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Florida – Orthopedic Surgery – Documentation Error Of Laceration Of Flexor Pollicis Longus Leads To Wrong Site Surgery
On 5/16/2014, a patient presented to an orthopedic outpatient surgery center with a left-hand work-related injury. During the visit, an orthopedic surgeon properly diagnosed the patient with a flexor pollicis longus (FPL) tendon laceration of her left thumb.
The FPL tendon laceration was confirmed by the MRI scan performed on the patient on 7/3/2014.
On 8/7/2014, during the follow-up visit, the orthopedic surgeon wrongly documented the patient’s injury as an extensor pollicis longus (EPL) tendon laceration in the patient’s medical records
Consequently, on 9/10/2014, the patient presented to the orthopedic surgeon at the center, for an EPL tendon surgery (the wrong site, and/or medically unnecessary procedure) of her left thumb. During the EPL tendon surgery, the orthopedic surgeon realized that the FPL tendon laceration repair should have been performed on the patient instead. On 10/10/2014, the orthopedic surgeon performed the FPL tendon laceration repair on the patient’s left thumb.
The Board ordered the orthopedic surgeon pay a fine of $3,000 to the Board. Also, the Board ordered the orthopedic surgeon pay a reimbursement cost of $4,670.40. The Board ordered that the orthopedic surgeon complete five hours of continuing medical education in “Risk Management.” The Board ordered that the orthopedic surgeon complete one hour of lecture on wrong site procedure.
State: Florida
Date: December 2017
Specialty: Orthopedic Surgery
Symptom: N/A
Diagnosis: Musculoskeletal Disease, Trauma Injury
Medical Error: Wrong site procedure, Lack of proper documentation
Significant Outcome: N/A
Case Rating: 3
Link to Original Case File: Download PDF
North Carolina – Orthopedic Surgery – Wrong Site Surgery When Performing Arthrodesis Of The Left Great Toe
The Board was notified of a professional liability payment made on 8/30/16.
A patient presented to an orthopedic surgery for arthrodesis of her left great toe. In preparing the patient for surgery, the orthopedic surgeon stated that he did not see the markings on the left leg, given that they had been covered by stockings. The orthopedic surgeon erroneously prepared the patient for surgery on the right toe based on what he believed he saw on the x-ray. Despite performing appropriate timeout procedures, none of the surgical team appreciated the error until the end of the procedure.
The Board expressed concern that the orthopedic surgeon’s conduct was below the standard of care. The Board acknowledged that the orthopedic surgeon implemented several practice improvement procedures in response to this event.
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: June 2017
Specialty: Orthopedic Surgery
Symptom: N/A
Diagnosis: Musculoskeletal Disease
Medical Error: Wrong site procedure
Significant Outcome: N/A
Case Rating: 2
Link to Original Case File: Download PDF
Washington – Orthopedic Surgery – Bilateral Shoulder Pain After A Motor Vehicle Accident And Repair Attempt Of Os Acromiale
On 1/4/2011, a patient was involved with a head on motor vehicle collision. The patient sought care the following day at a hospital.
On 1/20/2011, the patient followed up with his primary care provider (PCP). A magnetic resonance imaging (MRI) of the patient’s right shoulder was performed. The MRI showed an abnormal rotator cuff, areas of a partial tear, and an injury to the tendon.
On 2/3/2011, the patient presented to an orthopedic surgeon’s clinic with complaints of right shoulder pain. The orthopedic surgeon reviewed the previous MRI and performed a physical examination. The orthopedic surgeon diagnosed the patient with rotator cuff tendinosis with possible tear, degenerative arthritis of the acromioclavicular joint, and inflammation of the tendon around the biceps muscle.
For the following four months, the orthopedic surgeon continued to see the patient. Though the orthopedic surgeon encouraged the patient to engage in conservative treatment, including physical therapy, the patient’s pain did not completely resolve.
On 6/1/2011, the patient complained of pain in both of his shoulders. The orthopedic surgeon discussed surgical options with the patient. The patient consented to have surgery.
On 6/9/2011, the orthopedic surgeon performed right shoulder surgery. During the surgery, the orthopedic surgeon discovered the patient had an unfused os acromiale (a developmental aberration in which the acromion fails to fuse). Without the patient’s consent, the orthopedic surgeon decided to attempt to repair the os acromiale. The orthopedic surgeon claims he placed two pins within the acromion and a screw down the center. K wires (stainless steel sharpened pins) were cut and placed.
