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.
Question(s) For Expert Witness
- 1. Are you familiar with the signs and symptoms of stroke patients?
- 2. If a patient presents with vomiting, dizziness, and an unsteady gait, would that raise the suspicion level for a stroke?
- 3. Under what circumstances should a patient be sent to the emergency room?
Expert Witness Response E-006953
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. 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. The most frequent finding in patients with posterior cerebral artery territory infractions is visual loss. Visual loss from stroke is usually permanent, as is the case with this patient. In this instance, the woman’s primary care physician violated the standard of care by not recognizing the patient’s symptoms of posterior circulation TIA. As a result of this failure to diagnose, the physician missed the window of opportunity to prevent the stroke and improve this patient’s outcome. 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.
Expert Witness Response E-032272
I am very familiar with the traditional signs and symptoms of stroke, and my expertise is in adult primary care. For a patient like this one who presented with vomiting, dizziness, and unsteady gait, some additional factors that would indicate the possibility of a stroke include the acuity of onset displayed here, the patient’s history of high blood pressure, the unspecified nature of the dizziness, as well as any notable findings on physical examination, such as rotary nystagmus, or other significant on neurological examination. In this case, the patient should probably have been sent to the ED if there was a concern about stroke which, given the symptoms described here, should have been a concern. Had the primary care physician sent this patient to the ER after her first appointment, it is likely that she would have experienced a more favorable outcome, perhaps avoiding her blindness and the full extent of her current neurological injuries.