On 4/16/2012, a 23-year-old female presented to the emergency department with chest pain, acute nausea, vomiting, and diarrhea.  The patient had a history of pulmonary hypertension. Laboratory measurements were taken that revealed a hemoglobin of 17.2, hematocrit of 49.9, an acidotic pH of 7.12, an elevated WBC count of 15,900, potassium of 6.6, BUN of 31, and creatinine level of 1.4.  These measurements were consistent with mild renal insufficiency. An electrocardiogram test revealed sinus tachycardia, which was consistent with the findings of an electrocardiogram performed on the patient approximately 1 year earlier.

On 4/17/2012, the patient was admitted to the hospital.  The patient was initially treated with sodium bicarbonate to treat her lactic acidosis and IV fluids for dehydration.  The patient also received a dialysis catheter in her right femoral artery due to the increase in the BUN/creatinine measurements.  However, this catheter was never used.

On 4/17/2012, a cardiologist performed a telephonic cardiology consult with the hospitalist and ordered a CT coronary angiogram due to the patient’s chest pain, abnormal electrocardiogram, right atrial enlargement, and elevated cardiac enzymes (troponin).  The cardiologist also ordered 100 ml of ionic contrast to facilitate the CT angiogram despite the patient’s continued elevated BUN and creatinine levels. The cardiologist also ordered 50 mg of metoprolol orally and 5 mg intravenously to improve visualization on the CT angiogram despite the patient’s clinical condition.  The cardiologist did not perform a physical examination of the patient, measure the patient’s pulmonary pressure, or review the patient’s diagnostic or laboratory tests prior to ordering ionic contrast, CT angiogram, or administering metoprolol.

On 4/17/2012, the patient deteriorated and became hypotensive approximately 90 minutes after the CT angiogram and administration of metoprolol.  At approximately 8:00 p.m., the patient expired due to cardiac arrest.

The Medical Board of California judged that the obstetrician’s conduct departed from the standard of care because he failed to physically examine the patient prior to ordering a potentially dangerous procedure and drugs, review the patient’s previous diagnostic testing and laboratory testing prior to ordering a potentially dangerous procedure and drugs, and order a pulmonary artery catheter to measure pulmonary pressure in a hemodynamically compromised patient.

The Medical Board of California placed the cardiologist on probation for 3 years and ordered the cardiologist to complete a medical record keeping course and an education course (at least 40 hours per year for each year of probation).  The cardiologist was also assigned a practice monitor.

State: California

Date: March 2017

Specialty: Cardiology

Symptom: Chest Pain, Diarrhea, Nausea Or Vomiting

Diagnosis: Cardiovascular Disease, Renal Disease, Sepsis

Medical Error: Failure to examine or evaluate patient properly, Failure to order appropriate diagnostic test, Improper medication management

Significant Outcome: Death

Case Rating: 5

Link to Original Case File: Download PDF