On 7/6/2011, the patient had x-rays taken of his right shoulder. The orthopedic surgeon believed the x-rays showed the hardware was placed appropriately in the patient’s shoulder. Later, the patient saw a different physician, who took a new set of x-rays and believed the hardware was angled inappropriately and the wires were loose. He also believed based on the new x-rays that the screw thread appeared to be just barely in the bone.
Following the patient’s surgery, the patient continued to experience varying degrees of shoulder pain and soreness. On 9/9/2011, the orthopedic surgeon took x-ray images of the patient’s left shoulder, which revealed the patient had bilateral os acromiale.
On 11/21/2011, x-rays were taken of the patient’s right shoulder and showed the screw had pulled out, the bone had not fused, and the wire was broken. The orthopedic surgeon had allegedly failed to appropriately place the original fixation and should have been aware of this when reviewing earlier x-ray images.
The Commission stipulated the orthopedic surgeon reimburse costs to the Commission and write and submit a paper of at least 1000 words with annotated bibliography on the diagnosis and proper treatment of os acromiale.
State: Washington
Date: February 2017
Specialty: Orthopedic Surgery
Symptom: Extremity Pain
Diagnosis: Musculoskeletal Disease
Medical Error: Procedural error, Diagnostic error, Ethics violation
Significant Outcome: N/A
Case Rating: 2
Link to Original Case File: Download PDF
Florida – Orthopedic Surgery – Incidentally Found Soft Tissue Mass on Scapula In Patient With Shoulder Pain
On 2/2/2012, an orthopedic surgeon first saw an 81-year-old male when he performed surgery on the patient’s left shoulder for shoulder impingement, subacromial decompression, and distal clavicle resection.
Prior to the date of the surgery, the patient had been seen once in the emergency department on 12/13/2011 for complaints of shoulder pain.
On 12/22/2011, the patient was seen by the orthopedic surgeon’s physician assistant, at which time the patient reported 70% improvement. The physician assistant provided the patient with anesthetic and steroid injections.
On 1/5/2012, the patient returned to the physician assistant and reported that he was 50% improved from the last visit and had full range of motion.
On 1/5/2012, the physician assistant ordered an MRI of the patient’s shoulder, which was performed on 1/12/2012.
The orthopedic surgeon did not see the patient during his visit to the physician assistant, did not sign off on any of the physician assistant’s notes or treatment plan, and did not order the MRI of the patient’s shoulder.
On 1/16/2012, the physician assistant discussed the radiology report and options for care with the patient.
On 1/12/2012, the MRI report stated three impressions: one related to degenerative changes of the lateral end of the clavicle; one related to degenerative changes of the acromioclavicular joint; and one related to a “3.1 X 1.5 cm expansile soft tissue mass of the scapula. Etiology [was] unknown. Neoplastic process cannot be excluded. Clinical correlation [was] recommended.”
The radiologist documented that the “report [would] be notified to the referring physician by the department staff.” The MRI report was forwarded to the physician assistant.
The physician assistant failed to recognize the significance of the reported mass on the MRI and failed to report the mass to the orthopedic surgeon.
The standard of care requires that an orthopedic surgeon review the MRI and the MRI report prior to initiating surgery. The orthopedic surgeon failed to do either. Instead, he proceeded with the surgery based only on the diagnosis of his physician assistant.
The pre-procedure verification sheet states that the relevant radiographic images and results were available. A nurse signed, verifying that these images and reports were available to the orthopedic surgeon prior to the procedure.
Had the orthopedic surgeon reviewed the MRI report it would have been evident that the patient had a lesion in his scapula that needed immediate attention and referral. Instead, the orthopedic surgeon failed to recognize the lesion, discuss it with the patient, or make any appropriate referrals. By failing to take any of these actions, the orthopedic surgeon fell below the standard of care.
The orthopedic surgeon is the physician responsible for the action and supervision of his physician assistant. The physician assistant’s failure to adequately review the MRI report or discuss it with the orthopedic surgeon was also a failure to meet the standard of care on the part of the orthopedic surgeon.
