Physical Exams
by Donna Knight, CPHQ, CPHRM
Princeton Insurance Healthcare Risk Consultant
Printable Version of this Article
Scenario
Prior to acceptance on the soccer team, this adolescent female student received a sports physical by the school physician. The student informed the school physician that at times she experienced chest pain associated with exertion and that she was therefore not allowed to participate in sports. It was recommended that she see her personal physician as soon as possible and obtain a chest x-ray and EKG. Upon approval and completion of the sports physical form by her personal physician, she would be permitted to join the team. Several days later, the student’s family practitioner performed a physical examination, without performing an EKG or chest x-ray. The required sports participation form was completed indicating she was able to play soccer. Two weeks later, while on the soccer field, the student experienced cardiac arrest. Emergency interventional cardiac catheterization and pacemaker insertion were performed. It was immediately determined that she required transfer to a university medical center for a heart transplant. She expired just prior to transfer. Autopsy indicated congenital coronary artery defect without any prior indication of myocardial infarction as the cause of death.
Allegation & Outcome
The parents brought suit against the family practitioner for failure to perform the appropriate testing, failure to diagnose cardiac disease and wrongful death. The claim was dismissed with prejudice.
Clinical Perspective
1. Chest pain is a frequent complaint among adolescents and is commonly musculo-skeletal in nature.
2. Congenital coronary artery disease can be clinically silent and recognized only at the time of autopsy.
Defense Perspective
1. There was significant disparity between the plaintiff and defense expert’s reports and depositions regarding whether congenital coronary artery disease is recognizable by chest x-ray, EKG, or any other cardiac testing.
2. The defense expert refuted the plaintiff’s expert opinion that the chest pain was due to the underlying anomaly. The student had a rare and lethal congenital anomaly which usually presents with sudden cardiovascular collapse during exercise with no prior warnings. Rarely are there warning signs.
Patient Safety & Risk Management Perspective
1. Carefully review the student/parent’s completed history section of the New Jersey Department of Education’s Annual Athletic Pre-Participation Physical Examination Form for clinical indications that may raise suspicion of underlying significant disease (e.g. a relative who expired at a premature age or of sudden cardiac death).
2. Pay close attention to complaints of chest pain in adolescents even though it is not always non-cardiac in nature. Document the details of the type of chest pain experienced by the patient (e.g. burning, sharp, dull) and whether it occurs at rest or on exertion.
3. Clearly document the rationale for decisions not to perform tests recommended by other physicians.