Found 21 Results Sorted by Case Date
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North Carolina – Nephrology – Abdominal Pain And Hypotension After Renal Biopsy



In December 2011, a nephrologist performed a renal biopsy on a patient, a 70-year-old male with a diagnosis of temporal arteritis and presumed acute tubular necrosis.  The procedure was uncomplicated and the nephrologist provided care of the patient following the procedure.

Approximately two hours after the procedure, the patient developed abdominal pain.  After receiving a call from the nursing staff, the nephrologist ordered hydromorphone 2 mg and ondansetron 4 mg for pain and nausea.  The nursing staff contacted the nephrologist two hours later to notify the nephrologist that the patient’s blood pressure had dropped.  The nephrologist ordered an ampule of intravenous naloxone and normal saline bolus for the patient.  One hour later the patient was transferred to the ICU, where he suffered a cardiopulmonary arrest, but was resuscitated.  The patient became hemodynamically unstable and, despite aggressive resuscitation, died.

The Board obtained the patient’s records and sent them to a qualified independent medical expert for review.  The independent medical expert judged the nephrologist’s conduct to be below the minimum standard of competence given failure to sufficiently appreciate the significance of post-biopsy pain; failure to recognize the significance of the patient’s drop in hemoglobin; and failure to order appropriate follow-up laboratory evaluation to assess the patient’s status when he began to complain of abdominal pain which was treated with what was thought to be an excessive dose of hydromorphone.

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: January 2016


Specialty: Nephrology


Symptom: Abdominal Pain, Bleeding


Diagnosis: Hemorrhage, Renal Disease


Medical Error: Diagnostic error


Significant Outcome: Death


Case Rating: 4


Link to Original Case File: Download PDF



Washington – Internal Medicine – Incidental Finding Of Glucose Level Of 283 mg/dl Without Fasting



On 2/11/2011, a 76-year-old man saw an internist in a clinic to address the patient’s report of a wound on his head that was not healing, hand lesions, diarrhea and white stools, gassiness, and having to go to the bathroom more frequently than normal.  The internist was the patient’s primary care provider and ordered a complete blood count (CBC) and complete metabolic panel.  The lab work identified that the patient had worsening renal function and a blood glucose level of 132 mg/dl (non-fasting).  The internist asked the patient to return in one month for a follow-up basic metabolic panel.

On 3/13/2011, the patient’s follow-up lab work identified improved kidney function; however, the patient’s blood glucose level increased to 283 mg/dl, indicative of diabetes even if the patient had not fasted prior to the lab test.  Medical staff documented that the clinic’s physician assistant called and spoke with the patient’s wife regarding the improved kidney results only.  The patient’s high glucose level was not identified as an issue and the staff did not raise it with his wife.  The internist did not see or speak to the patient following the lab results for the next ten months.

The internist saw the patient on 11/20/2011 to address the patient’s wife’s concerns about changes in the patient’s mentation, including a time when he got lost coming home.  The internist administered the Mini-Mental State Exam, on which the patient scored 28/30.  The internist did not order any lab tests.  The internist failed to discuss the March lab results and failed to review the patient’s significantly increased blood glucose level from February to March 2011.  The internist’s notes indicated that he reviewed medications, allergies, and past medical history as reported during the February 2011 visit, and social history as reported during a December 2009 visit.  The internist’s notes did not indicate that he reviewed the February 2011 lab results or the March 2011 lab results.

On 12/27/2011, the patient called the clinic to request a fasting blood sugar test because he reported he had lost seven pounds in a week and was thirsty all the time.  When his glucose level tested at 655 mg/dl, the clinic staff called the patient and directed him to be seen immediately, either at the clinic or at the emergency department (ED).  The patient was seen in the clinic and was diagnosed with Diabetes Mellitus Type 2.  Due to his altered mental state, the patient was directed to go to the ED for insulin and IV fluids.

The patient was diagnosed with acute renal injury secondary to dehydration.  The patient’s A1C test result indicated that he had had elevated blood sugars at least over the past three months.  The patient was discharged the following day without evidence of diabetic ketoacidosis or a hyperosmolar state.

The Commission stipulated the internist reimburse costs to the Commission and develop and submit a protocol which will ensure that the internist reviews the results of any lab work or tests he orders, follows up on forwarded reports and pertinent test results, documents his review of all lab work, test results and reports, and follows up in a timely manner with patients about test results or missed tests which had been ordered.

