Found 19 Results Sorted by Case Date
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Florida – Neurosurgery – Wrong Site Procedure When Performing Surgery On A Subdural Hematoma



On 11/6/2016, a 61-year-old female presented to the emergency department, suffering from confusion and weakness after a fall.  A CT scan revealed that the patient had a large, left-sided subdural hematoma.

That same day, a neurosurgeon was asked to evaluate the patient.  The neurosurgeon correctly documented that the patient was suffering from a left-sided subdural hematoma.  The neurosurgeon further documented his intention to remove a blood clot from the left side of the patient’s subdural space.

Shortly thereafter, the patient was brought to the operating room and preparations were begun for a left-sided craniotomy.  However, at some point during the preparation process, the patient’s head was turned and the neurosurgeon began to operate on the right side.

After the neurosurgeon made an incision through the skin, he removed a bone flap and punctured the dura mater on the right side of the patient’s brain.  The neurosurgeon realized that he was operating on the incorrect side.  The neurosurgeon closed the operating site and proceeded to perform the correct procedure.

It was requested that the Board order one or more of the following penalties for the neurosurgeon:  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: December 2017


Specialty: Neurosurgery


Symptom: Confusion, Weakness/Fatigue


Diagnosis: Intracranial Hemorrhage, Trauma Injury


Medical Error: Wrong site procedure


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



Florida – Gynecology – CBC Tests Show Neutropenia And Leukopenia At An Annual Gynecological Exam



On 8/15/2013, a 34-year-old female presented to a gynecologist for an annual gynecological exam.  At the exam, the patient expressed concerns about infertility.  The gynecologist and the patient discussed various tests that may be used to address infertility and the gynecologist began ordering tests.

On 2/23/2015, the patient gave blood for a complete blood count (“CBC”) test that was ordered by the gynecologist.

On 3/5/2015, the gynecologist received and signed for the results of the CBC test.  The CBC test indicated the patient had an abnormal white blood cell count, marked leukopenia, and severe neutropenia.

The gynecologist failed to notify the patient of the abnormal results of the CBC test.

The gynecologist failed to ensure that the patient had otherwise established a plan of care to address the abnormal results of the CBC test.

On 5/28/2015, the patient presented to the gynecologist for an annual gynecological exam.  At the exam, it was determined that the patient was pregnant, and the gynecologist ordered blood tests for the patient.  The gynecologist failed to order a repeat CBC test.

On 7/17/2015, the gynecologist received and signed for the results of the repeat CBC test.  The repeat CBC test indicated that the patient’s white blood cell count had decreased further, the neutropenia had worsened, and she now had pancytopenia with a drop in the red blood cell and platelet count.

On 7/30/2015, the gynecologist notified the patient of the results of her repeat CBC test and referred her to a hematologist.

On 8/8/2015, the patient experienced a massive intracranial hemorrhage with herniation, as well as severe pancytopenia.

On 8/12/2015, the patient expired in the hospital.  The fetus was also lost at that point.

The Medical Board of Florida judged the gynecologists conduct to be below the minimal standard of competence given that she failed to ensure that the patient had been notified of the abnormal results of the CBC test.  The gynecologist failed to ensure that the patient had otherwise established, a plan of care to address the abnormal results of the CBC test.  The gynecologist failed to order a repeat CBC test at the patient’s May exam.

The Medical Board of Florida issued a letter of concern against the gynecologist’s license.  The Medical Board of Florida ordered that the gynecologist pay a fine of $8,500 against her license and pay reimbursement costs for the case at a minimum of $3,126.31 and not to exceed $5,126.31.  The Medical Board of Florida ordered that the gynecologist complete five hours of continuing medical education in “risk management.”

State: Florida


Date: December 2017


Specialty: Gynecology, Obstetrics


Symptom: N/A


Diagnosis: Hematological Disease, Intracranial Hemorrhage


Medical Error: Failure to follow up, Delay in proper treatment, Failure of communication with patient or patient relations


Significant Outcome: Death


Case Rating: 4


Link to Original Case File: Download PDF



North Carolina – Internal Medicine – Three Emergency Department Visits With Persistent Severe Headache And A Negative CT Head Scan



The Board was notified of a professional liability payment paid on 3/8/16.

