Failure to diagnose pneumonia

Presentation
A five-year-old girl was brought by her parents to a clinic and seen by a pediatrician as a new patient. The patient came with a one-day history of fever recorded as 104.5 degrees, along with vomiting, mild diarrhea, nasal congestion, myalgia, dry cough, paleness, and decreased appetite.

A physical exam revealed that her lungs were slightly coarse bilaterally without rhonchi or rales. No pulse oximetry was recorded. The patient tested positive for Influenza A and the pediatrician diagnosed influenza with fever. The pediatrician prescribed oseltamivir phosphate and advised the patient’s parents to give the patient acetaminophen and ibuprofen as needed for fever and pain.


Physician action
The next day, the patient’s mother called the clinic to report that her daughter could not lift her right arm, had severe pain under her right armpit and in her back, and required assistance to sit up. During the night, the patient had labored breathing and became very pale with blue lips, the latter of which had resolved. The pediatrician recommended the patient be brought back in to check her oxygenation and status.

The patient was seen that afternoon and her oxygen saturation was noted at 97% on room air. No pallor was noted and her fever had resolved. The patient was also drinking and urinating well, but she was still complaining of right arm pain and a poor appetite. Her lungs were slightly coarse bilaterally with some splinting, without localized abnormal sounds. The child resisted the pediatrician’s examination of her right arm.

The pediatrician’s diagnosis was again influenza with fever. The pediatrician also noted that the patient’s joint pain was possibly due to toxic synovitis from viral illness versus myalgia from influenza.

The following morning, day three, the patient’s mother called again with concerns that she heard rattling in the patient’s chest and intensified coughing. She described the patient’s nail beds as white to violet and her face was “bluish.” The mother reported that the patient did not have a fever. She was advised to monitor the patient at home.

Later that same day, the mother took the patient to another pediatrician. The patient complained of shortness of breath, fever, and cough for three days. The physician noted her oxygen saturation at 80% and decreased breath sounds on her right side. He had her emergently transported to a local emergency department.

The patient’s admitting blood cultures were positive for Streptococcus pneumonia. A chest x-ray showed bilateral infiltrates compatible with pneumonitis and possible right parapneumonic effusion. The patient was placed on antibiotic therapy, admitted to their PICU, and intubated due to severe respiratory distress.

A CT of the thorax indicated loculated right pleural fluid with air with significantly necrotic right upper lobe pneumonia. The patient’s disease progressed to bilateral pneumonia with empyema requiring two thoracoscopic decortication surgeries to drain the fluid from her lungs.

After 19 days in the hospital, the patient’s respiratory symptoms resolved and she was eating a regular diet. She was discharged to home on IV levofloxacin and prescribed physical therapy to treat her deconditioning. The patient’s pulmonary function has fully recovered.
 

Allegations
A lawsuit was filed against the first pediatrician and the clinic. The allegations included failure to perform a chest x-ray, administer antibiotics, and order a appropriate lab work.
 

Legal implications
The plaintiff’s expert stated that the pediatrician could have prevented the progression of the patient’s pneumonia, the need for surgery, and the resulting hospitalization.

TMLT had two independent consultants review the case and both were critical of the pediatrician’s care. Each consultant felt that a chest x-ray and labs were warranted when considering the patient’s presentation of cyanosis, labored breathing, and severe pain.

Ultimately, a defense pediatric expert and infectious disease expert were found to support the pediatrician’s actions. The infectious disease expert focused on the serotype of pneumococcus responsible for the patient’s infection, serotype 19A, which is an aggressive bacteria known to cause a more complicated type of pneumonia. Given the nature of this serotype, this specialist felt a causation argument could be made that even if the pneumonia had been treated 24 hours earlier, the patient still would have needed surgery.

The defense of the pediatrician’s care hinged on explaining why a chest x-ray was not ordered to rule out pneumonia, especially when the patient’s mother reported worsening symptoms for three days. Due to the patient’s fever and signs of hypoxia, it was felt many pediatricians would have ordered a chest x-ray and laboratory testing. The patient’s pneumonia was susceptible to amoxicillin and its earlier administration may have shortened her hospitalization and the severity of her illness.


Disposition
The case was settled on behalf of the pediatrician.
 

Risk management considerations
According to national claims data for pediatrics from January 1, 2003 to December 31, 2012 compiled by the Physician Insurers Association  of America (PIAA), the most prevalent medical misadventure is “errors in diagnosis.” (1)

This case demonstrates the challenges of making a correct diagnosis of an influenza-only illness without ordering additional diagnostic testing. If the parent or patient calls reporting recurring symptoms, it may be time to pursue additional testing or a referral. Ordering a chest x-ray and laboratory testing might have resulted in an earlier diagnosis, or made the case more defensible.
 

Source
1. Physician Insurers Association of America. Semi-Annual Data Sharing Report. 2012 Edition. January 1, 2003 to December 31, 2012. Rockville, MD. Accessed May 2014.

 

 

These closed claim studies are based on an actual malpractice claims from TMLT. These cases illustrates how action or inaction on the part of physicians led to allegations of professional liability, and how risk management techniques may have either prevented the outcome or increased the physician’s defensibility. These studies have been modified to protect the privacy of the physicians and patients.

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