Found 28 Results Sorted by Case Date
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North Carolina – General Surgery – Alcohol Based Solution For Surgical Prep And Electrocautery Device Causes Complications During Lipoma Removal



The Board was notified of a professional liability payment made on 7/17/2015.

In preparation for the removal of a lipoma on a patient’s posterior neck, the surgery area and the hairline were treated with an alcohol based antibacterial solution called DuraPrep.  Although the manufacturer’s recommended drying time is two to three minutes, the general surgeon allowed the DuraPrep to dry for approximately ten minutes.  The general surgeon also blotted the patient’s neckline with a sponge.  Seeing no visible residue on the blotting sponge, the patient’s head was covered with a drape.  During the procedure, which was performed using open oxygen under monitored anesthesia care, strands of the patient’s hair covered with DuraPrep solution residue were ignited from the electrocautery.  The oxygen, which had accumulated under the drapes, served as a fire accelerant.  The patient was transferred by air with an endotracheal intubation to a burn center for flash burns to the midface, nose, mouth, eyelids, and right ear.

The Board believed the general surgeon responded appropriately to the intraoperative emergency and noted that the general surgeon sustained second degree burns to his hand trying to extinguish the flame.  The Board also acknowledged the general surgeon and his operating team’s rapid response minimized harm to the patient.

The cause of the fire was multifactorial; however, the Board believed the surgeon was ultimately responsible for the patient’s safety during the operation.  They recommended that in similar cases, the general surgeon should use a non-alcohol based skin prep, allow additional drying time, or use a non-sparking cautery, minimize the use of open oxygen, and use draping techniques that would allow adequate ventilation when open oxygen is used.  The Board acknowledged that the general surgeon received additional training in surgical fire prevention and safety.

The Board issued a public letter of concern, which was reported to the Federation of State Medical Boards.  It was not reported to the National Practitioner Data Bank.

State: North Carolina


Date: October 2016


Specialty: General Surgery


Symptom: Mass (Breast Mass, Lump, etc.)


Diagnosis: Post-operative/Operative Complication


Medical Error: Procedural error


Significant Outcome: N/A


Case Rating: 5


Link to Original Case File: Download PDF



Kansas – Pediatrics – Unnecessary Use of Azithromycin In Viral Infection



On 2/27/2013, a 13-year-old female presented to a pediatrician for follow-up five days after a visit to the emergency department where she had complained of chest pain and had an abnormal D-dimer lab value.  No patient education was documented related to the significance of the finding or the risk of a pulmonary embolism.  The patient record appeared to have been signed with a stamp and not dated.

On 4/24/2013, the patient presented with complains of bilateral ear pain and sore throat.  The patient’s past medical history stated “Significant for allergies.”  However, at her previous appointment, it listed only left knee injury. There was no other information contained in her past medical history.  The record was electronically signed by an advanced practice registered nurse (“APRN”) on 5/23/2013.

On 10/21/2013, the patient was seen by the APRN with complaints of vomiting, diarrhea, and abdominal cramping. At this appointment, the patient’s past medical history stated, “Noncontributory.”  The APRN documented putting the patient on Phenergan 25 mg tablets #40 one by mouth every eight hours as needed, Bentyl 20 mg #40 one by mouth every eight hours as needed, and acidophilus tablets #20 one by mouth twice daily for ten days.  The record was electronically signed by the APRN on 11/15/2013.

On 1/28/2014, the patient presented with cough, sore throat, hoarseness, body aches, and headache.  Vitals were taken and documented within normal limits; however, no blood pressure or heart rate was documented.  The patient was positive for cervical lymphadenopathy and flu A, rhonchi and wheezing were noted, and the pediatrician prescribed azithromycin.  Azithromycin is not indicated for a viral infection and not otherwise justified in the absence of a non-current bacterial infection.

The patient record was signed electronically by the APRN on 3/19/2014.

