Found 22 Results Sorted by Case Date
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California – Internal Medicine – Missed Diagnosis With Repeated Visits For Wheezing, Extremity Swelling, And Uncontrolled Type 2 Diabetes



On 4/12/2010, a 60-year-old male complained of wheezing and had a history of Type 2 diabetes.  An internist obtained a sparse history, consisting of four sentences, even though the internist had not previously known the patient.  The internist stated that the patient complained of “asthma” and had been non-compliant with diet, exercises, and medications required for control of his Type 2 diabetes.  The internist did not obtain or document a history of present illness regarding the wheezing, asthma, or diabetes. Some vital signs were obtained, but an abnormal pulse of 120 bpm was not commented upon by the internist, and a respiratory rate was not obtained.  A review of symptoms was documented and reported to be normal, but its accuracy was uncertain given the internist’s use of an electronic template. Despite the absence of wheezing in the documented examination, and even though the internist did not perform a standard workup for asthma, the internist prescribed a burst course of a systemic corticosteroid and inhaler to the patient.  The internist did not perform and/or did not document a cardiorespiratory physical examination of the patient. He ordered a series of laboratory tests to assess the patient’s Type 2 diabetes, and the patient was given home instructions, but these related to Type 1 rather than Type 2 diabetes. On the following day, the internist did request that staff contact the patient regarding a nutrition course for diabetics.

On 4/25/2010, the patient was seen by another physician for complaints of swelling to his left foot.  The patient reported that the swelling had started 2 days previously, was not the results of trauma, and did not prevent him from walking.  Physical examination revealed swelling over the dorsal foot. The plan was for the patient to follow up with his primary care physician, the internist.

On 4/27/2010, the patient had a telephone encounter with the internist regarding the patient’s edema.  The patient was advised to have laboratory tests performed and scheduled an appointment the following week.  The patient complied with the request, and the test results included glucosuria, normal hemoglobin and WBC count, an estimated glomerular filtration rate of 57, Hemoglobin A1c of 13.6, albumin of 3.2, and urinary protein/creatinine ratio of 0.57.  These were documented in the patient’s chart on 4/28/2010, but there was no documentation that any physician reviewed the results on that date.

On 5/2/2010, the patient sent an email to another physician in which he stated that he had not been contacted after his last telephone encounter with the internist and that he was concerned about the swelling in his feet and legs, which he stated had been ongoing since 4/22/2010.  The patient was instructed to make an appointment with the internist when he returned on 5/3/2010.

On 5/10/2010, the patient was seen by the internist.  A brief history was recorded, which stated the patient’s concerns about the swelling of his lower extremities and the patient’s uncontrolled diabetes due to his non-compliance with diet and exercise.  The patient apparently also complained of a cough, which was only referenced in the assessment and plan, and which the internist attributed to a medication the patient had been prescribed for hypertension.  Again, some vital signs were recorded, and the patient was noted to have a rapid heart rate (110 bpm), but this was not commented upon. Neither respiratory rate nor SpO2 was recorded at this visit. An incomplete cardiovascular and pulmonary examination was reported as normal, despite the patient’s tachycardia.  A jugular venous distention examination was not performed. The internist’s assessment included diabetic nephropathy (kidney disease or damage caused by diabetes). He ordered tests, including a 24-hour urine protein and albumin tests. At the same visit, however, he prescribed both metformin (an antidiabetic drug that is contraindicated in patients with renal insufficiency) and Lasix.

On 5/16/2010, the patient contacted the advice nurse and reported that he was having difficulty sleeping.  On 5/17/2010, the patient’s wife emailed the internist and stated that the patient “still has a horrible hacking cough which doesn’t [sic] allow him to sleep much…his legs and feet are still swollen…”  Th internist advised the patient to make an appointment to return to see him regarding these problems.

On 5/25/2010, the patient had his third face-to-face encounter with the internist.  A chief complaint was not listed. The subjective portion of the examination was brief and cursory.  It stated that the patient’s blood sugars had been testing in the mid-200’s and that the edema of the legs continued despite taking a daily dose of Lasix.  The patient’s heart rate was again elevated, this time at 108 bpm, but the internist neither commented on the patient’s persistent tachycardia nor did he document a heart examination that included listening for a third sound.  The patient’s cough was again briefly noted, and this was attributed to his being “apparently allergic” without any documented examination of the throat or nose. Although the internist continued to believe that the edema was related to renal insufficiency, he also continued the patient on metformin 500 mg BID, which was contraindicated as mentioned above.  Although a differential diagnosis was not charted, the internist did order an EKG and a chest x-ray for what he later described as cardiac concerns. However, the tests were not ordered urgently, and the more appropriate procedure, an echocardiogram, was not ordered at that time. The internist placed the patient on disability for one month.

On 5/28/2010, the patient underwent the chest x-ray, which was interpreted as showing an enlarged heart and pleural edema consistent with congestive heart failure, but this was not reported until 6/8/2010.  On 6/1/2010, the patient sent the internist an email in which he stated that he had not had any real improvement in the swelling of his feet and legs despite an increased dose of Lasix, compression stockings, and a low sodium diet.  The internist replied: “I will see you soon. I might need to refer you to nephrology.”

The patient returned on 6/3/2010, at which time his recorded vital signs were significant for low blood pressure (96/89) and an elevated pulse (103).  The chief complaint was stated to be edema, but the history was limited to a brief comment that “…persists with edema. It is less today.” Although, as set forth above, the internist had ordered a chest x-ray, he did not follow up to find out the results of that exam during this patient encounter.  The examination was reported to be the same as the exam on 5/25/2010, likely as the result of the use of an electronic template. The internist’s impression was peripheral edema “probably due to hypoalbuminemia but will check for other possibilities.” The internist ordered multiple diagnostic tests, including a renal ultrasound.

