Found 36 Results Sorted by Case Date
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Washington – Internal Medicine – Proper Monitoring Of Thyroid Dysfunction And High Blood Pressure



Beginning in June 2014, a physician began treating Patients A and B for thyroid dysfunction and Patient C for high blood pressure. The physician communicated with Patient A and B through phone consultation and met Patient C in social situations and during at least two office visits. The physician reviewed previous lab work on thyroid functions for Patients A and B. The physician based Patient C’s treatment upon his physical observation of her conditions, two Zytoscans (device that measures electrical currents in the skin), and taking her blood pressure. Patient A and B’s lab work indicated both patients having lower than normal thyroid function. The physician started both Patients A and B on a thyroid hormone supplement. He prescribed medication commonly used for treating high blood pressure for Patient C based upon his observations, oral reports of Patient C, and the Zytoscans. The physician failed to do lab work, took minimal chart notes, and did not schedule follow-up examinations for Patients A, B, or C.

For several months, the physician continued prescribing for Patients A, B, and C without ever seeing the patients in person for further work up. The physician’s interactions with Patients A and B were solely over the phone, while the physician notes state that he had two office visits with Patient C. The physician did not order thyroid stimulating hormone (TSH) testing to further verify if continuing the thyroid hormone supplement would be appropriate in managing Patient A and B’s conditions.

In June 2015, Patient A presented to another provider with concerns of heart palpitations. Patient A told the provider he noticed the palpitations reduced when he reduced his thyroid hormone supplement dosage. During this consultation, Patient A disclosed his treatment with the physician which alerted the provider to have Patient A’s TSH levels checked. Patient A’s lower than normal TSH result prompted the provider to immediately begin weaning Patient A off of his thyroid hormone supplement.

Patient B also presented to the same provider in June 2015. At her visit, Patient B presented with a rash on her chest which she had for over a month. The new provider assessed the rash being unrelated to her treatment with the physician; however, due to her receiving similar treatment as Patient A, the provider had Patient B’s TSH level tested. Patient B’s results indicated her TSH level was below the normal range.

On 8/26/2015, the physician saw Patient C for what he thought was a urinary tract infection. The physician first prescribed Keflex but changed it to ciprofloxacin based upon the results of a Zytoscan. Caution is required when giving ciprofloxacin to patients with hypokalemia.

On or about 9/9/2015, Patient C presented to the hospital emergency department where she was diagnosed with significant hypokalemia (lowered levels of potassium in the blood) and hyponatremia (lowered levels of sodium in the blood) which caused Patient C to suffer fatigue and heart palpitations. Patient C went immediately from the emergency department to a new care provider. After an oral interview with Patient C, the new care provider learned that Patient C was taking a number of medications prescribed by the physician. The new care provider attempted to contact the physician a number of times to obtain the physician’s chart notes, lab studies, and other medical records for Patient C but was unsuccessful. Patient C told her new care provider that the physician had been giving her medications for a number of years. She stated, “I tell him what I need.” In the physician’s response to the Commission, he stated that “if [Patient C] called me to have a prescription filled, I would do that for her.”

The Commission stipulated the physician reimburse costs to the Commission and write and submit a paper of at least 2000 words, with references and annotated bibliography, regarding Washington State rules for physicians forming and maintaining patient/physician relationships, the differential diagnosis of hyperthyroidism and hypothyroidism, the proper monitoring of electrolyte levels for patients with high blood pressure, and the importance of complying with Commission sanctions.

State: Washington


Date: November 2017


Specialty: Internal Medicine, Family Medicine


Symptom: Palpitations, Rash


Diagnosis: Endocrine Disease


Medical Error: Failure to follow up, Failure to properly monitor patient, Improper medication management


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



Florida – Emergency Medicine – A Patient With Diabetes Presents With Hyperglycemia, Nausea, Vomiting, And A Bicarbonate Level



On 4/28/2015, a 69-year-old female presented to the emergency department with complaints of nausea and vomiting, which had persisted for two to three days.

