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Specialist Referrals Are Not Always Enough

One of the great balancing acts in medical care is the family practitioner’s decision about what to take on oneself and what to send to a specialist. This column has frequently shown the risks of the primary care physician doing too much, but sometimes, he or she may have the tools readily available to handle an urgent situation.

A 42-year-old woman had been the patient of Dr. FP, a family practitioner, for 10 years with a history of smoking, hypertension, anxiety, and panic attacks. She was taking Procardia, Lidex, Adderall, Seroquel, and Viibryd when she presented to Dr. FP with complaints of dizziness, chest pain, and numbness in her feet over the previous two days. She reported that at one point she had been unable to stand and had called her mother for assistance while on the floor. She said that her heart rate at the time was in the 40s to 50s.

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Dr. FP noted vital signs of BP 90/60 and 84/56; and a heart rate of 80. Physical examination noted no cardiomegaly or thrills, a regular rate and rhythm, and no murmurs or gallops.

Dr. FP discontinued the Procardia out of concern for hypotension, but because the patient expressed a worry about a blood pressure spike, Dr. FP prescribed HCTZ and recommended a cardiologist referral if the patient experienced no improvement. Dr. FP finished by ordering the patient’s annual lab studies but did not perform an EKG, though she had the apparatus to do so.

The patient returned three days later for follow-up and was still experiencing lightheadedness but no syncope. Examination showed a temperature of 101.9, a heart rate of 80-90, and blood pressure readings of 100/60 and 90/60 sitting and 82/52 standing. Lab work showed an elevated AST and WBC. Dr. FP was not sure if the patient was experiencing a viral or bacterial infection. She prescribed a Z-Pak and recommended that the woman go to the ER for IVF/BP support and further workup. The patient declined because of lack of insurance but promised to go if her symptoms worsened. A chest x-ray showed findings consistent with bronchitis with no evidence of pneumonia.

Two days after her last visit with Dr. FP, the patient presented to the emergency room with shortness of breath and chest pain. At the hospital, tests revealed findings consistent with acute inferior lateral myocardial infarction, an occluded right coronary artery, global hypokinesis and inferior akinesis, and an ejection fraction of 30 percent. A balloon pump was placed but surgery could not proceed because of the Plavix administered in the ER. When a stent failed to establish reflow, the patient was treated with TPA, verapamil, and nitroglycerin. After transfer to ICU and intubation, the patient experienced multiple recurrences of cardiac arrest before CPR was terminated, followed by her death.

Family members filed a lawsuit against several healthcare defendants over the care rendered. In addition to alleging that Dr. FP should have been more urgent in her cardiology referral, they claimed that Dr. FP’s failure to perform an EKG on the first of the visits contributed to her death. The lawsuit against Dr. FP resolved informally.

Patients lacking insurance coverage may frequently decline a general practitioner’s advice to see a specialist for more targeted care. Documenting the advice given and declined is important in the defense of a later lawsuit, but it will likely never be enough to overcome not doing a test routinely performed at a family practice. 

Gordon Ownby is CAP’s General Counsel. Questions or comments related to “Case of the Month” should be directed to