California – Family Medicine – Lack Of Proper Examination And Diagnosis Of 23-Year-Old Female With Rash, Cough, Fever, And Vomiting

In November 2009, California was near a second peak of the bimodal H1N1 influenza pandemic that began in Mexico in April 2009.  Rapid flu testing at this time was of limited value in detecting H1N1.  Healthcare facilities were inundated with patients complaining of influenza-like illnesses.

On 11/2/2009, a 23-year-old female with a history of current smoking, mild asthma, and allergic rhinitis was seen by a physician assistant at an urgent care clinic where a family practitioner worked.  She presented with headache, nausea, fatigue, and body aches for days.  She was afebrile and had no skin rash.  Rapid flu A&B testing was negative.  The patient was diagnosed with a viral syndrome and treated with fluids and rest.

On 11/16/2009, the patient returned to the urgent care clinic for a chief complaint of bug bites on her legs.  She was seen by the family practitioner.  She no longer complained of flu-like symptoms.  Insect bites were noted to have been present for one week.  The family practitioner documented that she was afebrile and had multiple maculopapules and pustules on the left lower extremity.

The family practitioner did not obtain a skin culture.  He diagnosed the patient with cellulitis of the leg and insect bites.  The family practitioner failed to document in the patient’s medical record the basis for his diagnosis of cellulitis.  The family practitioner started the patient on Bactrim DS twice daily for 10 days.

The patient was evaluated by a dermatologist on 11/17/2009 for multiple insect bites with swelling and itching.  She did not complain to the dermatologist of fever, chills, weakness, or muscle aches.  She was instructed to take Bactrim DS as prescribed by the family practitioner and was given Altabax and Lidex cream for topical wound care.

The patient returned to urgent care on 11/22/2009.  She was seen by a different physician with fever to 104, cough, malaise, body aches, and bug bites.  The patient had stopped taking Bactrim due to nausea but then resumed taking it after seeing the dermatologist.

On exam, an elevated temperature of 100.2 and tachycardia at 114 were noted, as were congested nares, red throat, and swollen neck lymph nodes.  The rash on the left lower extremity persisted, so a scab was removed from one of the lesions for a culture.  The culture result was negative when reported on 11/23/2009.  Rapid flu testing was also negative.  The treating physician suspected flu and prescribed Tamiflu, 75mg per day, and Phenergan for nausea.  The patient was continued on other treatments, per the dermatologist’s orders, for left lower extremity rash.

On 11/22/2009, the patient’s mother telephoned the urgent care clinic and reported that the patient had a rash all over her back.  A physician assistant advised the patient to stop Tamiflu and to replace Bactrim with Omnicef.  The patient’s mother was advised to return to the clinic or to go to the emergency department if the patient’s condition worsened.  On the morning of 11/23/2009, the patient’s mother telephoned the clinic again, reporting that the patient had a fever and was nauseated.  She was advised to bring the patient to the clinic.

On 11/23/2009, the family practitioner saw the patient with her mother present.  The patient presented with a history of continued fever, chills, cough, nausea, and vomiting.  The family practitioner was aware that the patient was told to stop using Tamiflu and that her Bactrim prescription was replaced with Omnicef.  The family practitioner did not perform and/or document a skin examination, even though one of the patient’s complaints was that she had a new rash.  On exam, the patient had a fever with a temperature at 101.2, tachycardia with heart rate at 118, and a normal blood pressure.

The family practitioner charted that she was “ill appearing but in no acute distress.”  HEENT, heart, lung and abdominal exams were negative.  The family practitioner’s assessment was “fever not otherwise specified, URI, and nausea with vomiting.”  The family practitioner’s medical record does not support a diagnosis of URI, as the only recorded symptom consistent with that diagnosis is a cough.  Other symptoms of URI, such as red throat, enlarged lymph nodes, and nasal congestion, which were documented by another doctor on 11/22/2009, were absent from the record of the patient’s visit on 11/23/2009.  The family practitioner later stated that on 11/23/2009, he was primarily concerned about the patient’s dehydration, though he failed to document this concern in the patient’s chart.  He ordered an intramuscular injection of Reglan 10 mg for nausea.  His plan was to continue with Onmicef for the URI, even though this medication was originally prescribed for a skin rash.

