Washington – Family Practice – Accidental Fall With Pain In Hands, Twitching In Extremities, And Muscle Spasms In Legs Months Later

On 2/15/2012, a woman in her late forties met with her family practitioner to address pain in her right knee two days after slipping on the kitchen floor.  The patient reported her knee hurt when bearing weight on it and when turning to the right.  Upon examining the patient’s knee, the family practitioner instructed the patient to wait over the next month for the inflammation to subside and to see if she was able to function as she did before the fall.

On 3/6/2012, the patient sent the family practitioner a secure message requesting a massage prescription, as she had been receiving intermittent massage treatment for many years and felt it helped her with her shoulder pain.  The patient clearly stated the pain was caused by bruxism and caused or increased her tinnitus.  A referral was placed that afternoon by a physician covering for the family practitioner.  The patient responded on 3/12/2012 requesting a prescription, instead of a referral, for insurance purposes.  On 3/13/2012, the family practitioner issued the requested document.  In a subsequent correspondence, the patient also brought up feeling tension in her shoulders when she went down the stairs, feeling nerve pain in her hands and elbows when she sneezed, and walking with numbness in her hands.  The family practitioner did not comment on the patient’s newer symptoms and did not ask her to make an appointment to be seen by the family practitioner.  The family practitioner failed to appreciate the significance of hand numbness and sneeze-induced pain described by the patient.

In May 2012, the patient saw an orthopedic surgeon to further examine her knee.  The orthopedic surgeon’s formal assessment was patellofemoral syndrome.  After the appointment, the patient wrote to the orthopedic surgeon seeking a clear answer regarding the muscle spasms in her legs she was experiencing in about 10-20 times a day and sometimes in her arms.  The orthopedic surgeon told her this issue is not common for someone with her condition and could be a result of a number of things including electrolyte imbalances, dehydration, or neurologic causes and to talk to her primary care provider for further work up.  The orthopedic surgeon provided a report to the family practitioner.

On 6/27/2012, the family practitioner saw the patient to address concerns of increased pain in her hands and how she still felt she had not fully recovered from her fall earlier that year.  She also felt increased pain during exercise and twitching in her extremities.  The patient reported a history of carpal tunnel.  The family practitioner performed an examination of the patient’s wrists and found symptoms consistent with carpal tunnel in the patient’s left wrist.  The family practitioner also noted the patient gained 17 pounds in approximately a year and a half and discussed the long-term importance of staying active.  The family practitioner suspected the patient could be diabetic (as both her parents were diabetic, increasing her risk) and that her possibly having diabetes could be contributing to her neurologic symptoms.  The family practitioner ordered testing for diabetes.  Although diabetes may have been a concern, the symptoms and history are not compatible with a diagnosis of diabetic neuropathy.  Through a secure message two days after the appointment, the family practitioner told the patient that while not yet diabetic, her sugars were higher than before, and that she wanted her to find ways to increase her activity and reduce her weight, and offered to refer her to another provider for a steroid injection in her knee.

On 7/6/2012, the patient sent the family practitioner a secure message in which she described the pain in her hands as “incredible” and when she bent her head down, her left arm went numb.  This symptom is a clear sign of origin in the spinal cord and should have resulted in urgent patient evaluation and prompt referral to neurology or neurosurgery.  The patient reported she wanted to wait six to eight more weeks to see if the pain resolved.  The family practitioner said that six weeks is an appropriate time to wait, and if it was not improving, she would refer the patient for nerve conduction testing and a neurosurgery referral.

On 7/20/2012, after the patient’s pain did not resolve, the family practitioner referred the patient for nerve conduction studies and a neurosurgery referral.  In August 2012, the patient met with a neurologist who confirmed the patient had left-sided carpal tunnel as well as myelopathic symptoms.  Magnetic resonance imaging (MRI) revealed the patient had suffered damage to her spinal cord at C4-C5, C5-C6, and C6-C7 from her fall earlier that year and required surgery.  The patient underwent surgery in late September.

The family practitioner failed to provide an appropriate and timely referral to a specialist.  The patient experiences ongoing symptoms.

The Commission stipulated the family practitioner reimburse costs to the Commission, complete 6 hours of continuing education in the areas of diagnosis and management of spinal cord and nerve root injuries and long-term complications of glucose intolerance and diabetes mellitus, and write and submit a paper of at least 1000 words on the subjects of her continuing education courses and the ways her practice will change based on the experience.

State: Washington

Date: June 2016

Specialty: Family Medicine, Internal Medicine, Neurology

Symptom: Extremity Pain, Numbness

Diagnosis: Spinal Injury Or Disorder

Medical Error: Delay in proper treatment

Significant Outcome: Permanent Loss Of Functional Status Or Organ

Case Rating: 4

Link to Original Case File: Download PDF

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