State: Washington


Date: September 2015


Specialty: Internal Medicine, Family Medicine


Symptom: Urinary Problems, Confusion, Diarrhea


Diagnosis: Diabetes, Renal Disease


Medical Error: Diagnostic error, Failure to follow up


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



California – Family Medicine – No Follow-Up Care After Renal Cyst Found



On 8/30/2006, a patient presented with episodes of dizziness.  No neurologic exam was documented.  The patient’s family practitioner ordered a carotid duplex.  On 4/2/2007, the patient presented for a follow-up visit complaining of dizziness, which had persisted since the visit on 3/15/2007.  No neurologic exam was documented again.

On 5/28/2008 and 6/18/2008, a renal cyst was identified.  The cyst was identified as a simple cyst by ultrasound.  The family practitioner didn’t comment on the cyst, and he did not order a CT scan or any other imaging study to further evaluate it.  On 3/15/2007, 4/28/2008, 9/30/2010, and 11/16/2010, the family practitioner documented abdominal pain but did not list a differential diagnosis, did not order lab tests, and there was minimal additional history. Patients with persistent or ongoing abdominal pain should have a CT scan or endoscopy.

The Medical Board of California judged that the family practitioner’s conduct departed from the standard of care and was grossly negligent in the care and treatment of the patient because he failed to appropriately evaluate the renal cyst, take an adequate history, work up a differential diagnosis, order labs with regards to complaints of abdominal pain, and appropriately evaluate dizziness.

For this case and others, the Medical Board of California placed the family practitioner on probation for 5 years and ordered that he complete a medical record-keeping course and an education course (at least 20 hours for 5 years) equivalent to the Physician Assessment and Clinical Education Program offered at the University of California San Diego School of Medicine.

State: California


Date: February 2015


Specialty: Family Medicine, Internal Medicine


Symptom: Abdominal Pain


Diagnosis: Renal Disease


Medical Error: Failure to examine or evaluate patient properly, Failure to order appropriate diagnostic test, Failure to follow up, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



California – Urology – Performing Nephrectomy For Renal Mass Causing Gross Hematuria Without Reviewing CT Scans



On 1/3/2012, a 53-year-old male with a history of cerebral palsy presented to the emergency department complaining of gross hematuria.  CT scans, both with and without contrast, were taken of the patient, which showed a mass on his right kidney.  The original reports from the radiologist, however, listed the mass as being on the left kidney.  An addendum report was created noting this error and that the mass was indeed on the right kidney.  The same day, the patient was seen by Urologist A, to whom the patient’s care had been transferred.   Urologist A consulted with Urologist B, a specialist in renal transplantation and renal vascular surgery, about the patient via telephone.  Urologist A generally referred surgeries to Urologist B, and it was anticipated that the patient would require laparoscopic surgery.  While on the telephone with Urologist A, Urologist B viewed the patient’s CT scans on his office computer.  Urologist B admitted that the CT scans showed the mass to be on the patient’s right kidney, but made no notes in his records to this effect.

On 1/11/2012, Urologist B first saw the patient in his office for consultation.  Urologist B’s computer notes pertaining to the patient had already been populated with Urologist A’s notes since Urologist A and B were part of the same medical group.  The patient’s problem list included “Renal mass, Left.”  The first paragraph of Urologist B’s computerized notes carried forward an exact duplication of Urologist A’s original notes.  Since Urologist B cloned Urologist A’s notes, portions of his records were inaccurate beyond simply which kidney was compromised.  For example, Urologist B’s notes stated that “the patient was seen by me in the ER two days ago for gross hematuria and a 5 cm renal mass” was found.  This statement was not true because it was Urologist A, not Urologist B, who had seen the patient in the emergency department, and as of 1/11/2012, it had been well over 2 days prior.  Urologist B’s notes also stated, “I have discussed the case at some length on two occasions with [Urologist B.]”  Again, this statement was inaccurate coming from Urologist B as it is meant to reference conversations between Urologist A and Urologist B and not conversations Urologist B had with himself.  Urologist B made no note as to whether the patient’s tumor was on the right or left kidney, and the problem list from Urologist A denoting the tumor as being on the left was carried forward in Urologist B’s notes.  Urologist B concluded that a renal laparoscopic nephrectomy was an appropriate plan of treatment for the patient after which a determination could be made as to whether the mass cell type was transitional cell carcinoma (in which case Urologist B would perform a complete ureterectomy at the same time) or a renal cell carcinoma (in which case a total nephrectomy would be sufficient).  Urologist B concluded his diagnosis related to a left-sided renal mass.

