This case involves a fifty-three-year-old female who visited her primary care physician with complaints of right facial dropping and numbness down her right arm. The previous day, while preparing breakfast, she began to have difficulty formulating sentences. Her medical history included diabetes mellitus, hypercholesterolemia, and hypertension. She was using multiple medications to treat her condition, including Onglyza, Benicar and Lipitor. The internist found no abnormalities on physical examination and laboratory work. He scheduled her for a follow-up appointment two weeks after the initial visit. A week later, the woman’s leg buckled and she fell to the ground while on a walk with her husband. He asked her what was wrong, but she was unresponsive. She was rushed to the emergency department, where they performed a CT scan. The scan revealed bleeding in her brain indicative of a stroke. Additionally, they found evidence of earlier bleeding. The medical team questioned her husband, and he told the ER physician that she experienced fifteen minutes of right facial drooping and numbness in her right arm. The physician told her husband that she most likely suffered a transient ischemic attack, which is a “mini-stroke,” and, subsequently, would require lifelong anticoagulation. She also suffered permanent damage from the stroke requiring occupational and physical therapy.

This physician did not properly work-up the patient’s complaints in this case. The patient was exhibiting classic stroke-like symptoms. Additionally, the woman had significant risk factors for the development of a stroke. When a patient presents with facial drooping, arm or leg weakness, and difficulty speaking, a stroke should be ruled out. Sometimes patients will experience what is known as a transient ischemic attack (TIA) before a stroke. TIA is characterized by symptoms of stroke that last between a few minutes and twenty-four hours. Once a stroke is identified, the patient should be taken to the hospital for proper treatment. The diagnosis of stroke can be made with imaging, most commonly using a CT scan, which reveals bleeding in the brain. Patients found to experience TIAs should be placed on aspirin to prevent the development of a stroke. Many times, those experiencing strokes will require lifelong anticoagulation. If a thrombus is present, the patient may also require thrombolytic therapy to break up the clot. Rehabilitation is often recommended to help people regain motor functioning.

1. Did the internist follow the standard of care when treating this patient, and what could have been done to prevent future damage in this patient?

Internist Fails to Diagnose Stroke

This case involves a twenty-eight-year-old female who presented to an urgent care center with complaints of a headache, sweating, and heart palpitations. She also noted that she had experienced anxiety during the previous months. The woman’s blood pressure was recorded to be 210/90 mmHg at the urgent care center. Her past medical history included thyroid cancer and primary hyperparathyroidism, which were both treated successfully prior to the plaintiff’s presentation to the urgent care center. She was started on metoprolol and lisinopril to help control her blood pressure. Once stabilized, the woman was discharged and recommended to establish care with a primary care physician. Three months later, she visited her primary care physician with similar complaints. Given her symptoms and past medical history, the physician wanted to do further testing. Laboratory testing revealed that she had elevated catecholamine levels. A CT scan of her abdomen showed that she had a left-sided adrenal tumor which was confirmed to be a pheochromocytoma. Genetic studies were also ordered, which showed a mutation consistent with multiple endocrine neoplasia type 2B (MEN 2B). The diagnosis of MEN 2B explained the constellation of medical conditions she had encountered throughout her lifetime. She was immediately scheduled for resection of the pheochromocytoma. After surgery, she required care with a cardiologist to address the cardiac damage that had developed.

The urgent care center, in this case, treated the woman’s hypertension without further investigating its cause. This patient had a significant medical history that was associated with her hypertension. This should have clued the physician into the possibility of a multiple endocrine neoplasia. This woman had MEN 2B, a triad of medullary carcinoma of the thyroid, hyperparathyroidism, and pheochromocytoma. Due to the delay in diagnosis, this woman suffered cardiac damage. The urgent care center should have performed the proper testing that her primary care physician ordered. If that testing was unavailable, they should have referred her to someone who could. Pheochromocytoma is a catecholamine-secreting tumor that causes individuals to experience a classic triad of a headache, tachycardia, and sweating. Other signs and symptoms of pheochromocytoma include flank pain, hypertension, anxiety, pallor, and weight loss. Hypertension is a serious concern with these patients because it can affect cardiac functioning.

1. Did this urgent care center properly work up this woman’s medical condition, and what could have been done to diagnose and treat this patient properly?

