Would the suggested pelvic exam have detected the problem in time to prevent appendiceal rupture?

Dr. T was busily growing a family practice in a suburb in the Southwest. A 20-year-old woman came to him complaining of distension and cramping, which she noted had occurred previously in an ongoing struggle with constipation. Her abdomen seemed distended with gas, and Dr. T noted normal or increased bowel sounds. On percussion, she seemed to have distended loops of transverse colon.

The patient declined a pelvic examination because a recent such exam done by her gynecologist had been normal. Dr. T wrote in her chart “ref. pelvic.” He prescribed a mild OTC laxative that had worked for the patient on other occasions and asked her to call his office if her condition did not improve.

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The next day, the patient reported (through the office nurse) that she still had cramps and distension. Moreover, she continued to feel bloated despite having passed some gas. Dr. T advised continuing with the prescribed course. The next afternoon, the woman’s mother reported that her daughter had suffered increasing pain and been rushed to the hospital. She was diagnosed with acute peritonitis from a ruptured appendix. The acute infection was treated with IV antibiotics and several days of rehydration prior to surgery, which consisted of laparotomy, evacuation of infection, appendectomy, and placement of drains. The patient spent seven days in the hospital. Recovery took several months. After discharge, she claimed difficulty in getting pregnant due to peritoneal scarring.

The patient consulted a plaintiff’s lawyer who had her chart reviewed by an expert. The result was a malpractice suit against Dr. T for failing to diagnose appendicitis and causing, among other things, “a life-threatening infection” and “permanent sterility” from the peritonitis.

During the depositions, Dr. T was called on to interpret his notes, especially the one on the patient’s refusal to undergo pelvic examination. This refusal presented a problem for the plaintiff’s lawyer, especially since the patient denied refusing the exam even though it was noted in the clinical record.

Dr. T confirmed that the chart notation indicated the patient had refused a pelvic exam and testified that although the results of his exam might also have been negative, it would have made the alternative diagnosis of pelvic inflammatory disease very unlikely. This was important, said Dr. T, because every piece of evidence—even negative evidence—contributes to the overall clinical picture and helps in determining the final diagnosis. Using nothing more than a two-word chart entry, Dr. T was able to vanquish the plaintiff’s lawyer’s attempt to minimize the patient’s refusal to have a pelvic exam.

At trial, the plaintiff’s lawyer suggested to the jury that “ref. pelvic” might have meant “referred to pelvic specialist,” which Dr. T had not done. Dr. T reiterated that the notation meant “refused pelvic exam.” Also in Dr. T’s favor, a fertility specialist testified that cervical mucus, not fallopian-tube obstruction, was the primary culprit in the patient’s infertility.

The jury found unanimously for Dr. T, rejecting both arguments—that he should have diagnosed the atypical appendicitis despite the refused pelvic examination and that peritoneal scarring made it difficult for the woman to get pregnant.

Legal background

A number of medical malpractice lawsuits hinge on the patient’s chart. These notes are considered an independent source of information, recorded before there was any thought of litigation. Medical notes are generally admissible as evidence under the business records exception to hearsay and can be used during examination to refresh the recollection of the defending clinician as to what happened during the clinical encounter.

Protecting yourself

Because their goal is to build an invincible wall of defense around every clinical encounter, risk managers often set unrealistic goals with regard to the extent of documentation required. The severe financial and time constraints of today’s practice environment limit the time clinicians are able to spend on charting.

The pragmatic test for adequate charting is whether you can reconstruct the significant events of the patient’s visit from the notes, when all direct memories of the encounter have faded. Juries are amazingly forgiving in allowing you to interpret your writing and abbreviations of medical jargon.

Dr. Starr is a retired physician and lawyer in the Austin, Tex., area. His legal practice included defending clinicians in malpractice litigation.