The Board judged the pediatrician’s conduct to be below the minimum standard of competence given his failure to keep written medical records which accurately describe the services rendered to the patient, including patient histories, pertinent findings, examination results and test results.  Also, the pediatrician prescribed, dispensed, and administered or distributed a prescription drug, in an improper or inappropriate manner.

The Board ordered that the pediatrician attend and successfully complete the Medical Record Keeping Seminar at the Center for Personalized Education for Physicians (“CPEP”). Also, the Board ordered that the pediatrician hire a medical scribe. Finally, the Board ordered that the pediatrician have another pediatrician monitor his work.

State: Kansas


Date: October 2016


Specialty: Pediatrics, Emergency Medicine


Symptom: Cough, Headache, Pain


Diagnosis: Infectious Disease


Medical Error: Improper medication management, Failure of communication with patient or patient relations, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



Kansas – Obstetrics – Administering Vaccines In A Pregnant Patient Without Consent



On 3/6/2013, a patient presented for a newborn screening. No pregnancy or labor and delivery history were documented.  A family history was documented; however, no detail of family history was documented.  The patient was not seen until eleven days after discharge.

On 7/3/2013, the patient presented to the obstetrician for her four month well exam.  At that appointment, the patient was administered the following vaccines: Hib, PEDIARIX, PCV 13, and Rota.  No consent form for the aforementioned vaccines was found in the record.

On 9/10/2013, the patient presented to the obstetrician for her six-month exam.  The obstetrician electronically signed the record on 9/27/2013, approximately seventeen days later.

The Board judged the obstetrician’s conduct to be below the minimum standard of competence given his failure to describe the services rendered to the patient.

The Board ordered that the obstetrician attend and successfully complete the Medical Record Keeping Seminar at Center for Personalized Education for Physicians (“CPEP”). Also, the Board ordered that the obstetrician hire a medical scribe. Finally, the Board ordered that the obstetrician have another obstetrician monitor his work.

State: Kansas


Date: October 2016


Specialty: Obstetrics


Symptom: N/A


Diagnosis: N/A


Medical Error: Failure of communication with patient or patient relations, Ethics violation


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



Kansas – Pediatrics – Improper Documentation In A Patient With Cough, Wheezing, and Runny Nose



On 12/5/2012, a newborn patient presented for his two-week check.  No family history, pregnancy, or labor and delivery history were documented.  The patient was not seen until thirty-three days after discharge.

The patient was seen only a total of three times by six months of age.  The medical record did not discuss why immunizations were late.  The plan/treatment section of the record was word-for-word the same information as in other patient records.

On 8/26/2013 a pediatrician saw the patient.  The pediatrician documented the patient had a cough, wheezing, and a runny nose.  No other information regarding an exam was given outside of the patient’s vitals being taken.  The pediatrician administered Microephrine 0.2 ml in the office.  The record appears to have been stamped in the pediatrician’s signature, but there was no corresponding date.

On 9/3/2013, the patient presented to the pediatrician after being admitted to the hospital the week prior with croup, bronchiolitis, and respiratory distress.  No information regarding the patient’s hospital stay was found in the pediatrician’s record.

The Board judged the pediatrician’s conduct to be below the minimum standard of competence given his failure to keep written medical records which accurately describe the services rendered to the patient, including patient histories, pertinent findings, examination results and test results.

The Board ordered that the pediatrician attend and successfully complete the Medical Record Keeping Seminar at Center for Personalized Education for Physicians (“CPEP”). Also, the Board ordered that the pediatrician hire a medical scribe. Finally, the Board ordered that the pediatrician have a pediatrician to monitor his work.

State: Kansas


Date: October 2016


Specialty: Pediatrics


Symptom: Cough


Diagnosis: N/A


Medical Error: Lack of proper documentation, Failure to examine or evaluate patient properly


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



Kansas – Pediatrics – Improper Documentation For Reactive Airway Disease And Improper Use of Bactrim



On 2/4/2013 a 7-year-old female presented to a pediatrician and saw the advanced practice registered nurse (“APRN”).  The patient presented with chief complaints of allergies, congestion, and diarrhea.  The patient was prescribed albuterol, Qvar 40 mcg, Bactrim, and triamcinolone.  The Bactrim was prescribed inappropriately for diarrhea.  The pediatrician agreed but thought that he had perhaps forgotten to document otitis media.