The Medical Board of Florida judged the orthopedic surgeons conduct to be below the minimal standard of competence given that the orthopedic surgeon failed to adequately supervise the physician assistant when the orthopedic surgeon proceeded with the surgery based on the physician assistant’s diagnosis and without personally reviewing the MRI and MRI report. The orthopedic surgeon was ultimately responsible and, regardless of whether he was told by his physician assistant of the lesion, he should have reviewed the MRI and MRI report, discovered and followed up on the existence of the lesion, and not have inappropriately followed through with the surgery. The orthopedic surgeon failed to document the existence of the lesion in the 1/12/2012 MRI and to document making the appropriate referrals. He failed to document what the patient was told regarding the MRI reports and what procedures were listed on the consent for the 2/6/2012 surgery. The orthopedic surgeon failed to document personally reviewing the 1/12/2012 MRI or MRI report.
The Medical Board of Florida issued a reprimand against the orthopedic surgeon’s license. The Medical Board of Florida ordered that the orthopedic surgeon pay a fine to the Board for $7,500 and pay reimbursement costs for the case at a minimum of $6,139.35 and not to exceed $8,139.35. The Medical Board of Florida also ordered that the orthopedic surgeon complete ten hours of continuing medical education in imaging studies and five hours of continuing medical education in “risk management.”
State: Florida
Date: January 2017
Specialty: Orthopedic Surgery, Physician Assistant
Symptom: Mass (Breast Mass, Lump, etc.)
Diagnosis: Musculoskeletal Disease
Medical Error: Failure to examine or evaluate patient properly, Failure of communication with other providers, Lack of proper documentation
Significant Outcome: N/A
Case Rating: 3
Link to Original Case File: Download PDF
North Carolina – Orthopedic Surgeon – Questionably Necessary Carpal Tunnel Release Surgery Leads To Post-Operative Complication
The Board was notified of a professional liability payment made on 03/25/2016 on behalf of an orthopedic surgeon.
A patient presented to an orthopedic surgeon with right hand numbness and tingling in the thumb, index and middle fingers. The orthopedic surgeon performed a carpal tunnel release. During this procedure, the patient suffered an injury to her right median nerve resulting in right median neuropathy.
The Board raised concern that the orthopedic surgeon recommended surgery after a cursory examination and failed to recommend or first try recognized alternative treatment modalities, such as non-steroidal anti-inflammatory drugs, injection, or splinting before proceeding to surgery.
In addition, the Board noted that the orthopedic surgeon’s operative report does not provide details on how the carpal tunnel was released, and the orthopedic surgeon’s documentation of the patient’s post-operative evaluation was sparse and contradictory.
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: December 2016
Specialty: Orthopedic Surgery
Symptom: Extremity Pain, Numbness
Diagnosis: Musculoskeletal Disease
Medical Error: Improper treatment, Lack of proper documentation, Procedural error
Significant Outcome: Permanent Loss Of Functional Status Or Organ
Case Rating: 2
Link to Original Case File: Download PDF
Florida – Orthopedic Surgery – Lack Of Justification For Surgery For Right Carpal Tunnel Release And Decompression Of The Ulnar Nerve At The Canal Of Guyon
On 1/3/2014, a 32-year-old female presented to an orthopedic surgeon for a “Pre-Op” exam. The orthopedic surgeon obtained a history for the patient’s “Pre-Op” exam. The orthopedic surgeon documented that the patient suffered right wrist pain, that her symptoms were unchanged, that her pain increased with cold weather, and that she had no complaints of numbness or tingling.
The orthopedic surgeon also performed a physical exam at the patient’s “Pre-Op” exam. The orthopedic surgeon documented that the patient’s motor and sensory function and pulses were intact in her upper extremities; she had no right upper extremity atrophy; her upper extremity neurovascular examination was normal; she had moderate first dorsal compartment discomfort in her right wrist.
The orthopedic surgeon diagnosed the patient with tenosynovitis of the wrist and obtained a written consent to perform a release of the first dorsal compartment in her right wrist.
The patient had no symptoms indicative of ulnar and/or median nerve compression at either of the carpal tunnel or the Canal of Guyon at the “Pre-Op” exam.
The orthopedic surgeon’s physical exam at the patient’s “Pre-Op” exam did not reveal any signs indicative of ulnar and/or median nerve compression at either the carpal tunnel or the Canal of Guyon.
