Arizona – Internal Medicine – Left Pleuritic Pain With Small Pulmonary Embolism Seen On CT Scan

On 08/04/2014, a 75-year-old man with a history of benign prostatic hyperplasia, osteoarthritis, and congenital deafness, reestablished care with an internist whom he had previously seen at a prior practice.  The patient reported that he had visited the emergency department the month prior for left-sided pleuritic chest pain.  Workup was normal, and he was given a prescription for oxycodone.

On 08/11/2014, the patient was again seen by a nurse practitioner in the internist’s practice with complaints of chest pain.

On 08/13/2014, the patient followed up with the internist and complained of increasing left pleuritic chest pain.  The internist requested the patient’s emergency department records.  He ordered an EKG, echocardiogram, and labs.  An empiric trial of colchicine was prescribed for the possibility of pericarditis.  The EKG showed a borderline 1st degree AV block and nonspecific T wave changes to the septal leads not present on the prior EKG.

On 08/18/2014, a CT angiogram ordered by the internist revealed a small focal pulmonary embolism to the left lower lobe pulmonary artery with no other findings.  The internist instructed the patient to follow up in a week.

On 08/28/2014, the patient was seen by a different provider who worked at the same practice as the internist.  He was seen to undergo a hypercoagulable work up.  At the time of this appointment, the patient was not on any medications for pulmonary embolism.  The provider ordered anticoagulation to treat the pulmonary embolism.  He ordered labs to assess for a hypercoagulable state and ordered ASAP lower extremity venous Doppler studies.  The studies revealed a non-occlusive deep vein thrombosis involving the right popliteal, posterior tibial, and peroneal veins.  There was also deep veno-occlusive disease involving the left peroneal veins.

During a hearing, the internist testified that when he obtained the results of the chest CT, he had discussed the finding with the interpreting radiologist, who agreed that the patient likely had a resolving pulmonary embolus.  The internist testified that based on this discussion, he believed the patient did not need to be anticoagulated.  The Board noted that the internist did not have the results of the Doppler studies at the time he decided against anticoagulation therapy.

The Board judged internist’s conduct to be below the minimum standard of competence given failure to immediately treat the patient’s symptomatic pulmonary embolism.

On 04/2016, an interim order was issued for the internist to complete a competency evaluation.  The internist appealed.  On 08/04/2016, the Board denied the internist’s appeal of the interim order.  The provider submitted his intention to retire.  Given concern that the internist had also performed below the standard of care in a multitude of cases, the Board elected to restrict his practice and prohibited from practicing medicine in the state of Arizona.  They ordered that he complete and pass a competency evaluation in order to reverse the practice restriction.

State: Arizona

Date: January 2017

Specialty: Internal Medicine

Symptom: Chest Pain

Diagnosis: Pulmonary Embolism

Medical Error: Improper treatment

Significant Outcome: N/A

Case Rating: 3

Link to Original Case File: Download PDF

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