On 2/19/2013, the pediatrician saw the patient for a follow-up appointment.  The pediatrician documented that the patient was there for a follow-up for her asthma, even though the patient previously presented with reactive airway disease.  The pediatrician did not document his thought process in how reactive airway disease developed in asthma.  The pediatrician did not electronically sign the record until 4/11/2013.

On 6/11/2013, the patient presented to the pediatrician for a school physical.  The pediatrician failed to document the patient’s asthma.  In the school health examination, the pediatrician stamped signature appears on the form with the date 6/11/2013.  The pediatrician stamped the document “No” to the question, “Is this student subject to any condition which might cause a possible classroom emergency such as seizures, fainting, diarrhea, diabetes, asthma, allergies, etc.”

The Board judged the pediatrician’s conduct to be below the minimum standard of competence given his failure to keep written medical records, and inappropriately prescribing a medication.

The Board ordered that the pediatrician attend and successfully complete the Medical Record Keeping Seminar at Center for Personalized Education for Physicians (“CPEP”). Also, the Board ordered that the pediatrician hire a medical scribe. Finally, the Board ordered that the pediatrician have a pediatrician monitor his work.

State: Kansas


Date: October 2016


Specialty: Pediatrics


Symptom: Allergic Reaction Symptoms, Diarrhea


Diagnosis: Asthma


Medical Error: Lack of proper documentation, Improper medication management


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



Kansas – Pediatrics – Inability To Diagnose Patient And Use of Improper Medications Due To A Lack of Documentation/Diagnostic Testing



On 2/19/2013, a 17-month-old male presented to a pediatrician’s office for his fifteen-month check.  The pediatrician documented a past medical history of transposition of great vessels at three weeks and open heart surgery.  During the appointment, the pediatrician failed to document family history entirely.  The pediatrician’s section is word-for-word the same information as in other patient records.  The pediatrician failed to provide a detail of treatment plan unique to the patient

On 4/10/2013, the patient presented with a chief complaint of progressively worsening cough with concerns for respiratory syncytial virus, and bronchiolitis.  The review of systems documented ENT evaluation and did not assess the heart. No pulse oximetry was performed.  The physical assessment did not document any GI, musculoskeletal, or skin assessments.

On 5/2/2013, the patient presented for nasal congestion and cough for the last two to three days.  No review of systems was documented.  No oximetry was performed.  It is unclear whether budesonide and albuterol were prescribed, although the pediatrician indicated treatments of budesonide and albuterol in his plan.

On 5/13/2013, the patient presented for coughing coupled with wheezing and rales in the chest.  No pulse oximetry was performed.  The pediatrician signed the patient’s record electronically ten days following the patient visit.

On 6/13/2013, the patient presented with chief complaints of croupy cough, very phlegmy, audible wheezing, rales in the chest, and low-grade fever.  No pulse oximetry was performed.  The pediatrician failed to document his impression regarding why the patient has had the same symptoms since 4/10/2013.

The pediatrician signed the patient record electronically on 7/9/2014.

The pediatrician eventually administered Rocephin and IV methylprednisolone, which was identified as being inappropriate.

The Board judged the pediatrician’s conduct to be below the minimum standard of competence given his failure to keep written medical records and given his failure to prescribe appropriate medications for the patient’s diagnosis.

The Board ordered that the pediatrician attend and successfully complete the Medical Record Keeping Seminar at Center for Personalized Education for Physicians (“CPEP”). Also, the Board ordered that the pediatrician hire a medical scribe. Finally, the Board ordered that the pediatrician have another pediatrician monitor his work.

