Case Study
A Less-Than-Thorough Work-up for Chest Pain
Description
A 32-year-old male was diagnosed with acute myocardial infarction after earlier same-day ED evaluation and discharge.
Key Lessons
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Personal and family history taking often involves perseverance.
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A broad differential diagnosis list provides a greater chance of discerning life threatening conditions from common illnesses.
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A thorough discharge process includes patient/family feedback to verify comprehension of how to act on recurring or new symptoms.
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Explaining your uncertainty to the patient can initiate a discussion that closes any gaps in expectations.
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Documentation of vital signs and medical decision-making is essential to both optimal care and defense of that care.
Clinical Sequence
A 32-year-old male smoker presented to his local emergency department (ED) after two days of chest pain radiating to both arms. The pain, which had last occurred one hour prior to presentation, occurred at rest and was associated with shortness of breath and palpitations. The patient denied any drug use. He told the triage nurse his father had suffered an MI at age 35.
In the ED, the patient, who also presented with a hard cough, was found to be tender over the anterior part of his chest wall; his EKG and chest X-ray were read as normal (no enzymes test done). The patient was diagnosed with costochondritis and sent home with anti-inflammatory medications, narcotic pain medications, antibiotics, and instructions on chest pain. The patient’s vital signs at discharge were not recorded; he was noted to be pain-free.
Eight hours later, the patient returned to the ED complaining of crushing chest pain, shortness of breath, dizziness, and radiation of his pain to his left arm. He told the triage nurse, “I was just discharged, but I’m still having chest pain.” He was seen by a different physician and he now reported cocaine use a week prior. This attending interpreted a repeat EKG as showing elevations of the patient’s ST segments in the inferior leads consistent with an acute inferior myocardial infarction. He was given aspirin and morphine, and was placed on heparin and nitroglycerin. His cardiac enzymes were negative. He was immediately transferred to a tertiary teaching hospital for emergent cardiac catheterization.
During this history taking at the receiving hospital, the patient explained that his father had had his first MI at age 20, and died of an MI at age 37. The cardiology service took the patient to the catheterization lab. Almost 12 hours after his initial visit to the community hospital, the patient’s repeat cardiac enzymes were positive for a myocardial infarction. Catheterization revealed 95 percent left circumflex stenosis. A stent was placed and medications were started. Two days later, an echocardiogram performed prior to discharge revealed a significantly reduced ejection fraction of 35 percent. At discharge, the patient was pain free.
Six days later, the patient was readmitted to the cardiology service with a recurrence of his chest pain. His diagnostic work up, including a repeat catheterization, did not reveal significant disease. His medical treatment was optimized and he was discharged home.
Allegation
The patient filed a claim against the community hospital and the (first) ED physician for failure to timely diagnose, report, and/or treat acute myocardial infarction. This negligence, he claimed, shortened the patient’s life expectancy and left him permanently disabled and unable to care for his minor twin sons.
Disposition
The case was dismissed after a favorable tribunal session, when the patient failed to present a full order of proof and plaintiff expert opinion.
Analysis
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The initial ED physician did note the family history of CAD, but did not document the severity or extent of the history. The patient denied cocaine use, at first, but may not have understood the clinical importance of being truthful.
A thorough clinician-patient initial interview gives providers a better basis for diagnosis and patient management. An incomplete patient and family history can lead to a less aggressive initial workup.
- The ED physician did not explain anywhere in the chart why he thought this patient was at such low risk that he could be discharged without serial cardiac enzymes and EKGs or further chest pain workup.
Documentation in the patient chart is key to communicating the overall picture of the patient, his/her examination and treatment, as well as the provider’s medical decision making. Chest pain, even in young patients, may require longer observation and a more comprehensive diagnostic work up.
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The initial ED assessment appears to have stopped at the diagnosis of costochondritis. The patient’s EKG was documented as normal sinus rhythm, without any other (EKG) changes suggestive of acute myocardial infarction. No vital signs, or discharge instructions were reported; a review of systems was not documented.
Incomplete documentation can negatively impact future care. While most likely diagnoses are usually the common diagnoses—especially in otherwise well appearing and young patients—emergency deparment physicians should document differential diagnoses and their probability (for that patient).
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If the patient had initially reported his cocaine use, he would likely have been held for observation in the ED.
Admitting a patient to rule out an MI, when there is low probability, is difficult to justify. Consideration of a battery of toxic screen blood work may have been warranted but, given that the patient was less than forthcoming, the decision to discharge was not unreasonable.
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The patient alleged that inadequate testing was ordered, which prevented his MI from being diagnosed during his initial visit. He said he was not told that there is not a precise way to diagnose an MI, especially a recent one.
If your concerns don’t match the patient’s, the patient is likely to feel marginalized. If your decision process is not well documented, an allegation of substandard care is difficult to defend. Clarifying the patient’s key concerns and his or her understanding of the diagnostic process can close any gaps between the patient’s expectations and yours.
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The ED physician’s medical decision making (e.g., clinical rationale for not drawing serial enzymes) was not well documented.
Fully appreciating the circumstances surrounding an encounter is, generally, impossible without written evidence. Explaining why certain tests were ordered and not others is instrumental in understanding the disposition of the patient. For example, even though myocardial infarctions are a rare occurrence in this age group, the reasons for not pursuing this possibility should be well explained.
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The patient’s statement upon re-presenting to the ED (“I was just discharged and I’m still having chest pain.”) indicates that he did not have a clear understanding of why he had been discharged. Because of the shift change, the physician who saw him earlier in the day was not available to follow up on his concerns.
This patient was given discharge instructions, including those specific to chest pain, so his contention that he was inappropriately discharged may be debatable. However, recently discharged patients may set the bar higher before they will return to the ED—even in the face of more troublesome symptoms. Patients may return to the ED more willingly if they’ve been properly instructed on how to appropriately respond to various symptoms or circumstances.
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Jurors and arbitrators are sympathetic to the complaints of a young father with a life-long disability.
This case has many of the elements that can lead to a claim: dismissed historical factors, unanswered questions, and limited documentation. But, it also had elements that made it defensible, e.g., the first discharge was likely appropriate based on the information provided (or not provided) by the patient to the physician.
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