Patient Suffers Blindness Due to Delayed Stroke Diagnosis

Case Overview

This case involves a middle aged female with a medical history of several chronic conditions, including high blood pressure, stomach ulcers, and a restricted diet. She presented to her general practitioner for an appointment complaining of sudden onset vomiting and dizziness. She also displayed an unsteady gait at the time she was seen by the doctor. After a standard physical examination, the doctor diagnosed her with an infection and sent her home with instructions to follow up in a week if symptoms did not improve. No additional testing or lab studies were done by the doctor at the time. Over the next few hours the patient’s symptoms continued to get worse, until eventually the patient’s son called an ambulance and the patient was transported to the ER. The patient was waiting to see the doctor in the hospital for about an hour when she suddenly became blind in both eyes. Eventually, it was determined that she had suffered a stroke that had caused her initial symptoms before she saw her primary care physician, and that she may have suffered a subsequent stroke or strokes after she had been sent home following her appointment. The patient was severely and permanently injured by the alleged delay in treatment, is permanently blind, and will require ongoing care for the rest of her life.

Questions to the Internal Medicine expert and their responses

Are you familiar with the signs and symptoms of stroke patients?

I am familiar with the signs and symptoms of stroke in patients. This patient displayed several important risk factors for stroke including her age, hypertension, and nutritional requirements.

If a patient presents with vomiting, dizziness, and an unsteady gait, would that raise the suspicion level for a stroke?

This patient's symptoms are consistent with a posterior circulation stroke, and twenty percent of ischemic events in the brain involve posterior circulation structures, so this is not an uncommon presentation. In a patient with the acute onset of vomiting, dizziness and an unsteady gait, posterior circulation insufficiency must be ruled out quickly to avoid progression from a TIA (transient ischemic attack or 'mini stroke') to a stroke.

Under what circumstances should a patient be sent to the emergency room?

The standard of care for this patient required immediate neurologic evaluation with neuroimaging, cardiac monitoring (to rule out atrial fibrillation), labs, and echocardiography. In addition, the use of antiplatelet therapy would have decreased the likelihood of a full stroke and visual loss.

About the expert

This highly qualified, well published expert earned his Bachelor's degree from Cornell University and his MD from Drexel University. He completed a residency in Internal Medicine at Allegheny General Hospital, where he was named chief resident. He has authored dozens of academic peer-reviewed papers, being cited more than a hundred times in the lay press. He previously served as an Associate Program Director for the Internal Medicine Residency Program at Allegheny General and an Assistant Professor of Medicine at Drexel University College of Medicine. He treats patients as an attending physician at a group practice in Pittsburgh, while serving as the Director of Perioperative Medicine at a major Pennsylvania medical center.