The defendant claimed that there was no negligence involved, that the decedent had not kept the appointment for an echocardiogram, and that no physician who evaluated the decedent in the intervening years had ever detected a murmur.
Outcome
According to a published account, a $1.6 million verdict was returned.
Comment
A newly found murmur, whether loud or soft, deserves a complete work-up. This is particularly true when an athlete is involved. Even though an echocardiogram was ordered in this case, standard of care requires the clinician to follow up with the patient or to refer the patient to ensure adequate follow-up. —RDD
Failure to Make a Diagnosis of Colon Cancer
In October 2001, a 31-year-old man from Massachusetts went to his primary care physician’s office and was seen by a nurse practitioner. He complained of burning, cramping abdominal pain and inability to eat, which had resolved by the time of his appointment. The NP prescribed ranitidine and scheduled an appointment for a complete physical exam the following month.
During the subsequent physical exam, the patient complained of occasional abdominal pain and increased defecation. His family history included his mother’s diagnosis with colon cancer at age 54. The man also mentioned a history of chewing tobacco use and heavy coffee intake. No rectal exam was performed during this visit, nor was the patient provided with a fecal occult blood test. A colonoscopy was not ordered.
The NP changed his prescription to pantoprazole and ordered an upper GI series with contrast to rule out gastritis or ulcer; test results were negative for either. The patient’s primary care physician was given the test results, and neither the NP nor the physician initiated any discussion regarding what should be done next. The primary care physician never saw the man, nor did he review his chart at the time of this appointment.
In early December 2001, the man was seen again by the NP. He reported that his symptoms had improved on pantoprazole, but he continued to have eating problems. The NP maintained the original diagnosis of gastritis and discharged the man with instructions to call with any concerns and to return in six months. The NP did not include colon cancer in the differential diagnosis because of the patient’s age.
The man returned to the primary care physician’s office in April 2002 and was seen by the same NP. At this time, he reported worsening stomach cramps and a burning stomach. The NP switched his medication to lansoprazole while maintaining a diagnosis of gastritis. The NP made arrangements for the man to see a gastroenterologist for a possible esophagogastroduodenoscopy. The gastroenterology consult was not scheduled to take place until July.
The patient returned in May complaining of increased pain and loose stools whenever he ate cereal with milk. The NP’s revised diagnosis was gastritis and ulcer with lactose intolerance or nicotine addiction from chewing tobacco.
The gastroenterology consult was moved up, but the patient went to an ED before the scheduled visit. A work-up at the hospital, which included abdominal CT and a colonoscopy, resulted in a diagnosis of near obstruction of the right side of the colon by a stage IV tumor and metastasis to the peritoneum and lymph nodes. Immediate surgery was performed, followed by several rounds of chemotherapy, further abdominal surgery, and a cingulotomy for pain relief. The man died in December 2004.
The plaintiff claimed that the NP was negligent in failing to perform a rectal exam, conduct a fecal occult blood test, or order a colonoscopy. The plaintiff also claimed that after results from the upper GI were negative, a colonoscopy was required. The plaintiff claimed that in the fall of 2001, the colon cancer had probably been at stage IIIA with a 65% chance of survival, or stage IIIB with a 45% chance of survival, and that there was no chance of survival by the time the correct diagnosis was made.
The defendants claimed that a colonoscopy was not required because “burning” pain is more consistent with an upper GI process, and that the decedent’s history of chewing tobacco and excessive coffee consumption accounted for his eating difficulties. The primary care physician also claimed that a random review of patient files constituted adequate supervision and that there was no independent duty to review individual patient charts and sign off on them on a regular basis.
The defendants claimed that the decedent’s cancer was already at stage IV in the fall of 2001 and that nothing they could have done at that time would have changed the outcome. In addition, the defendants claimed that the decedent’s cancer was signet ring cell cancer, a very aggressive form of cancer that is nearly always fatal.