On the morning of 1/19/2012, Urologist B prepared to perform a radical nephrectomy on the patient.  Urologist B claimed that it is his custom to review scans or to have scans available in the operating room when performing surgery.  Further, the hospital’s rules and regulations require that either the scans themselves or a report of the scan findings be available in the operating room at the time of surgery.  Though Urologist B made some efforts to obtain them,  he was unable to access the radiographic images taken of the patient prior to the scheduled time of surgery.   It was noted that he “forgot the necessary login information needed to access the images remotely.”  Instead of reviewing the radiographic images prior to surgery, Urologist B relied on his notes, dictations, and surgical markings made with respect to the patient and patient’s consents, which all consistently referenced a left-sided tumor, and proceeded with the surgery.  There was no urgency or time pressure on the operating team to go forward with the surgery before the images could be obtained.  Urologist B performed a laparoscopic radical nephrectomy, removing the patient’s left kidney.  After the left kidney was removed, it was dissected in the operating room to access the nature of the tumor, but no tumor was found.  Urologist B then reviewed the CT scan images of the patient and realized he had removed the wrong kidney.  Consequently, the malignancy remained within the patient, and the patient would require additional surgery on his right kidney once stabilized.

In his Operative Report,  Urologist B listed the post-operative diagnosis as a “left renal mass,” when, in fact, he knew at this time that there had been no mass in the left kidney.  After Urologist B informed the patient and his family that a wrong-sided surgery had been performed, another urologist assumed responsibility for the patient’s care.  Ultimately, the patient’s right kidney was also removed in its entirety.

It is the standard of care for a surgeon to personally review images of renal pathology before operating on a patient to, among other things, confirm the nature of the pathology and its location.  The images or a report of these images should be present in the operating room during the time of surgery.

The Medical Board of California judged that Urologist B’s actions represented an extreme departure from the standard of care because he failed to obtain and personally review the radiographic images or a report of those images at the time of surgery, cloned Urologist A’s notes for the patient without using quotation marks or modifying or updating them to ensure accuracy, and described in his Operative Report the postoperative diagnosis as “Left renal mass” when he was aware that there was no mass in the left kidney.

The Medical Board of California ordered that Urologist B complete a wrong-site surgery course and a medical record-keeping course equivalent to the courses offered at the University of California San Diego School of Medicine (Program).

A medical malpractice lawsuit was filed by the patient.

State: California


Date: January 2015


Specialty: Urology


Symptom: Bleeding


Diagnosis: Renal Disease


Medical Error: Wrong site procedure, Lack of proper documentation


Significant Outcome: Permanent Loss Of Functional Status Or Organ


Case Rating: 5


Link to Original Case File: Download PDF



North Carolina – Internal Medicine – Oral Lesions, Odynodysphagia, Weight Loss, And Poor Appetite



On March 2007, a patient with a history of diabetes, hypertension, and hyperlipidemia presented to a primary care physician who was board certified in internal medicine and nephrology for management of his medical issues.

On 07/16/2013, the patient presented to the nephrologist with oral lesions and painful swallowing.  The patient was on lisinopril, clonidine, triamterene/hydrochlorothiazide, and metformin.  The patient was diagnosed as having oral and possibly esophageal candidiasis.  The patient was initiated on clotrimazole and fluconazole.  The patient returned the next week with poor appetite and weight loss.

Labs were not reviewed by the nephrologist until two days later.  They revealed elevation of BUN, creatinine, and potassium as well as a low TSH.  The nephrologist requested the patient present to the hospital.

When the patient arrived to the emergency department, she was told she required transfer to another hospital for treatment.  While en route, the patient coded.  She stayed on life support for nine days before passing away secondary to acute renal failure and thyroid storm.

The Board expressed concern that the nephrologist’s conduct was below the minimum standard of competence.  They noticed disorganized documentation and missing information along with failure to obtain an adequate history and failing to document relevant physical findings.