A 48-year-old female presented to the emergency department three times over the course of two days with complaints of severe headache.

During the 7/28/12 visit, she had a non-contrast CT head, which was reported as normal.  The patient’s headache was treated as an acute migraine attack.  She was discharged with anti-migraine, anti-nausea, and anti-anxiety medications.

On 7/29/12, the patient returned with persistent symptoms, was treated symptomatically, and discharged.  Later that day, the patient again returned to the emergency department with continuing headache and persistent nausea and vomiting.

The patient was admitted to the hospital under the care of an internist.  The patient was started on maintenance IV fluids to treat dehydration and was treated for the underlying migraine with analgesics and antiemetic.

During the internist’s care of the patient, the internist did not order a spinal tap or additional CT scan, instead relying on the 7/28/12 emergency department CT scan.

On hospitalization day three, the patient was discharged with anti-migraine and anti-nausea medications, and was advised to follow up with her primary care physician or neurologist within a week.

On 8/2/12, the day after discharge, the patient returned to the emergency department with a continuing headache and a CT scan of her head showed intracranial hemorrhage in the right temporal lobe.

The patient was then airlifted to a tertiary care center and had clipping of a brain aneurysm/hematoma removal and ventriculoperitoneal shunt placement.

The Board obtained the patient’s records and sent them to a qualified independent medical expert for review.

The independent medical expert judged the internist’s conduct to be below the minimum standard of competence given failure to provide adequate care for severe persistent headache with normal neurological exam.  The medical expert found that the internist failed to perform a lumbar puncture and repeat imaging or seek neurology input.

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

State: North Carolina


Date: July 2017


Specialty: Internal Medicine, Hospitalist


Symptom: Headache, Nausea Or Vomiting


Diagnosis: Intracranial Hemorrhage


Medical Error: False negative, Delay in proper treatment, Failure to order appropriate diagnostic test, Underestimation of likelihood or severity


Significant Outcome: Permanent Loss Of Functional Status Or Organ, Hospital Bounce Back


Case Rating: 4


Link to Original Case File: Download PDF



Florida – Radiology – Failure To Diagnose Subdural Hematoma From Radiology Report



On 10/27/2015, a patient presented to the emergency department after suffering a fall.

An emergency department physician ordered a computerized tomography (CT) scan of the patient’s head.

Radiologist A reviewed the CT scan.  Radiologist A failed to recognize or failed to report the presence of a significant subdural hematoma.  Radiologist A erroneously reported that the CT scan showed no acute intracranial abnormalities.

The patient’s wounds from the fall were treated, and the patient was discharged home.  That night, the patient became unresponsive at home and was transported back to the hospital.

A second CT scan was performed and was reviewed by Radiologist B.  Radiologist B compared the second CT scan to the first CT scan performed earlier that day.

Radiologist B noted that the first CT scan showed a 6 mm hematoma.  He reported that the second CT scan showed that the hematoma had markedly increased in size to 28 mm since the first scan taken approximately six hours before.

The patient expired the morning of 10/28/2015, due to complications from an acute subdural hematoma.

The Board judged Radiologist A’s conduct to be below the minimal standard of competence given that she failed to recognize and report any significant abnormalities present on a patient’s CT scan.

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

State: Florida


Date: June 2017


Specialty: Radiology


Symptom: N/A


Diagnosis: Intracranial Hemorrhage, Trauma Injury


Medical Error: False negative


Significant Outcome: Death, Hospital Bounce Back


Case Rating: 3


Link to Original Case File: Download PDF



Arizona – Internal Medicine – Managing A Patient Using Alternative Medicine As Opposed To Allopathic Medicine



In November 2009, an 87-year-old man, who was Physician A’s family member, began seeing Physician A for hypotension, autonomic dysfunction syndrome, osteoarthritis, hypothyroidism, and “hormonal imbalance.”  Physician A prescribed over-the-counter herbs and supplements, prescription strength hormonal replacement therapy, and acupuncture treatments.

