Nurse Practitioner Fails to Diagnose Advanced Thyroid Cancer

This case involves a middle-aged male patient in Idaho who had a previous medical history significant for diabetes and hepatitis c, who had been under the care of an Advanced Registered Nurse Practitioner. He was taking multiple medications to treat his condition, including Onglyza. At one point, the patient developed a worsening persistent cough, with swelling of his lower face and neck as well as upper shoulder and neck pain. The nurse practitioner treated him with hydrocodone for pain, as well as repeated course trials of different antibiotics. After several months of no improvement, the patient was referred to another clinic. At the new clinic, the patient was seen by a physician assistant who managed and followed his care for diabetes and hepatitis. Years passed by with the patient still complaining of throat pain and enlargement; however, no further studies nor investigations for the neck swelling were carried out. Eventually, another provider at the clinic noticed the swelling in the patient’s neck and promptly referred him to a surgeon. Further workup revealed the patient suffered from Stage IV thyroid cancer, requiring a complete thyroidectomy.

Question(s) For Expert Witness

1. Are you capable of determining if there was deviation from the standard of care?

Expert Witness Response E-053814

Clinically; when there is a lack of clinical response to empiric treatment for a soft tissue infection the clinician may opt in treatment in a patient without risk factors, to change to an antibiotic which would treat MRSA if suspected or other regional resistant strains of commonly occurring bacteria. If there is a resulting lack of clinical response, or there are systemic symptoms, a thorough evaluation and consultation or referral is the standard of care.

In this case, however, the patient was a diabetic which increased his risk status for infectious complications and also had Hepatitis C, with the possibility of immunosuppressive treatment. As this patient remained symptomatic despite treatment, a thorough evaluation including possible hospitalization, depending on the severity of the infection and systemic symptoms, as well as consultation and/or referral, depending on the nature of the infection, and resources available was the standard of care. One is not able to comment beyond the fact that the patient had a lack of clinical response to antibiotic treatment, and it does not appear that the patient received a timely thorough evaluation and consultation with either an ID specialist in the case of infection, or ENT in case of persistent difficulty swallowing and residual neck pain.