The patient reported that members of her family had recently experienced similar symptoms.

The patient presented with a history of diabetes and high blood pressure.

An ED physician ordered a general chemistry lab.  The patient’s lab work revealed a high blood glucose level of 383 with a reference range of 65-99.  The patient’s lab work also showed that her bicarbonate level was low at 15 with a reference range of 21-32.  The low bicarbonate level indicated possible acidosis.

The ED physician treated the patient with insulin and antinausea medications and discharged her.  The ED physician did not further investigate the patient’s low bicarbonate level.  The ED physician did not assess the patient for diabetic ketoacidosis.

On 4/29/2015, the patient returned to the emergency department with recurrent nausea, vomiting, and worsening shortness of breath.

The patient was diagnosed with diabetic ketoacidosis and severe sepsis.

The patient’s condition deteriorated and she expired in the hospital on 5/4/2015.

The Board judged the ED physician’s conduct to be below the minimal standard of competence given that he failed to further investigate a low bicarbonate level by ordering additional laboratory studies such as a serum ketone, serum beta-hydroxybutyrate, or serum pH.

It was requested that the Board order one or more of the following penalties for the ED physician: 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 Board deemed appropriate.

State: Florida


Date: October 2017


Specialty: Emergency Medicine


Symptom: Nausea Or Vomiting, Shortness of Breath


Diagnosis: Diabetes, Sepsis


Medical Error: Failure to order appropriate diagnostic test


Significant Outcome: Death


Case Rating: 4


Link to Original Case File: Download PDF



Florida – Internal Medicine – Daily Dose Of 1200 Milligrams Of Gabapentin For Patient With End Stage Renal Disease



On 5/8/2014, a 74-year-old female presented to an internist for the purpose of establishing care.  The patient had multiple medical problems, including diabetes, end-stage renal disease, and recurrent C. difficile infections.

At all times pertinent to this complaint, the patient was undergoing chronic hemodialysis treatment.

On 6/10/2014, the patient presented to the internist for a follow-up visit.  The internist prescribed 600 mg tablets of gabapentin to the patient to treat her diabetic neuropathy.  The patient’s prescription directed her to take the 600 mg of gabapentin twice daily, totalling 1200 mg of gabapentin per day.

On 6/14/2014, after taking her prescribed dosage of gabapentin, the patient lost control of her leg muscles and fell, resulting in a fracture of the T12 vertebrae in her back.

The prevailing professional standard of care required the internist to prescribe the patient a dosage of gabapentin not to exceed 150 mg per day, due to her end-stage renal disease.  The internist prescribed the patient an inappropriate and/or excessive dosage of gabapentin.

According to the internist, he verbally instructed the patient and/or her family members to modify the gabapentin prescription.

The internist failed to document and/or accurately document the alleged verbal instruction to the patient and/or her family members to modify the patient’s gabapentin prescription.

The Board issued a letter of concern against the internist’s license.  The Board ordered that the internist pay a fine of $5,000 against his license and pay reimbursement costs for the case at a minimum of $30,433.57 and not to exceed $32,433.57.  The Board also ordered that the internist complete a medical records course and complete five hours of continuing medical education in clinical pharmacology and drug dosing.

State: Florida


Date: June 2017


Specialty: Internal Medicine, Nephrology


Symptom: Weakness/Fatigue


Diagnosis: Drug Overdose, Side Effects, or Withdrawal, Diabetes, Neurological Disease, Spinal Injury Or Disorder, Renal Disease, Fracture(s)


Medical Error: Improper medication management, Accidental Medication Error, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



Florida – Pain Management – Increase In Dosage Of Nature-Throid In A Patient With Normal TSH And T4 Levels



On 6/3/2013, a 67-year-old female presented to a pain management specialist for treatment of her previously diagnosed hypothyroidism.  The pain management specialist prescribed the patient 65 mg of Nature-Throid daily and drew blood for lab tests.  Each 65 mg Nature-Throid medication consists of 38 mcg of levothyroxine and 9 mcg of liothyronine.  The results of the patient’s blood tests showed normal TSH levels, normal T4 levels, and slightly elevated T3 levels.