State: Kansas


Date: October 2016


Specialty: Pediatrics


Symptom: Cough, Fever


Diagnosis: Pulmonary Disease


Medical Error: Improper medication management, Failure to order appropriate diagnostic test, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



California – Dermatology – Rosacea Treated With Intense Pulsed Light Treatment



On 5/5/2011, a patient presented to a cosmetic laser clinic.  At this initial appointment, a nurse recommended that the patient receive Intense Pulsed Light treatment (“IPL”) utilizing the Lumenis One machine to treat rosacea, redness, and discoloration on his neck and chest.  On 5/5/2011, a dermatologist approved the nurse’s treatment recommendations.  The proposed IPL treatments were to be administered over three clinical visits.  The patient was not informed of the potential risk of severe burn and significant scarring associated with IPL treatment.

On 5/16/2011, the patient underwent his first IPL treatment without any adverse outcome.

On 8/15/2011, the dermatologist performed the second IPL treatment on the patient’s neck and chest using the Lumenis One machine.  At the time that respondent performed the second IPL on the patient, she had not previously reviewed the clinic’s written IPL protocol.  The dermatologist did not adjust the settings on the Lumenis One machine and instead relied on the preset settings.  The patient complained of extreme pain during this administration of the IPL treatment.  The patient asked the dermatologist to stop the IPL treatment at least four times during the course of the treatment.  The dermatologist did not stop the treatment, but only hesitated momentarily to wait for the patient to regain his composure.

The dermatologist continually made comments to coax the patient to proceed with the IPL treatment.  The dermatologist did not adjust the settings on the Lumenis One machine during the course of the IPL treatment.

On 8/15/2011, following the IPL treatment, the patient observed two large purple spots with blistering on his chest.

On 8/19/2011, the patient returned to the clinic for an IPL follow-up appointment with the dermatologist.  During this visit, the dermatologist diagnosed the patient with post-IPL second-degree burns to the neck and chest area.

On 6/7/2012, the patient returned to the clinic for an IPL follow-up appointment with the dermatologist.  The dermatologist noted that the patient had hypopigmented rectangles on his chest.

The dermatologist failed to adequately inform the patient of the potential risks of IPL treatment including burns and scarring.  The dermatologist failed to read the protocol governing the Lumenis One machine prior to treating the patient and failed to adjust the machine to a lower energy prior to treating the patient.

The Board issued a reprimand to the dermatologist and ordered the dermatologist to enroll in a clinical in-service training provided by the vendor of the IPL medical device.

State: California


Date: October 2016


Specialty: Dermatology


Symptom: Dermatological Abnormality


Diagnosis: Dermatological Issues


Medical Error: Procedural error


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



Florida – Urology – Insertion Of Catheter Without Removing Protective Sheath During A Cystoscopy-Assisted Balloon Dilation And Stenting Procedure



On 9/15/2014, a patient presented to a urologist for a cystoscopy-assisted balloon dilation and stenting procedure to correct a stricture in his left ureter.

The urologist performed the cystoscopy-assisted balloon dilation and stenting of the patient’s left ureteral stricture.

The cystoscopy-assisted balloon dilation and stenting procedure required the urologist to utilize a catheter to move a balloon and stent into place in the patient’s left ureter.

The catheter utilized by the urologist for the patient’s procedure was equipped with a protective catheter sheath.  This sheath had to be removed prior to the insertion of the catheter into the patient’s ureter.

Neither the urologist nor his support staff removed the protective catheter sheath from the catheter prior to the insertion of the catheter into the patient’s ureter.

The urologist successfully placed the stent into the patient’s left ureter during the cystoscopy-assisted balloon dilation and stenting procedure, but following the procedure the patient experienced intense persistent pain with accompanying nausea.

On 12/11/2014, an exploratory ureteroscopy was performed on the patient’s left ureter.  This procedure revealed the presence of the protective catheter sheath from the cystoscopy-assisted balloon dilation and stenting procedure performed by the urologist on 9/15/2014.  The sheath was successfully removed the patient’s left ureter and the patient’s pain and nausea subsided.

The Medical Board of Florida judged the urologist’s conduct to be below the minimal standard of competence given that he left a foreign body in a patient.

