Delayed Diagnosis of Stroke Results in Total Left-Side Paralysis

This case involves a sixty-three-year-old male patient who presented to his family physician complaining of light-headedness and dizziness. The doctor examined the patient without doing a full neurological exam and sent him home with a prescription to treat an inner ear infection. The patient returned to the office the next day with the same symptoms but, during his visit, he displayed facial drooping. The patient was rushed to the emergency room where it was determined that he was having an ischemic stroke. An emergent CT scan was performed and showed a small, old, right, perifrontal lacunar infarct. An MRI/MRA performed the following day revealed that there was no blood flow to the patient’s right vertebral and basilar arteries. The patient was determined to be beyond the window period for the administration of thrombolytics and no clot-busting intervention was initiated. The delay in diagnosis for more than twenty-four hours allowed for a significant amount of neural tissue death, which resulted in total paralysis on the patient’s left side. Following the incident, he required around the clock nursing assistance and no improvement occurred after six months of rehabilitation.

Question(s) For Expert Witness

1. Is it ever acceptable for a physician to not perform a neurological exam when a patient exhibits neurological symptoms?

Expert Witness Response E-000689

Stroke mimics commonly confound the clinical diagnosis of stroke. One study reported that 19% of patients diagnosed with acute ischemic stroke by neurologists before cranial CT scanning actually had noncerebrovascular causes for their symptoms. It is never acceptable for physicians to skip their physical exam when the first plausible diagnosis makes sense. This patient deserved a more complete workup for obvious reasons.