A patient in his mid-sixties with a known history of exposure to asbestos and other chemicals several years prior presented to his ENT physician with complaints of nasal congestion, sinusitis, bronchitis, left ear pressure, recent hearing loss, and a history of nosebleeds with associated blood clots upon coughing.
A physical exam was performed, but it did not include endoscopic evaluation of the nose, nasopharynx, or larynx. The ENT physician diagnosed allergic rhinitis and Eustachian tube dysfunction. No documentation was made regarding the nosebleeds.
The patient returned several times for appointments over the next 2 months. He was treated with antibiotics and steroids, and he underwent a procedure to drain fluid from behind his eardrum. The ENT physician later stated that a CT scan had been ordered for the patient during the last office visit, but the order was not documented in the chart.
Two months later, the patient consulted with a second ENT physician, who performed a scope procedure and diagnosed a malignant nasal mass completely blocking the nasopharynx and left Eustachian tube. The patient underwent chemotherapy treatments, but he developed bony metastasis and subsequently died.
Risk Management Issues for This Claim
- Insufficient documentation of the clinical rationale for treatment and missing documentation related to the order for additional diagnostic testing
- Inadequate patient assessment related to the patient's prior history of exposure to known carcinogens
- Failure to order additional diagnostic testing
- Inappropriate selection of a course of treatment for the patient's continuing symptoms