Monday, May 16, 2005

The Doctor and The Patient (and the lawyers)

Jan 2, 2000.

Data from triage sheet:
Time of presentation to ER: 2:45 a.m.
Time of vital signs and triage: 2:32 a.m.
Time of evaluation by position: 2:35 a.m.
History: Ms. Walker, a 78-year-old woman presented to the emergency room at a small community hospital with a chief complaint of left eye pain and diplopia 2-3 hours (indicated as 2-3 and then the small circle symbol) prior to presentation, left face pain and weakness. Pain was constant, sharp and stabbing and not ameliorated or exacerbated by anything. No photophobia. Further history revealed that the "weakness" was more fatigue and she had no complaints of any paresthesias or focal weakness.

No h/o glaucoma. No significant history of headaches.

PMH: hypertension, peripheral vascular disease. No h/o CVA, CAD. No known carotid stenosis.

PSH: cataract surgery with lens replacements years PTA.

Soc: Lives alone. Manages her own affairs with some help from her granddaughter. Smokes 2-3 packs per day. No alcohol use.

FH: no specific recall

ROS: Anxiety. no specific c/o chest pain or respiratory complaints. No difficulties walking. No bowel or bladder complaints.

PE: BP 145/88. Temp 98. HR 105. RR 16. Pulse ox 98% on RA.
General: Elderly appearing woman in no acute distress. Seems agitated and uncomfortable.
HEENT: normal ears, mouth and skin. Muscles slightly tender to palpation left frontoparietal area. No temporal artery tenderness.
Unable to visualize fundi secondary to patient agitation. Pupils slightly eccentric and slowly responsive to light.
No relief of left eye pain with gentle massage. Tactile tonometry normal.
Ocular pressures with TonoPen approx 17 bilat.

Neck: No carotid bruits. Supple, NT, no masses.

Chest: Lungs slight wheezing, no use of accessory muscles. Heart Reg, slightly tachycardic, normal S1S2, no murmurs.

Abd NABS, soft, NT. No HSM or masses. No pulsatile mass.

GU not examined secondary to patient request.

Ext: no edema, no cyanosis. FROM. No lesions.

Neuro:CN 2-12 intact except as noted above (pupils)
Motor 5/5 throughout
Sens intact to LT throughout
DTR's 1+ and symmetric with downgoing plantars. No frontal release signs.
Gait not tested.

What is your differential? What would you order? What other history or PE would you like?

Orders written at 0300: CBC, CMP, PT/PTT, UA, EKG, CT HEAD, CXR. Old records requested.

Labs relatively normal. No old records available. CT head done at 5:15 a.m. with radiology intepretation officially timed at 7:15 a.m. Wet read called to ED at 6:00 a.m. Read as "normal head CT."

What would you do now?

Call placed to ophthalmologist. Case discussed. Agreed to see patient in clinic when they opened at 8 a.m.

Discussed with patient and granddaughter. Uncertainty of dx discussed with concern for primary ophthalmologic problem. Patient elected to go home and agreed to present to Ophthalmology at 8.

Review of medical records from the eye clinic on Jan 2, 2000: Patient presented to the ophthalmologist's office at 9:15 a.m. Was seen quickly by an optometrist and reported that she awoke with her symptoms at about 2 a.m. VA was normal for her but VF testing revealed right nasal and left temporal visual field defects. Optometrist spoke to ED physician at a large referral hospital and was told to send the patient right over. Recorded diagnosis as "Occipital stroke RIGHT NOW."

Patient reportedly left the Optometrist at 9:45 a.m. ED records from referral hospital recorded her arrival as 12:45. (The hospital was about a 30 minute drive from the optometrist's office.)

Evaluated by ED physician at 1:15 p.m. History recorded as awoke with left eye complaints (didn't specify the complaints) at 2 a.m. and presented to local emergency room. Referred from eye clinic for VF deficit and dx of stroke. PE: patient lying on exam table in NAD. Neuro exam normal, including CN II-XII normal, then recorded "obvious VF deficit to confrontation." CT scan revealed mild area of edema in left occiput consistent with acute CVA. ER record did not record motor, sensory or gait examination. Nurse's note recorded that the patient was taken to the room in a wheelchair and transferred with assistance to the exam bed.

Consulted neurology who recommend IV heparin infusion. Patient was hospitalized for 2 days and discharged. While an inpatient, MRI revealed acute CVA left occiput.

Continued tomorrow.