Looking for reviews from office based Family Medicine providers as opposed to hospitalists.
52 year old female called her Family Medicine PCP on 07-07-21 and the chart indicates the patient reported "she thinks she may have a cyst in her ovary. Having some pain on the right lower abdominal side. States the pain is worse when walking and standing. If she sits she tends to have relief. Denies any bleeding. Has tenderness to the touch. Mentions she has had cysts before. Doesn't have a GYN."
The PCP's office tells the patient they will order a STAT Pelvis Complete/Transvaginal Non-OB Ultrasound. The patient contacted the Hospital imaging center that day to schedule and she was told the imaging order was entered as a routine order and not a STAT order. Thereafter, she was told the next available appointment for the test was a week later on July 14, 2021 at 10:00 a.m.
She was able to get the study performed at another imaging facility two days later on 7-9-21 , which reported “Tubular structure right lower quadrant blind-ending with the appearance of an enlarged appendix. Findings worrisome for appendicitis given history.” The recommendation was “Surgical consultation advised. CT abdomen pelvis with IV contrast would offer further evaluation/confirmation as clinically directed.”
She presented to Hospital ED that same day on 07-9-21 and underwent a CT Abdomen and Pelvis with IV Contrast. Her associated symptoms were nausea and vomiting. The impression was: (1) Acute appendicitis with suspected early infiltration changes; and (2) no abscess identified at this time. The radiology report also noted there were intense inflammatory changes about the appendix which was dilated up to 13mm. There were also small amounts of periappendiceal fluid and she was admitted with consult for surgery.
On July 10, 2021 the patient underwent a diagnostic laparoscopy, exploratory laparotomy, right colectomy, drainage of appendiceal abscess, peritoneal lavage, and bilateral tap block. The surgeon's operative report indicated that the patient’s postoperative diagnosis was acute perforated appendicitis with phlegmon and abscess formation. Post-op she was diagnosed with intractable diarrhea secondary to the ileum being removed with colectomy.
Was there a failure to obtain a complete history or have patient come to office for physical exam? Was there a failure to order the appropriate outpatient study including ordering the appropriate the timing of the study?
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Do you believe there might have been medical error?
Patient described classic symptoms of acute appendicitis. Given patient’s age, an ovarian etiology is much less likely. A physical exam in office would have likely been consistent with acute appendicitis.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Delay in the diagnosis and treatment of acute appendicitis likely led to the perforation and need for the extensive surgery.
What makes you a good expert for this case?
I’ve been practicing family medicine for over 25 years in outpatient and urgent care settings. Evaluation and treatment of abdominal pain is a common complaint in most outpatient settings.
How often do you encounter cases similar to this one in your practice?
This is relatively uncommon, but when patients present with right lower quadrant pain, one of the top three considerations should be acute appendicitis.
Do you believe there might have been medical error?
The patient presented with pain in right lower abdomen. The PCP appears to have anchored to the diagnosis of "ovarian cyst" It is well known to medical providers that acute appendicitis is an emergency and the actions of this physician suggested that they did not consider this to be a strong possibility. The initial imaging study was ordered as "routine" rather than "stat" which may have delayed obtaining the correct diagnosis. Additionally, the appropriate initial imaging study should have been CT rather than Ultrasound. Ultrasound is often non diagnostic in the case of acute appendicitis in adults
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
The diagnosis of acute appendicitis was delayed by 2 days from the initial office visit. Same day imaging should have been obtained. If this was not possible then the patient should have been referred to an emergency department. The treatment course was complicated by perforated appendicitis, which resulted in a more complicated surgery requiring right colectomy leading to intractable diarrhea. If the correct diagnosis was made earlier, there is good reason to think that many of these complications could have been avoided.
What makes you a good expert for this case?
I have a extensive experience from working in Family Medicine and Urgent Care clinics. I regularly encounter similar cases that require me risk stratify in order to not miss an acute diagnosis.
How often do you encounter cases similar to this one in your practice?
In my urgent care career I encounter patients presenting with acute abdominal pain on a daily basis. In many of these cases I am required to make a decision about obtaining stat vs. routine imaging, vs. referring immediately to the emergency department.
Do you believe there might have been medical error?
My thoughts based upon the information provided in this case: I assume that there was an established relationship (continuity of care) with the practice when she called to c/o pain. Was the patient offered an in-person visit during or after the call? What was documented for that phone conversation? Key elements of the discussion would be presence of fever, chills, prior hx of an ovarian cyst, and the providers assumed diagnosis at the time of the call. Was the PCP concerned about appendicitis based upon the telephone encounter? If a visit was not offered on the telephone, then the standard of care, without an exam, would be to tell the patient to call back if symptoms worsened, or to go to an ED if symptoms worsened. What was documented? When patient discovered that the US was not ordered STAT, did she call the practice back to ask for a STAT study? I assume not and she pursued seeking an US on her own. At that point the PCP is removed from the scenario and she presents to the ED for care. The delay in establishing a diagnosis amounts to about one day. A diagnosis was established via CT less than or equal to 48 hours after her inital telephoine call to her PCP. We do not know when the appendix actually ruptured.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
I do not believe a medical error occured based upon the my comments above.
What makes you a good expert for this case?
I am a BC family physician and am very familiar with abdominal pain and presentations of appendicitis. I have recently served on the Arizona Medical Board (allopathic board) as a physician member for seven years adjudicating complaints and interogating physicians and their attorneys at monthly open meetings.
How often do you encounter cases similar to this one in your practice?
Abdominal pain is a very common complaint that I encounter at least daily in practice.
Do you believe there might have been medical error?
Yes, should have immediately referred for in office H&P or sent to ER. Abbreviated Alvarado Score could have been done to predict probability of appendicitis. Surgical consultation and immediate diagnostic testing on day of call or at least day following call would have avoided perforation and subsequent bowel resection.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
We never can state definitely yes or definitely no in medicine, but all the evidence repeated demonstrates the earlier we diagnose and treat appendicitis the more likely we are to have positive outcomes. We know that left undiagnosed that untreated usually progresses to rupture and peritonitis, sepsis and occasionally death.
What makes you a good expert for this case?
Have 27 years experience, in multiple settings from outpatient to inpatient large and small. I have testified on behalf of defense and plaintiff alike and have represented a similar case of missed appendicitis with similar presentation that had a similar bad outcome. It was settled out of court after reading my expert witness testimony with my experience and medical references and the questions I provided to the attorney to ask the provider at deposition.
How often do you encounter cases similar to this one in your practice?
Abdominal pain is a daily thing and appendicitis always, always needs to be considered for just this reason.
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