This documentation made missed PE claim very defensible

This documentation made missed PE claim very defensible

A primary care physician sued for failure to diagnose a pulmonary embolism (PE) was able to successfully defend the case, despite the fact that the patient died 30 minutes after leaving the physician's office.

"It was a very sympathetic case, as the man died in front of his young children at a park," says Tammi J. Lees, Esq., an attorney with Roetzel in Cleveland, OH.

The physician was able to show that he spent a considerable amount of time with the patient. "Although he had a differential diagnosis that included PE, he was able to adequately explain why PE was low on the list and why lung cancer and pneumonia were highest on his list," says Lees. Here are the facts of the case:

The 44-year-old patient presented to his family practice physician with a principle complaint of shortness of breath with exertion. The patient related a two-week history of rib pain after lifting heavy steel plates at work, blood in his sputum, and shortness of breath.

The physical exam was unremarkable with normal lower extremities, and only mild tachypnea and exertional dyspnea. "Our physician noted that the resting pulse oximetry was 93%. The pulse oximetry on exertion was 78%, but recovered quickly back to 93%," says Lees.

The physician explained to the patient that although PE was on his differential, the most likely cause of his symptoms was resistant pneumonia or lung cancer. A complete blood count was ordered, and blood was drawn at the physician's office, but results were not available that day. The physician arranged for a chest CT scan at the hospital two days later and prescribed an antibiotic.

"The patient passed out at a park 30 minutes after leaving our physician's office," says Lees. "After being transported to the hospital, he became unresponsive and died." An autopsy confirmed that the patient died from a PE.

The resulting malpractice suit alleged that the physician failed to diagnose the PE and failed to send the patient immediately to the hospital to rule out a PE. This documentation allowed him to successfully defend the case:

• The physician clearly documented his differential diagnoses: (1) resistant pneumonia; (2) lung cancer; (3) PE.
• His documentation also corroborated his explanation as to why he had PE lowest on the list and why it was reasonable for him not to send the patient to the hospital for an urgent CT of the chest or ultrasound of the legs to rule out the imminent life-threatening condition.
• The history of present illness was documented. The patient was seen by two physicians within the previous two weeks and was diagnosed with pneumonia.
• Family, social, and medical history was discussed with the patient and relevant history was documented: that the patient's father died from lung cancer and the patient was a 25-pack a year smoker with no family history of clotting disorders.
• The physician documented his physical findings and assessment.

Notably, he documented that his exam of the lower extremities was normal and unremarkable, with no edema or swelling, which would not be consistent with DVT.

"Although the absence of this finding does not mean there is no DVT, its presence would have increased the possibility of DVT," says Lees.

During his deposition, the physician admitted that the decrease in the pulse oximetry on exertion and history of blood in the sputum were consistent with a PE. "However, he further explained that each of these findings is more consistent with the established diagnosis of pneumonia," says Lees.