On 1/16/2014, the patient presented to a surgery center for the orthopedic surgeon to perform the first dorsal compartment release. Prior to the administration of sedation, the orthopedic surgeon and the patient spoke in the pre-operative area. At that time, the patient advised the orthopedic surgeon that, in addition to the first dorsal compartment symptoms, she was experiencing symptoms of right-hand numbness and tingling. In response, the orthopedic surgeon suggested performing right wrist ulnar and median nerve releases in addition to the planned first dorsal compartment release. The patient gave verbal consent for the orthopedic surgeon to perform the right wrist ulnar and median nerve releases.
The orthopedic surgeon did not assess, or did not document assessing, the degree of severity of the patient’s complaints of right-hand numbness and tingling on the day of and prior to performing the surgery for right carpal tunnel release and decompression of the ulnar nerve at the Canal of Guyon.
The orthopedic surgeon did not perform, or did not document performing, a physical exam of the patient’s right wrist and hand on the day of the and prior to performing surgery for right carpal tunnel release and decompression of the ulnar nerve at the Canal of Guyon.
The orthopedic surgeon did not adequately assess, or did not document adequately assessing, the patient’s complaints and symptoms that would support a pre-operative diagnosis of ulnar and/or median tunnel syndrome.
The orthopedic surgeon did not recommend, or did not document recommending, that the patient pursue a course of non-operative treatment on the day of and prior to performing surgery for right carpal tunnel release and decompression of the ulnar nerve at the Canal of Guyon.
The orthopedic surgeon did not have, or did not document having, a pre-operative medical justification for performing surgery for right carpal tunnel release and/or decompression of the ulnar nerve at the Canal of Guyon.
Immediately prior to surgery, the orthopedic surgeon performed a time-out, also known as a pause, for the first dorsal compartment release procedure.
The orthopedic surgeon failed to perform a time-out for either the right carpal tunnel release or decompression of the ulnar nerve at the Canal of Guyon prior to initiating the procedures.
The Medical Board of Florida issued a letter of concern against the orthopedic surgeon’s license. The Medical Board of Florida ordered that the orthopedic surgeon pay a fine of $10,000 against his license and pay reimbursement costs for the case at a minimum of $4,759.65 and not to exceed $6,759.65. The Medical Board of Florida ordered that the orthopedic surgeon complete a medical records course and complete five hours of continuing medical education in “risk management.”
State: Florida
Date: August 2016
Specialty: Orthopedic Surgery
Symptom: Extremity Pain, Numbness
Diagnosis: Musculoskeletal Disease
Medical Error: Unnecessary or excessive treatment or surgery, Failure to examine or evaluate patient properly, Lack of proper documentation, Procedural error
Significant Outcome: N/A
Case Rating: 2
Link to Original Case File: Download PDF
Virginia – Physician Assistant – Administration Of Orthovisc Instead Of Cortisone
On 3/14/2014, without verifying the medication/dosage or consulting the patient’s record, a physician assistant confirmed that the patient was to receive an injection of Orthovisc when asked for guidance by a registered nurse.
In actuality, the patient’s treatment plan provided that he was to receive cortisone injections, not Orthovisc. The physician assistant administered the Orthovisc medication laid out for her without confirming what medication was needed or what medication she was injecting. Upon realizing her error, she noted in the patient’s record that she “assumed” the patient was to receive Orthovisc due to the note that “bilateral knee injections” were due.
Further, the physician assistant claimed in a written statement to the Board’s investigator that, before injecting a patient, she did “not make a habit of questioning [the] nurses because they have all been extremely competent.”
The physician assistant told the Committee that she never tried to cover up her error. She informed the patient about the error, documented it in the patient’s record, and discussed the issue with the clinic supervisor. In an effort to avoid this type of error from recurring, the physician assistant told the Committee that she now draws up the medications herself, checks the chart, and counts back the appropriate number of months to ensure that the administration of a particular medication is timed correctly.
When she was contacted by a Board investigator, she panicked and feared that she was about to lose her job. As a consequence of her anxiety, she took a family member’s alprazolam. On 2/27/2015, she submitted to a urine drug screen as part of the Board’s investigation, which turned up positive for the benzodiazepine.
The Board investigated two other medication errors that had occurred as well as a posting of the physician’s assistant on Facebook that contained sensitive medical information.