On 6/8/2010, the renal ultrasound was reported as showing pleural effusion and ascites.  The previously ordered x-ray, as stated above, was read as showing congestive heart failure.  The internist contacted the patient and advised that the x-ray showed changes that suggested heart failure.  The internist asked the patient to have the EKG done and to come in for examination the following day. An electrocardiogram was also ordered but was not scheduled until 6/23/2010.  On 6/9/2010, the patient suffered a cardiac arrest and was taken to another facility. He was found to have anoxic brain injury and died on 6/15/2010.

The Medical Board of California judged that the internist’s conduct departed from the standard of care because he failed to obtain a complete history, appropriately work-up the patient for a diagnosis of asthma, perform an adequate physical examination for possible causes of the patient’s complaints at each of the four encounters, recognize signs and symptoms of congestive heart failure, formulate an appropriate differential diagnosis, and respond emergently to a patient in a decompensated clinical state.  The internist also inappropriately prescribed a corticosteroid and an antidiabetic drug and persevered in consideration of remote diagnoses and unreasonably delayed in considering likely causes of the patient’s cough, wheezing, tachycardia, hypotension, and edema.

The Medical Board of California placed the internist on probation for 5 years and ordered the internist to complete a medical record keeping course, an education program (at least 40 hours per year for each year of probation) and a clinical training program equivalent to the Physician Assessment and Clinical Education Program offered at the University of California San Diego School of Medicine and be assigned a practice monitor.  The internist was prohibited from supervising physician assistants.

State: California


Date: May 2015


Specialty: Internal Medicine


Symptom: Shortness of Breath, Cough, Swelling


Diagnosis: Heart Failure, Diabetes


Medical Error: Failure to order appropriate diagnostic test, Delay in diagnosis, Failure to examine or evaluate patient properly, Failure to follow up, Improper medication management, Lack of proper documentation


Significant Outcome: Death


Case Rating: 5


Link to Original Case File: Download PDF



California – Internal Medicine -A Patient With Alcoholic Liver Disease, Ascites, And Diabetes With Abdominal Pain



On 10/3/2006, an internist commenced providing care as a primary care practitioner to a 37-year-old male patient.  According to the internist’s chart notes of this date, the patient presented “for follow up” after discharge from the hospital “due to hepatic failure and massive s ascitates [sic].”  The patient’s blood pressure was 110/42, and his blood sugar was noted as 243. The internist performed a physical examination. His impression included alcoholic hepatic failure, massive ascites, and diabetes mellitus.  The internist continued the patient on “Lactulose” and added Amaryl 2 mg daily to the patient’s medications. However, the internist failed to inquire into and note all the medications the patient was taking. Thereafter, the patient made office visits until 8/1/2011.

On 10/10/2006, 10/24/2006, and 11/11/2006, the patient made follow-up visits during which he complained of “abdominal distention,” “insomnia,” and “bloating,” respectively.  The internist failed to obtain and note a history of abdominal distention, insomnia, and bloating conditions during these visits. The internist’s diagnosis for the patient included hepatic failure and diabetes mellitus.  The internist failed to document all the medications the patient was taking during these meetings.

On 6/19/2007, the patient made a follow-up visit during which he complained of diarrhea from the Neurontin medication the internist was prescribing for him.  The internist failed to perform and document a thorough evaluation to determine whether the patient’s diarrhea was an adverse effect of the Neurontin medication.  Moreover, the internist failed to note the medical justification for prescribing Neurontin for the patient. On this visit, the internist prescribed Lyrica for the patient.  The internist failed to document the reason for the Lyrica medication; however, on the patient’s follow up visit on 7/10/2007, the internist noted that the patient’s “neuropathy was better on Lyrica,” and he continued the Lyrica medication to treat the patient’s neuropathy.  Thereafter, the internist continued to prescribe and refill prescriptions for Lyrica and Neurontin for the patient until his final visit on 8/1/2011. At no time during the period of treatment did the internist perform or document any medical findings that would justify a diagnosis and treatment of peripheral neuropathy.  Moreover, the internist failed to refer the patient to a specialist for evaluation of peripheral neuropathy during the period of treatment.

On 12/3/2008, the patient made an office visit during which he complained of abdominal pain in the right upper quadrant for two weeks.  Under subjective findings, the internist noted that the upper right quadrant pain was not associated with constipation, diarrhea, or vomiting.  Under physical examination, the internist noted the patient’s abdomen was soft, “non-tender,” “non-distended,” and had “normal bowel sounds,” but the right upper quadrant was tender to palpation (TTP).  The internist’s diagnosis was “right upper quadrant pain,” and he ordered laboratory tests including an ultrasound of the abdomen. The internist failed to obtain and document a differential diagnosis for the right upper quadrant pain.  The patient presented on 12/10/2008, requesting the results of the labs ordered on 12/3/2008. The internist failed to discuss or note a discussion with the patient about the results of the ultrasound.

The patient made a visit on 12/18/2008, during which he complained of vomiting after a hamburger meal and also requested the results of the laboratory tests.  Under review of systems, the internist noted that the patient had “vomiting and nausea,” however, the internist failed to note the nature of the emesis. Under physical examination, the internist noted that the patient’s abdomen was non-tender, was not distended and the bowel sounds were normal.  On this visit, the internist noted he reviewed the result of the ultrasound performed on 12/15/2008. His diagnoses included cholelithiasis, and he advised the patient to avoid fatty food “since he has gallstones.” The internist’s plan included surgical consultation “to remove gallstones.” There was no medical justification or basis for the cholelithiasis diagnosis.  Specifically, the diagnosis ignored previous abdominal imaging studies on the patient which did not show any evidence of biliary tract stone disease or kidney stone disease. Moreover, the diagnosis ignored the following statement under FINDINGS in the 12/15/2008 ultrasound report: “the gallbladder is unremarkable without ultraluminal structures, gallbladder wall thickening or pericholecystic fluid.  There is negative sonographic Murphy’s sign.”

