Found 5 Results Sorted by Case Date
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Washington – Physician Assistant – Groin Rash, Swelling, And Hard Left Testicle Found On Infant



On 1/3/2015, a seven-month-old patient was brought to an urgent care facility where he was seen by a physician assistant.  His history included over several months of groin rash that was being treated with steroid cream.  The patient’s mother reported that the patient’s left testicle was hard.  Over the past two days, his symptoms had worsened.  The physician assistant examined the patient and found a rash and swelling at the scrotum only.  He diagnosed the patient with a diaper rash.

On 1/4/2015, the patient’s grandparents brought the patient to the emergency department, where he was examined by a second provider.  The patient’s grandparents reported that the patient seemed uncomfortable and that his left scrotum appeared red, swollen, and firm.  An ultrasound found the patient’s left testicle with decreased blood flow.  The patient was transferred to another facility and testicular torsion was confirmed.  The patient underwent emergency surgery where his testicle was found nonviable and removed.

The physician assistant did not consider testicular torsion in the differential diagnosis and failed to order an ultrasound to rule out this condition.

The Commission stipulated the physician assistant reimburse costs to the Commission, complete a continuing medical education course in assessment and diagnosis of acute scrotal conditions, and submit a paper of no less than one thousand words, with references, on the subject of acute scrotal conditions.

State: Washington


Date: April 2017


Specialty: Physician Assistant, Pediatrics, Urology


Symptom: Rash, Swelling


Diagnosis: Testicular Torsion


Medical Error: Failure to order appropriate diagnostic test


Significant Outcome: Permanent Loss Of Functional Status Or Organ


Case Rating: 3


Link to Original Case File: Download PDF



North Carolina – Pediatrics – Testicular Pain, Tenderness, And Swelling With Ultrasound Scheduled In 2 Days



In June 2015, the Board received report of a malpractice settlement payment.

On 08/27/2011, a 14-year-old male presented with pain, tenderness, and swelling of the right testicle for two days.  The internist’s diagnosis was “testicular swelling, rule out hydrocele.”  He prescribed ibuprofen and Augmentin.

The internist scheduled an ultrasound for 08/29/2011, at which time the patient was diagnosed with testicular torsion.  The testicle had become necrotic and was surgically removed on that day.

The independent medical expert judged the internist’s  conduct to be below the minimum standard of competence given failure to order an ultrasound to be done immediately or failure to refer the patient to a urologist on an emergency basis and failure to document a suspicion for testicular torsion.

The Board ordered the internist to be reprimanded and pay a $1,000.00 disciplinary fine.

State: North Carolina


Date: March 2016


Specialty: Pediatrics, Internal Medicine


Symptom: Pelvic/Groin Pain


Diagnosis: Testicular Torsion


Medical Error: Delay in proper treatment, Diagnostic error


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



Florida – Urology – Painful, Inflamed Testicle And Swollen, Tender Lymph Gland Diagnosed As Epididymitis



On 3/9/2009, a pediatrician began treating a 19-year-old male, who presented with a complaint of a painful, inflamed testicle and a swollen, tender lymph gland.

Upon examination of the patient, the pediatrician concluded that the patient’s testicle was “not twisted,” despite having similar morphology; the pediatrician diagnosed the patient with epididymitis and prescribed Levaquin and Lortab.

On 3/23/2009, the patient presented to another physician with continued complaints of pain and swelling in his left testicle.  The patient was ordered to undergo an ultrasound, which indicated testicular torsion.  The patient then underwent emergency surgery to remove the left testicle and complete a surgical movement of the undescended right testicle into the scrotum.

The Board judged the pediatrician’s conduct to be below the minimum standard of competence given her failure to keep legible medical records to justify the course of treatment.

The Board ordered the pediatrician to pay a fine of $500.

State: Florida


Date: October 2014


Specialty: Urology, Pediatrics


Symptom: Pelvic/Groin Pain, Swelling


Diagnosis: Testicular Torsion


Medical Error: Diagnostic error, Lack of proper documentation


Significant Outcome: Permanent Loss Of Functional Status Or Organ


Case Rating: 2


Link to Original Case File: Download PDF



Florida – Pediatrics – Painful, Inflamed Testicle And Swollen, Tender Lymph Gland



On 3/19/2009, a 19-year-old male patient presented to a pediatrician with chief complaints of a painful and swollen left testicle after waking that morning and a tender and swollen lymph gland.  The patient informed the pediatrician that he had fallen two days prior to his presenting to the pediatrician, had no recent sexual contact, and did not suffer from dysuria.

The pediatrician examined the patient and determined that his testicle was “not twisted” but had similar morphology.  The pediatrician diagnosed epididymitis, which is an inflammation or infection of the epididymis.

