Presentation
A 6-year-old boy, accompanied by his mother, came to Pediatrician A for a sick visit on October 21. The child had a five-day history of fussiness, sore throat, coughing, vomiting, stomach pain, and fatigue. He had been a patient of Pediatrician A since birth.
Physician action
Pediatrician A examined the patient and documented the exam as normal with an additional comment of “benign” written to describe the abdomen. The patient had a fever of 102.6 degrees. A urinalysis showed 3+ red blood cells, trace protein, and 1+ leukocytes. Pediatrician A diagnosed the patient with a urinary tract infection (UTI) and prescribed cefexime. A CBC was ordered, but a urine culture was not.
The next day the patient’s mother called the office and reported that the patient was having diarrhea. She was instructed to “push fluids,” start him on a BRAT (bananas, rice, applesauce, and toast) diet, and call back in the morning. The signature of the person giving these instructions was illegible.
The mother reported in a call to Pediatrician A’s triage nurse the next day that the patient had not improved. She was advised to continue pushing clear liquids.
On October 24, the patient returned with his mother to the pediatric clinic. Pediatrician B, who shared office space with Pediatrician A, examined the child, as Pediatrician A was not available.
The previous symptoms were reported: the patient had a temperature of 100.4 degrees and his weight was down two pounds from the previous appointment. An influenza test was negative. A CBC had been previously ordered, but had not been completed. The documentation of the physical exam, including the abdomen, was checked off as “normal.” The diagnosis was fever and UTI. The patient was to continue on cefexime. Pediatrician B would later recall that the child was able to jump on the exam table and move around without any restrictions or distress.
On a third visit to the clinic — on October 26 — the patient came accompanied by both his parents. His symptoms were the same and he was still taking cefexime. The child was afebrile and his weight had increased by one-half pound. Although Pediatrician A ordered a urinalysis, it was not completed because the patient could not provide a specimen. A catheterized specimen was deemed not necessary since the child was afebrile. The abdominal exam was checked off as normal and the final diagnosis was gastroenteritis/viral syndrome.
On November 5, the boy returned to Pediatrician A. The mother reported that the patient continued with the same complaints for “2 weeks on and off.” The patient’s temperature was 97.4 degrees. His weight had increased by another one-half pound, but still down one pound from his original weight. Documentation from the physical exam noted the abdomen to be soft and non-tender with increased bowel sounds. A urinalysis showed 3+ red blood cells and 2+ protein. The final diagnosis was dysuria and diarrhea. Pediatrician A ordered a gastroenteritis protocol, stool culture, and stool for ova/parasites.
The next day, the mother took the patient to a freestanding emergency room. The physical exam showed the patient had a temperature of 102.9 degrees; blood pressure 114/72 mm Hg; a pulse of 120 bpm; and a tender right lower quadrant. The physician suspected appendicitis and transferred the patient to a hospital.
At the hospital, a CT scan of the abdomen showed a large intra-abdominal abscess. The patient was taken to surgery that day and was found to have a perforated appendix with an intra-abdominal abscess and compromised vasculature to the terminal ileum. The abdominal abscess was washed out. The surgeon could only partially close the abdomen and a wound vac was placed. The patient was in the ICU and intubated for several days. On postoperative day five, he had return of bowel function in the colostomy bag.
On postoperative day 10, the patient was febrile with increasing abdominal pain. A CBC showed leukocytosis and a CT scan of the abdomen revealed an additional intra-abdominal abscess near the site of the previous abscess. An interventional radiologist placed a drain. IV antibiotics were started again. Eventually the drain produced scant purulent material. He was discharged after 16 days in the hospital.
Nearly three months later, a pediatric surgeon reversed the ileostomy and repaired a mucous fistula. The patient was hospitalized for one week with this procedure.
Allegations
A lawsuit was filed against Pediatrician A. The allegations were failure to recognize the signs and symptoms of appendicitis that led to a ruptured appendix, requiring multiple surgeries and extensive hospitalizations. The plaintiffs also claimed that Pediatrician A’s conduct and omissions rose to the level of gross negligence.
Legal implications
The plaintiff‘s attorney retained a pediatrician who was critical of the defendant for diagnosing a UTI without obtaining a urine culture. He further stated that since the symptoms did not resolve, a further work up should have been considered that included an abdominal ultrasound and lab work. The second plaintiff’s consultant, a pediatric surgeon, agreed and criticized the defendant for failing to consult or refer the patient to a general surgeon to assess the abdomen.
Two pediatricians who reviewed this case for the defense were lukewarm in their support of Pediatrician A’s care. The first pediatrician stated that the clinical findings did not suggest appendicitis. He speculated that the antibiotic prescribed for the UTI may have reduced the patient’s pain and hid the symptoms until the appendix became encapsulated. A pediatric surgeon noted that at each visit it was documented that the patient did not have abdominal tenderness. The diagnosis of a UTI was consistent with the patient’s symptoms.
However, these physicians criticized Pediatrician A for an inadequate clinical examination and follow up on a patient whose symptoms were not improving over two weeks. The failure to order appropriate labs and treatment led to a delay in diagnosing appendicitis, resulting in the perforation and more involved treatment.
Disposition
The case was settled on behalf of Pediatrician A.
Risk management considerations
Timely follow up on test results is always prudent risk management practice. In this case, a CBC was ordered at the first visit. At the next visit, there was no mention of following up on the results – nor was there follow up at any of the subsequent office visits. Had the results of the CBC been reviewed, further testing may have led to an accurate diagnosis.
There was no mention in the medical record of a differential diagnosis. Documentation needs to demonstrate that the physician provided the patient and/or patient’s family with education on the diagnosis and treatment, as well as the risks of any treatment. The Texas Medical Board has criticized physicians who did not document that a diagnosis was adequately explained to the patient, including the differential diagnosis and the effect on the method of treatment.