On 3/6/2009, the patient made a visit during which he complained of, among other things, occasional bulge in the upper stomach which caused pain when he fastened the seat belt in his automobile.  On 6/12/2009, the patient made a visit during which he complained of nausea, among other things. On 6/17/2009, the internist ordered another gallbladder ultrasound procedure. The result was negative for cholecystolithiasis.  However, the internist continued to list “cholelithiasis confirmed” as an on-going diagnosis for the patient. The internist again failed to consider the patient’s chronic liver disease as a differential diagnosis for the patient’s nausea.

On 8/18/2009, the patient made a visit during which he complained of right abdominal pain.  The internist’s diagnosis was “abdominal pain.” His plan was to order an abdominal ultrasound.  The ultrasound result showed no gallstones in the patient’s gallbladder and the kidneys were “normal.”  The internist failed to consider chronic liver disease as a differential diagnosis for the patient’s right abdominal pain.  Thereafter, the internist continued to list “cholelithiasis confirmed” as an on-going diagnosis for the patient until 8/1/2011.

Between 11/1/2007 and 2/9/2010, the patient presented with symptoms of cough, runny nose, sore throat, and shortness of breath on approximately 10 separate visits.  On the visit of 11/1/2007, the patient complained of “productive cough.” The internist’s diagnosis was acute bronchitis, and he prescribed Zithromax Z-pak 250 mg. On the visits on 3/18/2008, 10/23/2008, 11/20/2008, the internist prescribed Zithromax to treat the patient’s complaints that included cough, congestion, fatigue, sore throat, and nausea.  On the visit of 10/16/2009, the patient complained of fever with a temperature of 102 F, cough with green phlegm, and diarrhea described as green. The internist failed to obtain and note an adequate history for the complaints, however, he diagnosed the patient with acute bronchitis and prescribed antibiotics including Zithromax. On the visit of 4/23/2010, the patient complained of cough, sore throat, fever, and congestion “for two weeks.”  The internist failed to perform and document an appropriate physical examination related to the patient’s complaints. The internist’s diagnosis included acute respiratory infection and “probable acute sinusitis,” and he again prescribed antibiotics including Zithromax for the patient.

During the period of treatment, the internist prescribed multiple sleep medications to treat the patient’s insomnia.  The medications included Ambien, flurazepam, temazepam, and Lunesta.

For this allegation and others, the Medical Board of California ordered the internist to attend an education course.

State: California


Date: August 2014


Specialty: Internal Medicine


Symptom: GI Symptoms (GERD, Abdominal Distention, Dysphagia), Cough, Diarrhea, Fever, Nausea Or Vomiting, Abdominal Pain, Shortness of Breath, Weakness/Fatigue


Diagnosis: Liver Disease, Diabetes


Medical Error: Diagnostic error, Failure to examine or evaluate patient properly, Referral failure to hospital or specialist, Failure of communication with patient or patient relations, Improper medication management, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



Wisconsin – Physician Assistant – Weight Loss, Sore Throat, Body Aches, Fatigue, Labored Breathing, And Runny Nose



On 9/17/2014, a 13-year-old male presented to Physician Assistant A with sore throat, body aches, fatigue, runny nose, and congestion for 3 days.

The patient normally received healthcare in a different health system.  Records were not accessible to Physician Assistant A.  The patient was accompanied by his mother, who informed the staff that the patient had been experiencing weight loss, voiding of sweet smelling urine, and labored breathing.  The mother asked the staff to inform Physician Assistant A of these findings.  Neither the nurse nor Physician Assistant A stated that they were notified of these symptoms.  The mother mentioned enuresis to Physician Assistant A and questioned if it could have been caused by a chronic urinary tract infection, but declined additional testing.

Physician Assistant A diagnosed the patient with bilateral acute otitis media, an upper respiratory tract infection, and sore throat.  He prescribed antibiotics for otitis media and presumptive UTI.  He recommended over-the-counter medications and recommend increased fluid intake.

On 9/18/2014, the patient was taken to the emergency department where the ED physician noted increased shortness of breath, progressive weakness, global aches, polydipsia, and polyuria.  Labs revealed a sodium of 127, glucose of 826, and carbon dioxide of 3.

The ED physician made the diagnosis of diabetic ketoacidosis, and the patient was admitted to the pediatric ICU.  On 9/22/2014, the patient was discharged home with endocrinology follow up.

Physician Assistant A was given the stipulation to take 6 hours of education in diabetes diagnosis and management.

State: Wisconsin


Date: August 2014


Specialty: Physician Assistant, Emergency Medicine, Pediatrics


Symptom: Urinary Problems, Shortness of Breath, Weakness/Fatigue


Diagnosis: Diabetes


Medical Error: Diagnostic error, Failure of communication with patient or patient relations


Significant Outcome: Hospital Bounce Back


Case Rating: 4


Link to Original Case File: Download PDF



Wisconsin – Family Medicine – Burning Bilateral Sciatic Pain, Canker Sores, Vomiting, Anxiety, And Poor Sleep



On 2/20/2009, a 48-year-old man presented to the Family Practitioner A for a routine physical exam.  The patient was considered a new patient given that it had been a long time since he had been seen.  Family Practitioner A documented that past medical history included bipolar disease, depression, hyperlipidemia, erectile dysfunction, obesity (BMI 32.73), migraine headaches, and alopecia.  The patient was taking finasteride 1 mg daily for alopecia.  A TB test was administered.  Further recommendations included exercise, a low-fat diet, and follow up in a month “to recheck his cholesterol with a fasting lab.”  Lithium 300 mg twice a day and sildenafil 100 mg as needed for sexual dysfunction were ordered.