On 6/18/2013, the pain management specialist increased the patient’s prescription for Nature-Throid to 130 mg daily.  The results of the patient’s blood tests did not justify increasing the dosage of Nature-Throid prescribed to the patient.  A reasonably prudent physician would only have increased the dosage of Nature-Throid prescribed to the patient with justification.  The pain management specialist did not document justification for increasing the dosage of Nature-Throid prescribed to the patient.  The blood tests did not justify prescribing the 130 mg of Nature-Throid daily.  A reasonably prudent physician would have waited for the patient’s hormone levels to properly balance and reach equilibrium before altering the dosage of Nature-Throid prescribed to the patient.

On 7/16/2013, the pain management specialist increased the patient’s prescription for Nature-Throid to 195 mg daily.  A reasonably prudent physician would not have altered the dosage of Nature-Throid prescribed to the patient without having ordered blood tests for the patient.  The pain management specialist did not document justification for increasing the dosage of Nature-Throid prescribed to the patient.  A reasonably prudent physician would have waited for the patient’s hormone levels to properly balance and reach equilibrium before altering the dosage of Nature-Throid prescribed to the patient.

On 7/16/2013, the pain management specialist informed the patient that he was increasing her dosage of Nature-Throid based on her body temperature.  A reasonably prudent physician would not have increased the dosage of Nature-Throid prescribed to the patient based on the patient’s body temperature.  Also, a reasonably prudent physician would have ordered blood tests for the patient, and he did not order or document ordering any blood tests for the patient.

The Board issued a letter of concern against the pain management specialist’s license.  The Board ordered that he pay a fine of $5,000 against his license and pay reimbursement costs for a minimum of $5,857.09 and not to exceed $7,857.09.  The Board also ordered that he complete a records course and complete ten hours of continuing medical education in endocrinology and complete a course in quality assurance consultation/risk management assessment.

State: Florida


Date: June 2017


Specialty: Pain Management, Endocrinology


Symptom: N/A


Diagnosis: Endocrine Disease


Medical Error: Improper medication management


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



Florida – Internal Medicine – Failure To Order Appropriate Diagnostic Testing For A Patient With Migraine Headaches And Suspicion For Adrenal Insufficiency



On 1/24/2014, a patient presented to an internist with symptoms of intractable migraine headaches.  The internist proceeded to test cortisol levels in the patient.

The Board judged the internists conduct to be below the minimal standard of competence given that he failed to use the proper lab data for diagnosing Addison’s disease or any related conditions, treat the patient with a standard dosage treatment of prednisone to start with, and utilize a taper of the prednisone dosage within a few days of starting.

It was requested that the Board order one or more of the following penalties for the internist: 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 Board deemed appropriate.

State: Florida


Date: June 2017


Specialty: Internal Medicine, Endocrinology


Symptom: Headache


Diagnosis: Endocrine Disease


Medical Error: Failure to order appropriate diagnostic test, Improper medication management


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



Florida – Emergency Medicine – Pelvic Pain And Vaginal Bleeding With Urinalysis Revealing A Glucose Level >1000



On 8/21/2014, a patient presented with complaints of pelvic pain and vaginal bleeding.  The patient was examined by a physician assistant supervised by an ED physician.

The physician assistant ordered laboratory evaluation for the patient, which included bloodwork, cervical/vaginal swabs, pelvic ultrasound, and urinalysis.

The urinalysis revealed the patient’s glucose level to be >1000, which was so high that it could not be measured.

The physician assistant gave the patient a prescription for Flagyl, an antibiotic, gave her education materials on uterine bleeding, bacterial vaginosis, dehydration, and ovarian cysts, and instructed her to follow up with her primary care physician and gynecologist.   The physician assistant discussed the patient’s case with the ED physician and the ED physician agreed with the plan of care.

