Internist Fails to Diagnose Stroke

This case involves a fifty-three-year-old female who visited her primary care physician with complaints of right facial dropping and numbness down her right arm. The previous day, while preparing breakfast, she began to have difficulty formulating sentences. Her medical history included diabetes mellitus, hypercholesterolemia, and hypertension. She was using multiple medications to treat her condition, including Onglyza, Benicar and Lipitor. The internist found no abnormalities on physical examination and laboratory work. He scheduled her for a follow-up appointment two weeks after the initial visit. A week later, the woman’s leg buckled and she fell to the ground while on a walk with her husband. He asked her what was wrong, but she was unresponsive. She was rushed to the emergency department, where they performed a CT scan. The scan revealed bleeding in her brain indicative of a stroke. Additionally, they found evidence of earlier bleeding. The medical team questioned her husband, and he told the ER physician that she experienced fifteen minutes of right facial drooping and numbness in her right arm. The physician told her husband that she most likely suffered a transient ischemic attack, which is a “mini-stroke,” and, subsequently, would require lifelong anticoagulation. She also suffered permanent damage from the stroke requiring occupational and physical therapy.

Question(s) For Expert Witness

1. Did the internist follow the standard of care when treating this patient, and what could have been done to prevent future damage in this patient?

Expert Witness Response

This physician did not properly work-up the patient’s complaints in this case. The patient was exhibiting classic stroke-like symptoms. Additionally, the woman had significant risk factors for the development of a stroke. When a patient presents with facial drooping, arm or leg weakness, and difficulty speaking, a stroke should be ruled out. Sometimes patients will experience what is known as a transient ischemic attack (TIA) before a stroke. TIA is characterized by symptoms of stroke that last between a few minutes and twenty-four hours. Once a stroke is identified, the patient should be taken to the hospital for proper treatment. The diagnosis of stroke can be made with imaging, most commonly using a CT scan, which reveals bleeding in the brain. Patients found to experience TIAs should be placed on aspirin to prevent the development of a stroke. Many times, those experiencing strokes will require lifelong anticoagulation. If a thrombus is present, the patient may also require thrombolytic therapy to break up the clot. Rehabilitation is often recommended to help people regain motor functioning.