Medical Expert Witness Discusses Urgent Care Center’s Diagnosis

This case involves an overweight middle-aged female patient who was diagnosed with an endometrial polyp following a hysteroscopy. She presented to an OB/GYN for a second opinion regarding treatment options. The OB/GYN discussed hysterectomy versus hormonal treatment but the patient chose to undergo a total abdominal hysterectomy. During the procedure, the surgeon realized the uterus had grown too large to be removed from the vagina. It was decided that the uterus would be removed in pieces through an abdominal incision. Surgical pathology later revealed the patient had stage II endometrial cancer. When the patient asked how she could have cancer, the surgeon informed her the physician who performed the hysteroscopy had missed a polyp. Following her surgery, the patient had persistent abdominal pain and was referred for an abdominal CT. The scan showed several masses at the abdominal incision site and a CT-guided biopsy revealed metastatic adenocarcinoma. It was alleged that the tumors were of gynecological origin with endometrial histology. The patient underwent chemotherapy and many sessions of radiation therapy but continues to suffer from recurring fluid collections. An expert in gynecological oncology was sought to discuss how hysterectomies can lead to metastasis.

I currently perform approximately 100 hysterectomies via various approaches per year including abdominal, laparoscopic and robotic. While the summary states the patient had a TAH/BSO, it seems more likely that she had a TLH/BSO (a laparoscopic hysterectomy) as there would be no reason to remove the uterus via the vagina for an abdominal hysterectomy. Had the patient had a pre-operative diagnosis of cancer (i.e. if the polyp were removed pre-op), then she should not have undergone a surgery requiring morcellation of her uterus as this would be strictly contra-indicated. Given the size of her uterus, she should have either had an open hysterectomy (a TAH/BSO) or had the uterus morcellated within a containment bag. There is every reason to believe that the morcellation of the uterus caused the spread of her cancer. The real issue is that she had undiagnosed postmenopausal bleeding and therefore underwent a laparoscopic hysterectomy with morcellation which was inappropriate. The red flag is that the only uterine sampling you have shown squamous tissue suggesting it was a cervical specimen and not from the endometrial cavity. Thus there could be no assurance that she did not have endometrial pathology (i.e if the polyp described showed only squamous tissue, it was likely an endocervical polyp and not an endometrial one). According to the narrative, she appears to have had a Stage II grade 1 endometrial cancer which should not have recurred the way that it did. The fact that it recurred within the abdominal wall is extremely suggestive that the morcellation of the uterus caused the recurrence and metastases.

1. How often do you perform hysterectomies? 2. Can the type of approach to a hysterectomy eventually lead to metastasis? Please elaborate. 3. How does a delay in cancer diagnosis affect the prognosis of a patient? How does a delay in diagnosis have an effect on metastasis?

Patient Receives Delayed Uterine Cancer Diagnosis Following Misread Hysteroscopy

By the time she presented to the emergency room, her speech was coherent and as a result, she was given a stroke assessment score of 0. A stat CT was ordered for the patient which came back unremarkable. The patient was diagnosed with a possible transient ischemic attack. No stroke alert was called for the patient, and she was not given IV tPA. The patient later suffered a change in mental status while in the emergency room and called out in pain. Following the incident, the patient was sent for a stat MRI of the spine and brain which revealed a small focus of insufficient blood flow to the inferior parietal lobe. There was also a small focus of petechial hemorrhage in the area of insufficient blood flow. The patient then suffered a lack of normal flow void in the left internal carotid artery at the skull base. Per the record, the radiologist was also suspicious of carotid artery stenosis and recommended a CT angio of the neck and head. The CT angio suggested a subtotal blockage of the carotid artery on the left and also showed evidence of stenosis affecting the left M1 segment. The patient was left wheelchair-bound with right-side paralysis, limited verbal communication, and frequent seizures.

This patients Cincinnati stroke scale score was 2 out of 3, considering that she had both a droop and speech affected. I would need to review the records to establish an NIH score, however the patient's Cincinnati score and presentation were classic for stroke. Drift is not mentioned as measured. She more likely than not qualified for TPA being that she was within the 3-hour window and it doesn't sound as if she had any contraindications. She may have also qualified for endovascular treatment which allows for a 6-hour window. A CT scan is not done to identify an ischemic stroke, as is ischemia can take an average of 6 hours to show up on CT. CT is instead done to rule out hemorrhage. Nursing had an independent duty to recognize this woman's classic signs of stroke and call a stroke alerts. Nursing further had a duty to advocate for a STAT telephonic neuro consult as part of the stroke alert pathway. Neuro along with the ER physician would then have been able to make the decision to initiate brain-saving TPA or transfer to a center capable of endovascular treatment. This was a clear breach of the well defined national standards set by the American Heart Association. American Stroke Association and Emergency Nurses Association to have failed to recognize signs of stroke and call a stroke alerts. I would, of course, need to review the records in order to make certain opinions.

What sort of changes in a patient's status would prompt you to page or inform a doctor (VS, mental status, neurologic exam of extremities, etc)?

This case involves a 66-year-old female patient who became aphasic, suffered facial drooping, and was unable to recognize her family members.

