My thought was that the PA considered a PE because the respiratory symptoms plus a possible DVT (swollen leg). If the leg wasn’t swollen, then the consideration of PE likely would not have been mentioned. I don’t think this is a slam dunk
My first thought is this would have passed the PERC rule. But, in fact it wouldnt have. Sat of 94% screens positive for PERC. An ER doc would have done a D-dimer, but of course the setting is different in a primary care clinic than an ER - the needle is hiding in a much bigger haystack in primary care than in the ER.
It saddens me that this case is a slam dunk. I thought the PA did a good job, and certainly documented better than I would with a stable patient with URI symptoms. I would really like to know why they were considering PE in the first place. Nonsmoker, no recent travel, no OCPs, no steroids, etc. Would it have been a more defensible chart if the PA had not mentioned/investigated PE at all? If so, that seems like a grim commentary on the reality of our system.
So she brought it up but didn't rule it out, OK. But we can't CT scan every cough. The US is the wrong test, and as a screen for PE will only be positive in about half of cases. But they did investigate the diagnosis.
The only thing in her care I would really call out beyond what's here is the steroids. There's no indication and obviously in this case it's not great to heighten the thrombotic state.
As for not bringing her back, writing her a z-pack…well, again, some telephone medicine is inevitable, especially in primary care. I'm sure they would have brought her back to the office promptly and a z-pack is a low-risk thing to try in the meantime.
I get a strong "But for the grace of God" vibe off this case.
I am also going to disagree on it being a slam dunk. It saddens me whatever lawyer they had didnt even mount a witness.
1) Was SOC met. I think the initial work up was prudent and reasonable - and what an ordinary Doc or PA would have done. Was the 94% a true reading? Without any treatment - it bounced to 97%. No outward physical exam findings outside normal. LE ultrasounds have an NPV of 98-99% (I think if I aint misrememberin :))... CXR to look for pneumonia. No tachycardia. For an office work up on someone with cough, dyspnea, and normal vitals - I would say that is pretty good. Shortcomings: lack of ACS thought with DOE. But obviously that wasnt the issue.
I hate the complaint of "short of breath walking in from car". That is the one complaint that truly isnt congruent with bronchitis.... And lastly...the question I would ask the treating PA - if the patient is complaining of shortness of breath - and your concerned about a PE - (by extension of you looking for DVT in the legs) - why not just order the CT Angio? Not sure what their answer would have been.
But. What would a prudent PA/MD have done? I think you could argue this workup or even LESS.
Agree Marc f - PERC may or may not be ruled out ...not sure if you can take any vital sign within the visit and use it for PERC purpose? (Can you take the 97% pulse ox and say she passed PERC rule?).
2) 3 days later. The office call. Tough to say on that one - out of my league (Im an ER doc) on what is expected SOC for those patients. Truly curious to those who run offices - is this typical?
3) I think the biggest weakness of the case - is on the plaintiff's medical witness opinion. It is scattered with ridiculous statements. As mentioned above, 94% is in the grey zone - of not technically "normal" (95-100) but not hypoxic. They also mentions gold standards of pulmonary angiography or using a VQ scan. Nary a mention of CT. (My hunch is this is an expert who hasnt seen the inside of a hospital for 10+ years). They claim a d-dimer should have been used initially and dont realize that has similar NPV as the US that was performed (slightly less I believe).
Furthermore, they mention that if PE is within the differential, it has to be "ruled out". Which is factually incorrect - the job of any physician is to provide a plausible and reasonable diagnosis for a condition. Bronchitis/URI at the time - was just that. Normal vitals (save for 94%). No risk factors. Just because we think of a diagnosis - the SOC is not to "rule out" everything. That is impossible and illogical. Nor is it expected medicolegally. A good witness for the defense can make this argument with ease.
I think a good lawyer could have picked apart this expert witness writing, or at least make them buckle in a few places.
Am guessing this was an ileocaval DVT.
Causation...did the missed diagnosis cause the saddle embolus to occur. More probably than not.
So...I think its tough to call it a slam dunk. Certainly tougher case to win for the Defense. But holy smokes - not even hiring a expert witness to defend? Seems crazy.
