that all tests were “unremarkable” in the presence of an abnormal result reduced the PCP’s credibility.
Patient notification is an important step in completing the test result management process. Rather than provide a blanket statement such as “unremarkable,” physicians are better served by telling the patient that a result is abnormal and including both the rationale for dismissal and/or potential next steps in monitoring.

Legal Defense Perspective

Lack of documentation of the patient’s refusal to go to the emergency department late in the day, reduced defensibility.
Contemporaneous documentation of a patient’s informed decision to decline care must be included in the medical record. Appropriate documentation includes both the recommendation and review of the risks incurred by delay. This provides evidence of patient education and involvement in the decision to delay treatment.