This case involves a young woman who had a fever and congestion for a week. The patient’s vitals were normal but her white blood cell count was elevated. She was told to take over-the-counter cold medication and was sent home. The next day, the patient still felt ill so she went to a family medicine doctor. At this point, the patient had severe sinus congestion, extreme nasal discharge, swollen lymph nodes, and an even higher WBC count. The family doctor diagnosed her with possible flu and prescribed antibiotics to be taken only if symptoms did not clear up by the end of the week. In the days that followed, the patient’s eyes began to protrude and she was advised to return to the hospital. A CT showed inflammation of the eye tissues behind the orbital septum and infection in the eye socket from the sinuses. An ENT immediately operated to remove the infected tissues blocking sinus drainage. The following day, the patient had fixed pupils with no vision. Despite many additional surgeries, the patient was rendered permanently blind.
Question(s) For Expert Witness
- 1. How often do you treat patients similar to the one in this case?
- 2. What goes into the decision of whether to give patients antibiotics (length/type of symptoms, degree of fever)?
- 3. What goes into decision making of whether to send a patient to the ED?
Expert Witness Response E-004648
I see patients frequently for the diagnosis of acute sinusitis. The two features that are typically most helpful to diagnose an acute sinus infection that could be helped by an antibiotic are the duration of symptoms and the sick-well-sick pattern of illness. If the symptoms have been present for 10 days or more, the likelihood of a bacterial infection, and benefit from an antibiotic, increase. Similarly, if the patient was sick, got better, and then got sick again (double sickening syndrome or sick-well-sick pattern), this pattern suggests that the patient had a viral upper respiratory infection that then turned into a bacterial one.
Your narrative is completely different from the typical presentation. The way you have written it – it sounds like the physician made a mistake. The patient had already been to the ED days before and was known to have an elevated WBC count. He then comes to the office with tachycardia, an elevated WBC count with a history of recent fever, and copious nasal discharge. With the advantage of hindsight, we are able to write this narrative in the most damning way, and – yes – the way it’s written sounds bad. The physician should have prescribed an antibiotic immediately for what turned out to be severe bacterial sinusitis. If that is the narrative truly in the documentation, then it was a mistake not to prescribe an antibiotic, and advise the patient to take it immediately – because he had severe symptoms for more than 4 days.
It is odd that the patient had a WBC count obtained at the visit to the family medicine office. I really would never have thought of getting a WBC count, and so maybe there is something else going on here, that was concerning to the family physician. Something about the ED visit and the elevated WBC count there. And obtaining a WBC count in the office was done to make sure that it was improving – which it was, in number, though with a left shift suggesting an active response to infection, still. I am confused about the act of obtaining a WBC count at the office visit.
I would not have sent the patient to the ED at that family medicine office visit. It sounded like an acute bacterial sinusitis, at most; and the patient needed to be started on an antibiotic.The subsequent two-day delay in initiating antibiotics certainly could have caused the complications that this patient experienced.