My thought was that the PA considered a PE because the respiratory symptoms plus a possible DVT (swollen leg). If the leg wasn’t swollen, then the consideration of PE likely would not have been mentioned. I don’t think this is a slam dunk
My first thought is this would have passed the PERC rule. But, in fact it wouldnt have. Sat of 94% screens positive for PERC. An ER doc would have done a D-dimer, but of course the setting is different in a primary care clinic than an ER - the needle is hiding in a much bigger haystack in primary care than in the ER.
It saddens me that this case is a slam dunk. I thought the PA did a good job, and certainly documented better than I would with a stable patient with URI symptoms. I would really like to know why they were considering PE in the first place. Nonsmoker, no recent travel, no OCPs, no steroids, etc. Would it have been a more defensible chart if the PA had not mentioned/investigated PE at all? If so, that seems like a grim commentary on the reality of our system.
So she brought it up but didn't rule it out, OK. But we can't CT scan every cough. The US is the wrong test, and as a screen for PE will only be positive in about half of cases. But they did investigate the diagnosis.
The only thing in her care I would really call out beyond what's here is the steroids. There's no indication and obviously in this case it's not great to heighten the thrombotic state.
As for not bringing her back, writing her a z-pack…well, again, some telephone medicine is inevitable, especially in primary care. I'm sure they would have brought her back to the office promptly and a z-pack is a low-risk thing to try in the meantime.
I get a strong "But for the grace of God" vibe off this case.
Klippel-Trenaunay syndrome
I am also going to disagree on it being a slam dunk. It saddens me whatever lawyer they had didnt even mount a witness.
1) Was SOC met. I think the initial work up was prudent and reasonable - and what an ordinary Doc or PA would have done. Was the 94% a true reading? Without any treatment - it bounced to 97%. No outward physical exam findings outside normal. LE ultrasounds have an NPV of 98-99% (I think if I aint misrememberin :))... CXR to look for pneumonia. No tachycardia. For an office work up on someone with cough, dyspnea, and normal vitals - I would say that is pretty good. Shortcomings: lack of ACS thought with DOE. But obviously that wasnt the issue.
I hate the complaint of "short of breath walking in from car". That is the one complaint that truly isnt congruent with bronchitis.... And lastly...the question I would ask the treating PA - if the patient is complaining of shortness of breath - and your concerned about a PE - (by extension of you looking for DVT in the legs) - why not just order the CT Angio? Not sure what their answer would have been.
But. What would a prudent PA/MD have done? I think you could argue this workup or even LESS.
Agree Marc f - PERC may or may not be ruled out ...not sure if you can take any vital sign within the visit and use it for PERC purpose? (Can you take the 97% pulse ox and say she passed PERC rule?).
2) 3 days later. The office call. Tough to say on that one - out of my league (Im an ER doc) on what is expected SOC for those patients. Truly curious to those who run offices - is this typical?
3) I think the biggest weakness of the case - is on the plaintiff's medical witness opinion. It is scattered with ridiculous statements. As mentioned above, 94% is in the grey zone - of not technically "normal" (95-100) but not hypoxic. They also mentions gold standards of pulmonary angiography or using a VQ scan. Nary a mention of CT. (My hunch is this is an expert who hasnt seen the inside of a hospital for 10+ years). They claim a d-dimer should have been used initially and dont realize that has similar NPV as the US that was performed (slightly less I believe).
Furthermore, they mention that if PE is within the differential, it has to be "ruled out". Which is factually incorrect - the job of any physician is to provide a plausible and reasonable diagnosis for a condition. Bronchitis/URI at the time - was just that. Normal vitals (save for 94%). No risk factors. Just because we think of a diagnosis - the SOC is not to "rule out" everything. That is impossible and illogical. Nor is it expected medicolegally. A good witness for the defense can make this argument with ease.
I think a good lawyer could have picked apart this expert witness writing, or at least make them buckle in a few places.
Am guessing this was an ileocaval DVT.
Causation...did the missed diagnosis cause the saddle embolus to occur. More probably than not.
So...I think its tough to call it a slam dunk. Certainly tougher case to win for the Defense. But holy smokes - not even hiring a expert witness to defend? Seems crazy.
Beckwith -Weiderman Syndrome (Hemihypertrophy) ?