Stroke Patient Left Paralyzed After Negligent Misdiagnosis

This case involves a 28-year-old male patient who underwent an IV infiltration at a radiology clinic prior to having imaging. In the process of having a CT scan with contrast, the contrast extravasated into the patient’s left hand. The patient noted severe swelling and pain and notified the technologist. Once the technologist was notified, the patient was sent to the emergency room. The patient was then urgently sent to the operating room where he had a fasciotomy due to compartment syndrome in the left hand with a carpal tunnel release. Following the surgery, the patient was put on a 5-pound lift, push, and pull restriction for his left hand.

I'm a CT technologist with a master's degree in health administration and a certification as a radiology administrator. IV's are used commonly in CT to provide enhancement of infections, lesion/tumors, and highlight structures, such as arteries and veins and bleeds. Approximately 25-35% of cases require contrast injections. Contrast must also be given at specific speeds based on the enhancement required. Pulmonary emboli studies have to be injected at a high rate and contrast given and the machine engaged within 25 seconds of the start of that injection. Based on this, many variables can lead to contrast extravasation including patients habitus, injection site, etc.

1. How often do you place IVs in patients prior to the performance of imaging studies? 2. What factors contribute to contrast extravasation?

CT Contrast Injection Leak Causes Patient Compartment Syndrome

: United States Court of Appeals for the Seventh Circuit 

When the plaintiff’s daughter was five months old, she was dropped and suffered a skull fracture. The fracture expanded over time and a cyst also formed in the area. The head injury and the cyst did not cause concern until, at the age of seventeen, the daughter was hit in the head and suffered blurred vision, dizziness, and a loss of consciousness. After CT and MRI scans revealed the severity of the fracture and the cyst, she underwent cranioplasty surgery to patch the split and the region of the dura (the thick membrane around the brain) where the cyst had developed. The day after the surgery, the daughter was released but she was found dead in her room three days later.

Her mother filed a suit against the hospital and the doctors. She claimed that surgery led to her daughter suffering a seizure that led to her death. The plaintiff also asserted that the doctors treating her daughter should have administered anti-seizure medicine. In response, the defendants argued that no seizure had occurred and that a heart-related disease was the probable cause of death. A jury decided in favor of the defendants, and the plaintiff appealed. The appellate court examined the admissibility of the defendant’s pediatric surgery expert.

The defendants’ pediatric surgery expert witness had been a practicing pediatric neurosurgeon for nearly 25 years. The expert worked as the director of pediatric neurosurgery for the Advocate Health Care program, which consisted of two large children’s hospitals and about ten other hospitals. He was also licensed in neurological surgery, affiliated with several scientific associations, and a former member of an editorial board for neurological publications. More prominently, he also worked on increasing fractures of the skulls, including the deceased’s and had written papers on numerous pediatric neurosurgery subjects, like epilepsy, cranial cysts, and severe head injuries.

The pediatric surgery expert witness opined that the daughter’s cause of death was not a seizure but rather, a focal interstitial chronic inflammation of the heart. He arrived at his conclusions on the deceased’s based on his examination of the autopsy report, the deceased’s medical reports, including MRI and CT scans, reviewing the attending doctor’s report and post-surgery notes, and deposition testimony. The expert’s testimony was also based on his extensive professional experience, especially concerning pediatric neurosurgery.

The plaintiff claimed that the trial judge erred in permitting the pediatric surgery expert witness to testify that the cause of death of the deceased was due to this underlying heart problem. The plaintiff further asserted that the expert had given his cause-of-death opinion without being qualified and without using a reliable methodology. The plaintiff argued that the expert did not have the necessary credentials since pathology was not his area of expertise, thus making his opinion on the alleged heart condition inadmissible.

The appellate court stated that the pediatric surgery expert witness had ample qualifications to opine on the deceased’s surgical procedure and the probable risk of a seizure afterward. Moreover, the court concluded that the expert’s seizure-related findings were based on a reasonably accurate approach. However, the court noted that while the expert was qualified to analyze the surgery and the risk of seizures, this expertise did not apply to his belief that the child’s heart-related condition was the most probable cause of death. The court explained this was because the expert did not have any expertise related to focal interstitial chronic inflammation directly, or more generally, to cardiology.

The plaintiff’s motion to exclude the pediatric surgery expert witness’s testimony was granted in part and denied in part.

Teen Dies After Skull Surgery to Repair Fracture Sustained as an Infant

Location: Maryland College of Notre Dame of Maryland Radiologic/MRI Technical Certification: Johns Hopkins School of MRI, Mercy Medical School of Radiologic Technology Certification: Medical Radiation, MRI, CT, Mammography Member, American Society of Radiologic Technologists Former, CT/MRI Supervisor, Union Memorial Hospital Former, CT/MRI Technologist, American Radiology Services Current, MRI Technologist at private imaging group

This expert has reviewed 12 cases, been deposed 6 times.

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