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From October 2005 to November 2006, a family practitioner treated a patient for symptomatic and severe hypertension. The patient had a history of poorly controlled blood pressure requiring multiple medications for treatment. The patient, an American Samoan and 46-year-old mother of six children, had a limited understanding of the English language. Additionally, she also had significant hearing loss caused by recurrent ear infections. During his treatment of the patient, the family practitioner failed to appreciate the significance of the patient’s cultural and physical barriers and the potential adverse effects these barriers had on her medical care. The family practitioner did not employ an interpreter during the patient’s office visits; rather, he relied on the patient’s family members to interpret and convey important medical information.
The family practitioner began treating the patient in October 2005, following the patient’s hospital emergency department (ED) visit two weeks prior where she sought treatment for headache and hypertension. The family practitioner described the patient as “deaf,” although he also noted in the patient’s records that she frequently answered her phone while in the exam room. During this office visit, the family practitioner recorded the patient’s blood pressure as 162/94. The patient’s CT test from the hospital indicated negative results, and the blood work that the family practitioner ordered indicated normal results. The family practitioner prescribed hypertension medication. There is no documentation regarding follow-up visits.
On 1/5/2006, the patient called the family practitioner’s office and reported headache, chest discomfort, stomach ache, and neck pain. The family practitioner’s nurse instructed the patient to immediately go to the hospital ED. The family practitioner’s records for the patient included only the report of two-view chest imaging and did not include the notes from the outpatient emergency record.
On 3/21/2006, the patient returned for an office visit with the family practitioner. The patient’s blood pressure was recorded as 192/106. Although the family practitioner noted an audiometric evaluation (to address hearing loss) and provided the patient a referral to an otolaryngologist, the family practitioner failed to document any discussion about the patient’s January visit to the hospital ED.
The family practitioner’s records for the patient indicated the patient had a hospital ED visit for 6/29/2006 and included a report of a non-contrast head CT performed at the hospital which was ordered to rule out a bleed. The family practitioner’s records did not include the notes from the outpatient emergency record.
The family practitioner examined the patient on 7/26/2006 when she presented with severe headaches, neck pain, and trouble sleeping. The family practitioner documented the patient had not been taking her medication. The patient’s blood pressure was recorded at 190/130. The family practitioner did not document a discussion about the patient’s hospital ED visit the month prior or the results of the patient’s head CT. The family practitioner noted that the patient had “poor compliance” taking her blood pressure medications, and counseled the patient about medication compliance. The patient’s husband was present during this exam and likely interpreted the family practitioner’s counsel. The family practitioner also recognized that medication expense was likely a factor in the patient’s non-compliance, so he prescribed a less expensive medication as well as provided the patient with free samples of hypertension drugs.
On 8/1/2006, the patient returned to see the family practitioner. The patient’s blood pressure was recorded as 210/110. The family practitioner noted that the patient was suffering from headaches caused by elevated blood pressure, that she was “not taking free BP pills,” and that she was “unreliable.” He directed her to return for a blood pressure check in three weeks, but there was no follow-up appointment scheduled. The patient did not return for the three-week follow-up with the family practitioner.
On 10/13/2006, the patient returned to see the family practitioner complaining of headache, vomiting, and neck pain. She had also missed work. The patient’s blood pressure was noted as 280/152. There was indication that the family practitioner considered having an interpreter present to communicate to the patient the significance of malignant hypertension. Instead of treating the patient’s hypertensive emergency, the family practitioner noted that the patient should follow-up in three days.
On 10/14/2006, the patient presented to the hospital’s ED with mental status change, vomiting, headache, and nausea. The patient was admitted and remained in the hospital for four days. The family practitioner noted that the patient’s “blood pressure came down throughout the hospital stay.” The ED physician requested an adrenal evaluation and diagnosed the patient with hyperaldosteronism. The patient had an appointment with a nephrologist scheduled to be seen a few weeks.
The day after the patient’s hospital discharge she returned to the family practitioner’s office for a follow-up. The patient’s documented blood pressure was 140/90. The patient’s blood pressure improved because of the treatment received during the four-day hospitalization to control her blood pressure. The family practitioner also noted that he counseled the patient, recommended she be off work for seven days, follow up with the nephrologist, and return to see the family practitioner for a blood pressure check in six days.
On 10/25/2006, the patient returned for the six day follow-up appointment with the family practitioner. The patient’s blood pressure reading showed an increase to 218/150. When repeated it was 220/150. The family practitioner’s plan included lab tests and instructions for the patient to return in two weeks.
On 11/8/2006, the patient returned to see the family practitioner for a follow-up. The family practitioner reviewed the patient’s lab results and noted the patient’s upcoming nephrology appointment to address her hyperaldosteronism. He recorded the patient’s blood pressure as 220/140, and 210/120 when repeated. The family practitioner also documented that the patient took her medications, but her elevated blood pressure was poorly controlled. The family practitioner increased the patient’s carvedilol medication dosage and asked her to return for a blood pressure check in one month.