The patient did not follow up in a month as had been recommended.  The patient was next seen on 3/22/2010, for follow up of bipolar disease, erectile dysfunction, hyperlipidemia, and medication renewal.  The patient asked for a sleep study.  He had concerns that sildenafil was leading to migraines.  He reported sciatic discomfort improved with massage.  Physical exam was performed along with a review of systems.  Labs revealed a TSH of 4.88 (range of 0.47-4.68), hyperlipidemia with total cholesterol of 269 (range of 100-199), C/HDL of 8.97 (range 0-4.88), and triglycerides 2862 (range of 0-149).  Fenofibrate 145 mg daily was ordered for hypertriglyceridemia.

On 4/7/2010, the patient reported having burning bilateral sciatic pain, mouth canker sores, vomiting for 3-4 days, anxiety, and poor sleep.  Blood pressure was noted to be 166/110.  Family practitioner A documented anxiety, insomnia, sciatic discomfort, and oral thrush.  He prescribed the patient Xanax 0.5 mg twice a day, Nystatin 4 times a day for 10 days, and replaced sildenafil with vardenafil.

On 4/9/2010, a family member found the patient dead in his home.

An autopsy reported that the “decedent’s cause of death is attributed to an acute diabetic ketoacidosis with features of renal failure and acute pancreatitis.  There is a marked, apparently reactive hypertriglyceridemia.  This is manifested by gross observation of lipid at autopsy as well as the antemortem test results.”  The care of the patient was thought to have fallen below the standard of minimal competence given lack of testing for diabetes.

Family practitioner A was ordered by the state to complete 8 hours of education on managing diabetes and diabetic ketoacidosis.

State: Wisconsin


Date: August 2014


Specialty: Family Medicine, Internal Medicine


Symptom: Back Pain, Nausea Or Vomiting, Psychiatric Symptoms


Diagnosis: Diabetes


Medical Error: Diagnostic error


Significant Outcome: Death


Case Rating: 4


Link to Original Case File: Download PDF



California – Internal Medicine – Right Leg Infection Complicated With Diabetes Fails To Improve Despite Treatment



On 10/26/2006, a patient was housed at a detention facility.  Medical treatment for detainees was provided by the DIHS at the detention facility.  On 12/12/2006, the patient presented to an internist in the DIHS facility with lesions with eschars on the right big toe, medial ankle, and shin.  An internist noted an abscess on the toe, erythema and warmth on the ankle, and ulceration on the shin. The internist ordered a finger-stick blood glucose test, which indicated a high blood sugar level at 300.  The internist further ordered x-rays of the ankle and toe, which showed no evidence of osteomyelitis. The internist then proceeded with debridement of the eschar and incision of the abscess. The internist started the patient on the antibiotics cefazolin and clindamycin and scheduled a follow up later that day.

On 12/12/2006 the patient was admitted to the short stay unit (SSU) for debridement of his wounds and the administration of antibiotics and insulin for presumed diabetes.  On 12/13/2006, the internist noted that the patient had a continued low-grade fever, right lower leg erythema and ecchymosis of the right medial ankle, and blister formation with leakage of dark serosanguinous fluid.  The internist’s assessment was diabetes with cellulitis and ulceration to the right lower leg. The internist ordered a new antibiotic, imipenem, and decided to keep the patient on his current antibiotics until the imipenem could be obtained.  The internist also ordered aerobic and anaerobic blood cultures. There was no documentation that the patient ever received Imipenem.

On 12/19/2006, the internist documented that the patient had not been getting up and that he had cellulitis and ulceration to his right lower leg that was improving over time.  On 12/20/2006, on the internist’s order, a physician assistant discharged the patient to the general population and changed the IV antibiotics to a 7-day oral course of Keflex and clindamycin.  The internist saw the patient and observed right lower extremity (RLE) with edema, woody induration on posterior area which decreased with elevation, large eschar on medial aspect from medial malleolus to mid shin, and right big toe with small eschar, easily debrided.  The internist further noted RLE medial toe eschar with small 3 mm x 3 mm circular area with poor tissue formation. The internist’s assessment was cellulitis resolved with edema and eschar.

On 1/3/2007, the internist noted that the patient had cellulitis resolved with edema and decreased eschar.  Despite this notation, the internist ordered an abdominal pad to soak up wound drainage. On 1/5/2007, the internist noted that the patient changed his own dressing and was worried about the smell.  On 1/8/2007, the internist noted the patient still had wound discharge with the smell of serosanguinous drainage. The internist’s assessment remained cellulitis resolved with edema and decreased eschar.  On 1/10/2007, the internist noted that the patient had increased wound drainage.

On 1/11/2007, the physician assistant noted the patient complained of burning pain and observed that his outer dressing was soaked through from serosanguinous leakage with a normal, healing tissue type odor.  On 1/16/2007, a registered nurse noted that the patient complained that he was bleeding through his dressing. The registered nurse observed the patient’s bandage was still intact with large amount of bright red blood noted on the outer dressing.  The registered nurse also noted a strong odor from the lower leg ulcer with moderate active bleeding.

On 1/16/2007, the internist evaluated the patient, and her assessment remained that the patient’s cellulitis resolved with edema and decreased edema.  Despite this assessment, the internist filed a TAR for surgery and wound clinic for potential debridement.

