Found 124 Results Sorted by Case Date
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California – Gastroenterology – Fevers And Chills After Endoscopic Retrograde Cholangiopancreatography (ERCP)



On 6/22/2010, Gastroenterologist A provided a consultation for a patient after an abdominal ultrasound showed that the patient had cholelithiasis and choledocholithiasis.  The patient’s elevated liver enzymes and dilated bile duct indicated a moderate to high probability of the possibility of stones and warranted a preoperative ERCP and sphincterotomy.  The purpose of the consultation was to remove a suspected common bile duct stone prior to a cholecystectomy.

On 6/28/2010, Gastroenterologist A performed an ERCP with sphincterotomy and balloon sweeping of the common bile duct.  He was unable to determine if he had successfully removed the suspected common bile duct stone from the patient’s dilated bile duct and placed an 8.5-French 5 cm stent into the common bile duct.

In the patient’s chart, Gastroenterologist A noted: “will pull the stent out in 2 months.”

On 11/24/2010, Gastroenterologist A next saw the patient in his office.  A second ERCP was scheduled for 2/10/2011 to remove the stent.  The patient’s medical chart contains no record of instructions given to the patient or his family members regarding the removal of the stent.  The patient’s medical chart contains no explanation for the passage of time between the placement of the stent on 6/28/2010 and the removal of the stent on 2/10/2011.  The Board noted that stents can be expected to occlude after six months and form a nidus for the formation of other stones, mud, and debris.

At 8:30 a.m. on 2/10/2011, Gastroenterologist A performed a second ERCP on the patient and removed the stent.  During the second ERCP, Gastroenterologist A performed a balloon sweep.  The patient’s medical chart contains no clear documentation that all ducts were swept.  No antibiotics were prescribed or administered to the patient immediately before, during, or after the second ERCP.  After the second ERCP, the patient was discharged from the endoscopy facility.  Several hours later, the patient’s wife called Gastroenterologist A’s office to report that the patient was experiencing chills and pain in his back and stomach.  Gastroenterologist A and/or his staff advised that the patient should be brought to Gastroenterologist A’s office right away.

At 6:00 p.m., after efforts to convince the patient’s wife to bring the patient to his office had been unsuccessful, Gastroenterologist A noted in the patient’s chart that he advised the patient’s wife to bring the patient to the office the following morning if the pain were to continue.

Thereafter, Gastroenterologist A prescribed amoxicillin 500 mg to be taken three times a day for the patient.

The following morning, the patient’s condition had not improved.  Further conversations took place between Gastroenterologist A and/or his office staff and the patient’s wife.

At noon on 2/11/2011, the patient arrived at the hospital.

On 10/7/2014, Gastroenterologist A testified that there had been several telephone calls between his office and the patient’s wife on 2/10/2011 and 2/11/2011.  Further, he stated that he and/or his staff had impressed upon the patient’s wife the severity of the patient’s condition and that it was matter of life and death that the patient receive urgent medical attention, but that patient’s wife apparently failed to understand and/or take Gastroenterologist A’s comments seriously.

However, Gastroenterologist A did not document in the cart for the patient.  He did not document the frequency of the conversations, the information given to the patient’s wife, or his wife’s failure or refusal to understand the information.

At 1:30 p.m. on 2/11/2011, the patient was admitted to a hospital and was found to be critically ill with severe sepsis.

Gastroenterologist A consulted Gastroenterologist B, who performed an ERCP on the patient on 2/12/2011.  Gastroenterologist B found “clear evidence of a biliary obstruction as evidenced by darkly pigmented bile and extensive amounts of bloody liquid and sand-like material concerning for hemobilia.”  Gastroenterologist B diagnosed “biliary obstruction resulting in ascending cholangitis and sepsis” and placed a stent in the common bile duct.

On 2/12/2011, the patient passed away.

On 2/16/2011, Gastroenterologist A completed a two-page note in the patient’s medical chart entitled “Death Summary” and marked “Final Report, ” in which he made the following comments.