On 02/20/2011, the patient suffered a right frontal hemorrhagic stroke with residual left hemiplegia. Physician A took the patient to the hospital after 12 hours of initial symptoms.  Physician A said that no neurologist was available at the local hospital and the weather made it hazardous for him to drive at that time.

On 09/22/2014, an osteopathic provider Physician B saw the patient.  He advised that the patient take his blood pressure medications on a regular basis as opposed to as needed as recommended by the Physician A.  Physician B recommended albuterol for dyspnea and a follow up spirometry.  He also recommended tamsulosin in addition to saw palmetto for benign prostatic hypertrophy.

In August 2016, Physician A was removed as the patient’s primary medical provider.

The Board judged Physician A’s conduct to be below the minimum standard of competence given failure to obtain written consent regarding the treatment plan, which involved over-the counter medicines, herbs, and an absence of allopathic treatment.

Physician A did not monitor the patient’s TSH.  He prescribed magnesium when the patient had chronic kidney disease and did not monitor the patient’s magnesium levels.  He prescribed iron supplements when there was no documentation that the patient suffered from iron deficiency.  He prescribed Natto and other supplements which had blood thinning effects and could have lead to the hemorrhagic stroke along with uncontrolled hypertension.

He prescribed testosterone when the patient had an elevated PSA level and uncontrolled hypertension.

The Board issued a Decree of Censure and placed Physician A on probation for 1 year.  He was ordered to complete the Professional/Problem-Based Ethics program offered by the Center of Personalized Education for Physicians for Ethics and Boundaries.

State: Arizona


Date: May 2017


Specialty: Internal Medicine


Symptom: N/A


Diagnosis: Intracranial Hemorrhage


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


Significant Outcome: Permanent Loss Of Functional Status Or Organ


Case Rating: 1


Link to Original Case File: Download PDF



Washington – Emergency Medicine – Elevated INR Level, Hypertension, And Administration Of Ketorolac



On 1/20/2012, a 54-year-old male with a history of chronic hypertension had right knee replacement surgery.  He was discharged on 1/21/2012 and Coumadin was prescribed to prevent deep vein thrombosis (DVT).   The patient was apparently confused about his Coumadin dosages and may have taken too much.  On 1/26/2012, his INR level was elevated at 3.2, when 2.0 to 3.0 is normal.  It is unclear whether the Coumadin dosage confusion was ever resolved.

On 2/1/2012, the patient was seen in the emergency department for severe post-operative knee pain.  His knee was evaluated and his symptoms were reviewed.  He had no stroke or seizure symptoms but did have a headache behind his right eye.  His blood pressure was elevated at 180/102.  The patient was given pain and anti-nausea medication, and a number of lab tests were done.  At 1:01 a.m. on 2/1/2012, his INR level was significantly elevated at 5.2.  The lab called the elevated INR results into the patient’s nurse who documented that she notified the ED physician immediately.

A dose of hydromorphone only slightly reduced the patient’s pain, so the ED physician ordered ketorolac (an intravenous NSAID with known risks of bleeding and hypertension complications).  The first dose of ketorolac was given approximately 19 minutes after the ED physician was notified of the elevated INR.  Approximately 45 minutes later, the ED physician ordered a second dose of hydromorphone.  At about the same time, the ED physician ordered a second dose of ketorolac, just 48 minutes after his first dose.  At 3:20 a.m., the patient’s blood pressure was noted at 178/102, and he was discharged at 3:25 a.m. with his knee pain improved.