On 1/17/2007, the physician assistant noted that there appeared to be moderate serosanguinous fluid and a very foul odor.  The physician assistant further noted that there were areas that were deteriorating quickly into necrosis, and there might have been some underlying necrotic tissue that the DIHS clinic would not be able to manage or debride.

On 1/17/2007, the patient was sent to a wound clinic.  The patient was subsequently admitted to the hospital where he was diagnosed with severe ulceration of his right lower extremity, osteomyelitis, and diabetes.  The patient had a 6-week course of antibiotics followed by a split-thickness skin graft.

The internist committed gross negligence in her care and treatment of the patient, which included: failure to perform and document an adequate evaluation on the patient with a diabetic foot infection; failure to use appropriate antibiotics when suspecting an anaerobic infection in the patient’s right lower extremity; failure to obtain wound cultures to determine optimal antibiotic therapy; failure to recognize that her treatments were not resulting in prompt and complete healing; and failure to recognize that appropriate consultation was necessary in this case.

The Medical Board of California ordered that the internist be placed on probation for three years and attend 65 hours of a CME course, a PACE program, a professionalism program (ethics course), a medical record keeping course, and a monitoring program. During this probation, the internist was prohibited from supervising physician assistants.

State: California


Date: July 2014


Specialty: Internal Medicine


Symptom: Dermatological Abnormality, Bleeding, Fever, Pain, Wound Drainage


Diagnosis: Infectious Disease, Diabetes


Medical Error: Improper medication management, Failure to examine or evaluate patient properly, Failure to order appropriate diagnostic test, Referral failure to hospital or specialist, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



Wisconsin – Emergency Medicine – 9-Year-Old Boy With Abdominal Pain, Nausea, And Vomiting For 4 Days



On 2/23/2008, at 11:34 a.m., a 9-year-old boy presented to the emergency department with abdominal pain, nausea, and vomiting for 4 days.  The patient had been drinking water “by the gallons,” had increased urinary frequency, and dry heaves.  Urinalysis revealed 4+ ketones, 2+ glucose, sodium 125, potassium 5.8, chloride 80, bicarbonate 7, albumin 5.6, alkaline phosphatase 502, BUN 34, creatinine 1.4, and glucose 978.9.  The patient was diagnosed with diabetic ketoacidosis and initiated on an insulin drip at 6 units per hour.

At 2:25 p.m., the nurses notified Family Practitioner A that they were unable to place an IV line.  Family Practitioner A ordered placement of the IV line in the patient’s foot.  Orders for IV insulin and lab draws were not administered until the IV line was placed.

At 7:40 p.m., the nurses documented: “Has started seizure-like activity where he’ll stiffen up for approx 10-20 sec then relax, along with Kussmaul respiratory pattern.  Also incontinent at intervals and small emesis of [illegible] pinkish opaque liquid which comes out of nose at times.  Ox to 80’s when stiffens up but back up to 95-100% when relaxed.  Does not respond to verbal stimuli.  [Family Practitioner A] made aware.  Orders received and instituted.”

Family Practitioner A ordered medications, the specifics of which were not noted.  At 8:30 p.m., it was documented that the patient was not responsive along with further objective findings: “Blood pressure was 110/70, pulse 150, T 98.5 ap, clear lungs, Kussmaul breathing, Na 142, Cl 103, and venous PH 7.18.”

Diagnosis was diabetic ketoacidosis with coma.  Further medication and laboratories were ordered.  The patient did not regain consciousness over the next several hours.  Despite administration of acetaminophen and aspirin suppositories, he developed a temperature of 105 rectal at 11:30 p.m., 104 rectal at 12:10 a.m., 105 rectal at 3:10 a.m., and 104.5 rectal at 6:30 a.m.  At 7:15 a.m., it was documented by Family Practitioner A that the fever was persistent along with the following: “BP 110/70, P 160, localized pain, heart RRR, lungs clear, Na+ 165, Cl 134, Phos 2.5, K+ 4.1, glucose 121.”  He documented plans to consult pediatrics, transfer the patient to a tertiary care facility, and obtain a CT scan of the head.  The CT head without contrast revealed: “Nonhemorrhagic right lacunar infarct and nonhemorrhagic thalamic infarct duration undetermined.”

At 10:45 a.m., the patient was transferred to a tertiary care facility.  He was diagnosed with extensive bilateral infarcts involving the basal ganglia, thalamus, splenium, parietal and temporal lobes thought to be secondary to severe dehydration, hypernatremia, and possible diabetes insipidus.

After 2 weeks, MRI revealed bilateral infarcts and there was no improvement in his condition.  Life support was removed and the patient expired.

A lawsuit was initiated against Family Practitioner A with the outcome of a confidential settlement.  The Board elected to reprimand Family Practitioner A with concerns that a delay in transfer increased the patient’s risk for harm, injury and death.  His license was limited to a work setting pre-approved by the Board and which excluded solo practice.  His conduct and work should allow for formal and informal peer review.

State: Wisconsin


Date: December 2013


Specialty: Emergency Medicine, Endocrinology, Family Medicine, Internal Medicine, Pediatrics


Symptom: Nausea Or Vomiting, Urinary Problems


Diagnosis: Diabetes


Medical Error: Delay in proper treatment


Significant Outcome: Death


Case Rating: 4


Link to Original Case File: Download PDF



California – Obstetrics – Noncompliant Patient With Poorly Controlled Diabetes At 30-Weeks Gestation



On 6/15/2010, a 26-year-old patient, gravida 2, para 1, and at 30-weeks gestation, presented to an obstetrician’s medical office for prenatal care.  She was an insulin dependent diabetic. Her estimated date of delivery was 8/22/2010. A single one-hour glucose test yielded a result of 326.