It was requested that the Medical Board of Florida order one or more of the following penalties for the urologist: permanent revocation or suspension of his license, restriction of practice, imposition of an administrative fine, issuance of a reprimand, probation, corrective action, payment of fees, remedial education, and/or any other relief that the Medical Board of Florida deemed appropriate.

State: Florida


Date: October 2016


Specialty: Urology


Symptom: Pain, Nausea Or Vomiting


Diagnosis: Post-operative/Operative Complication


Medical Error: Retained foreign body after surgery


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



California – Emergency Medicine – Chest Pain, Shortness Of Breath, Left Bundle Branch Block On EKG



On 1/19/2014 at 4:40 a.m., a patient arrived at the emergency department complaining of shortness of breath and weeks of intermittent chest pain.

At 4:50 a.m., an ED physician evaluated the patient.  The patient was hypotensive, mildly tachycardic, tachypneic, and hypothermic.  He had rales, rhonchi, and a few wheezes.  The ED physician documented “Today, his pain is less,” but otherwise did not document any further description of the patient’s pain.

In his dictated note, the ED physician explained that he was concerned with the patient suffering septic shock.  In a subsequently written narrative, the differential diagnosis was expanded to include cardiac causes.

Laboratory studies were ordered along with an EKG, a troponin level, and a brain natriuretic peptide level.  The EKG was performed timely and was abnormal.  While the ED physician identified a left bundle block pattern (“LBBP”) in his dictated notes, he neither offered further interpretation of the EKG nor referenced criteria known to be helpful in identifying myocardial infarction in those with an LBBP on EKG.  The ED physician wrote that the EKG showed an LBBP “consistent with a myocardial infarction…”

The small community hospital where the patient presented had an ST-elevated myocardial infarction (“STEMI”) protocol in collaboration with a larger regional hospital better equipped to handle patients with cardiac emergencies.  Once activated, the protocol provides for rapid transportation of the patient to the larger hospital by ambulance.  The ED physician did not activate this protocol.

45 minutes after the EKG was performed, the troponin and BNP results indicated myocardial infarction and congestive heart failure.  A subsequent chest x-ray revealed pulmonary edema.  At this point, the ED physician called the on-call cardiologist to discuss transfer of the patient for treatment at a larger regional hospital.

The Board issued a reprimand and expressed concern that the ED physician departed from the standard of care by failing to obtain and document a more robust history and failing to more promptly consult cardiology regarding the patient’s abnormal EKG.

The Board ordered 40 hours of continuing medical education.

State: California


Date: October 2016


Specialty: Emergency Medicine, Cardiology, Internal Medicine


Symptom: Chest Pain, Shortness of Breath


Diagnosis: Acute Myocardial Infarction, Heart Failure


Medical Error: Delay in proper treatment, Failure to examine or evaluate patient properly, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



California – Pediatrics – Persistent Left Thigh Pain After A Fall Diagnosed As Possible Fibromyalgia



On 4/22/2008, a twelve-year-old female presented to the emergency department after falling down a small grass-covered hill in front of the local library, landing hard on her left side causing severe pain and limping.  The patient was diagnosed with a left thigh contusion and strain, prescribed pain medications, and was given a written note to be out of school for the next two days.  On 8/19/2008, the patient presented to a pediatrician, who documented that she had fallen four months earlier in a library and injured her right thigh (she actually injured her left thigh), which was still hurting.  However, the pediatrician failed to document the level or severity of the pain or any characteristics of the pain.  He documented that he examined her head, face, eyes, ears, nose, throat, mouth, teeth, neck, chest, heart, lungs, abdomen, genitalia, extremities, hip, skin, back, lymph nodes, and central nervous system, which were all normal.  The pediatrician prescribed liquid Motrin for the pain; however, he failed to maintain a copy of the prescription in the chart.

On 9/24/2008, the patient returned with a fever and a sore throat. In an interview later with the Board, the pediatrician stated that he also examined the patient’s ears, nose neck, heart and lungs; however, he failed to document the examination and his findings in the chart.  The pediatrician prescribed liquid Motrin for the fever along with Amoxicillin; however, he failed to maintain copies of the prescriptions in the chart.

