Making a diagnosis via telephone is a risky endeavor. Many HMOs and insurance companies now offer ‘advice lines’ where patients can speak to an on-call nurse. In this month’s case, we look at a scenario where clinicians failed to recognize the seriousness of a patient’s complaints. 

The patient, Mrs. H, was a member of a large HMO’s medical group. Mrs. H was a healthy 41-year old mother of two little girls, four and two years old. Her husband worked as a long-haul trucker and was away for days at a time. 

Mrs. H began feeling unwell towards the end of January. She assumed she had caught a bug from one of her children, a common occurrence. However, this time she didn’t start feeling better after a day or two like she usually did. She had a cough and fever, and each time she coughed, her chest hurt. Mrs. H remembered that her medical group provided an on-call advice nurse, and she decided to call to get some help.

The first call, on January 27th, was answered by Nurse A. Mrs. H described her symptoms, including a fever, cough and chest pain. When Nurse A asked about the severity of the chest pain, Mrs. H described it as a 5 out of 10. “Coughing can definitely cause chest pain,” said the nurse, reassuringly. “Rest and fluids,” she advised, adding that Mrs. H could take an analgesic. The entire conversation took less than ten minutes. Nurse A advised Mrs. H to call back if she continued to feel unwell.

The next day, January 28th, Mrs. H felt worse than before. It didn’t help that her husband was working and wouldn’t be back for another day, leaving her with care of the children as well. She decided to call the advice line again to speak to a medical professional. Nurse B answered on this occasion. Mrs. H described her symptoms, which now in addition to the fever and cough, included chills and a sore throat. “My chest is hurting from all the coughing,” she told the nurse, describing it as a pain level of 7 out of 10. “Okay,” said Nurse B, “I am going to schedule you for a telephone appointment with our on-call physician. He will call you today, sometime this afternoon.”