Risk Management

Failure to Diagnose Temporal Arteritis

By Stacey Meyer
OMIC Claims/Litigation Associate

Digest, Winter 1998

ALLEGATION

Delayed diagnosis and treatment of temporal arteritis.

DISPOSITION

Claim settled on behalf of insured ophthalmologist.

Case Summary

A 70-year-old male was referred by his family practitioner for an eye exam. He was seen by one of the insured’s ophthalmic technicians, who noted the patient’s complaints of waking up in the morning with a history of headaches and difficulty with reading. Following the technician’s work-up, the insured performed a complete eye exam on the patient. Visual field testing and mobility were within normal limits. Funduscopic examination revealed spontaneous venous pulsation and a normal optic disc. The insured’s impression was conjunctivitis sicca and early cataracts. He noted that the patient’s headaches were most probably related to sinus problems and referred the patient back to his family practitioner.

The following week, the patient presented to his family practitioner with complaints of sporadic headaches during the previous three weeks, jaw pain and loss of appetite. The family practitioner diagnosed headaches secondary to sinusitis, polyuria and polydipsia.

The patient returned to the insured six weeks later with complaints of shutter type vision and blank veils of vision in his left eye. An examination revealed count finger vision. To rule out temporal arteritis and/or anterior ischemic optic neuropathy, the insured ordered a SED rate, which returned as 79. The patient was immediately started on 50 mg of Prednisone. A temporal biopsy two days later confirmed temporal arteritis.

The patient’s present visual acuity is no light perception OS and an altitudinal field defect OD with visual loss in the upper half and a small ring scotoma in the far peripheral field inferiorly.

Analysis

The patient alleged that the insured failed to obtain an adequate history and order appropriate testing, thereby resulting in delayed diagnosis and treatment of temporal arteritis. More specifically, the plaintiff attorney argued that the insured should have diagnosed temporal arteritits on the first visit, claiming that when an elderly patient presents with new headache complaints, temporal arteritis should always be part of the differential diagnosis. Because the insured took no steps to rule out temporal arteritis, the disease was allowed to progress, and the patient lost all vision OS and suffered a significant altitudinal vision defect OD. At the very least, the plaintiff maintained, the insured should have asked the patient questions about his headache complaints and any associated symptoms.

Defense experts pointed out that the insured did not chart any follow-up regarding the patient’s new onset of headaches. In light of the patient’s age, questions should have been asked to rule out giant cell arteritis and to elicit whether he was suffering from any other symptoms associated with this disease. The experts opined that while the complaints of headache alone may not be enough to warrant extensive neurological work-up, the do warrant asking the patient related questions and documenting pertinent negatives. Through discovery, it was apparent that while the insured did address the patient’s headache complaints, he did not record the relevant questions and responses in the medical record. Defense counsel was therefore unable to use the medical record to dispute the plaintiff’s argument that the diagnosis should have been made earlier.

Risk Management Principles

When failure to diagnose is alleged, any physician in the chain of events will be brought into the suit. In this case, both the family practitioner and the ophthalmologist were parties to the suit and each contributed to the settlement of the claim. That is why it is imperative to thoroughly explore and address any complaints described by a patient and to record all relevant questions and responses in the medical record. While it may be impractical to order a sedimentation rate for each older person presenting with a headache, it is a simple matter to question the patient about other symptoms that might indicate temporal arteritis. Finally, when referring at-risk patients to a primary care physician or specialist, do so promptly and follow up with a request for exam and test results.