During the first few months of pregnancy, the patient was treated with another physician.  She was placed on insulin isophane and regular insulin. A 4-month log demonstrated poor control.  The patient’s hemoglobin A1c (HbA1C) was 8.3. Medical notes from the patient’s previous physician demonstrated that she was noncompliant with medical advice.  Ultrasounds taken at 7 weeks and 5 days and 19 weeks and 2 days were normal.

The obstetrician prepared progress notes for visits on 6/28/2010, 7/8/2010, 7/15/2010, and 7/26/2010.  On 7/26/2010, the patient’s blood pressure was noted to be 126/90 with positive albumin. Despite being a high-risk diabetic patient, the obstetrician’s charts for the patient failed to include any referrals to other physicians, blood sugar values, HBA1c reports, perinatal consultations, and ultrasounds to monitor fetal growth and placenta maturity except for the mobile ultrasound of 8/16/2010, which revealed an intrauterine fetal demise with the size of 30 weeks (39 weeks by date).  There were notations of non-compliance several times in the records. Yet the records failed to include notations relating to serial nonstress tests, amniotic fluid indices, or serial fetal growth ultrasounds. Further, the obstetrician failed to note any TORCH studies or any workup for the cause of the intrauterine fetal demise (IUFD) in the patient’s medical records. At the time of admission to the hospital, the patient had a blood pressure of 153/110 and received a Cytotec/Pitocin induction. The toxicology panel was normal. The patient had a normal vaginal delivery of a stillborn fetus, but she did have a retained placenta and dilation and curettage.

The obstetrician was negligent in the care and treatment of the patient when he failed to prevent an IUFD with better prenatal care from the time he saw her until the time she delivered and also when he failed to evaluate the cause of the IUFD.

For this allegation and others, the Medical Board of California ordered that the obstetrician be placed on probation for one year, attend an education course, and be assigned a practice monitor.

State: California


Date: October 2013


Specialty: Obstetrics


Symptom: N/A


Diagnosis: Diabetes, Obstetrical Complication


Medical Error: Failure to order appropriate diagnostic test, Referral failure to hospital or specialist, Failure to properly monitor patient, Lack of proper documentation


Significant Outcome: Death


Case Rating: 2


Link to Original Case File: Download PDF



California – Obstetrics -A Patient At 16-Weeks Gestation With Diabetes And A Previous History Of Syphilis And Amphetamine Use



On 3/16/2010, a 37-year-old patient, gravida 9, para 2, ectopic 1 with a history of Cesarean section performed in Mexico in 2006, and at 16-weeks gestation, presented to an obstetrician’s office for prenatal care.  She was an insulin dependent diabetic but was stated to have been in good glycemic control. Her ultrasound taken on 4/6/2010, at 19-weeks gestation, was normal. The patient had a positive quad screen for Down’s Syndrome but refused amniocentesis.  A fetal nonstress test performed on 8/13/2010 was within normal range. Her estimated date of delivery was 8/27/2010. The patient was scheduled for a repeat Cesarean section on 8/19/2010.

The patient had tested positive for amphetamines, had a positive rapid plasma reagin, and had been treated for syphilis.  She stopped amphetamine use at 3-months gestation. Despite being a high-risk patient, the obstetrician failed to refer the patient or suggest a consultation with a perinatologist.  Also, he failed to perform bi-weekly nonstress tests and weekly amniotic fluid indices and biophysical profile testing.

On 8/19/2010, the patient presented to the medical center for a repeat Cesarean section, and an ultrasound revealed an intrauterine fetal demise.  The patient proceeded to undergo the Cesarean section. At the time of surgery, no nuchal cord was noted. The baby was in breech position with an anterior placenta.  The placenta was sent to pathology and was normal. There was neither any mention of the amniotic fluid at the time of the Cesarean section nor was there any description of meconium.  No studies were performed at the hospital to determine the cause of demise.

The obstetrician was negligent in the care and treatment of the patient when he failed to prevent an IUFD with better prenatal care and when he failed to schedule a Cesarean section earlier than 39 weeks gestation.

For this allegation and others, the Medical Board of California ordered that the obstetrician be placed on probation for one year, attend an education course, and be assigned a practice monitor.

State: California


Date: October 2013


Specialty: Obstetrics


Symptom: N/A


Diagnosis: Obstetrical Complication, Diabetes


Medical Error: Failure to order appropriate diagnostic test, Referral failure to hospital or specialist, Failure to properly monitor patient, Delay in proper treatment, Lack of proper documentation


Significant Outcome: Death


Case Rating: 1


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Wisconsin – Family Medicine – Sinus Pain And Tachycardia With Patient Seeing Her 6th Health Care Provider



On 01/31/2010, a 38-year-old woman presented to a family practitioner with persistent sinusitis after a 2 week course of Augmentin.  She had no improvement.  Vitals revealed a blood pressure of 180/100, heart rate 135, and temperature of 98.9.  There was no documentation of a respiratory rate.  The family practitioner was the 6th health care provider the patient had seen in the prior 7 days.  The family practitioner documented “Extraocular motions were intact without pain.  Conjunctiva are clear.  Tympanic membranes are clear.  She has some erythema and swelling below the right eye and maybe some mild tenderness in that area.  There is no crepitation or fluctuance.  Nasal mucosa appears normal.  Oropharynx appears normal.  Neck: supple.  There is no adenopathy.  Lungs: clear.”  Moxifloxacin, prednisone, and hydrocodone 5 mg/acetaminophen 500 mg were prescribed.  There was no comment documented regarding the abnormal vital signs.

While under investigation, the family practitioner testified that he offered hospitalization, ENT consult, and CT scan.  He reported that the patient had declined these options and preferred outpatient management.  There is no documentation of this discussion.