The ED physician did not perform or order a finger stick glucose test or a basic metabolic panel.

The ED physician did not discuss and/or did not order the physician assistant to discuss the patient’s glucose level in relation to her possible new onset of diabetes and did not recommend or order the physician assistant to recommend further evaluation and treatment of her elevated glucose levels.

The ED physician did not administer or order the administration of intravenous fluid and insulin.

On 8/26/2014, the patient expired due to diabetic ketoacidosis.

The Medical Board of Florida judged the ED physician’s conduct to be below the minimal standard of competence give that she failed to administer or order the administration of a finger stick glucose test or basic metabolic panel, discuss or instruct the physician assistant to discuss the patient’s glucose levels in relation to her possible new onset of diabetes and recommend further evaluation and/or treatment of her elevated glucose levels, and failed to administer or order the administration of intravenous fluid and insulin.

It was requested that the Medical Board of Florida order one or more of the following penalties for the ED physician: permanent revocation or suspension of her 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: April 2017


Specialty: Emergency Medicine, Endocrinology, Physician Assistant


Symptom: Pelvic/Groin Pain, Abnormal Vaginal Bleeding


Diagnosis: Diabetes


Medical Error: Failure to follow up, Failure to order appropriate diagnostic test, Failure of communication with other providers, Improper supervision, Improper medication management


Significant Outcome: Death


Case Rating: 4


Link to Original Case File: Download PDF



Florida – Pediatrics – Infant At 3 Percentile For Weight And 10 Percentile For Height One Year After Birth



A pediatrician began treating a newborn girl who was born on 1/2/2012.

On 1/18/2012, the patient was at the 30 percentile for weight and 10 percentile for height.  On 2/3/2012, the patient was at the 50 percentile for weight and 30 percentile for height.  On 3/2/2012, the patient was at the 60 percentile for weight and 25 percentile for height.  On 5/2/2012, the patient was at the 55 percentile for weight and 60 percentile for height.  On 7/2/2012, the patient was at the 45 percentile for weight and 45 percentile for height.

The pediatrician’s notes for that visit indicated that the patient should start taking vitamin D.

On 10/8/2012, the patient was at the 5 percentile for weight and 20 percentile for height.  The pediatrician’s notes for that visit indicated the patient was nursing three to four times per day.

On 1/8/2013, the patient was at the 3 percentile for weight and 10 percentile for height.  The pediatrician’s notes indicated a complete blood count would be done, but there were no indications of results.

The pediatrician never referred the patient for an endocrine evaluation.

The patient was admitted to a hospital on 3/3/2013. The patient was finally referred to another physician and diagnosed on 5/4/2012 with rickets secondary to a severe vitamin D deficiency.

The Medical Board of Florida judged the pediatrician’s conduct to be below the minimal standard of competence given that he failed to refer the patient for an endocrine evaluation when the growth curve started to drop drastically in July 2012 or thereafter.

It was requested that the Medical Board of Florida order one or more of the following penalties for the pediatrician: 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: January 2017


Specialty: Pediatrics


Symptom: N/A


Diagnosis: Endocrine Disease


Medical Error: Referral failure to hospital or specialist


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



California – Family Practice – Four Years Of Recurrent Perimenopausal Vaginal Bleeding



Since 2008, a 46-year-old-female began seeing a family practitioner as a patient.  Due to the patient’s agoraphobia, the family practitioner made house calls.  The family practitioner saw the patient several times a year on a cash basis.

