Patient Develops Vegetation On Heart Following Delayed Treatment For Infection

This case involves a female patient who suffered a range of complications following the delayed diagnosis of a brain infection. The patient presented his primary care physician with symptoms of chest and arm pain. Over the course of the next 3 months, the patient’s symptoms progressed to include cold sweats, jaw pain, fatigue, cough, congestion, chills. She sought medical attention and was discharged with suspicion of bronchitis and antibiotics. The following month, the patient was diagnosed with a leaky valve and scheduled for a stress test. A few days before the exam, however, the patient began to suffer from pain and swelling in her legs. The leg pain eventually became so intolerable that the patient was unable to walk. She presented to the emergency room and was given an MRI which showed a possible mini-stroke. The primary care physician allegedly never received the report from the emergency department during follow-up with the patient. Over a month later, the patient was diagnosed with a brain infection. It was discovered that the patient had initially contracted a bacterial infection which infected the mitral valve of her heart and led to a systemic infection. As a result of this delayed diagnosis and systemic infection, the patient developed sepsis secondary to vegetations on her heart valve and eventually succumbed to her infection.

Question(s) For Expert Witness

1. For a patient with such presentation that persists, what is the necessary workup/protocol?

2. What measures are taken to ensure that a primary care physician receives all necessary records from an emergency department?

Expert Witness Response E-100114

Presentation with a cough, congestion, and chills is consistent with an upper respiratory tract infection or sinusitis depending on evidence of sinus pain on physical examination. If the patient had a persistently elevated temperature after completing the antibiotics, he should have had a workup done for fever of unknown origin (FUO) which would have included blood cultures and urine cultures. This could have led to a diagnosis of subacute bacterial endocarditis (SBE) much earlier. Presentation with lower extremity edema and fatigue should have prompted a workup of congestive heart failure (CHF) with valvular involvement and a possible diagnosis of SBE with blood cultures which could have resulted in an earlier diagnosis. This diagnosis was missed by both the primary care physician and the emergency department. Not all EMR's communicate with one another. If there was EMR interoperability, the primary care physician would have easy access to the records. If not, they should have requested the test results be faxed to their office since the patient considered symptoms bad enough to seek attention in the emergency room. Receipt of all emergency department records is a systems issue that could be addressed by the primary care physician's practice, office staff, or hospital in the implementation of its EMR. SBE is common enough that it should have been considered at various points prior to his presentation with sepsis.