The epididymis is the long tube attached to the upper part of each testicle, where sperm matures and are stored.  Symptoms of epididymitis include abdominal pain, flank pain, testicular swelling, and dysuria. Epididymitis often results from sexually transmitted diseases and is treated with prescriptions of ceftriaxone and doxycycline.  The pediatrician prescribed Levaquin and Lortab, ordered the patient to elevate the area and apply a cool compress, and follow up in 4 days if his symptoms failed to improve.

On 3/23/2009, the patient presented to the pediatrician with continued complaints of pain to his left testicle.  The pediatrician ordered the patient to undergo an ultrasound, which indicated testicular torsion.

Testicular torsion is the twisting of the testicle, which results in the obstruction of blood flow.  Emergency surgery is necessary to restore the blood flow so that the testicle does not die. Symptoms of testicular torsion is commonly diagnosed by the performance of a physical examination that includes a Cremasteric reflex test.  Due to the serious nature of testicular torsion, an emergency ultrasound or referral to a specialist should be performed where testicular torsion is suspected.

The patient underwent emergency surgery, at which time the pediatrician performed an orchiectomy (surgical removal of the testicle) on the left testicle and an orchipopexy (surgical movement of an undescended testicle into the scrotum) on the right side.

The pediatrician  failed to meet the prevailing standard of care in regard to the patient in the following: the pediatrician failed to conduct an adequate physical examination of the patient; the pediatrician failed to adequately assess the patient’s complaints and symptoms; failed to order the patient to undergo an immediate urology consult; failed to order an immediate ultrasound with color flow to rule out testicular torsion; misdiagnosed the patient with epididymis; failed to prescribe the patient with appropriate medications to treat epididymitis; failed to diagnose testicular torsion and follow up in 4 days if his symptoms did not subside; and failed to respond timely to the patient’s complaints and symptoms.

The Medical Board of Florida issued a letter of concern to the pediatrician and ordered that he pay a fine of $500, complete five hours of continuing medical education in urologic conditions, complete five hours of continuing medical education in risk management, and pay for the costs of the proceedings.

State: Florida


Date: December 2013


Specialty: Pediatrics, Urology


Symptom: Pelvic/Groin Pain, Swelling


Diagnosis: Testicular Torsion


Medical Error: Diagnostic error, Failure to examine or evaluate patient properly, Failure to order appropriate diagnostic test, Referral failure to hospital or specialist, Failure to follow up


Significant Outcome: Permanent Loss Of Functional Status Or Organ


Case Rating: 3


Link to Original Case File: Download PDF



Wisconsin – Emergency Medicine – Abdominal Pain, Pain When Urinating, And Groin Pain



On 12/08/1999, a patient presented to the emergency department with 2 hours of left lower quadrant abdominal pain radiating to the group.  There was no flank pain.  The pain was described as a constant sharp stabbing pain.  There was pain when the patient urinated.  The patient was seen by ED Physician A, who documented: “c/o [left] abd. pain.”  “Was at home today, got up to get glass of water – had pain in [left] groin.”  “Pain 9/10, mainly in left groin [followed by an arrow pointing to] testicle.  Some discomfort in left flank.”

ED Physician A performed an exam, ordered IV fluids, and ordered analgesics.  She noted that the abdomen was soft, flat, with active bowel sounds, tender to deep palpation in the left inguinal area, and with no masses, rebound, guarding, hernias, or adenopathy.  ED Physician A suspected nephrolithiasis and ordered BUN/creatinine, urinalysis, both of which were normal, and an intravenous pyelogram, which was normal.

When the patient returned from radiology, he felt improved, and ED Physician A thought the stone had passed.  She discharged the patient at 4:10 p.m.  ED Physician A advised him that the diagnosis of nephrolithiasis was not definite and that he should return if the pain worsened or was persistent.

On 12/10/1999, the patient returned to the emergency department complaining of a painful, tender, swollen left testicle.  ED Physician B suspected testicular torsion and transferred the patient to another hospital where a urologist could perform an ultrasound scan of the testicle.  An ultrasound confirmed the diagnosis.  Permanent damage had occurred, and the testicle had to be surgically removed.

The Board judged ED Physician A’s conduct to be below the minimum standard of competence given failure to perform a physical exam of the scrotum and testicles and given failure to diagnose testicular torsion.

The Board ordered that ED Physician A be reprimanded and pay the costs of the proceeding.

State: Wisconsin


Date: June 2008


Specialty: Emergency Medicine, Urology


Symptom: Abdominal Pain, Pelvic/Groin Pain


Diagnosis: Testicular Torsion


Medical Error: Diagnostic error


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


Case Rating: 4


Link to Original Case File: Download PDF



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