She stated that these incidents occurred during a time when she had an extremely busy schedule and after another physician assistant left the clinic requiring her to increase her workload. She also was planning her wedding around this time.
She reported being employed by a new practice for almost a year. Her new position did not include nights or weekends, as did her last employment. She also has her own medical assistant compared to her prior practice when she had to share her medical assistant with another provider.
She submitted a letter written by her current supervising physician who reported that she “has performed well as a provider and an employee.” She told the Committee that she had learned from her mistakes and had made changes in her practice and personal life to ensure she would be diligent in her work and that she would avoid any repeat problems. In her current practice, she wrote all of her own prescriptions and her medical assistant double-checked each one behind her.
She was administered a reprimand. Within 45 days of the order, she was to submit a written statement certifying that she had read the laws and regulations governing the practice of Physician Assistants. She was to submit documentation that she completed courses in ethics and pain management.
State: Virginia
Date: April 2016
Specialty: Physician Assistant, Family Medicine, Internal Medicine
Symptom: Joint Pain
Diagnosis: Musculoskeletal Disease
Medical Error: Accidental Medication Error, Ethics violation
Significant Outcome: N/A
Case Rating: 4
Link to Original Case File: Download PDF
Virginia – Orthopedic Surgery – Multiple Pain Prescriptions For Ankle Injury
From 3/14/2011 to 6/19/2014, an orthopedic surgeon treated a 57-year-old female for an ankle fracture and subsequent chronic pain. Between 5/6/2013 and 6/19/2014, he prescribed the patient fifty-one prescriptions for oxycodone/acetaminophen absent an evaluation or physical examination during this time period.
The orthopedic surgeon failed to obtain Prescription Monitoring Program reports during his care and treatment of the patient. He failed to regularly conduct or fully document the results of random urine drug screens.
The orthopedic surgeon said that the patient had been well known to the office and had been a patient for over twelve years. He had performed five surgeries on the patient. The patient had come to his office frequently and for so long that he had the impression he was seeing her regularly, even though from May 2013 to June 2014, he had not seen the patient.
The orthopedic surgeon noted that the patient had never demonstrated any aberrant behaviors. In a review of the patient’s chart, the orthopedic surgeon noted that she had missed two appointments, but at the time the office did not have a policy in place to address missed appointments and the chart did not reflect that information in a clear way. Since this incident, the office policy was changed to correct both of these issues.
The orthopedic surgeon made changes to his practice. He required patients to be seen every ninety days. If a patient missed an appointment, the patient was notified that he must be seen before receiving a refill. His practice started to coordinate with chronic pain management and addiction providers in their building.
Given that some of his patients injure themselves due to substance abuse issues that lead to repeated falls, the orthopedic surgeon had met with treatment providers at the intensive substance abuse treatment program at his hospital in an effort to improve the referral process for substance abuse treatment.
The orthopedic surgeon submitted documentation that he had completed the Boston University School of Medicine, SCOPE of Pain: Safe and Competent Opioid Prescribing Education; the University of Nebraska Medical Center’s Risk Assessment, Patient Selection, and Treatment Planning; and the Case Western Reserve University, School of Medicine, Intensive Course in Controlled Substance Prescribing.
The Board issued the orthopedic surgeon a reprimand.
State: Virginia
Date: April 2016
Specialty: Orthopedic Surgery
Symptom: Extremity Pain
Diagnosis: Musculoskeletal Disease
Medical Error: Improper medication management, Lack of proper documentation
Significant Outcome: N/A
Case Rating: 2
Link to Original Case File: Download PDF
North Carolina – Orthopedic Surgery – Placement Of Wrong Sided Trochanteric Nail For Hip Fracture Repair
The Board was notified of a professional liability payment made in January 2015 on behalf of an orthopedic surgeon.
On 10/20/2012, in West Virginia, an orthopedic surgeon operated on an 87-year-old female who had recently fractured her right hip. The orthopedic surgeon used a trochanteric nail to repair the fracture. The orthopedic surgeon requested that an assistant provide the orthopedic surgeon with a right-sided trochanteric nail. The orthopedic surgeon was provided with a left-sided trochanteric nail, which was inserted. This insertion resulted in post-operative pain and complications.
On 10/29/2012, a subsequent surgery was required to replace the wrong sided trochanteric nail and repair the injury caused by placing it.