Less than 50 minutes after the visit, the patient presented to the emergency department of a nearby community hospital.  Vitals revealed a blood pressure of 150/105, heart rate of 76, temperature of 97.5, and a respirator rate of 26-28.

The nurse practitioner documented: “oropharyngeal inspection revealing what appears to be findings consistent with ANUG [acute necrotizing ulcerative gingivitis].  She has necrotic-appearing tissue as well as some punched out lesions along the buccal gingiva and the papillae are necrotic in appearance…respirations are deep and certainly suggesting the possibility of a Kussmaul’s type respiration pattern.”  Bicarbonate was 6.  Glucose was 592.  She was diagnosed with diabetic ketoacidosis and acute necrotizing ulcerative gingivostomatitis.  She was flown to a tertiary care hospital and treated in the intensive care unit where she recovered.

The Board reprimanded the family practitioner for conduct considered below the minimum standard of care.

State: Wisconsin


Date: February 2013


Specialty: Family Medicine, Emergency Medicine, Endocrinology, Internal Medicine


Symptom: Pain


Diagnosis: Diabetes


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


Significant Outcome: Hospital Bounce Back


Case Rating: 3


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California – Family Medicine – Failure To Timely Diagnosis Patient With Diabetes, Hypertension, Weight Loss, Back Pain, Anemia, And Leg Weakness



A 51-year-old male was seeing a family practitioner of several years regularly for his medical care.  In August 2007, the patient was seen by Family Practitioner A for multiple complaints which included low back pain, left groin pain, chest tightness, abdominal distention, and for Type 2 diabetes mellitus.  The patient weighed 316-318 pounds. His blood pressure was between 132/90-156/70 and his HgA1c was 8.0%.

On 8/31/2007, Family Practitioner A ordered a CT scan of the patient’s chest and abdomen, which was completed on 9/11/2007.  The CT scan report indicated essentially a normal abdomen and pelvis, however, with regard to the CT scan of the chest it stated, “Subcarinal mass measuring 3 cm in the widest diameter versus gastroesophageal hernia. (Difficult to distinguish between the two).”

The patient was last seen by Family Practitioner A on 9/21/2007 for complaints of tenderness in the upper chest area.  On that date, he weighed 316 pounds and his blood pressure was 132/89. The family practitioner’s assessment was anterior chest wall pain, musculoskeletal, and prescribed Toradol for pain.  On 9/24/2007, the patient was seen by a cardiologist for his chest pain, which was determined to be atypical and not consistent with angina pectoris. The patient decided to change his family practitioner.

On 11/2/2007, the patient was seen for the first time by a new family practitioner, for complaints of left leg weakness and pain and occasional back pain.  He weighed 313 pounds and his blood pressure was 144/100. Family Practitioner B’s assessment was spondylolisthesis with radiculopathy and diabetes mellitus type 2, and his plan for the patient was an MRI of the lumbar spine.  Family Practitioner B did not document that he addressed the management of the patient’s diabetes or elevated blood pressure. Family Practitioner 2 made a request for the patient’s medical records from the previous family practitioner, and the medical records were sent to the family practitioner on that same day.

On 12/1/200, the patient underwent an MRI of his lumbar spine  The MRI report noted,”relatively low signal intensity of the bone marrow of the spine, on both T1 and T2 weighted images.  The significance of this is unclear. This may simply represent a preponderance of red/cellular marrow. However, infiltrating processes cannot be excluded.  Correlation with other clinical data suggested.” This report was initialed by Family Practitioner 2 on 12/27/2007.

On 12/5/2007, the patient was seen by Family Practitioner B for review of his medications.  He weighed 303 pounds and his blood pressure was 144/86. No medications were listed in the Family Practitioner B’s notes for this visit.  Under History of Present Illness (HPI), Family Practitioner 2 noted that the patient had an MRI and that there was a possible hemolytic/bone marrow process. Family Practitioner B’s assessment was pain in the legs and back and diabetes mellitus  Family Practitioner 2 did not document that he addressed the management of the patient’s diabetes, his elevated blood pressure, or his 10 pounds weight loss from baseline. Laboratory tests were ordered and the patient was referred for an orthopedic consultation.

The laboratory tests were completed on 12/14/2007.  The tests showed a high white blood cell count (WBC) of 11.8, low hemoglobin (Hgb) of 12.6 gm/dl, and an elevated HgbA1c of 9.5%.  On 12/24/2007, the patient was seen by Family Practitioner B for his medication check and for complaints of poor bladder control. He weighed 299 pounds and his blood pressure was 130/80.  Family Practitioner B noted under HPI that the patient’s HgbA1c was 9.5%, that he had been seen by an orthopedist, and that he had been referred to a neurologist. Family Practitioner B also noted that the patient was on Vicodin and fentanyl patches for pain management, and his plan was to give the patient lisinopril and Mevacor.  Family Practitioner B did not address the management of the patient’s elevated blood pressure and diabetes, or his weight loss of 14 pounds from baseline.

On 1/9/2008, the patient was seen in consultation by a neurosurgeon who recommended an MRI of the thoracic spine to rule out thoracic herniated disc.  On 1/24/2008, the patient was seen by Family Practitioner B for a follow-up on his diabetes. He weighed 294.4 pounds and his blood pressure was 130/80.  Family Practitioner B noted under HPI the patient’s weight loss of 18 pounds and that his blood sugar was being maintained at 120-140. Family Practitioner B’s assessment was diabetes mellitus, elevated cholesterol, and back pain.  His recommendation was for the patient to have a thoracic MRI. Family Practitioner B did not document that he addressed the plan of action for the patient’s diabetes, mild anemia, or his weight loss of 18 pounds from baseline. During his interview with the Medical Board’s investigator, Family Practitioner B stated that it was at this office visit that he was concerned about the patient having cancer, however, Family Practitioner B did not document in his notes that he was concerned about cancer.