“Endoscopic retrograde cholangiopancreatography was performed 2 or 3 months ago … for common bile stone retrieval with stenting of the common bile duct … His condition continued to deteriorate.  During the night, his oxygen saturation began to deteriorate, suggesting acute respiratory distress syndrome.  He was intubated and put on the machine.  The blood pressure was kept on Dopamine and Neo-Synephrine.  But, in spite of this, on 2/12/2011 after all the resources have [sic] been pulled out, I have a hunch that he would not make it because of multiorgan [sic] failure.  Therefore, I called the family and explained the grave situation as best that I could.  The patient finally expired on 2/12/2011.”

Gastroenterologist A listed the final diagnosis as “septic shock, death.”

Gastroenterologist’s “Death Summary” for the patient contained no mention of the third ERCP, performed on 2/12/2011, or Gastroenterologist’s B diagnosis of biliary obstruction.

After a hearing, the State Medical Board concluded that Gastroenterologist A committed repeated negligent acts given failure to ensure timely removal of the temporary stent, failure to ensure that the patient had a clear understanding of the importance of timely removal of the temporary stent, failure to ensure that the patient had an understanding of the risks associated with performing the second ERCP and the possible warning signs to monitor after the procedure, and failure to maintain appropriate documentation of his care and treatment of the patient.

The State Medical Board placed Gastroenterologist A on probation with stipulations to complete a professionalism program, complete a medical record keeping course, complete 40 hours annually of continuing medical education for each year of probation, and undergo clinical practice monitoring with an emphasis on medical record keeping.  During probation, Gastroenterologist A was prohibited from performing ERCP procedures.

State: California


Date: May 2017


Specialty: Gastroenterology, Internal Medicine


Symptom: Fever


Diagnosis: Sepsis


Medical Error: Physician concern overridden, Delay in proper treatment, Failure of communication with patient or patient relations, Lack of proper documentation


Significant Outcome: Death, Hospital Bounce Back


Case Rating: 4


Link to Original Case File: Download PDF



California – Anesthesiology – Anesthesia Procedural Errors During Elective Right Carotid Endarterectomy



On 5/6/2014, a patient was scheduled for an elective right carotid endarterectomy procedure with her vascular surgeon.  An anesthesiologist was assigned to the surgery and was proctored by another anesthesiologist throughout the procedure. The anesthesiologist wrote his pre-operative note at 11:10 a.m.  The note included the patient’s admitting vital signs and past history, which included a recent stroke and that she was a former smoker. His note listed her most recent labwork. The anesthesiologist did not include the patient’s pre-operative Doppler studies or her recent ECG.  The anesthesiologist noted that the patient had a prior Cesarean section, but listed her prior anesthetics as “none.” The anesthesiologist did not perform an exam of her heart or lungs, and he noted that he discussed a risk of nausea.

The anesthesiologist placed a right radial 22-gauge arterial line with local anesthetic prior to the patient being moved to the operating room.  He connected the patient to the proper monitoring machines. The anesthesiologist began anesthesia at 11:36 a.m. He provided 1 mg of midazolam, 5 mg of rocuronium, 40 mg of lidocaine, 40 mg of propofol, and incremental doses of 50 mcg x2 fentanyl.  He also administered sevoflurane and oxygen. The anesthesiologist then administered an additional dose of rocuronium and easily intubated the patient. The anesthesiologist began a phenylephrine infusion of 200 mcg/hr. At 11:45 a.m., the patient’s vital signs were recorded from the arterial line reading 130/55 and from the left cuff measuring 90/55 with pulse of 55.  During intubation, the patient’s blood pressure rose to 135/65 with a pulse of 60. The phenylephrine infusion was increased to 1000 mcg/hr and then decreased to 800 mcg/hr prior to the surgical incision at 12:17 p.m.

Systolic blood pressure prior to incision was 180 and charted at 150/110 shortly thereafter.  Pulse rose from 58 bpm to 75 bpm. Heparin, 5000 units, was administered at 12:22 p.m. prior to surgical cross camp at 12:33 p.m.  During the cross-clamp period, anesthesia was maintained. The cross clamp was removed at 1:11 p.m. The phenylephrine infusion was continued until approximately 1:15 p.m.  Blood pressure during the cross-clamp period ranged between 145/70 and 170/60. At 1:15 p.m., the patient’s blood pressure was 200/60 with a pulse of 70 bpm. The anesthesiologist administered ondansetron at 1:15 p.m.  At 1:30 p.m., he administered 10 mg of hydralazine and 30 mg of esmolol. He provided another 40 mg dose of esmolol shortly thereafter. Surgery ended at 1:37 p.m. The anesthesiologist’s post-operative note, written the following morning, showed that the patient was essentially stable, and she was released home the following day.

