Spotting bacterial endocarditis in the ED

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A 35-year-old presents to the ED complaining of a swollen tongue of several hours duration. On arrival, he is having difficulty breathing and speaking. He believes that he is having an allergic reaction to erythromycin that was prescribed by his primary care physician. When he arrived, he told the medical staff that he had a heart murmur. In triage, the patient had a fever of 102 degrees and was mildly anemic. By the time the patient was evaluated by the physician, his tongue swelling had gone down. The EP called the patient’s primary care physician and discussed the case. The patient was instructed to see his primary care physician as soon as possible and went to see his physician that same day.
Four weeks later, the patient’s fever persisted and he went to another physician for further evaluation. At that time, he was diagnosed with subacute bacterial endocarditisa, immediately admitted to the hospital and was started on intravenous antibiotic therapy. During the third week of inpatient treatment, the patient suffered a significant stroke. The patient then filed a lawsuit alleging that the EP should have tested him for endocarditis during his ED visit seven weeks before he had his stroke. Because the EP failed to perform testing for endocarditis, the patient alleged that his treatment was delayed, causing him to have a stroke.
During depositions, the defendant EP testified that he knew the plaintiff had a fever during his examination but did not know the cause of the fever. He denied hearing the murmur, even though the PCP had previously testified that the patient’s murmur was “quite noticeable” and could have been heard just by putting an ear to plaintiff’s chest. The EP admitted that the patient probably did have a heart murmur during his ED visit even though he had failed to hear this murmur. He also acknowledged that subacute bacterial endocarditis should be considered in a patient with a fever of unknown origin and a heart murmur and speculated that if he had heard the murmur when he examined the patient, he might have diagnosed the patient’s endocarditis.
The plaintiff’s expert testified that the patient had symptoms typical of endocarditis and that diagnosis of endocarditis during the patient’s ED visit would have led to a good recovery. The expert testified that endocarditis often presents as a combination of a fever and a heart murmur, and that the failure to diagnose endocarditis would inevitably lead to the patient’s death. Finally, the expert gave the opinion that if the EP had performed a proper H and P, the appropriate testing would have been performed and the patient’s stroke would not have occurred.

Were the expert’s statements appropriate? Did the standard of care require the physician to diagnose bacterial endocarditis on the patient’s ED visit?

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SENIOR EDITOR DR. SULLIVAN, an emergency physician and clinical assistant professor at Midwestern University in Illinois, is EPM’s resident legal expert. As a health law attorney, Dr. Sullivan represents medical providers and has published many articles on legal issues in 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. He can be reached at his legal web site

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