The Board obtained the patient’s records and sent them to a qualified independent medical expert for review.
The independent medical expert judged the orthopedic surgeon’s conduct to be below the minimum standard of competence given failure to use a “time-out” procedure where the trochanteric nail box was reviewed to ensure that it was the correct side, failure to look at the trochanteric nail prior to insertion to ensure that it was bowed in the proper direction, and failure to take x-rays in the operating room at the end of the operation to verify that the correct trochanteric nail was inserted properly.
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. A fine of $1,000.00 was issued.
State: North Carolina
Date: March 2016
Specialty: Orthopedic Surgery
Symptom: Extremity Pain
Diagnosis: Post-operative/Operative Complication, Musculoskeletal Disease
Medical Error: Wrong use of medical device
Significant Outcome: N/A
Case Rating: 3
Link to Original Case File: Download PDF
California – Family Medicine – Nephrology And Urology Consults For Consistent Abdominal Pain, Back Pain, And Concern For Kidney Infection
On 1/25/2012, a 33-year-old female had her first visit with a family practitioner. The handwritten medical record for this visit was largely illegible. The patient’s blood pressure for this visit was 153/96. The chief complaint was listed as a one-year abscess on the patient’s right side with right-sided abdominal pressure for the past three days. On examination, the family practitioner noted skin and abdomen as abnormal and recorded “right lower abdominal wall. Cystic swelling, 2 x 2 cm, semi-solid, non-tender, mobile,” no discharge and no induration. The assessment was mild muscular sprain in the abdominal wall and right abdominal wall cyst, sebaceous possible. The family practitioner’s plan was to avoid manipulation of the lesion, take Keflex 500 mg q.i.d. For 14 days, use Estrace cream (vaginal cream with estrogen) t.i.d., Flexeril for muscle spasm, and topical antibiotics. There was no detailed history taken and/or documented regarding the patient’s elevated blood pressure, and there was no management plan discussed and/or documented concerning the patient’s elevated blood pressure.
On 8/3/2013, the patient was seen in the emergency department for abdominal pain, flank pain, and fever. The patient complained of flank pain, body aches, dizziness, and feeling weak. The patient’s blood pressure was 162/84, normal temperature, pulse 88, and pulse oximetry 100% on room air. The patient experienced right lower quadrant discomfort when her abdomen was palpated. She was diagnosed with a urinary tract infection (UTI) with pyelonephritis (bacterium or virus infecting the kidneys) and given Keflex q.i.d. for 7 days with instructions to increase her fluid intake and check back into the emergency department if her condition did not improve in 2 days or if her pain got worse. The clinical impression also included acute lumbar spasm with the patient being provided with a small dose of Flexeril for the muscle spasm.
On 8/16/2013, the patient was seen again in the emergency department for her complaints of back pain, headaches, muscle aches, and a rash. The medical record for this visit referenced the emergency department visit of 8/3/2013, and noted “patient has not followed up with her primary care [and] she wants to get rechecked at this time… [and] [s]he wants a school note and a work note and a refill on pain medicine and muscle relaxer.” The review of systems was unremarkable with the exception of “low back pain” with pain measured at 6 on a 10-point pain scale. The patient’s blood pressure for this visit was 138/92. The patient’s physical examination was unremarkable with the exception of mild tenderness of her paraspinal muscles bilaterally. The patient was “convinced that she had a kidney infection” which was not supported by her urinalysis or other laboratory results (but could not be specifically ruled out). The medical record for this visit stated, in pertinent part, “…[the patient] was convinced that she had a kidney infection, so we checked her urinalysis and it was negative. There was a high specific gravity at greater than 1.030, which goes with her dehydration. It was also contaminated with squamous epithelial cells, so I cannot rule out an infection, but there was no sign of an infection there.” The ED physician ultimately concluded the patient had “musculoskeletal back pain” and the diagnostic impression was low back pain, dehydration, and a skin rash, which appeared chronic. The patient was prescribed ibuprofen 400 mg #30, 1 tablet every 6 hours as needed for pain, Soma 350 mg #20, 1 tablet every 6-8 hours as needed for musculoskeletal pain and stiffness, and tramadol hydrochloride 50 mg #20, 1 tablet every 6 hours as needed for pain (not to be taken with the Soma).
