When your diagnosis doesn't explain the symptoms..... Take the pause.

Stroke is not only one of the leading causes of death and disability worldwide but is the third most frequently occurring medical condition involved in The Mutual’s malpractice claims. Specifically occurring at a higher frequency than in years past, are claims involving stroke in young patients. Diagnosis is not always straight forward, especially when complaints are vague and the patient does not have typical risk factors. Yet, when a young patient suffers a stroke and has a devastating outcome, a high exposure case ensues for all involved.

Most lawsuits related to stroke allege a failure or delay in diagnosis. While no two cases are the same, commonalities and trends occur. The reoccurring contributing factors are patient assessment issues such as failure to appreciate and reconcile relevant signs and symptoms, inadequate history and exam, failure (or delay) in ordering tests, and failure to broaden a differential diagnosis. Other contributing factors you may not expect are misinterpretation of diagnostic studies and overreliance on negative imaging for patients with ongoing symptoms.

Even the most thorough and thoughtful clinician can be involved in an unexpected, catastrophic patient outcome. Most reading this article will find the legal outcome frustrating, and many may have followed the same clinical course as the physician involved. So why read it? When the same trends are happening industry wide, there IS something to learn.

Chief Complaint: N/V, congestion, dizziness, left side numbness.

HPI: A 24-year-old patient with a history of anxiety and hyperlipidemia presents to the ED for complaints of throat pain with associated cough and congestion for 1 week. The patient stated he woke up 2 hours PTA and began vomiting, felt dizzy, and started to experience left sided numbness. Patient also complained of left shoulder pain that began the night prior; however, denies recent trauma or falls. He denies fevers, SOB, chest pain, abdominal pain, diarrhea, flank pain, rash, or other symptoms. He denies taking any medications for his symptoms prior to arrival.

Family Hx: Unremarkable. Social Hx: Denies smoking, drinking or drug use.

Exam: O2 sat 99%, BP 110/62, Temp 97.4, Pulse 76, Resp 20
General: NAD, alert
HENT: Normocephalic, no signs of dehydration, throat clear
EYES: EOMI, PERRL, no scleral icterus, no conjunctival pallor
Neck: Normal inspection, supple, no meningeal signs
Resp: No distress, breath sounds normal
Cardiovascular: RRR, pulses normal, no murmur
GI: Soft, non-tender, non-distended, no masses
Back: Normal inspection
Skin: No rash
Extremities: Full ROM
Psych: Mood normal, A&Ox3
Neuro: CN II-XII intact, subjective numbness to left arm and leg, motor strength 5/5 in all extremities, finger to nose intact, heel to shin normal, Reflexes 2+ at knees/elbows

ED course. Treatment. MDM.
EKG: Normal sinus. Non-specific ST changes. Intervals: Normal.
CXR: Normal.
ED Medications: Decadron 10mg IV, Zofran 4mg IV, Toradol 15mg IV, Reglan 10mg IM, NS 1L.

06:16: Pt was evaluated, course of treatment was discussed. Given age and risk factors I have low suspicion for CVA but will pursue workup to exclude. At this time his symptoms are not significant enough to warrant consideration of TPA and risks can potentially far outweigh the benefits.

07:45: Labs unremarkable. CT Head without IV contrast impression: No acute intracranial abnormality. Sinus inflammatory disease with small amount of layering right maxillary secretions. MRI ordered.

11:00: Upon re-eval, patient is feeling better after receiving treatment in the ED and tolerating PO. I updated the patient on lab and imaging results. Normal brain MRI. No cancer history, no immunosuppression or history of IVDA. I doubt osteomyelitis, spinal mass, or abscess. Pt will be discharged home with a prescription for Augmentin, Zofran, Afrin, and Zyrtec. Pt was advised to follow up with PCP in 2-3 days or return to the ED for worsening symptoms or condition. I discussed return precautions with the patient. Pt understands reasons to return.

Differential diagnosis includes but not limited to stroke, ICH, MS, anemia, electrolyte abnormality, ACS, meningitis.

Impression: Sinusitis and Paresthesia.

The following day, this same patient was transported via ambulance to another ED where he was diagnosed with a dissecting cerebral aneurysm and CT angio of the head demonstrated evolving infarctions. The patient’s strokes resulted in left-sided paralysis, loss of gross and fine motor skills, dizziness, inability to urinate and perform activities of daily living without assistance. The initial MRI from the prior day was grossly misinterpreted by the radiologist. Repeat read identified an acute stroke in the left pons, specifically, a short perforation off the basilar artery; and a second stroke at the left inferior cerebellum (PICA). Both strokes appeared hyper-acute. The primary target of the suit was the radiologist who misinterpreted the study; however, the plaintiff was focused on obtaining maximum damages to cover expenses for this young patient and the EM physician was not dismissed. Some defense experts felt the EM physician met the standard of care for considering stroke and performing a work-up in a 24-year-old. On the flip side, the plaintiff attorney noted reasonable criticisms for the care that could be persuasive to the public and a jury.

Focusing on the reasonable plaintiff’s criticisms, we can identify the practice improvement points that may prevent this outcome for you and a future patient.

1. Patient assessment: The history and exam. Mother testified the patient’s dizziness was severe enough to require a wheelchair at arrival and discharge. Gait testing is a crucial element of the physical exam when evaluating neurologic complaints. If a patient can normally otherwise walk and still cannot walk at the time of discharge, you must take the cognitive pause. Options may include but not be limited to: Obtain a neurological consult, admission for observation, and a discussion with the radiologist regarding the clinical scenario.
2. Deviation from hospital policies can be a hindering factor in defense. In this case the plaintiff would have argued our physician failed to initiate a Code Stroke pursuant to their ED policy. In doing so, even with the misread by the radiologist, this would have triggered the ED physician to obtain a neurology consult. If you are going to deviate from an established policy, ensure your documentation justifies your decision. Plaintiff’s expert opined the "great extent of the harm" suffered by the patient were due to the "failure by healthcare providers" to obtain a neurology consult.
3. MDM: Failure to provide an alternative diagnosis explaining the etiology of the patient's left-sided symptoms before the time of discharge. The diagnosis of sinusitis would not explain the patient's nausea, vomiting or left-sided numbness and weakness.
4. Overreliance on negative findings. Failure to consider TIA or treating the normal results of the CT scan and MRI of the brain as having ruled out a stroke or TIA. TIA or strokes in early stages do not always appear on CT or MRI.

Medicine is an art, and the job is hard. Slam dunk strokes may be easy to diagnosis, and some may also be easy to rule out. The work is cut out for us in the vague and atypical presentations. Be thorough. Take the cognitive pause. Ultimately, trust your gut. And, when you do, document clearly your reasons for the rationale you had.

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