Family Medicine Experts Opine on Delayed Recognition of Cardiovascular Emergency

Case Overview

This case involves a female patient who presented to her family medicine doctor with complaints of generalized, flu-like symptoms. The patient did not have any chest pain, nausea, or other gastrointestinal symptoms. The patient was diagnosed with a viral syndrome and treated with Tamiflu, and was told to drink oral re-hydration solution in order to prevent dehydration. Nevertheless, the patient continued to suffer from progressively worsening symptoms over the week, and presented to her family medicine physician on two additional occasions. The doctor did not order any additional testing, and no blood pressure reading or EKG was taken despite earlier signs for concern. Eventually, the patient suffered cardiac arrest while at home and passed away shortly after.

Questions to the Internal Medicine expert and their responses

How often do you see patient's like the one described in this case?

I am a Board Certified Family Physician with 24 years of experience. I see patients with similar complaints on a fairly frequent basis. Although my current practice is low-volume, generally over the years I have seen approximately 10 patients monthly with similar complaints.

Based on the patient's presentation what would the standard of care be for workup?

The initial work-up gives me pause; I don't see an indicator for an EKG per se unless the initial pulse rate was slow, but would like to have seen orthostatics prior to administration of fluids. If those tests had been performed and had not revealed orthostatic changes in blood pressure and pulse, an EKG would have been indicated on the first visit. Also, I never like to see Tamiflu administered empirically in the absence of respiratory symptoms and/or a positive point-of-care influenza screen, unless the symptoms are completely obvious (copious rhinorrhea/cough/high fever/bodyaches). Orthostatic measurements were clearly indicated on the second visit and the narrow pulse pressure with relatively low pulse rate an indicator for an EKG. Post volume replacement blood pressure and pulse readings would also have been indicated. A travel history, pet exposure, insect exposure and cardiac history of the patient and patient's family, as well as drug and alcohol use history all would be helpful to view.

About the expert

This expert is a board certified Family Physician with a quarter century of clinical experience, comprised of a diverse career in multiple states and countries. In addition to her work as a family physician, she also has experience as an Urgent Care Physician and Hospitalist. After earning her BA in Chemistry and Biology from Pomona College, she obtained her MD at the University of California, Irvine. Her postgraduate work included a General Surgery internship at the University of Washington and a residency in Family Medicine in Ventura County via the University of California, Los Angeles. She is currently the Principal Physician with a focus on Primary Care at a clinic in Hawaii and has volunteered her expertise to assist patient populations in both Haiti and Fiji.

E-171942

Specialties:

Internal Medicine