On 2/2/2012, the patient returned home in the early morning hours and stayed up to perform some knee exercises in his living room.  He was hard to arouse when his teenage daughter found him there.  911 responded and obtained his history from the hospital.  The paramedics concluded the patient had been over-medicated and told his family that he would recover with time.  Three hours later another 911 call was made as the patient’s condition had worsened, and he was transported to the hospital. Upon arrival at the hospital, the patient was unresponsive.  His blood pressure was 178/106, his INR was 5.5, and his right pupil was unresponsive.  His head CT showed a large brain hemorrhage in the right temporal-parietal lobe.  The patient died at 1 p.m. and the cause of death was catastrophic intraparenchymal hemorrhage.

The ED physician’s treatment of the patient fell below the standard of care and may have caused or contributed to the patient’s brain hemorrhage and death in the following ways:

1)     The ED physician gave the patient an initial 30 mg IV dose of ketorolac (which may only be given with caution for patients with hypertension and coagulation disorder) after he knew the patient had chronic hypertension and had critically elevated blood pressure and INR levels.

2)     The ED physician gave the patient a second 30 mg IV dose of ketorolac less than an hour later when the recommended dose is 30 mg every six hours for a healthy individual.

The Commission stipulated the ED physician reimburse costs to the Commission, permit a representative of the Commission to make semiannual review visits, maintain a patient log with the name, date, and time he treats any patient with an elevated INR, complete 6 hours of continuing education covering the subject of risk factors involved in evaluating, prescribing, and managing post-operative emergency department patients with complications including impaired coagulation, hypertension, and elevated INR comorbidities, and write and submit a paper of at least 1000 words, with references, on what the ED physician learned from the courses above, discussing and analyzing the patient’s case, and explaining how he will incorporate what he learned into his practice.

State: Washington


Date: June 2016


Specialty: Emergency Medicine, Internal Medicine


Symptom: Extremity Pain, Headache


Diagnosis: Intracranial Hemorrhage


Medical Error: Improper medication management


Significant Outcome: Death, Hospital Bounce Back


Case Rating: 4


Link to Original Case File: Download PDF



Colorado – Radiology – Headache, Vertigo, And Vomiting With Head CT Read As Having No Acute Pathology



In September 2009, a patient presented to the emergency department with complaints of headaches, vertigo, dizziness, and vomiting.  The treating ED physician ordered a non-contrasted head computed tomography (CT) as part of the patient’s workup.  The final report for this head CT recommended a contrast-enhanced head CT and magnetic resonance imaging for further evaluation.

The radiologist read the subsequent contrast-enhanced head CT as essentially negative with “no definite hemorrhage” and “no acute intracranial pathology.”  The patient was discharged home and the next day was readmitted to the ED with a decreased level of consciousness, went into a coma, and was ultimately diagnosed with posterior fossa subdural hematoma.  The finding was visible on the 2009 contrast-enhanced head CT.

The Board judged the radiologist’s conduct as having fallen below the generally accepted standards of practice for a radiologist.

The Board issued a letter of admonition.

State: Colorado


Date: February 2016


Specialty: Radiology


Symptom: Headache, Dizziness, Nausea Or Vomiting


Diagnosis: Intracranial Hemorrhage


Medical Error: False negative


Significant Outcome: Hospital Bounce Back


Case Rating: 2


Link to Original Case File: Download PDF



Washington – Family Practice – Warfarin Dose Texted To Nurse Who Enters Incorrect Dosing Schedule



A family practitioner saw an 81-year-old patient, who lived in an assisted living facility, to help manage his multiple chronic medical conditions which required several medications.  One of the medications was warfarin.  The family practitioner would have the patient’s blood level tested monthly using the prothrombin time (PT) test and the international normalized ratio (INR) method.  In March 2014, the patient’s INR level was measured at 2.3 and the family practitioner continued the patient’s dosage of warfarin to remain at 1 mg four days a week, alternating 2 mg for the other three days.