On 4/27/2009, the patient again presented to the pediatrician who noted that her left thigh had been hurting for ten months.  The pediatrician failed to inquire about and document the level or severity of the pain or any other characteristics of the pain.  During an interview with the Board, the pediatrician stated that he examined her lower extremities; however, he failed to document his examination and his findings in the chart.  The pediatrician’s impression was that the patient had “pain on leg.”  The pediatrician prescribed liquid Motrin again, but failed to maintain a copy of the prescription in the chart, the pediatrician also ordered x-rays of her left femur, and wrote a note excusing her from physical education at school for the next two weeks.

On 9/8/2009, the patient again presented to the pediatrician who noted that the back of her thigh still hurt; however, the pediatrician failed to document which thigh the patient was complaining of and failed to document any characteristics of or the level or severity of the pain.  The pediatrician has two separate progress notes for this visit.  On the first note, no physical examination is documented; however, on the second note, the pediatrician documented that he examined her head, face, eyes, ears, nose, throat, mouth, teeth, neck, chest, heart, lungs, abdomen, genitalia, extremities, hip, skin, back, lymph nodes, and central nervous system which were all reportedly normal. The pediatrician’s impression was “muscle spasm’ and again prescribed liquid Motrin, but failed to maintain a copy of the prescription in the chart.  Additionally, the patient had a comprehensive metabolic blood panel which showed significantly abnormal AST and ALT which were more than ten times the normal values; however, the pediatrician failed to document his plan to follow up on these abnormal lab findings and failed to address their etiology with further testing.

On 9/16/2009, the patient again presented to the pediatrician who noted that the back of her thigh hurt when she sat down.  However, the pediatrician failed to document which thigh the patient was complaining about and failed to document any characteristics of or the level or severity of the pain, the pediatrician documented that he examined her head, face, eyes, ears, nose, throat, mouth, teeth, neck, chest, heart, lungs, abdomen, genitalia, extremities, hip, skin, back, lymph nodes, and central nervous system again even though he had examined them eight days earlier.  The pediatrician’s impression was “pain on thigh” and diagnosed the patient with fibromyalgia, a condition which is very rare in adolescents and children.  The pediatrician requested approval for the patient to see an orthopedist and considered starting her on pregabalin to treat the fibromyalgia.

On 9/24/2009, the patient again presented to the emergency department and was noted to have pain and soreness in her left inner thigh and was favoring her right leg.  Upon examination, she was noted to have pain in the medial left thigh on left hip abductor on adduction and hyper-abduction, and tenderness and light spasms were palpated on the left medial thigh.  She was diagnosed with an acute left thigh strain, her thigh was wrapped with an Ace bandage, and she was discharged with a written note to school restricting her from physical education and sports for seven days.

On 9/28/2009, the patient presented to the pediatrician who noted her chief complaint was pain on her inner thighs; however, he failed to document the level or severity of the pain or any other information or characteristics of the pain.  The pediatrician noted that she was seen at the emergency room four days earlier and the emergency room doctor recommended crutches.  The pediatrician has two different progress notes for this visit.  On the first progress note, no physical examination is documented; however, on the second progress note the pediatrician documented that he examined the patient’s head, face, eyes, ears, nose, throat, mouth, teeth, neck, chest, heart, lungs, abdomen, genitalia, extremities, hip, skin, back, lymph nodes, and central nervous system areas he had examined two weeks earlier.  On both progress notes, the pediatrician’s impression is fibromyalgia; however, the first progress note lists his plan to prescribe Lyrica, and on the second progress note Lyrica is crossed out and the pediatrician wrote that he prescribed gabapentin; however, the pediatrician failed to date and initial the changes.  The pediatrician also failed to maintain a copy of the gabapentin prescription in the chart.  The pediatrician also requested authorization for crutches, which were approved.

