Primary care physician expert witness discusses delayed diagnosis of fatal heart attack

A primary care physician expert witness opines on a case regarding a delayed diagnosis of a fatal myocardial infarction (heart attack). This virology case involves a sixty-year-old female with a past medical history of chronic hypertension and lipidemia for which she was receiving treatment under the care of a cardiologist. She presented to her primary care physician complaining of sweating, nausea, chest, abdominal and shoulder pain. A brief physical examination was performed. The physician remarked that there were no significant findings on examination. The treating physician concluded the patient was suffering from a virus which was deemed to be the source of her aches and pains. She was sent home with the advice to rest and drink plenty of fluids. The physician did not order an EKG. The patient’s husband called the physician’s office later that same day, reporting that she had begun experiencing pain from her neck to her stomach. This was noted in the patient’s medical records but the chest pain was not noted during the original evaluation of the patient. The physician did not advise any further action to be taken and reiterated that the symptoms were most likely due to a virus and would soon resolve.The patient’s condition continued to deteriorate. She was taken to the ER via ambulance five days after her visit to the treating physician. An EKG was performed and it was determined that the patient had suffered a myocardial infarction. A bypass was performed but the patient did not recover. She died shortly after the procedure. It was noted that, based on blood test results, that an EKG most likely would have detected the patient’s heart problems five days earlier.

Question(s) For Expert Witness

1. Should a more thorough workup have been performed on this patient?

2. If so, what other tests could have been done?

Expert Witness Response E-006273

This is an unfortunate example of why diagnosing coronary artery disease and acute myocardial infarction can be challenging, particularly when the presenting symptoms may be atypical as was the case here. Did the physician ask specifically about chest pain during the review of systems and did the patient clearly deny chest pain? Much depends on how thorough the physician was in obtaining and documenting a history and how forthcoming the patient was about her symptoms. However, the presence of shoulder pain in a hypertensive patient with associated sweating and nausea should have raised the suspicion for an acute coronary syndrome and prompted an EKG. In an acutely ill individual like this, obtaining labs would have been appropriate. Because the patient had high lipids and was likely on a statin, some of the symptoms (muscle aches, weakness) could have been due to the medication and checking a serum CPK would have been justified; this lab test alone may have identified an acute cardiac process (it can distinguish between muscle and cardiac sources).