The Medical Board of California judged that the anesthesiologist departed from the standard of care because he failed to mention the patient’s prior ECG or Doppler studies in his pre-operative note.  The anesthesiologist did not ask her about a prior history of chest pain or exercise intolerance during his pre-operative evaluation, did not list the type of prior anesthetic that she had received in her prior surgery in his pre-operative note, did not review the degree of patency or stenosis that the non-operative side would provide cerebral blood through the Circle of Willis, did not inform the patient that there would be a small, but not uncommon, risk of stroke, heart attack, or death, and did not examine or document a heart of lung exam of the patient during his pre-operative examination.  He also failed to anticipate the patient’s hemodynamic changes related to surgical incision and cross-clamping and unclamping during surgery. When the anesthesiologist did respond to hemodynamic changes, he provided inadequate responses and prolonged response times. The anesthesiologist failed to adequately reflect the wide variations in the monitored vital signs in his clinical chart and failed to terminate the phenylephrine infusion following removal of the cross-clamp despite the patient’s hypertension. The anesthesiologist failed to promptly adjust the mechanical ventilator after intubation and failed to proactively anticipate blood pressure increases and decreases in response to carotid de-clamping.

The Medical Board of California placed the anesthesiologist on probation for 4 years and ordered him to complete a medical record-keeping course, an education course for at least 20 hours for the first year of probation, and a clinical training program equivalent to the Physician Assessment and Clinical Education Program offered at the University of California San Diego School of Medicine.

State: California


Date: May 2017


Specialty: Anesthesiology


Symptom: N/A


Diagnosis: Cardiovascular Disease


Medical Error: Failure to examine or evaluate patient properly, Failure of communication with patient or patient relations, Delay in proper treatment, Improper medication management, Lack of proper documentation, Procedural error


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



California – Pediatrics – Fourteen-Year-Old Male With A Hemoglobin Of 8.2



On 7/30/2013, a 14-year-old male was seen by a pediatrician for a well-child assessment.  The pediatrician reviewed the patient’s height, weight, temperature, and blood pressure and administered hearing and vision tests.  She reviewed the patient’s development, including body image, home situation, education, school progress, risk-taking behaviors, sexuality, and mental health.  A complete physical examination was performed.

On 7/30/2013, the patient received a routine HPV immunization.  Routine diagnostic laboratory tests were ordered, including urinalysis.  A hemoglobin test by finger stick was performed.  The patient’s urinalysis test result was normal, but his hemoglobin result of 8.2 was significantly lower than normal.  The pediatrician repeated the hemoglobin test by finger stick but did not order a complete blood count by venipuncture.  The patient’s hemoglobin result was again 8.2.  The pediatrician started the patient on iron supplement therapy and instructed him to follow up in three months.  No additional diagnostic tests were done during this visit.

On 8/18/2013, the clinic received a report that the patient was experiencing shortness of breath and chest pain.  The patient was instructed to go to an emergency room.

At the emergency room, the patient experienced a full cardiac arrest.  His complete blood count revealed severe anemia, with a hemoglobin result of 7.5, a hematocrit of 21, 99 atypical lymphocytes, and a critically low platelet count of 39,000.  The patient’s cause of death was acute lymphoblastic leukemia/lymphoma.

The Board deemed the pediatrician’s level of conduct to be below the standard of care given failure to order a complete blood count by venipuncture for the follow-up blood test, failure to schedule a visit and lab check at an earlier date, and failure to consider other diagnoses in addition to iron deficiency anemia.

The Board issued a public reprimand against the pediatrician.  Stipulations included performing sixty hours of free services to a community or a non-profit organization, conducting 40 hours of continuing medical education, enrolling in a professionalism program, and undergoing a clinical competency assessment program.

