Enlarging Breast Mass in 69-Year-Old Woman With History of Cysts

Dermatology Clinic

reduces skin fibrosis and dermal myofibroblasts.4,7 The anti-IL6 receptor antibody tocilizumab has also been shown to reduce skin thickening, though not significantly when compared with placebo.4 Pigment alterations in skin including increased skin tone and postinflammatory hyperpigmentation may cause cosmetic concerns for the patient but, unfortunately, few treatments are available for these concerns.4

For the patient in this case, punch biopsy of the arm was consistent with scleroderma and, given the clinical findings,

the patient was diagnosed with diffuse SSc. The patient was seen in conjunction with rheumatology and has been put on a trial of methotrexate, then mycophenolate mofetil, and more recently she was started on tocilizumab. ■

The pathogenesis of SSc is described as an interaction between an environmental event and genetically susceptibility.

Sarah Friske, BBA, is a medical student at Baylor College of Medicine; Tara L. Braun, MD, is a dermatologist at Elite Dermatology in Houston, Texas.

References

1. Asano Y. Systemic sclerosis. J Dermatol. 2018;45(2):128-138. 2. Medsger TA, Benedek TG. History of skin thickness assessment and the Rodnan skin thickness scoring method in systemic sclerosis. J Scleroderma Relat Disord. 2019;4(2):83-88. 3. Allanore Y, Simms R, Distler O, et al. Systemic sclerosis. Nat Rev Dis Primers. 2015;1:15002. 4. Denton CP, Khanna D. Systemic sclerosis. Lancet. 2017;390(10103): 1685-1699. 5. Bairkdar M, Rossides M, Westerlind H, Hesslestrand R, Arkema EV, Homqvist M. Incidence and prevalence of systemic sclerosis globally: a comprehensive systematic review and meta-analysis. Rheumatol. 2021;60(7):3121-3133. 6. Nikpour M, Stevens WM, Herrick AL, Proudman SM. Epidemiology of systemic sclerosis. Best Pract Res Clin Rheumatol. 2010;24(6):857-869. 7. Furue M, Mitoma C, Mitom H, et al. Pathogenesis of systemic sclerosis— current concept and emerging treatments. Immunol Res. 2017;65(4):790-797. 8. Derk CT, Jimenez SA. Systemic sclerosis: current views of its pathogenesis. Autoimmun Rev. 2003;2(4):181-191. 9. Van Den Hoogen F, Khanna D, Fransen J, et al. 2013 classification criteria for systemic sclerosis: an American College of Rheumatology/European League against Rheumatism collaborative initiative. Arthritis Rheum. 2013;65(11):2737-2747. 10. Tyndall A, Fistarol S. The differential diagnosis of systemic sclerosis. Curr Opin Rheumatol. 2013;25(6):692-699. 11. Showalter K, Gordon JK. Skin histology in systemic sclerosis: a relevant clinical biomarker. Curr Rheumatol Rep. 2020;23(1):3.

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CASE

Injured Wife Brings Suit Against NP

Is a clinician liable for misdiagnosis of a patient that results in injury to a third party?

BY ANN W. LATNER, JD

In 2001, Mr R began having numerous episodes of syncope. In 2002, he was diagnosed with swallow syncope, which is associated with intense vagal afferent activation from esophageal stimulation. A pacemaker was implanted to remedy the situation and Mr R did not have a passing out episode again until 2016.

A month earlier, Mr R began to experience episodes of dizziness and lightheadedness when he got up from bed. The episodes did not occur if Mr R stood, sat still, or swallowed liquids. They only occurred in the morning and not throughout the day. To have this checked out, Mr R went to a cardiology practice where he was seen by Ms N, a nurse practitioner, and Dr I, an internal medicine resident.

During the visit, Dr I performed a physical examination and took a medical history. He noted in the appointment progress report that Mr R received a pacemaker in 2002, but no mention was made of why the pacemaker was installed. Ms N ordered a pacemaker interrogation to evaluate how well the leads were working and to determine if the patient was having arrhythmias.

