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CASE STUDY: Inadequate Communication Between Provider and Patient Leads to Misdiagnosis

CASE STUDY: Inadequate Communication Between Provider and Patient Leads to Misdiagnosis

Case Details

A doctor on call for his group practice received an after-hours call from a male patient in his sixties. The patient was complaining of weakness and reported that he had started a new blood pressure pill (hydrochlorothiazide) 3 days earlier. He also reported taking lisinopril daily for more than a year.

The doctor quickly attributed the patient's weakness to the new medication; he told the patient to stop taking the hydrochlorothiazide and to check his blood pressure using a home blood pressure cuff. The doctor instructed the patient to seek immediate care if his systolic pressure went above 180 mmHg, but to otherwise make an appointment to see his regular doctor to get a different blood pressure medication.

Three days later, the patient was hospitalized with sudden onset of right arm and leg weakness, as well as difficulty speaking. He was diagnosed with atrial fibrillation. Based on the patient's symptoms and medical history, the admitting physician determined that the patient's weakness was a result of the arrhythmia, rather than the side effects of hydrochlorothiazide.

The findings on neuroimaging strongly suggested an embolic stroke. The patient was treated with warfarin for the atrial fibrillation and received rehabilitation while in the hospital; however, he was still experiencing weakness and some word-finding difficulties 6 weeks later.


This case demonstrates several communication problems. Because the doctor was conversing with the patient over the phone, he did not have the benefit of performing a complete physical or gathering visual evidence of the patient's condition. Thus, taking the patient's history became the most crucial aspect of the encounter. However, once the patient reported his new blood pressure medication, the doctor focused on that information and terminated the data-gathering process.

Further, when speaking with the patient, the doctor did not ask open-ended questions about the patient's symptoms — e.g., "How would you describe the weakness?" This strategy may have revealed further information about the patient's condition, which potentially could have indicated the severity of the patient's situation.

Finally, other than noting that the patient should seek immediate care if his systolic pressure rose above 180 mmHg, the doctor did not provide the patient with any further instructions, such as what to do if the weakness continued or worsened, how to respond if new symptoms occurred, or when to schedule the follow-up appointment.

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