Commentary:
The defendant family medicine physician evaluated and managed a hypertensive patient sporadically over a period of several years. Despite an appropriate medication regimen, the plaintiff alleged a failure to monitor that resulted in a stroke, and the claim was settled.
The Case:
A 48 YOM (6’, 179 lbs.) established care with the defendant family medicine physician after a blood pressure reading of 200/100 at his dentist’s office. Additional symptoms included intermittent left arm discomfort, paresthesia, and occasional chest discomfort. An EKG performed at the initial visit showed no evidence of ischemia and his blood pressure was deemed “acceptable.” A stress test was also ordered and the results were normal. Home blood pressure monitoring was ordered and the patient was instructed to return if he had consistent readings over 150/85. As instructed, the patient scheduled a complete physical for nine weeks later. He was a no-show for the appointment.
Almost two years later, the patient presented to the defendant physician complaining he had experienced a mild right-sided headache for two weeks. The patient’s BP was 158/90; he had no chest pain or blurred vision. The defendant physician started the patient on a daily anti-hypertensive (Lisinopril® 10 mg) and instructed the patient to continue periodically monitoring his blood pressure during the week. The patient was supposed to return in a month, or sooner for worsening symptoms. A month later, the Lisinopril was refilled. Two days after that, a prescription for HCTZ 20/25 was filled.
One month later, the patient returned for scheduled follow-up during which he reported a frontal headache. His blood pressure was improved at 140/90. The patient stated he was eating a healthy diet and attempting to get more exercise. Diagnostic testing included laboratory work and a CT of the brain and sinuses. He was instructed to continue to monitor his blood pressure and call if it was consistently greater than 130/80. The patient was to return in a month or sooner if needed, and was provided the warning signs that would require immediate re-evaluation. A month later, a prescription for Zestoretic® 20/25 was filled.
At the one-month follow-up visit, the patient’s headache had improved but his blood pressure levels remained slightly elevated. Zestoretic was discontinued and Azor® 5/40 daily was started. The patient was instructed to call for blood pressure consistently greater than 120/80, and to schedule a complete physical in three to four months. He presented for his physical five months later. His blood pressure was 130/84. Diagnostic testing was ordered, including an EKG, stress test, chest x-ray, and laboratory testing. Azor 5/40 was continued with regular refills. The patient did have lab work and a CXR, but did not undergo an EKG or stress test. A six-month return visit was scheduled, but the patient was a no-show. Over the course of the next several years, Azor was refilled on a regular basis despite not being evaluated in the office by the defendant physician.
Five years later, the patient presented to an ED complaining of weakness. The patient’s spouse found her husband on the floor in the early morning hours; he was unable to speak and had difficulty moving his extremities. He was experiencing stress at work and dizziness. Findings included a blood pressure of 150/80, significant right-sided motor and sensory deficits, reduced reflexes, and dysarthria. An initial non-contrast CT found no evidence of hemorrhage but a subsequent CT revealed an acute CVA involving the left-middle cerebral artery. He was also diagnosed with a patent foramen ovale (PFO). When examined, the patient had severe expressive aphasia, attention deficits, and difficulty with concentration, problem solving, memory, and thought organization. He required maximal assistance with ADL and mobility. At discharge, however, the patient had experienced significant improvement and was independent in ADL. He continued with speech pathology, OT, and PT as an outpatient.
The patient followed up with the defendant physician post-hospital discharge. The plan included scheduling a cardiology referral regarding management of the PFO, continuing the current medication regimen, and calling the office for blood pressure consistently greater than 130/80. The patient never returned to the defendant physician.
Subsequent follow-up care by cardiology and vascular neurology showed a large PFO with right to left shunting. Based on published trials, closure of the PFO was not recommended, and they believed the stroke was a result of uncontrolled hypertension. Continued care noted blood pressures ranged from 160/98 to 132/87 with anti-hypertensive medication modification. Six months post-CVA, the patient’s speech was fluid and near normal, gait was intact, and he had right-hand coordination difficulty.
The plaintiff filed a claim alleging a failure to properly monitor and treat his elevated blood pressure, resulting in a CVA. Expert support of the defendant physician’s care was tempered by the lack of follow-up for missed appointments. Support was also tempered by the defendant’s continued renewal of anti-hypertensive medication over five years—despite no office visits or the documenting of blood pressure readings when the medication was refilled. With the defendant physician’s consent, the case settled prior to trial.
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