State: California


Date: May 2017


Specialty: Pediatrics, Hematology


Symptom: Shortness of Breath, Chest Pain


Diagnosis: Cancer, Hematological Disease


Medical Error: Failure to order appropriate diagnostic test, Delay in proper treatment


Significant Outcome: Death


Case Rating: 5


Link to Original Case File: Download PDF



Florida – Gynecology – Bilateral Tubal Ligation Error Results In Complications Of Tachycardia, Hypotension, Respiratory Failure, And Hypotension



On 4/21/2014, a gynecologist performed a Cesarean section and bilateral tubal ligation on a 29-year-old female at 36 weeks gestation.

The patient suffered from gestational hypertension associated with right upper quadrant abdominal pain and elevated liver function tests consistent with HELLP (Hemolysis, Elevated Liver Enzymes, and Low Platelet Count) Syndrome.

At 5:00 p.m. on 4/21/2014, the patient became hypotensive and tachycardic and was pale and lethargic.

Between 5:00 p.m. and 6:30 p.m. on 4/21/2014, a critical care consultant diagnosed the patient with acute hemorrhagic shock, possibly due to an intraabdominal bleed, transferred the patient to the ICU, ordered a transfusion of 4 L of blood, and called the gynecologist for a possible exploratory laparotomy to control the bleeding.

At 7:11 p.m., the patient was intubated and placed on ventilation due to respiratory failure.

At 9:10 p.m., an ultrasound examination was performed on the patient’s abdomen and pelvis that revealed moderate fluid in the right and left upper quadrants of the patient’s abdomen.

Immediately following the ultrasound examination, the gynecologist diagnosed the patient with a liver rupture.  The patient’s lab testing results did not support or corroborate the gynecologist’s diagnosed.

The gynecologist called the on-call general surgeon and discussed the patient’s case.  After the conversation, at 9:23 p.m., the gynecologist initiated the transfer of the patient to a medical center.

At 1:45 a.m. on 4/22/2014, the patient was transferred to the medical center with a tachycardic heart rate of 140 beats per minute and a hypotensive blood pressure of 89/44.  The gynecologist and a surgeon performed an exploratory laparotomy on the patient, which revealed that the patient had an arterial bleed from the tubal ligation procedure.

The Medical Board of Florida judged that the gynecologist did not appropriately assess, or did not create or maintain adequate documentation of assessing, the patient’s symptoms and condition. He did not timely diagnose, or did not create or maintain adequate documentation of timely diagnosing, the patient with an intraabdominal bleed and hemorrhagic shock.  The gynecologist did not timely perform or order an exploratory laparotomy based on the patient’s deteriorating vital signs.  He did not timely order an ultrasound examination of the patient’s abdomen and pelvis on the patient’s deteriorating vital signs.  Also, the gynecologist did not timely perform or order an exploratory laparotomy based on the patient’s respiratory failure.  He did not recognize, or did not create or maintain adequate documentation of recognizing, that the fluid in the right and left upper quadrants of the patient’s abdomen, in conjunction with the patient’s other symptoms, indicated an intraabdominal bleed.  He did not perform or order an exploratory laparotomy based on the fluid in the right and left upper quadrants of the patient’s abdomen.  The gynecologist inappropriately diagnosed the patient with a liver rupture when the patient’s lab testing results did not support or corroborate the diagnosis.  He also did not order, or did not create or maintain adequate documentation of ordering, a surgery consultation for a surgeon to physically examine the patient upon diagnosing the patient with liver rupture.  He did not consult, or did not create or maintain adequate documentation of consulting, with one or more other OB/GYNs who might have had experience dealing with a patient with a liver rupture or a patient with similar complications and symptoms as the patient had.  The gynecologist did not timely perform or order an exploratory laparotomy after diagnosing the patient with liver rupture.  He also inappropriately transferred the patient to a medical center when the patient was unstable due to being tachycardic and hypotensive.  The gynecologist did not create or maintain adequate documentation related to his diagnosis and treatment of the patient.

The Medical Board of Florida issued a reprimand against the gynecologist’s license.  The Medical Board of Florida ordered that the gynecologist pay a fine of $22,500 against his license and pay reimbursement costs for the case at a minimum of $4,335.85 and not to exceed $6,335,85.  The Medical Board of Florida also ordered that the gynecologist complete ten hours of continuing medical education in diagnosis management of complications relating to cesarean sections, complete five hours in emergency obstetric care, and complete five hours of continuing medical education in “risk management.”

