It's common in our education and training to learn the textbook (usually dramatic) presentations of various entities. In reality, a lot of these, such as SJS, present insidiously and piecemeal. SJS sometimes takes a few visits to diagnose. It's good to know that conjunctivitis and nonspecific URI-like sxs can precede the more classic ones. Though I think the conjunctivitis would have to be pretty notable to start seriously considering SJS, unless there were oral symptoms or rash too. I suppose I would be suspicious given the recent sulfa-drug. Easy to say retrospectively....
Yep, I don’t think I would have gotten this on the first few visits either. Conjunctivitis is so vague, but in the context of recently starting Bactrim or allopurinol or anti-epileptics, it would definitely catch my attention. That being said, I don’t usually ask about recent med changes in conjunctivitis patients.
Thank you, med mail reviewer for an excellent critique and for all of the insightful and honest comments. I will probably never look at a case of conjunctivitis quite the same way again.
Me neither! Bilateral conjunctivitis without any obvious cause - think about med history. I love finding these little nuggets and sharing them with people, thanks for reading the case!
The decision to sue the hospital rather than the ER docs is a little puzzling here. I may be wrong, but generally my instinct is that suits against hospitals should allege a problem with hospital policies/procedures, either that they were inadequate or that they were not followed. It's surprising to see a case against only the hospital for what seems like a straightforward allegation of malpractice by the physicians, again unless the hospital was somehow negligent in how they were hired. (Is this a case from Florida? My impression is that suits against physicians there are so limited in damages that they're kinda pointless.)
Agree that the expert opinion is shockingly bad. In the absence of any analysis of what was or was not done on each visit, I have no idea whether any of the care was negligent.
If I'm understanding the law correctly (not a lawyer so take it with a grain of salt), if a company's agent/employee is negligent, the company can be held responsible. I'm sure there are tons of legal nuances and variation between states. "Respondeat superior" and "vicarious liability" are the search terms if you want to read more about it.
Whether or not it was the case here, I do want to touch on a pet peeve of mine - prescribing antibiotics for an abnormal UA without any clinical signs or symptoms of UTI. I’m not talking about for a demented pt obviously, but for a normal person able to provide a clear history. This is something iv noticed, esp with mid levels.
Seems like the tide has really turned on this the last few years. What about lower abdominal pain or flank pain but no dysuria/frequency, are you giving antibiotics for that?
I know that ED visits following inpatient discharge are tracked; however, are repeat ED outpatient visits also tracked? Because the visits were probably coded differently based on presenting symptoms (suggested in the "expert" reviewer's statement), perhaps this caused a failure in linking etiology. Is it possible the ED documentation was sufficiently robust that the staff were unassailable, and the hospital settled because it was cheaper?
I also think there may have been difficulty establishing patient-provider rapport because of comments of noncompliance in the record.
I would have appreciated knowing if the culture actually identified a UTI as well as the sensitivities. I wonder if there were any case management notes from the ED that might have resulted in recommendations to stop taking the medication or convert to a more appropriate medication.
There's just not a lot of information in this case. I do appreciate the advice on conjunctivitis as a presenting symptom of SJS, though!
I doubt the documentation was so robust that it was unassailable... it doesn't matter what gets documented, if there's a bad outcome they'll try to sue. It helps with defense once a lawsuit is filed, but won't stop a lawsuit. Agree that a lot of info is lacking here, but there's always a few little pearls we can glean from these cases!
Drives me crazy how the so-called expert witness keeps saying an adverse reaction is an "allergic reaction"...
Yep... so many things wrong with this expert.
It's common in our education and training to learn the textbook (usually dramatic) presentations of various entities. In reality, a lot of these, such as SJS, present insidiously and piecemeal. SJS sometimes takes a few visits to diagnose. It's good to know that conjunctivitis and nonspecific URI-like sxs can precede the more classic ones. Though I think the conjunctivitis would have to be pretty notable to start seriously considering SJS, unless there were oral symptoms or rash too. I suppose I would be suspicious given the recent sulfa-drug. Easy to say retrospectively....
Yep, I don’t think I would have gotten this on the first few visits either. Conjunctivitis is so vague, but in the context of recently starting Bactrim or allopurinol or anti-epileptics, it would definitely catch my attention. That being said, I don’t usually ask about recent med changes in conjunctivitis patients.
Thank you, med mail reviewer for an excellent critique and for all of the insightful and honest comments. I will probably never look at a case of conjunctivitis quite the same way again.
Me neither! Bilateral conjunctivitis without any obvious cause - think about med history. I love finding these little nuggets and sharing them with people, thanks for reading the case!
The decision to sue the hospital rather than the ER docs is a little puzzling here. I may be wrong, but generally my instinct is that suits against hospitals should allege a problem with hospital policies/procedures, either that they were inadequate or that they were not followed. It's surprising to see a case against only the hospital for what seems like a straightforward allegation of malpractice by the physicians, again unless the hospital was somehow negligent in how they were hired. (Is this a case from Florida? My impression is that suits against physicians there are so limited in damages that they're kinda pointless.)
Agree that the expert opinion is shockingly bad. In the absence of any analysis of what was or was not done on each visit, I have no idea whether any of the care was negligent.
If I'm understanding the law correctly (not a lawyer so take it with a grain of salt), if a company's agent/employee is negligent, the company can be held responsible. I'm sure there are tons of legal nuances and variation between states. "Respondeat superior" and "vicarious liability" are the search terms if you want to read more about it.
If you’re a state employee and physician your damages can be limited too.
Whether or not it was the case here, I do want to touch on a pet peeve of mine - prescribing antibiotics for an abnormal UA without any clinical signs or symptoms of UTI. I’m not talking about for a demented pt obviously, but for a normal person able to provide a clear history. This is something iv noticed, esp with mid levels.
Seems like the tide has really turned on this the last few years. What about lower abdominal pain or flank pain but no dysuria/frequency, are you giving antibiotics for that?
Absolutely. Only a mid level problem. A physician would never do this.
Oops—just pulled a muscle with my eyeroll.
I know that ED visits following inpatient discharge are tracked; however, are repeat ED outpatient visits also tracked? Because the visits were probably coded differently based on presenting symptoms (suggested in the "expert" reviewer's statement), perhaps this caused a failure in linking etiology. Is it possible the ED documentation was sufficiently robust that the staff were unassailable, and the hospital settled because it was cheaper?
I also think there may have been difficulty establishing patient-provider rapport because of comments of noncompliance in the record.
I would have appreciated knowing if the culture actually identified a UTI as well as the sensitivities. I wonder if there were any case management notes from the ED that might have resulted in recommendations to stop taking the medication or convert to a more appropriate medication.
There's just not a lot of information in this case. I do appreciate the advice on conjunctivitis as a presenting symptom of SJS, though!
I doubt the documentation was so robust that it was unassailable... it doesn't matter what gets documented, if there's a bad outcome they'll try to sue. It helps with defense once a lawsuit is filed, but won't stop a lawsuit. Agree that a lot of info is lacking here, but there's always a few little pearls we can glean from these cases!