The Board issued a public letter of concern and reported the letter to the Federation of State Medical Boards.

State: North Carolina


Date: January 2015


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


Symptom: Weakness/Fatigue, GI Symptoms (GERD, Abdominal Distention, Dysphagia)


Diagnosis: Endocrine Disease, Renal Disease


Medical Error: Failure to follow up, Delay in proper treatment, Referral failure to hospital or specialist


Significant Outcome: Death


Case Rating: 3


Link to Original Case File: Download PDF



Virginia – Family Medicine – Hypertension And Failure To Monitor And Determine Cause



A family practitioner treated a 32-year-old male from July 2001 through May 2006.

Around July 2001, the family practitioner diagnosed the patient with hypertension.  Atenolol and hydrochlorothiazide were prescribed.  Over the next several years, the family practitioner failed to conduct a complete work up to determine the cause of the patient’s hypertension.  He failed to order lab work such as blood chemistries and urinalysis.

In December 2006, another provider diagnosed the patient with hypertension secondary to end-stage renal disease.  The patient was started on hemodialysis and subsequently received a renal transplant.

The Board believed the family practitioner’s conduct fell below the standard of care given that he failed to maintain accurate and complete records regarding the medications prescribed to the patient for the treatment of hypertension.  He failed to consistently document medications prescribed to the patient, including the strength, dose, and number of dosage units prescribed.

The family practitioner admitted that there were times where it would have been appropriate to order lab work, such as a lipid panel, complete metabolic panel, TSH, and urinalysis.  He was unsure why the patient “slipped through the cracks.”

The family practitioner completed 32 hours of continuing medical education on the subject of renal disease and hypertension.

The family practitioner was ordered to take a course in the subject of medical recordkeeping.

State: Virginia


Date: December 2014


Specialty: Family Medicine


Symptom: N/A


Diagnosis: Renal Disease, Cardiovascular Disease


Medical Error: Failure to order appropriate diagnostic test, Failure to properly monitor patient, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



Wisconsin – Oncology – Patient With Leukemia On Chlorambucil Found To Have Renal Failure



A 68-year-old man with chronic lymphocytic leukemia, splenomegaly, and acute renal failure presented to a hematologist.

Oral chlorambucil was initiated.  The hematologist conducted no further testing for the renal failure.  He had hoped that chlorambucil would treat the leukemia and consequently resolve the renal failure.  However, it is noted that leukemia is rarely the cause of renal failure, and one would not expect renal failure to resolve with leukemia treatment.

Subsequently, the patient did not get appropriate treatment for his renal failure.

State: Wisconsin


Date: September 2014


Specialty: Oncology, Hematology


Symptom: N/A


Diagnosis: Renal Disease, Cancer


Medical Error: Improper treatment


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



California – Family Practice – 8 Months To Refer And Follow Up On Abnormal PSA Test Result



On 6/18/2007, a 51-year-old male patient was seen by a family practitioner for medication follow-up. The family practitioner’s assessment of the patient included a blood pressure measurement of 181/85 (manual) and 174/76 (machine).  The family practitioner diagnosed situational anxiety and prescribed Wellbutrin 150 mg twice daily for the patient.

On 6/26/2007, the patient was seen in a walk-in clinic.  The patient was assessed to have uncontrolled hypertension and was prescribed lisinopril 10 mg once per day.  The patient also underwent lab testing, which included a complete blood count (CBC), Thyroid Stimulating Hormone (TSH), Direct LDL, Electrolyte Panel (Sodium, Potassium, Chloride CO2), Creatinine serum, SGPT (ALT), and SGOT (AST).  The patient was assessed to have stage 3 chronic kidney disease. His labs were noted in the progress note for this visit, including Creatinine of 1.4 and Potassium K of 3.4.

On 10/6/2007, the patient underwent further laboratory testing.  In addition to a cholesterol panel and an electrolyte panel, the patient underwent a PSA test.  The patient’s PSA level was measured at 14.47 and was flagged as high. The family practitioner saw these results on 10/8/2007 and noted “Referred to Urology.” However, the family practitioner failed to notify the patient of his elevated PSA or his referral to urology at the time.