The patient began experiencing recurrent episodes of vaginal bleeding and was told by the family practitioner that it was likely perimenopausal.  No further testing was performed or suggested other than a complete blood count (CBC) test.  The patient’s vaginal bleeding was known to the family practitioner as early as 2008.  In his 9/27/2008 medical record, all that was noted in regards to the bleeding was a “change in periods.”  There was no detail about the amount of bleeding and no recommendation for a gynecological evaluation.  A thyroid stimulating hormone (TSH) test was ordered, and the family practitioner diagnosed the patient with menometrorrhagia.  The family practitioner saw the patient two months later, but there was no follow-up on the bleeding and no reference to the labs that were ordered in September.

On 1/27/2009, the family practitioner noted irregular menses in his medical record.  There were no characteristics noted for the bleeding.  In his plan, he ordered thyroid testing again, a female hormonal panel, and neurotransmitter testing, but did not document whether the labs ordered months ago were completed.

On 3/21/2009, the family practitioner diagnosed the patient with piriformis syndrome, but there was no history and no pertinent exam recorded.

On 5/30/2009, the family practitioner placed the patient on iron pills for her anemia.  The family practitioner also noted that the patient’s hypothyroidism was “overcorrected.”  He increased her thyroid medication to 250 mcg and noted to check her labs in three months.  At this point, the TSH was 0.01.  There was a span of two years before the TSH was checked again.  The patient’s TSH never normalized while under the care of the family practitioner.

In February 2010, the patient had increased bleeding, which the family practitioner indicated was secondary to stress.  On 7/23/2010, the family practitioner diagnosed the patient with microcytic anemia, but did not do a rectal exam, and with digestive candidiasis, but did not include a basis for his diagnosis in the history of present illness or in his exam.  The patient’s hemoglobin dropped dramatically in November 2010 as compared to her previous visit in July and all that was recommended was more iron.  Although the family practitioner claimed he advised the patient to see a gynecologist, there was no documentation indicating that a gynecological referral was considered.

On 1/24/2011, the family practitioner noted that the patient was pale and ordered a repeat CBC.

On 10/10/2011, the family practitioner noted that the patient had seen a gynecologist and a PAP smear and ultrasound were planned.  However, at the next visit on 11/21/2011, the family practitioner did not follow up on whether the patient had gone back to see the gynecologist and was now charting that the patient had a fibroid uterus.  The patient did not go back to see the gynecologist.

On 3/4/2012, the family practitioner did not see the patient, but wrote in a chart entry that the patient was anemic, hypotensive, and was in need of a blood transfusion.  One week later, there was a message from the patient that she was still anemic and had been to the emergency department.  There was no plan to see the patient as documented by the family practitioner after the emergency department visit.

The family practitioner saw the patient for the last time on 4/5/2012 noting that the patient received a blood transfusion at a hospital and that the patient had plans to see a gynecologist for a possible ablation.

On 4/17/2012, the patient presented to a gynecologist for a PAP smear and biopsy.  However, the procedure could not be done due to significant vaginal bleeding.  The gynecologist suspected cervical cancer.

One month later, it was confirmed that the patient had uterine cancer.

The Board judged the family practitioner’s conduct as having fallen below the minimum level of competence given failure to sufficiently evaluate perimenopausal bleeding, mismanagement of hypothyroidism, and failure to sufficiently maintain a legible record of care for the patient.

The family practitioner was placed on probation for three years with stipulations to complete 40 hours annually of continuing medical education in any areas of deficient practice for each year of probation and complete a medical record keeping course.

State: California


Date: January 2017


Specialty: Family Medicine, Gynecology, Internal Medicine


Symptom: Bleeding


Diagnosis: Gynecological (Endometrial, Ovarian, Cervical) Cancer, Endocrine Disease


Medical Error: Diagnostic error, Referral failure to hospital or specialist, Failure to follow up, Failure to properly monitor patient, Improper medication management


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



California – Family Practice – Elevated Glucose Levels In A Patient On Aripiprazole, Asenapine, Quetiapine, And Olanzapine



On 11/6/2007, a family practitioner first began treating a patient and continued treating the patient until at least 6/9/2014.