On 4/24/2014, the family practitioner received a text message from a nurse at the assisted living facility stating that the patient’s INR had increased to 3.2.  This level was slightly higher than the 2.0-3.0 target range.  The family practitioner replied via text message ordering the patient’s warfarin to be decreased to 1 mg five a days a week with 2 mg administered on the other two days.  The nurse incorrectly transcribed the new order as “5 mg by mouth 5 days per week and 2 mg for 2 days per week” which increased the patient’s dosage exponentially.  The plan was for a lab recheck in one month.

The family practitioner made her routine visits over the next couple of weeks and signed off on the incorrectly transcribed 4/24/2014 order while also signing off on other orders and lab results she would review from a binder the facility collected for her.

On 5/4/2014, the family practitioner received a text message saying the patient had some bleeding from his gums while brushing his teeth.  The family practitioner ordered a new PT and INR to be done later that week.

On 5/8/2014, the patient had his blood work done.  On 5/9/2014, the family practitioner was advised the patient’s INR was at 15.2.  She inquired as to the amount of warfarin the patient had been receiving.  The nurse responded that he had been receiving 5 mg for five days and 2 mg for two days per week.  The family practitioner knew this was not the correct dosage she ordered on 4/24/2014.  She ordered the warfarin to be discontinued and to immediately administer 10 mg vitamin K as an antidote.

On 5/10/2014, the patient was found in his bed with “coffee ground emesis, and not responding.”  The facility called 911 and the patient was transported to a nearby hospital.  Later that day, the patient passed away from an internal brain hemorrhage.

The Commission stipulated the family practitioner reimburse costs to the Commission, allow a representative to conduct an annual audit of her records, and write and submit a paper of at least 1000 words, with references, on the proper management of anticoagulation therapy and critical INR patients and how she has changed her anticoagulation-related patient care.  She will also present this paper and discuss the events that occurred in this case and the policy and procedural changes that have since been implemented at the facility where the patient resided.

State: Washington


Date: January 2016


Specialty: Family Medicine, Internal Medicine


Symptom: Bleeding


Diagnosis: Drug Overdose, Side Effects, or Withdrawal, Intracranial Hemorrhage


Medical Error: Accidental Medication Error


Significant Outcome: Death


Case Rating: 5


Link to Original Case File: Download PDF



Arizona – Neurosurgery – Endovascular Treatment Of Aneurysm In Elderly Patient



An 81-year old-woman presented on 12/21/2013 with a subarachnoid hemorrhage.  She was found to be in a critical neurologic state and was intubated.  Initially, the neurosurgeon elected to treat the patient with expectant management.  However, the patient improved neurologically, and the neurosurgeon elected to endovascularly treat the aneurysm.

On 12/25/2013, the procedure was performed and was complicated by a thrombus in the carotid artery extending to the middle cerebral artery and anterior cerebral artery.  As a result, the patient sustained a major stroke.

On 12/27/2013, the patient expired.

The Medical Consultant of the Board stated that the neurosurgeon should not have first angiographically studied the non-ruptured aneurysm, which subjected the patient to a lengthier procedure with increased risk of stroke.  The Medical Consultant also stated that the neurosurgeon’s overall daily notes were not detailed with respect to the plan and discussion with the patient’s family.

In addition, the Board judged the neurosurgeon’s conduct to be below the minimum standard of competence given treatment of an elderly patient with aneurysmal subarachnoid hemorrhage as they have a mortality rate of greater than 60%.

State: Arizona


Date: December 2015


Specialty: Neurosurgery


Symptom: N/A


Diagnosis: Post-operative/Operative Complication, Intracranial Hemorrhage, Ischemic Stroke


Medical Error: Improper treatment, Lack of proper documentation, Procedural error


Significant Outcome: Death


Case Rating: 3


Link to Original Case File: Download PDF



California – Internal Medicine – 55-Year-Old Female Who Recently Started An Exercise Program Presents Develops Chest Pain Worsened By Raising Her Arms



On 9/17/2009, a 55-year-old female presented to an internist’s office at 8:45 a.m. for an outpatient visit.  The patient had not previously been seen in that clinic’s affiliated hospital system, so no prior medical records were available.  The patient reported that she had been experiencing a breathing problem for the last three days that was characterized by pain, usually during the evening and at night.  The patient characterized the pain as intermittent sharp, non-radiating pain around the sternum, which became worse when she took a deep breath or pressed on the sternum area.  The internist noted that the patient’s pain was not associated with shortness of breath, fever, chills, cough, nausea, vomiting, or diaphoresis.  The patient reported that the pain was exacerbated when she moved her arms into certain positions, such as raising them.  The patient indicated that she had started an exercise program the previous week that included push-ups.

