Vasovagal syncope, or something far worse?
A 48-YEAR-OLD WOMAN with a history of syncopal events was brought to the emergency department (ED) by her daughter, following an episode in which the mother lost consciousness and vomited while driving. (The daughter was able to get the car safely to the shoulder of the road.) The episode occurred after the woman had eaten, and followed a week in which she’d experienced several episodes in which her left arm and chin briefly went numb. In fact, she experienced another chin/arm numbing episode while in the ED. The ED physician gave her a diagnosis of vasovagal syncope, instructed her to follow up with her primary care physician, and included “rule out transient ischemic attack (TIA)” on the discharge note.
The primary care physician subsequently established a differential diagnosis of “vasovagal vs hypoglycemia vs both or neurocardiogenic syncope” and referred the patient to an electrophysiologist, who concluded that she’d had a vasovagal syncope episode triggered by a gastrointestinal cause.
The patient continued to have arm/chin numbness but was unconcerned because her physicians didn’t seem worried. Months later, she sought treatment for low back pain, for which her primary care physician prescribed celecoxib; her numbness was not discussed with her physician. The next day, she suffered a stroke from an occluded right carotid artery. She had hemiparesis with little to no movement of her left shoulder, elbow, hand, hip, and ankle.
PLAINTIFF’S CLAIM The numbness and fainting were TIAs and an ultrasound should have been performed, which would have revealed the carotid artery occlusion and helped avoid the stroke.
THE DEFENSE The events the plaintiff experienced were not TIAs and there was no way to show whether, or to what degree, the carotid artery was occluded before the stroke. The plaintiff should have reported the continuing symptoms. Given that the patient had a long history of syncopal events—and a history of smoking—the diagnosis was reasonable.
VERDICT $1.6 million Wisconsin verdict.
COMMENT I think the lesson here is that physicians need to take focal neurological findings seriously and continue the evaluation until one has a reasonably certain diagnosis. The cause of this patient’s recurrent arm and chin numbness should have been pursued.
Failure to take full sexual history has devastating consequences
A MAN WITH A HISTORY OF ABNORMAL BLOOD TEST RESULTS sought treatment in the emergency department for extreme leg pain. He was given a diagnosis of sepsis and renal failure. A positive human immunodeficiency virus (HIV) test led to a diagnosis of acquired immunodeficiency syndrome (AIDS). The patient had been seeing his primary care physician for 10 years, but the doctor never asked about his sexual history. The patient survived, but suffers from AIDS-related kidney disease and must undergo peritoneal dialysis for the rest of his life.
PLAINTIFF’S CLAIM The physician should have tested for HIV much sooner to prevent the loss of kidney function. The physician’s questions were not specific enough to obtain proper information on whether the patient was having unprotected sex, if he had multiple partners, and what gender his partners were.
THE DEFENSE No information about the defense is available.
VERDICT $5.2 million Illinois verdict.
COMMENT I’m not sure the jury got this one right. Nonetheless, the Centers for Disease Control and Prevention now recommends HIV screening for all adults so it is worthwhile to offer it to all patients and to document refusal if a patient doesn’t want to be tested.