On 8/23/2013 at 2 p.m., the patient was seen by a physician assistant. The documented history of present illness for this visit was document as “H/O [history of] enlarged [right] kidney” with symptoms reported as severe and “occur[ing] frequently” with a notation that “Patient has been to the Er where she had an abnormal CT and needs urology referral.” The history of present illness also documented a rash, which began approximately 3 weeks ago. The blood pressure for this visit was 136/94. The patient’s overall appearance was listed as “ill appearing,” and the “abdomen” section of the medical record indicated “CVA tenderness reveals Right kidney tenderness.” The assessment was “acquired asymmetrical kidneys” and the plan was referral to urology, continue Motrin as needed for pain, with an advisement to go to the emergency department if the patient’s condition worsened.
On 8/23/2013, the patient was seen at the emergency department at 7:30 p.m. for her complaint of right flank pain. The medical record for this visit indicated the patient’s history of present illness, which set forth her recent emergency department visits and medications with a notation that “[s]he sees the family practitioner [and] [s]he is trying to get referred to a nephrologist, but she says she is tired of waiting, the pain is persisting, so the family practitioner sent her to a different ER tonight.” The past medical history was listed as “Pyelonephritis, chronic back pain.” The patient’s review of systems was unremarkable and, on examination, she was noted as having blood pressure of 160/96 (later measured at 132/80). The patient’s physical exam was benign with the exception of “positive right CVA [costovertebral angle] tenderness.” A renal ultrasound showed a “small right kidney, otherwise negative.” The medical record for this visit noted that the patient was upset that she was not seen by a nephrologist as part of her visit and that “[s]he needs to see the family practitioner Monday to get rechecked and push this referral through for Nephrology and Urology.” The clinical impression was flank pain, a chronic appearing atrophic right kidney (as shown on the ultrasound), and chronic pain. The patient was instructed to discard her tramadol and was given a prescription for Percocet and a “muscle relaxer.”
On 8/31/2013, the patient had her second visit with the family practitioner. The history of present illness for this visit was documented as “f/u [follow up] on [right] kidney problem” and “eye discharge.” The medical record indicated that the patient had an appointment scheduled with a nephrologist and a urologist. The patient’s blood pressure for this visit was 137/91. The family practitioner documented benign examinations of the head, eyes, ear, nose, and throat, cardiac and respiratory, musculoskeletal, extremities, and neurological. The patient was noted as having “bilateral back pain, no deformity, no swelling.” The family practitioners assessment was back pain and acute conjunctivitis. The family practitioner recommended artificial tears for the conjunctivitis and continue previously prescribed pain medications of the back pain. Despite the patient’s history of elevated blood pressure, there was no detailed history taken and/or documented regarding elevated blood pressure, and there was no management plan discussed and/or documented concerning the patient’s elevated blood pressure. There also was no detailed history taken and/or documented concerning the patient’s back pain.
On 9/9/2013, the patient had her nephrology consultation with the nephrologist. The nephrologist noted the patient’s history for intermittent back pain and right-sided flank pain after UTI diagnosed on 8/4/2013. The family practitioner’s prior lab results were reviewed. The patient’s blood pressure was recorded at 150/80, and she was noted to not be in any acute distress. On examination, the patient’s back was noted to have mild tenderness, there was “some costovertebral angle tenderness” and “some pain with rotation, flexion and extension of the lumbar thoracic spine” Otherwise, the physical exam was normal. The nephrologist’s impression was mild ongoing lower back pain, which he believed was unrelated to any kidney abnormality and instead was likely musculoskeletal in nature. The nephrologist recommended flat bed rest, taper off and then discontinue pain medications, return to work in 2 weeks, and a conditioning program for the back pain once the pain subsided.
On 9/30/2013, the patient had a urology consultation with the urologist, who noted, among other things, the patient’s history of being diagnosed with a smaller sized right kidney and an injury to the kidney from a prior auto accident. On examination, the urologist noted no CVA tenderness and that the patient’s abdominal exam was normal. The urologist further noted the patient’s presumed pyelonephritis on the right side since August 2013 and her continued pain. The urologist prescribed Macrobid for one month (typically used to treat acute uncomplicated UTI’s) and other medication for the patient’s pain at night with a recommendation to follow up with him in one month if no significant improvement. The clinical impression also included back pain and right flank pain.