The patient gave a family history that included the facts that her mother had hypertension and that her sister had heart disease.  No further information concerning this family history of heart disease was in the record. The patient stated that she seldom consulted physicians, and she reported no personal history of heart problems.  The internist described the patient as a “self-professed health care avoider.”  No further social or medical history was obtained.  The internist indicated taking some further family history during her examination, but it was not indicated what additional information was added.  The patient’s vital signs were recorded as blood pressure 130/90, pulse rate 135 bpm, with no notation about rhythm, and temperature 98.3 F.  The patient’s height was 5’5”, and her weight was 172.5 lbs. (overweight).  The internist’s examination consisted of an ear, nose, and throat examination, respiratory auscultation, cardiac findings without mention of jugular venous distention or point of maximal impulse, and notations concerning normal extremity pulses and the absence of edema, clubbing, and cyanosis.  There was no mention of any attempt to reproduce the pain with anterior chest palpation or deep inspiration.  Although the internist noted that the patient’s heart rate was measured at 135 bpm, her electronic progress notes indicated that the heart rate was normal, and the rhythm regular, with no further information.

The internist diagnosed the patient with costochondritis and prescribed ibuprofen (600 mg. t.i.d. for 7 to 10 days, then prn), GI precautions, and push-up cessation, and the patient was sent home.  The tachycardia (135 bpm) was not addressed.  The patient declined immunizations and mammography.  The internist ordered the following tests for the patient: fecal globin, fasting glucose, lipid panel, and alanine transferase.  There is no indication in the record that these tests were taken or completed.  The internist encouraged the patient to make an appointment for a full physical examination and blood work, especially given her family history.  There was no immediate order or plan for further cardiac examination or for an electrocardiogram.

On 9/22/2009, the internist returned a telephone call from the patient.  The patient indicated that her research convinced her that costochondritis was a reasonable diagnosis, but that the ibuprofen prescribed brought only short-duration relief from her chest pain.  The internist then prescribed Relafen (nabumetone, 500 mg 1-2 tablets b.i.d. prn), a long-acting NSAID, and again advised limited activity.

On 9/26/2009, the patient experienced severe shortness of breath and chest pain, and an ambulance was summoned.  The patient was taken to the hospital. While at the hospital’s emergency department, the patient suffered a cardiac arrest and had to be resuscitated.  The patient was admitted to the hospital, and the admitting physician noted that the patient had had continued chest pain and mild shortness of breath for the week before admission.  Diagnosis was a probable ischemic event approximately a week ago, most likely an anterior myocardial infarction, persistent chest pain, and a likely inferior myocardial infarction on arrival at the emergency department as well as development of mitral regurgitation and pulmonary edema.  The patient eventually was diagnosed as having suffered a STEMI.

The admission history taken at the hospital confirmed a negative past medical history, but the family medical history taken included that fact that the patient’s father died of prostate cancer at the age of 77, the patient’s mother died of a myocardial infarction at age 75, and that the patient’s sister had suddenly died of a presume myocardial infarction at age 55.  The social history taken included the facts that the patient did no exercise, had not seen a doctor in 15 years, and drank 4 to 6 beers each night.

