Washington – Internal Medicine – Lack Of Follow-Up On Elevated Blood Glucose Followed By Foot Pain And Swelling

Between September 2000, and July 2013, an internist served as a patient’s primary care provider.  The patient suffered from hypertension, chronic back pain from a herniated disc, morbid obesity, and strabismus which impaired her vision.  The patient was also uninsured and unemployed.  The internist was aware the patient could not afford to pay for multiple office visits.  The internist arranged for the clinic’s charity foundation to pay for the patient’s medications.

Over a ten year period, the patient had three urinalysis screenings in which results revealed elevated glucose levels, a strong indication of diabetes.  Elevated glucose levels require monitoring and additional lab work, particularly with the patient’s obesity and hypertension.  There was no documentation to reflect the internist’s review of the patient urinalysis screens or consideration of a possible diabetes diagnosis.

In November 2011, the patient presented with complaints of right foot pain.  The internist diagnosed foot cellulitis with erythema and prescribed an antibiotic and a pain reliever.

By February 2012, the patient complained of nausea, fever, and persistent pain with swelling related to her right foot.  She also had a new complaint about her left foot where an ulcer formed over the top of the foot and over a bunion.  The internist changed the antibiotic but continued the patient’s medication regimen without documenting consideration of other possible conditions.

In March 2012, the patient presented to the emergency department with extensive erythema with swelling and black tissue in her left foot consistent with wound infection.  The hospital’s lab work showed a blood sugar level of 570 and a hemoglobin A1C of 12, compatible with a likely diagnosis of diabetes mellitus.

The hospital physician diagnosed the patient with osteomyelitis and diabetes mellitus with peripheral neuropathy.  The physician performed an emergency debridement of the gangrenous left foot, but this did not resolve the infection in the foot and ankle.  The patient then underwent a below-the-knee amputation of her left foot.

The Commission stipulated the internist reimburse costs to the Commission, allow a representative of the Commission to annually review his patient records, complete 6 hours of continuing education on the subject of screening for and treating diabetes in adults, write and submit a paper of at least 2500 words discussing what he learned in the continuing education course, how he will apply it in his practice, and how he will assure that this standard of care would be upheld despite a patient’s financial limitations.  The internist will also present this paper to staff and colleagues at his workplace.

State: Washington


Date: March 2016


Specialty: Internal Medicine


Symptom: Extremity Pain, Fever, Swelling


Diagnosis: Diabetes


Medical Error: Diagnostic error, Failure to follow up


Significant Outcome: Permanent Loss Of Functional Status Or Organ


Case Rating: 4


Link to Original Case File: Download PDF



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