On 11/10/2006, the patient’s family called the family practitioner’s office because the patient complained of intense headache, nausea, and vomiting. The family practitioner’s staff directed the family to immediately take the patient to the hospital. When the patient presented to the hospital ED, her recorded blood pressure was 240/140. Her diagnosis of hypertensive encephalopathy necessitated urgent treatment in the intensive care unit. Despite immediate medical response, the patient experienced respiratory arrest the next evening and she required intubation and mechanical ventilation. The patient suffered brain death and died on 11/12/2006. The cause of death is listed as hypertensive encephalopathy with cerebral edema resulting in respiratory and cardiac arrest.
The family practitioner did not take the additional steps necessary to assure that the patient understood the critical importance of her blood pressure medications, the importance of taking them as prescribed, and that she could easily die if she did not take the medications as prescribed.
The Commission stipulated that the family practitioner reimburse costs to the Commission, allow a representative of the Commission to make annual visits to his practice to review patient records, and write and submit a paper of at least 2000 words, with bibliography, on the management of malignant hypertension and the treatment of hypertensive emergencies.
Date: January 2016
Diagnosis: Hypertensive Emergency
Medical Error: Failure of communication with patient or patient relations
Significant Outcome: Death
Case Rating: 5
Link to Original Case File: Download PDF
Virginia – Cardiology – Nitroprusside And Furosemide For Shortness Of Breath, Tachycardia, Diaphoresis, Hypertension, And 5-7 mm Of ST Elevation
On 10/16/2012, a 51-year-old male presented to the emergency department with shortness of breath, tachycardia, diaphoresis, a blood pressure of 240/193, and a pulse of 151. The patient denied chest pain on admission, but he had experienced brief chest pain when his shortness of breath began, and his EKG showed 5-7 mm of ST elevation in the precordial leads.
Cardiologist A treated the patient with nitroprusside and furosemide that evening and admitted the patient to the intensive care unit. Over the next several hours, the Cardiologist A neither re-examined the patient nor re-evaluated him for cardiac catheterization. The following morning, the patient’s troponin was 185.66 versus 0.87 the prior evening. He underwent emergency stenting of his left anterior descending artery by Cardiologist B.
Cardiologist A testified that he believed the patient’s hypertension, pulmonary edema, and inability to lie flat for the procedure increased the risk of performing cardiac catheterization and angioplasty. He stated that the patient had not met criteria for emergency catheterization given that the patient had not experienced 30 minutes of constant chest pain.
The Board issued a reprimand.
Date: October 2015
Symptom: Shortness of Breath
Significant Outcome: N/A
Case Rating: 2
Link to Original Case File: Download PDF
On 1/10/2012, a teenage male presented to the emergency department after being referred for a psychiatric referral by his high school for making a “suicide pact” with his girlfriend. The patient’s mother accompanied him to the emergency department. His admitting diagnoses were suicidal thoughts and depression.
An ED nurse conducted a “suicide screening.” The nurse elicited and documented a history from the patient regarding the suicide pact that he made in September 2011 with his girlfriend who lived in Kansas. The patient told his friends about the suicide pact, and his friends reported the information to school officials.
The nurse evaluated and documented the patient’s vital signs, including his blood pressure, which was elevated at 182/114 mmHg.
There was no documentation in the patient’s medical record that his blood pressure was repeated.
The nurse started an intravenous line and obtained a urinalysis, drug abuse screen, comprehensive metabolic panel, complete blood count, thyroid stimulating hormone level, and an alcohol level. The patient’s BUN level was elevated at 33. His urine creatinine level was elevated at 3.5. His urine had red blood cells and protein present. A second nurse documented on a computer-generated form that she had conducted a physical assessment of the patient.
A social worker conducted a 27-minute mental health evaluation and determined that the patient could be discharged from the emergency department. She notified the ED physician.
The ED physician circled “major depression” on a pre-printed physical examination form and checked off the box stating “cleared medically for psychiatric referral” and discharged the patient home. The ED physician failed to document any history, physical examination, medical decision-making or any plan for the patient or that he had ordered and/or reviewed any laboratory tests or procedures.
The patient had a history of juvenile rheumatoid arthritis. He had been treated with methotrexate from 2000 to 2006. The ED physician failed to document this history.
On 1/4/2013, the patient was evaluated at a clinic for decreasing vision and headaches. His blood pressure was 200/130. The staff repeated the reading three times. He was diagnosed with hypertensive urgency/emergency. Later that day, he went to an emergency department where he was then transported by helicopter to another hospital, admitted to the intensive care unit, and diagnosed with end-stage renal disease and severe hypertension.
On 2/7/2013, the Board received a complaint from the mother of a patient. She alleged that the ED physician failed to address her son’s high blood pressure reading and abnormal laboratory results.
In May 2013, the patient received a kidney transplant.
The Board judged the ED physician’s conduct to be below the standard of care given failure to address the abnormal labs and hypertension of the patient.
The Board reprimanded the ED Physician, ordered him to pay a fine, ordered him to complete a course in medical recordkeeping, ordered him to complete a course in pediatric/adolescent emergency medicine, and stipulated that agents may conduct a chart review or peer review of ED physician A’s practice.
Date: June 2014
Specialty: Emergency Medicine
Medical Error: Failure to follow up
Significant Outcome: Hospital Bounce Back
Case Rating: 2
Link to Original Case File: Download PDF