The family practitioner’s follow-up plan, in its entirety, is documented as follows: “ER worse.”  The family practitioner later claimed that this annotation meant that he wanted the patient to be referred to the emergency department and that he discussed this issue at length with the patient’s mother who declined this because of cost.

However, the family practitioner failed to document this discussion in the patient’s chart.  The family practitioner decided to continue treating the patient on an outpatient basis instead of hospitalizing her or referring her to the emergency department.  Despite the fact that this patient had developed a new rash, continued to have fevers and cough for a week, and continued to have two days of vomiting to the point where she could not keep medications down, the family practitioner failed to order laboratory or imaging studies and did not formulate or document a sufficiently detailed treatment plan.

In the early evening of 11/23/2009, the patient was unarousable at home and was taken to the hospital by paramedics.  Upon arrival at the hospital, she suffered generalized tonic-clonic seizures, which continued despite medication.  Despite aggressive treatment in the emergency department, her condition did not improve, and she was admitted to the intensive care unit, where she received consultations from multiple specialists.

On 11/24/2009, after the family practitioner found out that the patient was admitted to the intensive care unit, he made an addendum to the patient’s chart regarding the 11/23/2009 visit. The information added to the patient’s chart was a report of a neurologic examination.  In this addendum, the family practitioner charted that the patient was alert and oriented X3 with normal cognition, cranial nerves II-XII grossly intact, normal strength bilaterally, and normal gait.  At least a portion of this neurologic examination did not actually take place.

The patient was examined on 11/23/2009, with her mother present, and she claimed, and the family practitioner later admitted, that he did not perform a cranial nerve examination or motor strength bilaterally.  The remaining portions of the added neurological examination note were based on the family practitioner’s recollected observation of the patient on 11/23/2009 and were not a result of a purposeful neurological examination, as his note made it appear.

On 11/26/2009, after a second neurological consultation, the patient was declared brain dead.  On the basis of a subsequent autopsy, the cause of death was determined to be Reyes syndrome and viral encephalitis.

The family practitioner departed from the standard of care in his treatment of the patient as follows:

1) The family practitioner’s inadequate history and physical examination, including a failure to perform a skin examination of the patient on 11/23/2009 was a simple departure from the standard of care.

2) The family practitioner’s failure to perform and/or document a neurological examination of the patient on 11/23/2009 was a simple departure from the standard of care.

3) After deciding to continue treating the patient on an outpatient basis, family practitioner’s failure to order any laboratory or imaging studies on 11/23/2009 was a simple departure from the standard of care.

4) The family practitioner’s failure to formulate a treatment plan that addressed the patient’s symptoms on 11/23/2009 was a simple departure from the standard of care.

5) The family practitioner’s 11/24/2009 recording of elements of the neurological examination of A.C. that he did not actually perform was a simple departure from the standard of care.

The Board judged the family practitioner’s conduct to have fallen below the standard of care.  Stipulations included enrolling in the Physician Assessment and Clinical Education Program offered at the University of California – San Diego School of Medicine.  The Board issued a public letter of reprimand.

State: California

Date: March 2014

Specialty: Family Medicine, Dermatology, Emergency Medicine, Infectious Disease, Internal Medicine

Symptom: Dermatological Abnormality, Cough, Rash, Fever, Headache, Nausea Or Vomiting

Diagnosis: Meningitis/Encephalitis

Medical Error: Failure to examine or evaluate patient properly, Failure to order appropriate diagnostic test, Ethics violation, Lack of proper documentation

Significant Outcome: Death

Case Rating: 5

Link to Original Case File: Download PDF

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