On 4/17/2008, the family practitioner saw the patient for nausea, vomiting, abdominal pain, and diarrhea.  The family practitioner assessed the patient to have gastroenteritis. The family practitioner did not follow up on the patient’s previous abnormal PSA finding or his referral to urology during this visit.

On 10/14/2008, the family practitioner saw the patient for pain and stiffness in his back following a motor vehicle accident.  The family practitioner ordered x-rays and prescribed Vicodin 5-500 mg and nortriptyline 10 mg. The family practitioner did not follow up on the patient’s previous abnormal PSA finding or his referral to urology during this visit.

On 11/8/2008, the patient underwent further laboratory testing.  In addition to a cholesterol panel and an electrolyte panel, the patient again underwent a PSA test.  His PSA level was measured at 33.39 and was flagged as high. The family practitioner saw these results on 11/17/2008.  However, he did not advise the patient of these abnormal PSA findings, did not order a follow-up visit to address the abnormal PSA findings, and did not order monitoring of the abnormal PSA findings.

On 7/17/2009, the family practitioner saw the patient again for back pain and neck pain. The family practitioner noticed the patient’s elevated PSA findings and referred him to urology for follow-up and management.

The family practitioner committed gross negligence in his care and treatment of the patient including: failure to timely investigate, diagnose, and follow up on the patient’s abnormal PSA findings.

The Medical Board of California issued the surrender of the family practitioner’s license.

State: California


Date: July 2014


Specialty: Family Medicine, Internal Medicine


Symptom: Nausea Or Vomiting, Diarrhea, Abdominal Pain


Diagnosis: Urological Disease, Renal Disease


Medical Error: Failure to follow up, Referral failure to hospital or specialist, Failure of communication with patient or patient relations, Failure to properly monitor patient


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



Virginia – Emergency Medicine – Presentation Of Suicidal Thoughts With Missed Incidental Findings



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.

State: Virginia


Date: June 2014


Specialty: Emergency Medicine


Symptom: Psychiatric Symptoms, Headache, Vision Problems


Diagnosis: Renal Disease, Hypertensive Emergency, Psychiatric Disorder


Medical Error: Failure to follow up


Significant Outcome: Hospital Bounce Back


Case Rating: 2


Link to Original Case File: Download PDF



California – Family Medicine – HCTZ And Benazepril Prescribed In Renal Failure Patient



A 54-year-old male inmate with multi-system diseases that included hypertension, hyperlipidemia, coronary artery disease with a history of a prior myocardial infarction, anemia, renal insufficiency, cardiomyopathy, aortic arch aneurysm with a history of stenting, and a history of alcohol abuse and methamphetamine abuse saw a family practitioner on 11/3/2006.  This visit was made shortly after the inmate arrived and was evaluated. He told the family practitioner that he had a history of hypertension for the past 9 years, and he was on drug therapy for that condition but had forgotten the names of his five medications. He also told the family practitioner he had a history of “heart enlargement.” His blood pressure was 166/100.  The family practitioner’s chart notes for this visit showed the family practitioner checked the patient’s heart, lungs, and abdomen and noted the patient’s legs were swollen with no pitting edema.

The family practitioner’s assessment of the patient included hypertension and rule-out hypothyroidism.  The family practitioner ordered a chest x-ray and several blood tests, including thyroid and hepatitis panels.  The family practitioner prescribed hydrochlorothiazide, enalapril, and clonidine. He also ordered that the patient’s blood pressure be checked in three hours and that it be taken daily for 7 days and if greater than 140/90 or lower than 90/60 to return to the “MD line for further evaluation.”  The family practitioner did not check the patient’s peripheral pulses nor did he do a fundoscopic examination of the patient’s eyes on any visit.

The family practitioner was the on-call physician on the day he first saw this patient.  As the family practitioner was leaving the facility, and per the custom and practice, a nurse handed him a stack of prescriptions to sign.  The family practitioner did so, without looking at the prescriptions for content or the name of the patient. Included in the stack of prescriptions was one prepared for the patient by the nurse at the initial intake.  The prescription included several drugs, most notably benazepril, which, like enalapril, is an ACE inhibitor.

