Not My Specialty

by Ann S. Lofsky, M.D., Anesthesia Consultant and Governor Emeritus

In this era of medical specialization, physicians are expected to keep up to date and maintain thorough knowledge bases in their areas of expertise. Sometimes, however, patients present with problems that “cross the lines” into areas in which a physician might not normally practice. The following case presents questions on how much physicians are expected to know about medical conditions that they do not normally diagnose and treat and how much responsibility they bear for routing patients to the correct practitioners.

A 32-year-old woman presented to her OB-GYN complaining of lower abdominal pain worsened by urination, fever, chills, and nausea of 10 days’ duration. The physician performed a pelvic exam, which was described in the chart as “essentially negative,” although he noted a vague fullness and possible increased tenderness in the right adnexal area. The chart lists the differential diagnosis as: “Rule-out urinary tract infection, ectopic pregnancy, sexually transmitted disease.”

A urine pregnancy test performed in the office was negative. A Chlamydia/STD panel was sent along with a urine culture and sensitivity. Although the results of those tests were not due back for three days, the insured elected to start the patient on Cipro and a nonsteroidal anti-inflammatory for a presumed diagnosis of urinary tract infection. A pelvic ultrasound was scheduled. The ultrasound facility was quite busy, however, so the patient was offered an appointment in four days—which was scheduled and confirmed by the insured’s office staff.

Was There Anything Wrong with This Treatment Plan?

The patient phoned the OB-GYN’s office two days after this visit to say that the pain was no better and she was feeling quite unwell. The insured was not in the office at the time. A nurse claims she told the patient to come into the office that day for another evaluation or to go to the emergency room. This conversation was not documented anywhere in the insured’s records, though, and the patient disputes the nurse’s account. She states that she was told to go to the emergency room only if the pain became more severe or if she had high fevers; otherwise, she was to await the results of the pending laboratory tests.

Three days after the initial office visit, the patient pre-sented to a hospital emergency room complaining of severe lower abdominal pain, diarrhea, nausea, and vomiting. Laboratory work at that time revealed an elevated white blood cell count of 28,000, and a CT scan was read as probable appendicitis with marked inflammatory changes noted in the area.

The patient was taken emergently to the operating room where she was found to have a ruptured appendix with considerable purulent material in her abdominal cavity. Postoperatively, she developed a prolonged ileus with small bowel obstruction and sepsis. She was discharged more than two weeks later after a stormy hospital course. She ultimately filed a lawsuit against the OB-GYN alleging failure to diagnose appendicitis.

Should the OB-GYN Have Made This Diagnosis Earlier?

Expert reviewers felt that the patient’s initial presentation with a 10-day history of nonescalating pain was atypical for appendicitis and that an OB-GYN would not necessarily be expected to come up with that diagnosis immediately. The patient did not have a surgical abdomen at the time of the exam, and it was reasonable to perform laboratory tests and await the results. The experts were critical of the OB-GYN’s failure to perform and document an abdominal examination in detail. They believed that a full abdominal exam would likely have demonstrated early rebound tenderness consistent with appendicitis.

A number of experts commented that appendicitis should at least have been on the differential list for any patient with right-sided pain or tenderness, even if it was not the main diagnosis entertained. Had it even been considered, the ultrasound exam would likely have been obtained earlier. The insured was also criticized for not obtaining a CBC; it was argued that a CBC is required whenever a diagnosis of appendicitis is a possibility. Additionally, a C-reactive protein test, while nonspecific for inflammation, might have helped in making a correct diagnosis.

The defense experts countered that even if the ultrasound had been performed and had showed a right-sided mass, it would most likely have been interpreted as an ovarian cyst, and the patient would have been advised to follow up for more testing. These experts also pointed out that the patient’s initial complaint did not describe the pain localizing to the right side, and therefore appendicitis was not something that needed to be in the differential diagnosis. They also argued that a CBC, which might have revealed an elevated white count at the time, would have been nonspecific and would not have been inconsistent with the other diagnoses being considered—including urinary tract infection.

The experts agreed, however, that this patient would not likely have developed such severe peritonitis had the surgery been performed earlier—when she first presented—although her initial complaint of pelvic rather than periumbilical pain indicated that there might already have been a rupture. It was argued that the surgery might have been performed laparoscopically had it been done earlier, minimizing the woman’s recovery.

Should This Case Be Tried?

There were a number of areas in this case in which the insured was felt to be vulnerable. Documentation was a problem, both in the failure to document the abdominal and pelvic examinations in detail and in the failure of the OB-GYN’s office staff to document a conversation with a patient in which medical advice was given. In the physician’s deposition, he admitted to being unsure after the patient’s first visit as to the exact cause of the right-sided pelvic tenderness and fullness. Under these circumstances, it was felt that a physician would have been expected to at least keep appendicitis within the “radar” of the diagnostic screen and, as such, to perform more specific tests or refer the patient to a general surgeon to rule it out by exam.

The plaintiff’s demand for settlement remained high. Although the woman seemed to have recovered completely from this episode, her treating physicians testified that she was still at increased risk for abdominal adhesions and episodes of bowel obstruction. The insured, after discussions with his attorney and claims staff, elected to try this case. The trial resulted in a verdict for the plaintiff, although the dollar amount was considerably less than the initial demand.

Interestingly, jury members commented afterward that had the insured even listed appendicitis on his differential diagnosis, they likely would have rendered a defense verdict, even though the end result for the patient might have been the same. Jurors felt that in this case, it had been convincingly argued that the standard of care includes suspecting appendicitis when a patient complains of pain that localizes to the right lower quadrant, unless an alternative diagnosis can be confirmed.