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A bad scare with a difficult diagnosis taught this doctor the importance of thorough treatment and careful records.
Despite diligent efforts to practice excellent, empathetic medicine, doctors still face a constant risk of being hit by a malpractice suit. Accordingly, we need to take extra precautions. In many cases, we can prevent unfounded negligence claims with careful documentation and record-keeping. While such precautions may seem annoying at times, hindsight often shows that they're essential.
Consider the case of Chris Evans (not his real name), a 28-year-old single male patient who appeared in my office late one afternoon in November 2004. A bond trader, he had rushed over after work in a sweat, complaining of tightness in his chest. When I examined him, he described his symptoms as a "dull, constant ache that had lasted nearly a month." On a scale of one to 10, he rated his pain as a six, but said it had worsened and he felt he couldn't "get a full breath." The pain didn't radiate, and he had no associated symptoms such as cough, heartburn, fever, leg edema, or weight loss.
In taking his history, I found that Chris had been treated for seasonal allergies and migraine headaches. His mother had hyperlipidemia, and his father had hypertension. His six siblings were all in good health. He said he smoked one cigarette a day, and admitted to occasionally having "a few beers," but denied using any illicit drugs. He had recently started an exercise program of weight lifting and running.
Chris's physical exam revealed that he was overweight and anxious, but had stable vital signs. His chest exam was unremarkable, his heart was regular, his pulse was 76 bpm, and there was no murmur or rub on auscultation. His lungs were clear, his abdomen benign, and his extremities were within normal limits. A sub-sequent ECG was normal, and his pulse oxygenation was 98 percent.
Without any clues so far, I decided to get lab work done, including a complete blood count with differential, a D-dimer, a complete metabolic panel, and a lipid panel. I also ordered a chest X-ray and pulmonary function tests.
Meanwhile, I recommended a trial of pantoprazole 40 mg daily, and gave him an albuterol inhaler to use before exercise and as needed. I also told him to stop smoking immediately, and asked him to follow up in seven to 10 days.
Failure to keep a follow-up visit
Later that week, I notified Chris that his tests and chest X-ray were normal. When he cancelled his follow-up appointment two weeks later, I assumed he had recovered. As far as I knew, he hadn't completed the pulmonary function tests at that point. But three months after his initial visit, he called for the test results. (Apparently, he'd decided to complete them the previous week.) I told him that the results were completely normal, including the methacholine challenge portion.
Again, I asked Chris to come in for a follow-up visit, but he refused, insisting he couldn't afford to take the time from his busy work schedule. Nevertheless, he requested more tests. I obliged, and ordered a thallium stress test and referred him to a cardiologist. Two weeks later, he had a normal stress test, and the cardiologist said his symptoms were musculoskeletal in origin.
In March 2005, Chris called again and asked for further testing, saying his chest pain had recently "inflamed." Somewhat annoyed by his prior failure to follow up, I demanded that he come in to be evaluated first. He reluctantly agreed, and finally returned to my office. This time he described his chest pain as radiating "through his chest to his back," and said it was so severe that he could no longer sleep.