California – Neurology – Headache Presentation And Unsupported Radiculopathy Diagnosis

On 12/16/2011, a 44-year-old female first presented to a neurologist with a chief complaint of headaches on the left side of her head only and rated her pain as a 4 out of 10.  The neurologist noted moderate tenderness in the paraspinal musculature of the cervical spine at C4-C7 with some limited range of motion, but the neurologist failed to specify how, and in what manner, the patient’s range was limited.

The neurologist ordered an MRI of the patient’s brain and cervical spine and performed an in-office NCV/EMG of the patient’s bilateral upper extremities.  The neurologist’s impression was that the patient had moderate radiculopathy at C5 and C6 of the left, mild radiculopathy on the right, and mild carpal tunnel syndrome on the right.  The test results, however, did not support the neurologist’s impressions of radiculopathy or carpal tunnel syndrome. Also, the patient had no clinical examination findings for radiculopathy, making the need for this test, along with its findings, questionable.  The neurologist also misinterpreted the normal findings of the median motor and sensory distal latency and amplitude responses in diagnosing carpal tunnel syndrome.

The neurologist billed $350 for the office visit, $2,160 for the NCV, $380 for the H-Reflex amp study, and $50 for venipuncture, a charge which was not supported by the certified records, for a total charge for this single visit of $2,940.

On 1/11/2012, the patient had the MRI of her brain performed and interpreted by an outside facility, which showed no significant abnormalities or evidence of acute disease.  On 1/16/2012, the patient returned for a follow-up visit and complained of continued headaches, now a 7 out of 10, and stated they were worse at night, and she was unable to lay on her left side.  The neurologist noted moderate tenderness of the cervical paraspinal musculature at C4-C7 with limited range of motion bilaterally. The neurologist performed an occipital block and cervical trigger point injection under ultrasound guidance, but there was no report documenting this procedure in the patient’s certified chart.

The neurologist billed $450 for the office visit, $1,250 for the trigger point and nerve injection using ultrasound guidance (for which there was no procedure report), $415 to interpret the essentially normal MRI scan of the patient’s brain performed and interpreted by the outside facility, and $50 for xylocaine, for a total billing of $2,165.  This appeared to be the patient’s last visit with the neurologist.

The Medical Board of California judged that the obstetrician’s conduct departed from the standard of care because he failed to accurately analyze and interpret the NCV/EMG, provide appropriate evaluation and treatment of the patient’s headaches, and refer the patient to physical therapy.  The neurologist also billed for a venipuncture that was not performed or supported by the chart, an H-Reflex study, which was either not obtained or performed, and interpreting an essentially normal MRI of the patient’s brain performed, which was interpreted by an outside facility as showing no significant abnormalities or evidence of acute disease.

For this case and others, the Medical Board of California revoked the neurologist’s license.

State: California

Date: June 2017

Specialty: Neurology

Symptom: Headache

Diagnosis: N/A

Medical Error: Failure to examine or evaluate patient properly, False positive, Referral failure to hospital or specialist, Lack of proper documentation

Significant Outcome: N/A

Case Rating: 2

Link to Original Case File: Download PDF

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