State: Florida


Date: May 2017


Specialty: Gynecology, Critical Care Medicine, General Surgery


Symptom: Abdominal Pain


Diagnosis: Post-operative/Operative Complication, Acute Abdomen, Hemorrhage


Medical Error: Diagnostic error, Delay in proper treatment, Failure to order appropriate diagnostic test, Referral failure to hospital or specialist, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



Florida – Gynecology – Increased Pain, Hypotension, Tachycardia, And Tachypnea After Cesarean Section And Bilateral Tubal Ligation



On 7/26/2014, a gynecologist performed a Cesarean section and bilateral tubal ligation on a 32-year-old female.

At 10:30 a.m. on 7/26/2014, the patient complained of increased pain.  After she complained of pain, the patient’s vital signs began deteriorating.

At 1:45 p.m., the patient was transferred to the ICU and a rapid response call was placed to the gynecologist because the patient was diaphoretic, pale, and hypotensive.  From 1:45 p.m. to 2:30 p.m., the patient was hypotensive, tachycardic, and had an increased respiratory rate.

At 2:30 p.m., the gynecologist called the patient’s primary OB/GYN for a consultation regarding her condition.

At 2:45 p.m. the patient was intubated and received a transfusion of 2 L of blood.

At 3:30 p.m., the patient underwent an ultrasound examination that revealed a mild amount of free fluid in the patient’s upper abdomen.

At 4:10 p.m., the patient underwent a CT scan that indicated mild to moderate fluid in the patient’s abdomen, especially adjacent to the liver and along the right paracolic gutter.

Between 7:00 p.m. and 8:52 p.m., the patient received a transfusion of 4 L of blood.  Subsequent to that transfusion, the patient had a hemoglobin level of 8.3

At 9:42 p.m., the patient underwent an exploratory laparotomy that revealed an inferior epigastric bleed, which was repaired.

The Medical Board of Florida judged that the gynecologist did not properly assess, or did not create or maintain adequate documentation of properly assessing the patient’s symptoms and condition.  He did not timely diagnose, or did not create or maintain adequate documentation of timely diagnosing, the patient’s intra abdominal bleed and hemorrhagic shock.  The gynecologist did not timely perform or order an exploratory laparotomy based on the patient’s pain and deteriorating vital signs.  He did not timely perform or order an exploratory laparotomy after the patient was intubated.  Also, the gynecologist did not recognize, or did not create or maintain adequate documentation of recognizing, that the fluid in the patient’s abdomen, in conjunction with the patient’s other symptoms indicated an intra abdominal bleed.  The gynecologist did not timely perform or order an exploratory laparotomy based on the fluid in the patient’s abdomen.  He did not create or maintain adequate progress notes related to his treatment of the patient or maintain adequate documentation elucidating a plan of treatment for the patient.  He did not create or maintain adequate documentation notes related to the diagnosis and treatment of the patient.

The Medical Board of Florida issued a reprimand against the gynecologist’s license.  The Medical Board of Florida ordered that the gynecologist pay a fine of $22,500 against his license and pay reimbursement costs for the case at a minimum of $4,335.85 and not to exceed $6,335,85.  The Medical Board of Florida also ordered that the gynecologist complete ten hours of continuing medical education in diagnosis management of complications relating to cesarean sections, complete five hours in emergency obstetric care, and complete five hours of continuing medical education in “risk management.”

State: Florida


Date: May 2017


Specialty: Gynecology


Symptom: Pain


Diagnosis: Post-operative/Operative Complication, Acute Abdomen, Hemorrhage


Medical Error: Diagnostic error, Delay in proper treatment, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



California – General Surgery – Nausea, Vomiting, And Diarrhea After Fissurectomy, Hemorrhoidectomy, And Sphincterotomy



A patient was referred to a general surgeon specialized in colorectal surgery by his primary care doctor.  The patient presented to the general surgeon on 4/10/2012 as a 35 year-old-man with anal pain since age 16.

