Florida – Internal Medicine – Patient With Worsening Chronic Kidney Disease Presents With Arm Pain, Numbness, And Shortness Of Breath

From 2009 until 2014, an internist served as the patient’s primary care physician.

In 2009, the internist referred the patient to Cardiologist A for a cardiology evaluation.  The results of the 2009 cardiology evaluation revealed that the patient’s electrocardiogram and stress test were both abnormal.

At this time, Cardiologist A recommended that the internist increase the patient’s medication as needed in order to get the patient’s cholesterol to below seventy.

The patient was evaluated by Cardiologist A again in June 2010.

The June 2010 cardiac evaluation revealed that the patient had shortness of breath on exertion at times, possibly related to hypertension and subclinical congestive heart failure.

On 7/17/2013, the patient underwent lab work, the results which showed that his glomerular filtration rate (GFR) was thirty-four.  The internist staged the patient’s chronic kidney disease (CKD) at a stage III/IV.

The patient’s next set of lab work was conducted on 11/18/2013, the results of which showed that his GFR was twenty-two.  The internist wrote in a progress note that the patient’s CKD was a stage III/IV.

On 1/13/2014, the patient had lab work done again, the results which showed that his GFR was twenty-six.  In his progress note he wrote that the patient’s CKD was now a stage IV.

Despite a dramatic decline in the patient’s GFR levels indicative of worsening CKD, the internist did not refer the patient to a nephrologist.

On 1/13/2014, the patient presented to the internist complaining of left arm pain, numbness radiating to both hands, and shortness of breath.  The internist ordered an EKG, chest x-ray, and lab work.  His assessment of the patient at this time was dyspnea on exertion, questionable coronary artery disease, questionable pulmonary disease, and questionable anxiety.

On 1/14/2014, the patient returned to the office for an echocardiogram.  After the echocardiogram, the internist referred the patient to Cardiologist B for a consult.  The patient could not obtain an appointment with Cardiologist B until 2/3/2014.

The internist ordered that a stress test be conducted prior to the patient’s visit with Cardiologist B, and advised that the patient bring the results of the stress test to his appointment with Cardiologist B.

On 1/23/2014, the stress test was performed and the results were abnormal.

The Medical Board of Florida judged that the internist failed to adequately evaluate the patient’s symptoms and recognize the patient’s worsening coronary artery disease, development of congestive heart failure, and worsening chronic kidney disease.  He failed to refer the patient to a nephrologist for further evaluation upon seeing a dramatic decline in the patient’s GFR levels.  He also failed to send the patient to the emergency department for treatment when the patient presented to him with exhibiting cardiac symptoms and had a known history of heart disease.

The Medical Board of Florida issued a letter of concern against the internist’s license.  The Medical Board of Florida ordered that the internist pay a fine of $2,500 against his license and pay reimbursement costs for the case at a minimum of $5,756.36 and not to exceed $7,756.36.  The Medical Board of Florida also ordered that the internist complete five hours of continuing medical education in the treatment of patients with chronic kidney disease and chronic heart disease.

State: Florida


Date: December 2017


Specialty: Internal Medicine


Symptom: Extremity Pain, Numbness, Shortness of Breath


Diagnosis: Heart Failure, Cardiovascular Disease, Renal Disease


Medical Error: Failure to examine or evaluate patient properly, Referral failure to hospital or specialist


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



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