Washington – Family Medicine – American Samoan Patient With Worsening Hypertension

From October 2005 to November 2006, a family practitioner treated a patient for symptomatic and severe hypertension.  The patient had a history of poorly controlled blood pressure requiring multiple medications for treatment.  The patient, an American Samoan and 46-year-old mother of six children, had a limited understanding of the English language.  Additionally, she also had significant hearing loss caused by recurrent ear infections.  During his treatment of the patient, the family practitioner failed to appreciate the significance of the patient’s cultural and physical barriers and the potential adverse effects these barriers had on her medical care.  The family practitioner did not employ an interpreter during the patient’s office visits; rather, he relied on the patient’s family members to interpret and convey important medical information.

The family practitioner began treating the patient in October 2005, following the patient’s hospital emergency department (ED) visit two weeks prior where she sought treatment for headache and hypertension.  The family practitioner described the patient as “deaf,” although he also noted in the patient’s records that she frequently answered her phone while in the exam room.  During this office visit, the family practitioner recorded the patient’s blood pressure as 162/94.  The patient’s CT test from the hospital indicated negative results, and the blood work that the family practitioner ordered indicated normal results.  The family practitioner prescribed hypertension medication.  There is no documentation regarding follow-up visits.

On 1/5/2006, the patient called the family practitioner’s office and reported headache, chest discomfort, stomach ache, and neck pain.  The family practitioner’s nurse instructed the patient to immediately go to the hospital ED.  The family practitioner’s records for the patient included only the report of two-view chest imaging and did not include the notes from the outpatient emergency record.

On 3/21/2006, the patient returned for an office visit with the family practitioner.  The patient’s blood pressure was recorded as 192/106.  Although the family practitioner noted an audiometric evaluation (to address hearing loss) and provided the patient a referral to an otolaryngologist, the family practitioner failed to document any discussion about the patient’s January visit to the hospital ED.

The family practitioner’s records for the patient indicated the patient had a hospital ED visit for 6/29/2006 and included a report of a non-contrast head CT performed at the hospital which was ordered to rule out a bleed.  The family practitioner’s records did not include the notes from the outpatient emergency record.

The family practitioner examined the patient on 7/26/2006 when she presented with severe headaches, neck pain, and trouble sleeping.  The family practitioner documented the patient had not been taking her medication.  The patient’s blood pressure was recorded at 190/130.  The family practitioner did not document a discussion about the patient’s hospital ED visit the month prior or the results of the patient’s head CT.  The family practitioner noted that the patient had “poor compliance” taking her blood pressure medications, and counseled the patient about medication compliance.  The patient’s husband was present during this exam and likely interpreted the family practitioner’s counsel.  The family practitioner also recognized that medication expense was likely a factor in the patient’s non-compliance, so he prescribed a less expensive medication as well as provided the patient with free samples of hypertension drugs.

On 8/1/2006, the patient returned to see the family practitioner.  The patient’s blood pressure was recorded as 210/110.  The family practitioner noted that the patient was suffering from headaches caused by elevated blood pressure, that she was “not taking free BP pills,” and that she was “unreliable.”  He directed her to return for a blood pressure check in three weeks, but there was no follow-up appointment scheduled.  The patient did not return for the three-week follow-up with the family practitioner.

On 10/13/2006, the patient returned to see the family practitioner complaining of headache, vomiting, and neck pain.  She had also missed work.  The patient’s blood pressure was noted as 280/152.  There was indication that the family practitioner considered having an interpreter present to communicate to the patient the significance of malignant hypertension.  Instead of treating the patient’s hypertensive emergency, the family practitioner noted that the patient should follow-up in three days.

On 10/14/2006, the patient presented to the hospital’s ED with mental status change, vomiting, headache, and nausea.  The patient was admitted and remained in the hospital for four days.  The family practitioner noted that the patient’s “blood pressure came down throughout the hospital stay.”  The ED physician requested an adrenal evaluation and diagnosed the patient with hyperaldosteronism.  The patient had an appointment with a nephrologist scheduled to be seen a few weeks.

The day after the patient’s hospital discharge she returned to the family practitioner’s office for a follow-up.  The patient’s documented blood pressure was 140/90.  The patient’s blood pressure improved because of the treatment received during the four-day hospitalization to control her blood pressure.  The family practitioner also noted that he counseled the patient, recommended she be off work for seven days, follow up with the nephrologist, and return to see the family practitioner for a blood pressure check in six days.

On 10/25/2006, the patient returned for the six day follow-up appointment with the family practitioner.  The patient’s blood pressure reading showed an increase to 218/150.  When repeated it was 220/150.  The family practitioner’s plan included lab tests and instructions for the patient to return in two weeks.

On 11/8/2006, the patient returned to see the family practitioner for a follow-up.  The family practitioner reviewed the patient’s lab results and noted the patient’s upcoming nephrology appointment to address her hyperaldosteronism.  He recorded the patient’s blood pressure as 220/140, and 210/120 when repeated.  The family practitioner also documented that the patient took her medications, but her elevated blood pressure was poorly controlled.  The family practitioner increased the patient’s carvedilol medication dosage and asked her to return for a blood pressure check in one month.

On 11/10/2006, the patient’s family called the family practitioner’s office because the patient complained of intense headache, nausea, and vomiting.  The family practitioner’s staff directed the family to immediately take the patient to the hospital.  When the patient presented to the hospital ED, her recorded blood pressure was 240/140.  Her diagnosis of hypertensive encephalopathy necessitated urgent treatment in the intensive care unit.  Despite immediate medical response, the patient experienced respiratory arrest the next evening and she required intubation and mechanical ventilation.  The patient suffered brain death and died on 11/12/2006.  The cause of death is listed as hypertensive encephalopathy with cerebral edema resulting in respiratory and cardiac arrest.

The family practitioner did not take the additional steps necessary to assure that the patient understood the critical importance of her blood pressure medications, the importance of taking them as prescribed, and that she could easily die if she did not take the medications as prescribed.

The Commission stipulated that the family practitioner reimburse costs to the Commission, allow a representative of the Commission to make annual visits to his practice to review patient records, and write and submit a paper of at least 2000 words, with bibliography, on the management of malignant hypertension and the treatment of hypertensive emergencies.

State: Washington

Date: January 2016

Specialty: Family Medicine, Internal Medicine

Symptom: Headache, Nausea Or Vomiting

Diagnosis: Hypertensive Emergency

Medical Error: Failure of communication with patient or patient relations

Significant Outcome: Death

Case Rating: 5

Link to Original Case File: Download PDF

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