On 9/30/2009, the pediatrician’s office requested authorization for a prescription of Lyrica to treat the patient’s fibromyalgia, and noted the medical necessity as “severe pain” left thigh and back “now walks with crutches.”  During an interview with the Board, the pediatrician stated that the patient never complained of severe pain and that his office manager wrote that in order to get authorization from the insurance company.

On 10/20/2009, the pediatrician’s office manager completed a preauthorization request form for the patient which stated that the clinic indications for the request was “13 yr. old c/o pain (severe) left thigh and back” who “needs crutches to help” ambulate.  The pediatrician, however, during an interview with the Board, stated that the patient, never complained of severe pain and that his office manager wrote that in order to get authorization from the insurance company.

On 10/21/2009, the patient again presented to the pediatrician who noted that she was still having pain in her thigh and it was not better.  The pediatrician failed to document which thigh the patient was complaining of and failed to document the level or severity of the pain or any other information or characteristics of the pain, the pediatrician documented that he examined her head, face, eyes, ears, nose, throat, mouth, teeth, neck, chest, heart, lungs, abdomen, genitalia, extremities, hip, skin, back, lymph nodes, and central nervous system areas, which he examined three weeks earlier.

The pediatrician’s impression was fibromyalgia, and continued prescribing gabapentin, but failed to maintain a copy of the prescription in the chart.  On 11/4/2009, the patient again presented to the pediatrician who noted she was doing well and was not having much pain in her thigh; however, the pediatrician failed to document which thigh the patient was complaining of.  The pediatrician documented that he again examined her face, eyes, ears, nose, throat, mouth, teeth, neck, chest, heart, lungs, abdomen, genitalia, extremities, hip, skin, back, lymph nodes, and central nervous system, areas he examined two weeks earlier. The pediatrician’s impression was fibromyalgia, and continued her prescription medication, but failed to maintain a copy of the prescription in the chart.

On 11/30/2009, the patient was again seen by the pediatrician who noted that her left thigh still hurt and she now had a fever.  The pediatrician examined her extremities and noted that her left thigh was slightly tender and had large swelling; however, the pediatrician failed to take any measurements of her thigh on this visit.  The pediatrician noted his impression as fibromyalgia, but stated during an interview with the Board that that was a very unlikely impression at the time.  The pediatrician decreased the dosage of gabapentin and prescribed liquid Motrin for her fever; however, the pediatrician failed to maintain copies of the prescriptions in the chart.

On 12/7/2009, the patient was again seen by the pediatrician who noted that her leg was still swollen and hurting.  The pediatrician examined her extremities and noted hard swelling on the left inner thigh.  The pediatrician documented that her right thigh measured 53% centimeters (cm) in circumference and her left thigh 57 cm; however, the pediatrician could not recall exactly how he took the measurements.

The pediatrician’s impression was fibromyalgia and his plan was to decrease the gabapentin and order an ultrasound of her right thigh.  In his chart note, the pediatrician documented that the ultrasound (performed on 12/22/2009) showed multifocal soft tissue cysts probably due to trauma and hematoma on the right thigh; however, the pediatrician failed to date this late entry.  Additionally, during an interview with the Board, the pediatrician stated that his notes under “Tests and Treatment’ section of the progress note referencing the right thigh ultrasound results was incorrect and that it should have said the left thigh; however, the pediatrician ordered an ultrasound of the patient’s right thigh not the left.

On 12/22/2009, an ultrasound of the patient’s right lower extremity was performed showing multifocal soft tissue cysts.

On 12/31/2009, the patient presented to the pediatrician again who noted that her left thigh was more swollen and she had pain on her right thigh during walking.  The pediatrician examined her extremities and noted that her left thigh was tender with swelling.  Her right thigh measured 55 cm and her left thigh 66 cm; however, the pediatrician did not recall exactly how he took the measurements. The pediatrician failed to document the level or severity of or any characteristics of the pain.  The pediatrician documented his impression as fibromyalgia, although during an interview with the Board, he stated that his impression was actually a cyst, based upon the ultrasound results of the right thigh.  The pediatrician’s plan was to discontinue the gabapentin and refer the patient to a pediatric rheumatologist for a second opinion.