On 12/21/2009, the family practitioner noted in the patient’s medical records that the patient was diabetic, writing “Lab-Spot glucose 242.”  A level of 200 mg/dL or higher often means one has diabetes.

On 1/11/2010, the next exam noted in the patient’s records, the family practitioner noted a refill was needed for glipizide.  However, there is no record that the patient was ever prescribed glipizide prior to this date.

During the course of treatment from the family practitioner, the patient was also prescribed aripiprazole, quetiapine, asenapine, and olanzapine for bipolar disorder.  Aripiprazole, asenapine, and olanzapine can cause or worsen diabetes.  According to medical notes, on 6/13/2011, the family practitioner was treating the patient with both aripiprazole and olanzapine as well as glipizide, which was to control diabetes.

On 7/11/2011, the patient’s blood sugars were noted to be in the 400 range, while 100 to 110 is considered to be the normal range for blood sugars in an individual.  The family practitioner started the patient on insulin glargine to address diabetes on a daily basis.

In an interview that occurred on 10/1/2015, the family practitioner admitted that the family practitioner had no idea if the patient was taking the prescribed medications while under his care.

The Board judged the family practitioner’s conduct as having fallen below the standard of care for multiple patients given failure to record a physical exam in the progress notes, failure to revise and update assessments or plans for those patients, and failure to include a problem list or medication list in his progress notes.  In addition, the family practitioner’s repeated, excessive and/or inappropriate prescribing of large doses of multiple strong antipsychotic medication and antidepressants to the patient with no regard or concern for drug interactions constituted a lack of knowledge and/or unprofessional conduct.

The family practitioner was placed on probation for 5 years with the stipulations of completing 40 hours annually of continuing medical education in the areas of deficient practice, a prescribing practices course at the Physician Assessment and Clinical Education Program, a medical record keeping course, an ethics course, a clinical training program equivalent to the Physician Assessment and Clinical Education Program, and undergo clinical practice monitoring.

State: California


Date: November 2016


Specialty: Family Medicine, Internal Medicine, Psychiatry


Symptom: N/A


Diagnosis: Diabetes, Psychiatric Disorder


Medical Error: Improper medication management, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



Washington – Endocrinology – Lack Of Communication Of Blood Test Results With Patient



On 7/16/2014, a patient saw an endocrinologist after being referred by her gynecologist for concerns about “not feeling well” and for questions about whether her hypothyroidism needed additional evaluation and management.

The patient described how the endocrinologist told her to throw out her other medications prescribed by her trusted long-term gynecologist, go on an antidepressant, and see a therapist.  This advice was upsetting to the patient.

At the close of the visit, the patient went to the laboratory and gave a blood sample for testing.  When the patient did not hear of the test results from the clinic after about 10 days, she contacted the clinic and was told that the results could not be found.

In a response to the complaint by the patient that she did not receive timely test results from the endocrinologist, the endocrinologist stated, through her lawyer, that the results were available through a patient electronic record portal called eCare.  However, the patient had not enrolled in eCare and thus did not have access to the test results.  The endocrinologist stated she planned to disclose and review the test results with the patient at a return visit in 3 months.  The patient eventually established care with another endocrinologist.

The endocrinologist’s treatment of the patient fell below the standard of care when the endocrinologist failed to timely communicate the test results which showed the patient’s Hemoglobin A1C was at 6.1%.  This test result is within a range that can be characterized as “prediabetes,” signifying that a patient may develop a diagnosis of diabetes within 10 years.  A diagnosis of diabetes requires a test result of 6.5% or higher.

The Commission stipulated the endocrinologist reimburse costs to the Commission, complete a course on how to maintain and improve communication between physician and patient, and write and submit a paper of at least 1000 words, with annotated bibliography, on the importance of timely communication of laboratory results to patients and others with a need to know.

State: Washington


Date: October 2016


Specialty: Endocrinology


Symptom: N/A


Diagnosis: Diabetes


Medical Error: Failure of communication with patient or patient relations


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



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