Physician’s Misdiagnosis Results in Patient’s Death

Case Summary

In this case, a patient with a history of smoking, obesity, and back injuries presented twice to Urgent Care complaining of shortness of breath.

Both times, a physician assistant saw him. The physician assistant diagnosed him with the flu and discharged him. The patient’s condition deteriorated two days later. It was eventually determined that the patient had a massive pulmonary embolism and passed away as a result.

Case Theory

Pulmonary embolism (PE) poses a serious risk of death and requires timely and adequate treatment. There is a high mortality rate, with 7.7–15% of patients dying within 3 months. PE symptoms are sometimes non-specific. As such, early recognition of PE remains a priority to prevent a delayed diagnosis and a higher rate of mortality. Shortness of breath is a major symptom.

There are many medical problems that can cause shortness of breath. A physician can easily treat several of these medical problems while others require immediate medical attention due to their severity and risk factors. Conditions such as allergies, the flu, and colds can cause difficulties breathing, but they may not constitute medical emergencies. In some cases, however, breathing difficulties may be a sign of serious medical conditions that require a visit to the emergency room. Knowing when to refer a patient to an emergency room is crucial.

Differential diagnosis and assessment of risk factors are imperative. Trouble breathing and a continued sense of breathlessness in a patient with multiple risk factors for PE require a referral to the ER. Both physician assistants and physicians are trained in awareness of the scenarios that require urgent care and those that require a referral to the emergency room.

Here, in this repeat patient with multiple risk factors for pulmonary emboli and other serious medical conditions, Urgent Care failed to properly evaluate, refer, and provide adequate care, leading to a drastic outcome.

Expert Witness Q&A

• What measures should the physician assistant have taken to ensure that a patient with shortness of breath is safely discharged?
• How might a delay in diagnosing pulmonary embolism affect prognosis?
• When does shortness of breath require a referral for further testing?
• What are the risk factors for pulmonary embolism?
• Did Urgent Care’s failure to refer to the emergency room fall below the standard of care?
• Should the physician assistant have consulted an attending physician regarding the care of this patient?
• Of what significance is the return of this patient with the same chief complaint of shortness of breath?

Expert Witness Involvement

Internal Medicine

An expert in urgent care internal medicine can address the standard for evaluation and discharge of a patient presenting with shortness of breath and risk factors.

Physician Assistant

A physician assistant with experience in urgent care can speak to the standard of care and protocol for a patient presenting with risk factors and shortness of breath.

Primary Care

An expert in primary care can speak to mortality rates and the need to promptly investigate and diagnose the cause of shortness of breath in patients.