On 1/13/2010, the patient saw the pediatrician again who noted that she complained of severe pain in her left thigh, which was more swollen.  The pediatrician examined her extremities, but noted no abnormalities or swelling.  The pediatrician again measured her thighs and noted that her right thigh now measured 51 cm and her left thigh 68 cm; however, the pediatrician could not fully explain how the patient’s right thigh measures changed from 53 cm on 12/7/2009, to 55 cm on 12/31/2009, and decreased to 51 cm in January 2010.

The pediatrician stated that maybe he measured 15 inches from the knee joint up and then measured the circumference the first time, and then he might have measured from a different level the second time, maybe only 10 inches up from the knee joint.  The pediatrician documented his impression as fibromyalgia, although during his interview he stated that his impression was actually a cyst based upon the ultrasound results.  The pediatrician’s plan was to continue her prescription for liquid Motrin for the pain and to have her return in five weeks.

On 1/14/2010, the patient was seen by a pediatric rheumatologist at the Long Beach Memorial Medical Center/Miller Children’s Hospital, who noted that the patient was having severe pain about once a week causing her difficulty when standing up.  The rheumatologist’s examination revealed that the patient’s left thigh was significantly swollen with a mass in the posterior aspect to the medial superior area with a circumference measuring approximately 70 cm.  The rheumatologist was concerned as the patient’s history and physical examination were not suggestive of fibromyalgia and the swelling and the mass was inconsistent with fibromyalgia.

The rheumatologist felt the 12/9/2009 ultrasound findings could be consistent with an infectious process and felt that the patient would benefit from hospitalization for further evaluation.  The rheumatologist expressed her concerns to the pediatrician and emphasized that such swelling cannot be attributed to fibromyalgia.

On 1/15/2010, the patient again presented to the pediatrician who noted she complained of swelling and pain in her left thigh.  The pediatrician examined her extremities and noted that her left thigh was swollen with a mass present; however, two days earlier, the pediatrician documented that he examined her extremities but did not note any swelling or mass.

The pediatrician’s impression was that she had a tumor in her left thigh and his plan was to admit her to a hospital for further evaluation.  Subsequently, the pediatrician added his first diagnosis as hematoma/lymphoma, and his second diagnoses as sarcoma; however, he failed to date these late entries.

On 1/15/2010, the patient presented to the hospital wherein she underwent a bilateral Magnetic Resonance Imaging of her left leg which reflected an elongated soft tissue mass measuring approximately 18 x 14 X 14 cm along with multiple cystic areas with fluid.  She also underwent a Magnetic Resonance Angiogram which reflected abnormal vasculature surrounding and partially coursing through the mass,

On 1/18/2010, the patient underwent a biopsy of her left thigh mass.  The final results reported that the patient had synovial cell sarcoma which had metastasized to her lungs.

The patient underwent a course of chemotherapy and surgery of her left thigh tumor at a children’s hospital; however, her pulmonary tumors continued to increase in size and the patient died of her illness on 1/15/2012.

The Board judged the pediatrician’s conduct as having fallen below the standard of care given failure to adequately perform further work-up of her persistent left leg complaints and order further diagnostic studies and tests, failure to follow up on the significantly abnormal AST and ALT results, and given failure to maintain adequate and accurate medical records.

The Board revoked the pediatrician’s license and placed him on probation for three years with stipulations to complete at least 45 hours of continuing medical education per year in areas of deficiencies, to complete a medical record keeping course, and to undergo monitoring.

State: California


Date: October 2016


Specialty: Pediatrics, Oncology


Symptom: Extremity Pain, Fever


Diagnosis: Cancer


Medical Error: Diagnostic error, Failure to examine or evaluate patient properly, Failure to follow up, Lack of proper documentation


Significant Outcome: Death


Case Rating: 5


Link to Original Case File: Download PDF



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