Family Medicine Doctor Fails to Investigate Altered Mental Status in Surgery Patient

This claim involves a male who had been scheduled for an appendectomy. The surgery was uneventful and the patient was scheduled for discharge. After the surgery, and before discharge, the patient had elevated white blood cell count. He experienced difficulty breathing, and a chest xray revealed infiltrates in his lung. The patient had acquired a serious blood infection, but he was nevertheless discharged home with a prescription for zithromax, and set for an office visit in 2 weeks. He was not seen by either an infectious disease specialist or a respiratory disease specialist. After being discharged, the patient began experiencing an altered mental status secondary to infection. He was brought back to the hospital by his family and was admitted that day, at which point he came under the care of his family doctor. During that time, he was treated as if he had psychiatric issues because of his altered mental status. No tests were done to determine the respiratory problem, and his blood oxygenation and related vital signs were not watched adequately. Repeated complaints by the patient and his family were ignored by the nursing staff, which presumably attributed them to an altered mental status. By the time the infection was recognized, it had progressed too far for effective treatment and the patient expired shortly thereafter.

Question(s) For Expert Witness

1. As the patient's family medicine physician, should the physician have further investigated the cause / origin of the patient's altered mental status?

Expert Witness Response E-006273

The event timeline based on the brief summary of the case suggests the need for a more vigorous work-up and aggressive treatment for this patient, prior to his initial discharge and even after his second admission. The differential of post-op shortness of breath and mental status changes would have included pulmonary embolus as well as infectious or medication-induced; a chest x-ray suggesting pneumonia and a significantly elevated white count would have certainly made infection a more likely diagnosis; because the patient was symptomatic and also had the diagnosis of "anaerobic septicemia" prior to his discharge, it seems premature and negligent to discharge him on the day those diagnoses were made, treating with oral zithromax alone. His altered mental status at readmission should have prompted an aggressive evaluation as well, particularly in light of his recent diagnosis of septicemia. Sepsis and hypoxia are important etiologies for his symptoms, although metabolic causes and delirium secondary to medications or recent surgery must also be considered. Clearly, a delay in recognizing the gravity of the problem contributed to his death.