The family practitioner next saw the patient on 11/8/2006.  Although the family practitioner would often see patients without having the patient chart available, he apparently had the patient’s chart on this visit.  The chart showed the patient had been prescribed 2 ACE inhibitors, so he discontinued the enalapril. The family practitioner’s chart notes showed the following under “subjective” complaints: “[Return to clinic for hypertension follow-up complained of] pain in both legs and lower back for 4 months.”  After examination, the family practitioner diagnosed the patient with hypertension, leg pain, and back pain and ordered an x-ray of the spine.

On 11/9/2006, the family practitioner received and reviewed the lab results for the blood tests.  The family practitioner noted that the patient had abnormally high blood urea nitrogen of 44.0 and abnormally high creatinine of 2.50.  The family practitioner also noted that the patient was slightly anemic, having low red blood cell, hemoglobin, and hematocrit levels. On this date, the family practitioner also reviewed the radiology report for the chest x-ray he had ordered.  The report stated, “Ectatic aorta with an endovascular stent, otherwise negative.”

The medical records for this patient were incomplete.  On 11/27/2006, the family practitioner reviewed a blood chemistry and hematology panel for this patient, the blood having been drawn on 11/22/2006.  There was no corresponding order in the chart calling for the blood draw. In any event, the test results showed the patient still had high BUN and creatinine levels, low blood counts, and a slightly elevated potassium level.  All these tests indicated that the patient had “renal insufficiency.” The chart next showed that on 12/4/2006, the family practitioner wrote and signed orders for this patient for bilateral knee x-rays and blood work, among other things.  The records did not contain any corresponding lab reports on the blood work, nor any chart notes showing the family practitioner examined the patient on this date. The only radiology report related to bilateral knee x-rays was dated 11/14/2006.

The family practitioner next saw the patient on 1/3/2007.  The patient told him that he had not taken his medications for hypertension “in many days.” The family practitioner conducted a physical examination but did not check the patient’s eyes or peripheral pulses.  The patient’s blood pressure was 216/113 with a repeat blood pressure of 181/103. The family practitioner made the patient aware of the 11/22/2006 lab results and made a specific chart note that the patient only drank two small cups of water per day.  His assessment included hypertension, fungal infection, and rule out renal insufficiency. The family practitioner ordered another round of blood tests and blood pressure monitoring, and prescribed medications, most notably HCTZ and benazepril. He ordered the patient to return in 1 week.  The family practitioner did not order a creatinine clearance test nor did he make an attempt to refer the patient to a nephrologist.

The patient returned to the clinic on 4/6/2007 when he complained of right knee pain.  The patient’s blood pressure was under control, reading 107/76. The family practitioner conducted a physical examination and noted that there was no swelling in the right knee, and further noted that earlier x-rays had shown the right knee with a “normal study.”  Although the family practitioner testified he often did not have a patient’s chart when conducting an examination, he apparently had the patient’s chart and noted under “plan” to prescribe Tylenol for pain and “PR/INR,” meaning the family practitioner wanted to order coagulation tests, which were common for anemic patients that may be taking blood thinners.

The family practitioner last saw the patient on 4/18/2007.  According to the chart notes, the purpose of this visit was for the family practitioner to discuss with the patient the results of the PT/INR tests, which were abnormal.  The patient told the family practitioner that he had not taken his blood pressure medication, which apparently resulted in the patient’s blood pressure being elevated to 136/105.  The family practitioner’s plan for this date was to keep the patient on warfarin and to monitor the patient’s blood pressure for 5 days with the admonition that if the blood pressure was greater than 140/90, the patient was to return for further evaluation.

The family practitioner’s prescribing of HCTZ and benazepril, in the presence of the patient’s renal failure, was an act of gross negligence.  These drugs when given in combination, can cause renal failure and can cause a patient’s potassium levels to increase with potentially devastating consequences and that the family practitioner’s ordering of these drugs in combination was an extreme departure from the standard of care.  The family practitioner also failed to refer the patient to a nephrologist, failed to perform any fundoscopic examination or check the patient’s peripheral pulses. This should have been done because the eye vessels are the “first to be blown” in an advanced hypertensive patient.  Assessment of the peripheral vascular system is done to determine, among other things, the characteristic of the pulse.

For this allegation, the Medical Board of California issued the surrender of the family practitioner’s license.

State: California


Date: April 2013


Specialty: Family Medicine, Internal Medicine


Symptom: Swelling, Back Pain, Extremity Pain, Joint Pain


Diagnosis: Renal Disease, Cardiovascular Disease


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


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



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