The report indicated that the patient had not experienced any arrhythmias and that the pacemaker’s right ventricular lead was not being used to pace his heart. Ms N was aware that the report showed an elevated number for impedance of the pacemaker’s right ventricular lead, and she attempted to determine whether the dizzy episodes were related to this. In light of the patient’s report that the dizziness lasted minutes to hours, occurred when he moved his head, and that the symptoms were lessened by the medication meclizine, Ms N believed that Mr R’s dizziness was caused by an inner ear problem. Ms N referred Mr R to an otolaryngologist, instructed him to stop taking his blood pressure medications, and asked him to return for a follow-up visit in 6 months. The cardiologist at the practice did not see or treat Mr R, but he signed off on the progress report of the appointment that Ms N prepared.

The defendants makes a motion to dismiss the malpractice claim by the spouse, asserting that she had no patient-physician relationship with the clinician.

Cases presented are based on actual occurrences. Names of participants and details have been changed. Cases are informational only; no specific legal advice is intended. Persons pictured are not the actual individuals mentioned in the article.

The following month, Mr R was driving with his wife. He took a sip of co ee and had a feeling similar to his prior experiences before passing out. Mr R pulled o the road but was unable to stop the truck and he crashed into a tree, injuring himself and his wife. Following the accident, Mr R was hospitalized and underwent a right ventricular lead revision. In January 2017, the cardiologist signed a letter indicating that the patient had su ered a syncopal episode caused by “malfunction of his right ventricular lead of his previously placed pacemaker” while driving that led to the automobile accident. The letter advised that the malfunction was corrected and that Mr R was able to resume driving without restrictions. Two years later, Mr R and his wife sued the cardiology practice and the cardiologist for medical malpractice. The complaint alleged that the cardiologist owed a duty to the

wife, as a foreseeable passenger, to properly treat Mr R and that the physician breached this duty by failing to: • Take a speci c history to determine the pattern, frequency, and duration of the episodes • Determine if there was a correlation between the dizzy episodes and the pacing of the right ventricular lead in the pacemaker • Implement a plan to repair or replace the right ventricular lead • Advise Mr R not to drive

The defendants made a motion to dismiss the medical malpractice claim by the wife, asserting that she had no patientphysician relationship with the cardiologist or the practice and, thus, they owed no duty to her. The trial court denied the motion and the physician appealed.

Legal Decision

On appeal, the defendants alleged that the wife was not owed a duty under the law and that it was not foreseeable that Mr R would have a swallow syncope episode while driving. The appeals court disagreed. “The duty owed by the health care professional arises from the health care professional’s relationship with the patient,” noted the court, “however, it does not follow that only a patient may bring a malpractice claim or that a physician never owes a duty to third parties.”

To the contrary, the court noted that other courts have sometimes recognized malpractice claims by a third party despite the lack of a doctor-patient relationship. To maintain such a claim, the third party must establish that the physician owed a duty to the third party. Generally, duty is based on a relationship between the parties. According to the court, “a duty of reasonable care may arise when one stands in a special relationship with either the victim or the person causing the injury.” Although the determination of duty is generally an issue of law, “the facts and circumstances of a special relationship may give rise to an issue for resolution by the jury,” noted the court, particularly in cases of a dangerous medical condition. Ultimately the court refused to dismiss the case and sent it back to the lower court for a trial.

Protecting Yourself

Both the nurse practitioner and physician failed to get enough information to determine whether Mr R was a danger to himself or others. Notably, Ms N ordered a pacemaker interrogation and the results determined that it was not functioning properly. Despite this, no further testing of the pacemaker was ordered, no e orts were made to x it, and the patient was not warned about the abnormality with the pacemaker or that he could faint while driving. He was not told that he should not drive.

Additionally, neither Ms N nor Dr I asked why Mr R had the pacemaker installed. Had they known about Mr R’s history of swallow syncope, they might have handled his treatment di erently. Information is power — gather as much of it as possible to make the best, most informed decisions. ■

The court argued that it does not follow that “a physician never owes a duty to third parties.”

Ann W. Latner, JD, a former criminal defense attorney, is a freelance medical writer in Port Washington, New York.

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