Presentation
On January 10, a 35-year-old man was taken by ambulance to a hospital’s emergency department (ED) reporting headache and dizziness. The patient had a history of hypertension and hypothyroidism.
Physician action
Family Physician A, the on-call physician, admitted the patient and documented the following: status migrainosus versus complicated migraine; hydrocephalus and ventriculomegaly; nausea and vomiting; and headache. Family Physician A requested consults from neurosurgery and neurology.
Neurologist A saw the patient and ordered an MRI of the brain. The MRI was completed on January 11, and showed a stable cystic dilation of the patient’s fourth ventricle. The radiologist’s impression was arachnoid cyst; Neurologist A thought it might be neurocysticercosis. Neurologist A consulted an Infectious Disease Physician A, who then ordered serology testing. Family Physician A deferred patient management to neurosurgery, neurology, and Internal Medicine Physician A.
On January 12, a lumbar puncture ordered by Neurosurgeon A indicated the patient had meningitis, though the patient did not have a headache and did not report nausea or vomiting. Infectious Disease Physician A prescribed antibiotics for meningitis.
On January 13, the patient’s diagnosis was uncertain and results that would confirm neurocysticercosis were pending. Family Physician A knew of the pending serologies and planned to discharge the patient the next day if he was fever free.
Neurologist B — who did think the patient had meningitis — had his CSF re-tested. No organisms were seen. Neurologist B discontinued the patient’s antibiotics, and Infectious Disease Physician A documented that the patient could be discharged with instructions to follow up with Internal Medicine Physician A.
On January 14, Neurosurgeon A’s physician assistant (PA) examined the patient and noted that his headache had recurred. The PA planned for Neurosurgeon A to discuss this with Infectious Disease Physician A. The patient was discharged and instructed to follow up in two weeks with the Internal Medicine Physician A while waiting for serology results.
On January 15, the patient went to a different hospital ED with a headache. After a CT scan, he was referred to neurosurgery and infectious disease for outpatient treatment.
The patient saw Family Physician B on January 17. He concluded the patient had possible 4th ventricle neurocysticercosis and mild hydrocephalus. The patient was told to follow up with neurosurgery and infectious disease.
In Family Physician A’s discharge summary dictated on February 6, he noted that the results of the CSF serologies found positive IgG cysticercosis. He documented that the patient probably had the infection during initial testing, but IgM was not tested. Therefore, it was not possible to determine if the infection was acute.
The discharge summary stated: “However, more than likely, the patient’s radiological findings on MRI of the cyst, which was suspicious for neurocysticercosis. It is likely that the patient was infected in the past with taenia solium, and this is the reason for positive IgG titers.”
Because the patient was not discharged on any anthelminthic medications, Family Physician A planned to ask if Infectious Disease Physician A was told of the positive IgG results. But Family Physician A did not follow up.
In August, the patient came to the ED reporting fainting, dizziness, vertigo, and nausea. After neurosurgery was consulted, the patient underwent ventriculostomy and craniotomy due to the fourth ventricle brain cystic mass. A ventriculoperitoneal shunt was placed due to hydrocephalus. The pathology report confirmed neurocysticercosis.
Allegations
The patient filed a lawsuit against Family Physician A and Internal Medicine Physician A. The allegations included failure to properly diagnose and treat the patient and failure to inform the patient of lab results after he was discharged.
Legal implications
Consultants who reviewed this case had mixed opinions. Two consultants believed both physicians met the standard of care. Family Physician A and Internal Medicine Physician A were noted for making appropriate referrals to neurosurgery, infectious disease, and neurology.
Others who reviewed the case agreed that Family Physician A should have followed up with Infectious Disease Physician A after the serology results were finalized because the patient could have been directed to a neurosurgeon.
It was also noted that the patient was noncompliant, as he did not follow up with neurosurgery and infectious disease. This led to a discussion among the consultants about causation. If the patient had been notified of the lab results in a timely manner, the outcome might have been the same, because patient’s ED visit at another hospital did not result in the prescription of an anthelmintic.
The plaintiff’s experts criticized the defendants for discharging the patient too soon. They claimed that delaying the patient’s discharge by 48 hours would have allowed lab results to arrive and treatment to begin during the patient’s first hospitalization. Defense consultants stated that it was appropriate to discharge the patient because his condition was stable.
Disposition
This case was settled on behalf of Family Physician A and Internal Medicine Physician A.
Risk management considerations
Failure to follow up and failure to communicate were significant issues in this case. It was the responsibility of Family Physician A to ensure lab results were reviewed and followed. However, the patient was discharged before all the laboratory test results were received. The patient’s cysticercosis was probably still active when the patient was discharged, as it was diagnosed and treated later at another hospital.
In addition, the infectious disease physician did not order a cysticercosis IgM antibody on the LP (spinal tap) fluid, which may have shown the infection was acute and needed antiparasitic treatment. This lack of action may have led to the delay in diagnosis and treatment.
Family Physician A dictated on his discharge summary that he would touch base with the Infectious Disease Physician A about the test results, but it is not clear if he did. In addition, Family Physician A did not notify the patient of his lab results.
When a patient is discharged, it is the physician’s responsibility to ensure outstanding labs, tests, referrals, etc. are followed up on. By implementing a standard follow up system for tests, labs, and referrals, physicians can ensure nothing “slips through the cracks” and treatment is initiated in a timely manner.
If lab results are not reported in a timely manner and a definitive diagnosis cannot established, it is recommended to hold off discharging a patient until the results can be obtained and evaluated.
In this case, if Family Physician A had waited to discharge the patient until after the lab results were obtained, there may not have been a delay in diagnosis and treatment could have begun during the first hospitalization.
This case was also complicated by multiple care providers and a non-compliant patient. For optimal patient outcomes, it is important to carefully and comprehensively communicate, evaluate, monitor, and follow up on a patient’s condition.