On the day of admission to the hospital, the patient underwent a full heart catheterization, including a coronary angiogram.  The results showed diffuse, severe coronary disease of the left anterior descending artery and circumflex and lesser disease of the right coronary artery and multiple smaller vessels.  Collateral flow from the distal right coronary artery supplied at least some of the left circulation.  Pressures were pulmonary artery pressure 45/28, mean 36; pulmonary artery wedge pressure 30/37, mean 30; cardiac output 3.75; and cardiac index 1.96.  A transesophageal echocardiogram revealed an ejection fraction of 30%, several mitral regurgitation, thrombus of the left atrial appendage, and probable ruptured tertiary chordae to the posterior leaflet.

Stenting of the left anterior descending artery and insertion of an intra-aortic balloon pump was done at the hospital, but the patient developed anoxic encephalopathy, so further treatment was curtailed in favor of transferring the patient to another hospital on 10/6/2009 for management of a small right occipital cerebral hematoma.  No surgery was done because the hemorrhage was small and stable.  The patient was transferred to a third hospital on 10/9/2009 for possible cardiac surgery, including mitral valve repair and coronary bypass, but upon arrival, the patient was in heart failure, ventilator-dependent, and agitated, so surgery was not performed.  The patient subsequently developed a fever and cardio-respiratory failure and expired at the third hospital on 10/15/2009. On 10/7/2009, after the internist had been informed of the patient’s admission to the second hospital, cardiac condition, and myocardial infarction, the internist placed an addendum note in her progress notes of 9/17/2009 indicating that the right sternal edge was tender to palpation.

The Medical Board of California judged that the internist’s conduct to be below the minimum standard of competence given that she failed to consider and rule out a cardiac origin for the patient’s pain, garner a detailed history on all cardiac risk factors, including family history, weight, blood pressure, lipids, alcohol consumption, amount of exercise, and diabetes, and perform a complete cardiovascular examination, paying particular attention to vital signs, including jugular venous distention, lung and cardio auscultation, PMI palpation, assessment of vascular bruits, and peripheral pulses.  After learning of coronary artery disease in the patient’s female family members, the internist also failed to take details concerning this familial heart disease, such as type of heart disease, age of onset, type of treatment, outcome, and age of death, if any.  The cardiology failed to do an EKG, take cardiac enzymes, or order a chest x-ray in light of the patient’s symptoms and her family history as well as not ruling out and examining for possible etiologies for the patient’s chest pain other than costochondritis.  The internist failed to explore the pain’s time of day, severity, duration, location, or possible association with activity, stress, food, or other precipitation factors and focused instead on the patient’s report of doing push-ups.  The internist did not pay attention to the patient’s tachycardia (135 bpm) and order an immediate EKG.  The internist ordered some testing for cardiac risk factors and a possible gastrointestinal cause for the patient’s symptoms, but only those useful for risk stratification purposes (ALT, blood sugar, fecal globin, and lipids).  The internist failed to order cardiac enzymes, an EKG, or chest x-ray, or other tests necessary to rule out a cardiac or other more serious cause for the patient’s immediate symptoms, specifically chest pain.  During the internist’s telephone call with the patient on 9/22/2009, the patient reported that ibuprofen provided only short-term relief from her chest pain.  The internist failed to recognize that the temporary efficacy of the ibuprofen could have indicated an etiology for the patient’s chest pain other than costochondritis.  The internist failed to inquire about the patient’s general condition and her chest pain, whether it had changed in character or duration.  The internist assumed costochondritis was the correct diagnosis, noting that the patient corroborated the diagnosis, and the internist missed the opportunity to ask questions about her general condition and her pain or to arrange for further examination or testing.

The Medical Board of California issued a public reprimand and ordered that the internist complete 8 hours of continuing medical education course in the diagnosis and treatment of heart disease.

State: California


Date: November 2015


Specialty: Internal Medicine, Cardiology, Emergency Medicine


Symptom: Chest Pain, Shortness of Breath


Diagnosis: Acute Myocardial Infarction, Intracranial Hemorrhage


Medical Error: Diagnostic error, Failure to examine or evaluate patient properly, Failure to order appropriate diagnostic test, Ethics violation, Lack of proper documentation


Significant Outcome: Death


Case Rating: 4


Link to Original Case File: Download PDF



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