On 3/18/2008, the patient was seen by Family Practitioner B for complaints of itching in the face, body aches, and chest tightness.  He weighed 289 pounds and his blood pressure was 120/80. Family Practitioner B noted normal heart, lungs, and his assessment was diabetes, elevated cholesterol, and anxiety.  Family Practitioner B’s plan was to give the patient Zoloft and to increase the “patch” dosage. Family Practitioner B did not document that he addressed the patient’s continued weight loss or that his patient had not undergone an MRI of the thoracic spine.

On 3/26/2008, the patient was seen by Family Practitioner B for complaints of dizziness, nausea, and lightheadedness.  He weighed 285.4 and his blood pressure was 104/60. Family Practitioner 2’ assessment was “adjust medication.” Family Practitioner 2Bdid not document that he addressed the patient’s continued weight loss or that the patient had not yet undergone an MRI of the thoracic spine.

On 4/19/2008, the patient underwent an MRI of the thoracic spine.  The MRI noted, “The possibility of a hematologic or marrow infiltrative disorder should be excluded.  Additionally, consider nuclear medicine bone scan to evaluate for the presence of hypermetabolic bone activity.”

On 5/9/2008, the patient was seen by Family Practitioner B for follow up on his medication and the MRI results.  He weighed 286 pounds and his blood pressure was 130/70. Family Practitioner B noted under his HPI that the patient needed a bone scan and that the patient was complaining of night sweats and fatigue.  Family Practitioner B’s assessment was diabetes mellitus, elevated cholesterol, and back pain. Family Practitioner B’s plan included a complete blood count (CBC) and bone scan to rule out bone marrow problems.

On 5/13/2008, the patient underwent a bone scan.  The bone scan report noted, “Trace uptake within the thoracolumbar spine is suggestive of degenerative changes; prominence of tracer uptake in the head of the humeri as well as in the sternum.  Findings could represent a normal variant; however, malignancy cannot be completely excluded. Correlation with MRI will be helpful for further evaluation (shoulders).” The patient’s laboratory test results showed low hemoglobin of 11.6 gm/dL and a low hematocrit of 35.2%.  Family Practitioner B circled the hemoglobin and hematocrit values on the laboratory report and wrote “mild anemia.”

On 5/19/2008, the patient was seen by Family Practitioner B for a follow-up on the bone scan and laboratory results.  He weighed 284 pounds and his blood pressure was 140/90. Medications listed were Soma, Vicodin, Janumet, fentanyl, and Zoloft.  Family Practitioner B’s assessment was diabetes mellitus, elevated cholesterol, and back pain. Family Practitioner B’s plan was an MRI of the patient’s bilateral shoulders and referral of the patient to an oncologist.  Family Practitioner B did not address the patient’s elevated blood pressure, mild anemia, or the weight loss of 29 pounds from baseline.

On 5/20/2008, the patient called Family Practitioner 2 asking if he could take iron supplements because, according to the patient, his blood test showed that he was anemic.  Family Practitioner B responded that it would not hurt to take iron supplements and that the patient needed a blood test. On 6/4/2008, the patient had his blood test which showed that his blood iron was low.  On 6/20/2008, the patient was seen in consultation by an oncologist, for symptoms of weight loss, anemia, and general fatigue. The oncologist noted that the patient seemed to have a left axillary lymph node approximately 4-5 cm in size and also a left supraclavicular lymph node approximately 1 cm in size.  According to the oncologist, these findings combined with the weight loss and anemia were suggestive of a possible lymphoma, and he recommended that the patient undergo a biopsy of the left axillary mass as well as a bone marrow aspiration biopsy. He also recommended a repeat CT scan of the chest, abdomen, and pelvis to see if other areas of adenopathy existed.

On 6/23/2008, the patient underwent a bone marrow biopsy which showed no specific diagnostic abnormalities.  The patient was also seen by a surgeon in consultation for a biopsy of the left supraclavicular adenopathy. On 6/27/2008, the patient underwent a left supraclavicular lymph node biopsy, which confirmed the diagnosis of Hodgkin’s disease.  The patient subsequently underwent months of chemotherapy under the care of the oncologist.

On 8/26/2008, the patient was seen by Family Practitioner B for infection in the right arm.  Family Practitioner B’s assessment was lymphoma, diabetes mellitus, and elevated cholesterol.  Family Practitioner B’s plan included Janumet twice a day and Bactrim DS.

The patient was also seen by Family Practitioner B on 5/22/2009 for complaints of hot flashes due to morphine and was referred to an addiction specialist, and also on 6/22/2009, for complaints of moderate shoulder and chest pain.  Family Practitioner B did not address the management of the patient’s diabetes at these visits.

Family Practitioner B committed gross negligence in his care and treatment plan of the patient which included the following: he failed to properly evaluate and timely diagnose the patient’s lymphoma despite progression in the patient’s signs and symptoms; failed to appropriately manage the patient’s diabetes; failed to appropriately manage the patient’s hypertension;  and failed to note the CT results with the subcarinal mass.

The Medical Board Of California ordered that Family Practitioner B be reprimanded, complete a clinical training or educational program equivalent to the Physician Assessment and Clinical Education Program (PACE), and complete a medical record keeping course.

State: California


Date: December 2012


Specialty: Family Medicine, Internal Medicine


Symptom: Chest Pain, Dizziness, Nausea Or Vomiting, Back Pain, Extremity Pain, Pelvic/Groin Pain, Urinary Problems, Weight Loss


Diagnosis: Cancer, Diabetes, Infectious Disease


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


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



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