This 70 year old man was treating regularly with the above IM doc from 5-3-06 to 8-29-07. Regular, frequent physical exams, but no documentation of any palpating exam of abdomen. Medical HX is hypertension and hyperlipidemia. Also LVH and diverticulitis. On 9-30-07 is admitted to Hospital with belly pain and found to have 10 cm dissecting aortic aneurysm. Intact bowel sounds and stable vital signs. This is resected with graft placement on an emergent basis and described as “huge inflammatory aneurysm in the retroperitoneum with a densely adherent duodenum and small bowel, induration in this neck”. General Surgeon performed the surgery. Did okay post op for a short while, then persistent hypotension, low hemoglobin and acidosis. Back to surgery 10-1-07, lots of blood, clots and ascites found as wll as foul orod, colon resection done for “ischemia and diverticulosis, inter diverticular hemorrhage.”

Liability Question for IM: Does SOC require abdominal exams with palpation and auscultation, does not doing so constitute a breach of SOC, and would aneurysm more likely than not have been diagnosed and monitored on that basis?

Causation Question for vascular surgeon: If aneurysm had been resected when it was smaller (say at 5cm) and had NOT dissected, would outcome, more likely than not (51%) have been better?

Expert Responses:

1. Outcome is worse for emergent aneurysm repair as compared with elective repairs.

2. An abdominal exam is standard of care for a primary care physician and a 10 cm aneurysm normally would be felt unless the patient was significantly obese. What did patient weigh?

I think this may be a good case.

– Dr. GN

Depending on patient’s body stature, even large aneurysms can be missed. Size is not a predictor, as far as I know, of the post-op complication of colonic ischemia.

– Dr. RN

An abdominal exam should include palpation for pulsatile masses in a patient at risk for an aortic aneurysm. The yield depends on the patient’s weight and body habitus. If the patient was obese, it would be difficult for even an experienced clinician to detect an aortic aneurysm.

– Dr. BF

Although the standard of care for patient examination includes auscultation and palpation of the abdomen, many abdominal aortic aneurysms are missed on physical examination unless the patient is very thin and able to relax his abdominal muscles. Obese patients, tense patients and patients with any degree of abdominal distension will be much harder to examine. Sensitivity of the physical exam for asymptomatic aortic aneurysms may be as low as 20%, but for aneurysms this size, the sensitivity is up in the 70’s%, again depending on whether the patient was obese, etc. All-in-all, about 30% of asymptomatic AAA’s are found on examination. Many AAA’s are discovered as incidental findings when the abdomen is imaged for some other indication. So it is a deviation from the SOC to fail to examine the abdomen, but it isn’t more likely than not that an aneurysm will be detected in that way.

– Dr. PG

If he was a smoker…then he should have been screened with a abdominal sono. RE: examination of the abdomen……medical standards would state that for a “full physical” or for a visit with abdominal complaints, that an exam should have been done.

With that, it is hard to prove that an exam would have revealed the aneurism. Was the patient thin or fat? How can you prove that the aneurism did not expand rapdily?

Again…..if he was older, hypertensive and a smoker, then a sonogram was indicated to screen…..not just an exam.

– Dr. SR