This case involves a 54-year old woman with a history of obesity, who suffered a previous stroke at the age of 43. Since the stroke, she was treated by a nephrologist and would undergo annual physical evaluations. 7 years after her first stroke, she presented to her primary care physician where she was evaluated by the nurse practitioner for her annual physical evaluation. She had elevated blood pressure levels at the time, and the nurse practitioner advised her to continue her medication regimen and consult her nephrologist. The following week, she informed the nephrologist’s office that her blood pressure was still elevated. Her nephrologist increased her medication dosage, but over the next 2 weeks her blood pressure continued to slowly climb. Over the next few days, her blood pressure was reportedly still high so her overall lifestyle was reviewed and it was determined that she should include daily exercise into her routine. Over the next 2 months, she followed a daily workout routine and her blood pressure slowly started to drop. At another evaluation with the nephrologist, it was noted that her blood pressure had stabilized and the nephrologist concluded that her elevated blood pressure levels were due to her lack of exercise. However, a checkup with her primary care physician a month later showed her blood pressure was elevated once again. The nurse practitioner noted that it was due to the patient’s lack of sleep the night before and did not conduct any further evaluation. Her medication regimen at that time included a myriad of over 10 medications. Less than 2 months after her last visit to the nurse practitioner, the patient collapsed at work and remained unresponsive. Upon arrival, EMTs immediately performed emergency services, but were unsuccessful. An autopsy later discovered she had suffered a second stroke due to a blockage in her artery.
Question(s) For Expert Witness
1. Do you routinely treat patients similar to the one described in the case? Please explain.
2. Have you ever had a patient develop the outcome described in the case? If so, please explain.
3. Given the patient's history of hypertension and a stroke, what measures should have been taken to closely monitor the patient and control his hypertension?
4. Have you ever served as an expert witness on a case similar to the one described above? If so, please explain.
Expert Witness Response E-005521
I routinely treat patients with stroke and seizures. I have had patients with massively disabling strokes and rarely with occlusions bilaterally over many years. Given the patient's history of hypertension and stroke, additional measures could have been taken to closely monitor the patient and control his hypertension. With an occlusion at a young age, serial vascular studies such as carotid dopplers, MRAs, or CTAs would commonly be done. In terms of blood pressure control, optimal management over years would be important. However, some patients are quite resistant to good blood pressure control. Management of these patients often falls to a nephrologist, as in this case. Her body may have required a higher blood pressure to maintain perfusion of the brain, particularly if she was slowly developing the right sided occlusion. In addition, if her stroke was cardiac in origin (embolus, for example), the occlusion could have been acute and not related to her blood pressure.
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