Patient Has a History of Hypertension and GERD… You Decide If the Physician’s Care Qualified As ‘Reasonable Practice’

4 Comments

A 55-year-old male with a history of hypertension and GERD was brought by ambulance to the emergency department for a syncopal episode that occurred while he was at his doctor’s office. The day prior he had been to the same physician for evaluation of a two-week history of dry cough, subjective fever and dyspnea on exertion. At that time, he was diagnosed with pneumonia based on his exam and chest x-ray and was started on ciprofloxin and azithromycin. He returned because he felt worse, had intermittent sweating, and had fainted twice earlier in the day. The primary care physician evaluated him briefly then sent him to the emergency department by ambulance.

The emergency physician obtained a similar history and also noted that the patient had complained of intermittent chest tightness for the prior two days. Triage vital signs showed temperature 96.8, BP 109/69, pulse 140, RR 24, and oxygen saturation 90% on face mask. The physical exam documented by the emergency physician was notable for tachycardia and rales about half way up both lungs. The rest of the exam was documented as being normal.

An EKG showed atrial fibrillation with a rate of 143 and non-specific ST and T wave changes, but no ST elevation. A portable chest x-ray showed bilateral infiltrates and cardiomegaly. Lab tests revealed a WBC count of 21.3, a BNP of 977, and a troponin of 0.8. BUN and creatinine were elevated at 35 and 1.9. The remainder of the CBC and chemistry panel were normal.

The patient was initially treated with IV fluids, aspirin, and diltiazem. His heart rate improved to the 90’s. When the CXR and BNP showed findings consistent with CHF, he was also given IV Lasix. He was admitted to the on-call internist to a telemetry bed with diagnoses of new onset atrial fibrillation, CHF, and possible pneumonia. No further testing or treatment was initiated in the emergency department.


Not knowing the outcome of this case, was the management by the emergency physician REASONABLE PRACTICE? Why or why not? Email your response to editor@epmonthly.com and we’ll include it in next month’s analysis.

ABOUT THE AUTHOR

SENIOR EDITOR
Dr. Sullivan, an emergency physician and clinical assistant professor at two residency programs in Illinois, is EPM's resident legal expert. As an attorney specializing in healthcare issues, Dr. Sullivan represents physicians and has published many articles on legal aspects of medicine. He is a past president of the Illinois College of Emergency Physicians and a past chair and current member of the American College of Emergency Physicians' Medical Legal Committee.

4 Comments

  1. This seems like a common presentation of a common problem. I agree with the dx impression, but… what about a lactate? This certainly could be undiagnosed A-Fib worsened by sepsis? An elevated lactate would have landed him in the ICU rather than tele bed. However, overall I think management is within standard practice.

  2. Kathryn Peilen on

    Atrial fibrillation of unknown duration (unless EKG obtained by PMD day prior showed NSR) should have received full dose anticoagulation and cardiology consulted for echocardiogram and consider angiography for elevated troponin.

  3. Reasonable but I would have scanned him for PE! Infiltrate on CXR the day before could have been pulmonary infarct and now he’s in CHF from the PE.

  4. Can anybody say for sure that the unexplained syncope has been determined by this point? I would not have left the chest pain and syncope for the inpatient team to figure out. To reply to Peilin comment, I would find it impossible for me to fully anticoagulate someone I am working up for chest pain and syncope (ie aortic dissection). However, pulmonary embolism would be a more likely explanation to the patient’s presentation, especially if there is no JVD or peripheral edema on physical exam….The BP is relatively low to give Lasix. Perhaps an ICU bed should have been considered (or stepdown).

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