On 1/20/2014, the patient had a urology follow up with the urologist. The medical record for this visit indicated that the patient did not have a UTI on this visit, but was noted as having hypertension, constipation, and proteinuria. The urologist recommended the patient’s renal etiology be evaluated by a nephrologist.
On 1/22/2014, the patient had her third visit with the family practitioner. The history of present illness for this visit was documented as back pain, “read specialist report” (referring to the urologist’s report), and “lab/nephrology.” The medical record for this visit documented “having atrophic unilateral kidney” and a chronic problem of “acquired asymmetrical kidneys.” The patient’s recorded blood pressure for this visit was 130/93, and her current medications were listed as tramadol and Soma. The review of systems was normal with the exception of the patient’s complaint of back pain. The family practitioner’s physical examination of the patient was unremarkable. The musculoskeletal examination noted “normal range of motion, muscle strength, and stability in all extremities with no pain on inspect.” The family practitioner’s assessment and plan for this visit listed low back pain to be treated with medication, patient referral to nephrology, neck pain (which was not listed in the HPI section) to be treated with medication, a neck collar, and physical therapy and occupational therapy. Despite the patient’s history of elevated blood pressure and/or hypertension, there was no detailed history taken and/or documented regarding elevated blood pressure and/or hypertension, and there was no management plan discussed and/or documented concerning the patient’s elevated blood pressure and/or hypertension. The “medications” section of the medical record indicated a prescription for hydrochlorothiazide, which is typically used to treat hypertension. However, the medical record failed to indicate the basis for the prescription, and hypertension was not listed in the “Assessment Plan” section of the medical record. There also was no detailed history taken and/or documentation concerning the patient’s back and neck pain, and there was no focused physical examination of the patient’s back and/or neck conducted and/or adequately documented.
On 3/1/2014, the patient had her fourth visit with the family practitioner. The history of present illness for this visit was documented as “hypertension (follow up)” and “f/u [follow up] on back pain” with the patient noted to be on medications for her hypertension. The medical record further indicated “f/u [follow up] with chiropractor,” an MVA in November 2013, and that the patient was taking medication for pain. The patient’s blood pressure for this visit was 149/101. The review of systems was normal with the exception of the back pain and constipation. The family practitioner’s physical examination of the patient was unremarkable. The electronic chart note for this visit did not indicate the results of any musculoskeletal examination and/or back examination. The family practitioner’s assessment and plan for this visit was low back pain with a recommendation to continue to treat with current medications and follow up with chiropractor and physical therapy; and constipation with a recommendation for a high fiber diet and a prescription for Colace 100 mg, 1 tablet every night, as needed. Despite the patient’s history of elevated blood pressure and/or hypertension, there as no detailed history taken and/or documented regarding elevated blood pressure and/or hypertension, and there was no management plan discussed and/or documented concerning the patient’s elevated blood pressure and/or hypertension. The “medications” section of the medical record indicated the prior prescription for hydrochlorothiazide on 1/22/2014, presumably for hypertension. However, hypertension was not listed in the “Assessment Plan” section of the medical record. Also, there was, once again, no detailed management plan for treating the patient’s history of elevated blood pressure and/or hypertension nor any documentation of any management plan being discussed with the patient.
The Medical Board of California judged that family practitioner’s conduct departed from the standard of care because he failed to obtain and document adequate histories for the patient’s back and/or neck pain as well as elevated blood pressure and/or hypertension, conduct and document adequate physical examinations, and manage and document a clear and thorough action plan to manage the patient’s elevated blood pressure and/or hypertension.
The Medical Board of California issued a public reprimand and ordered the family practitioner to complete 40 hours of continuing medical education as a medical record-keeping course and an education course.
State: California
Date: January 2016
Specialty: Family Medicine, Internal Medicine
Symptom: Mass (Breast Mass, Lump, etc.), Constipation, Dermatological Abnormality, Rash, Dizziness, Fever, Abdominal Pain, Back Pain, Head/Neck Pain, Weakness/Fatigue
Diagnosis: Musculoskeletal Disease
Medical Error: Failure to examine or evaluate patient properly, Improper treatment, Lack of proper documentation
Significant Outcome: Hospital Bounce Back
Case Rating: 1
Link to Original Case File: Download PDF