On 5/6/2009, a 35-year-old male was treated by a nurse practitioner for gout and received an order for further laboratory testing.  On 5/10/2008, the patient had laboratory testing done, which confirmed his chief complaint of gout.

On 6/27/2008, the patient was evaluated by a family practitioner.  The family practitioner evaluated the patient in the presence of the patient’s wife and their four boys.  The patient’s complaints included “fever, arm problem (swollen under right arm), vomiting, diarrhea,  dizziness, perspiration problem, and test results (labs).”  The family practitioner noted that the patient reported a fever the previous night of 103 F, had cold sweats and right arm pain.  The family practitioner noted that the patient had taken ibuprofen for his fever.  On examination, the patient appeared “malaised with profuse [sic] sweating.”  The patient’s pulse was 139, his blood pressure was 98/60, and he had a temperature of 99.68 F.  The patient kept his right arm raised throughout the exam because of pain and complained of shortness of breath.  The patient appeared seriously ill and presented with both hypotension and tachycardia.

The family practitioner informed the patient that he needed to seek medical treatment at the emergency department because he may have a serious bacterial infection.  The exam became confrontational with the patient’s wife demanded that the family practitioner provide treatment to the patient after the patient refused to go to the emergency department.  The exam was further truncated because the clinic was in the process of closing for the weekend, and the family practitioner needed to pick up her children from childcare.  The family practitioner refused to provide treatment, either parenteral antibiotics or oral antibiotics, at the clinic because she didn’t believe she could provide any treatments that would treat the patient’s illness.  The family practitioner failed to perform an examination of the patient’s right upper extremity for a portal of entry of infection or for active infection.  The family practitioner also didn’t accurately record information in the patient’s electronic medical record.

The Medical Board of California judged that the family practitioner’s treatment of the patient departed from the standard of care because she failed to immediately begin life-stabilization and treatment of the patient upon realizing that he was seriously ill, allowed outside logistical considerations to limit her ability to provide treatment to the patient, allowed the electronic medical record-keeping software to interfere with her treatment of the patient, allowed her relationship to become confrontational with the patient, did not administer a dose of parenteral antibiotics to the patient, did not prescribe oral antibiotics despite the patient asserting that he was not going to the emergency department, and didnot examine the patient’s right upper extremity for evidence of a portal of entry for infection or for active infection.  The family practitioner also failed to properly manage a noncompliant patient, never activated the Emergency Medical System when she realized that the patient was seriously ill, never had the patient sign a written formal acknowledgment form that the patient understood that the family practitioner believed he would die unless he received immediate emergency department treatment, never attempted to provide a dose of parenteral antibiotics or oral antibiotics to the patient after he asserted that he was refusing to go to the emergency department, lacked familiarity with how to discharge a patient Against Medical Advice, and failed to note that the patient was discharged Against Medical Advice.

The Medical Board of California also judged that the family practitioner’s record keeping departed from the standard of care because she didn’t record respiratory rate, did not carefully document the axillary examination, failed to document the examination of the upper right extremity, failed to document an accurate diagnosis in the medical record, failed to discuss the management options for the patient’s condition in the medical record, failed to document the patient’s refusal to comply with the family practitioner’s request that he go to the emergency department.  The family practitioner also failed to document the physical findings and care of the patient, document the patient’s respiratory rate, document that the patient may have been suffering from Systemic Inflammatory Response Syndrome or early stages of septic shock, document that the patient was holding his right arm away from his body at a 90 degree level of abduction, and document whether she performed a detailed examination of the patient’s right upper extremity.  The family practitioner documented that the patient’s resting heart rate was a “normal rate” despite having a pulse of 139, documented her discharge instructions only for mild to moderate acute gastroenteritis, and failed to document her actual clinical diagnosis: serious bacterial infection with impending septic shock.  The family practitioner did not document that she planned on sending the patient to the emergency department and had requested that he go to the emergency department, did not document that the patient refused to go to the emergency department, did not document that the patient left her office AMA, did not document provide the patient with an informed refusal of treatment, did not document that she considered activating EMS, did not document that she considered and rejected administering parenteral antibiotics in the clinic or prescribe oral antibiotics, and did not document that she had a discussion with the patient regarding his treatment options.

The Medical Board of California issued a public reprimand and ordered the family practitioner to complete a medical record-keeping course and education course.

State: California

Date: September 2015

Specialty: Family Medicine, Internal Medicine

Symptom: Fever, Diarrhea, Dizziness, Nausea Or Vomiting, Extremity Pain, Shortness of Breath, Swelling

Diagnosis: Infectious Disease, Gout

Medical Error: Physician concern overridden, Failure to examine or evaluate patient properly, Improper treatment, Lack of proper documentation

Significant Outcome: N/A

Case Rating: 4

Link to Original Case File: Download PDF