Legal Pearls: Ignoring Patient History Leads to Stroke

Clinical Scenario

The doctor was a 64-year-old primary care physician with his own practice. He had been in practice for many years and was beginning to scale down his business in preparation for retiring in the next few years. He looked forward to spending his days on the golf course or fishing rather than seeing an endless stream of patients. He had enjoyed the practice of medicine for a long time, but he was ready to retire.

One day in early March, one of his patients came in for an appointment. The patient was a 58-year-old Black man with a past medical history that included obesity, smoking, hypertension, hypercholesterolemia, and atherosclerotic vascular disease. The PCP had been treating the patient for the past decade. When the patient began seeing the PCP 10 years ago, he had been asked to fill out a form describing his family medical history. The patient’s family history was significant in that his mother had had a stroke and myocardial infarction at a young age. In addition, the patient noted on the form that 10 of his 11 maternal aunts and uncles had had strokes or myocardial infarctions while in their 50s. This medical history form was incorporated into the patient’s medical record but was never looked at again after his initial visit 10 years before. Since then, the patient had come in about once a year, mostly for minor symptoms such a sore throats and coughs. The PCP had not been successful in convincing the patient to stop smoking.

At this appointment, the patient came in with lightheadedness and nausea. He had no other signs of a virus or stomach bug. The PCP attributed his symptoms to otitis media and prescribed an antibiotic and an antihistamine.

“I’m sure you’ll be feeling better soon,” the physician kindly told the patient, “but I’d like you to come back for a follow-up visit in 2 weeks so we can check on your progress. And I’ll say it again, as I always do—you really should quit smoking.”

The patient smiled. “It’s one of my few joys left, doc.”

Two weeks later, the patient came back for his follow-up appointment. His symptoms were unabated, but now in addition he was experiencing double vision.

“Doc, I took my medicine like I was supposed to, but it didn’t help,” he said to the physician. “I’m still queasy and dizzy, and I’ve been seeing double some of the time.”

The PCP was concerned. “I’m going to write you a referral to an ear, nose, and throat doctor,” he told the patient. “I want you to make an appointment with her, and hopefully we’ll figure out what the problem is.” He handed the patient the referral, and the patient left.

Two weeks later, he was evaluated by the ENT physician, who was unable to determine a definitive cause of his dizziness and double vision. The ENT sent her findings to the PCP, where they were filed away in the patient’s medical record. The patient continued to experience nausea, dizziness, and double vision.

One morning in June, 3 months after his initial appointment with the PCP, the patient called the physician to report severe lightheadedness and double vision.

“I can squeeze you in at 1 pm,” said the PCP. “Come in then and we’ll take a look at you.”

But he never made it to the physician’s office that day. He left his home and was headed to the office but he never showed up. Instead, at 5 pm, the patient was found unresponsive in his car by the side of the road. He was rushed to the emergency department of the nearest hospital where he was found to be unresponsive to all but painful stimuli. Brain scans revealed that there was no blood flow through his major blood vessels supplying blood and oxygen to the brain.

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