The patient’s medical history included a 12/30/2003 colonoscopy with biopsies by a gastroenterologist, who made a postoperative diagnosis of anal fissure, rectal polyp, and two small sigmoid polyps.  The biopsies revealed benign hyperplastic polyps.  In 2009, the patient had a lumbar discectomy at L4-L5.  In October 2011, the patient was referred to, and seen by, a cardiologist.  The cardiologist found “no evidence of any fixed coronary arterial disease in the left dominant system…elevated resting left ventricular end-diastolic pressure suggests left ventricular diastolic non-compliance likely due to history of hypertension and obesity.”  In sum, the patient presented to the general surgeon with morbid obesity, hypertension, dyslipidemia, post-two back surgeries, with a resulting DVT, cardiac complaints, and a list of prescription medications; and a social history including a one pack per day smoking habit, cannabis use, and occasional alcohol use.

The patient appeared with his wife for his appointment with the general surgeon.  The patient was given a two-page medical questionnaire to complete.  The patient filled in page one of the questionnaire and the patient signed page two, leaving blank the box on page two asking the patient to circle symptoms applicable to their current condition (e.g., headaches, shortness of breath, chest pains, blood in stool, etc.).  The patient was called out of the lobby by a medical assistant, who took his vital signs and questioned him about the information listed on the questionnaire.  The medical assistant learned that the patient was allergic to penicillin, which the patient had not listed on the questionnaire.  The medical assistant reported that the patient’s vital signs to the general surgeon on a yellow sticky note was as follows: “Temp-98.2 F, Weight-341 lbs., Height-72 in., BP [Blood Pressure]-139/77, Pulse-84, RR[Respiratory Rate]-21, BMI [Body Mass Index]-46.3.”

The medical assistant then escorted the patient to an examination room. The general surgeon entered and spoke to the patient. The general surgeon took notes by hand, indicating the following:

“hemorrhoids three times after laminectomy[1l in January; symptoms greatly increased over the last six months; Bowel Habits-small stools, tenesmus [urge to defecate, but cannot], and mucus discharge; hiatal hernia; colonoscopy negative; History of polyps; no sigmoidoscopy.”

The general surgeon and the medical assistant created the chart note for the patient’s visit, which reports out the following:

CC [Current Complaint]: Hemorrhoids

HPI [History of Present Illness]: The patient is a pleasant 35- year-old referred here by [his primary care physician]. He is here because of a 3-year history of hemorrhoids with progressive painful BM’s [bowel movements], tenesmus, BRBPR [bright red blood per rectum], and small stools last 6 months. Known history of fissure. Last colonoscopy negative.

ROS [Review of Systems]: General-denies fever, night sweats, weight loss; Neurological-denies loc [loss of consciousness], ha [headaches], diplopia [double vision], tinnitus [ringing in the ears], vertigo [dizziness], numbness, tingling, incoordination; Respiratory-denies sob [shortness of breath], wheezing, coughing, hemoptysis [coughing up blood]; CV [cardiovascular system ]-denies angina, palpitation, leg cramps, pedal edema, pnd [ difficulty breathing], nocturia [ excessive urination at night], orthopmea [shortness of breath while lying down], claudication [cramping leg pain caused by exercise]; GI [gastrointestinal system]-denies nausea, vomiting, hematochezia [fresh blood in stool], hematemesis [vomiting blood], jaundice, diarrhea, incontinence, heartburn, indigestion, dysphagia [difficulty swallowing], poor appetite, constipation; GU [genitourinary]-denies dysuria [painful urination], hematuria [blood in urine], incontinence, impotence, pneumaturia [passage of gas with urine], fecuria [fecal matter in the urine]; MS [musculoskeletal]-denies stiffness, arthralgia joint pain], weakness, atrophy, bone pain, Raynaud’s [severe blood flow reaction to blood vessels in the cold in fingers and toes]; Endocrine-denies heat intolerance, cold intolerance, dry skin, dry hair, hoarseness, polydipsia [abnormally large thirst], polyuria [production of abnormally large levels of diluted urine]; Hematologic-denies bleeding, bruising, ecchymosis [discoloration of the skin resulting from bleeding underneath], pk [Pyruvate kinase deficiency, one of the most common enzymatic defects of the erythrocyte].

PMH [Past medical history]: Medical-hypertension, dyslipidemia [high cholesterol]; Surgical-lumbar laminectomy, micro-discectomy.

SH [Social history]: Patient denies recreational drug use; Smokes 1 pack/day for 15 years; Occasional alcohol consumption.

FH [Family history]: Mother- 69 alive with hypertension [high blood pressure]; Father-DEC [deceased] at 65 heart attack; Siblings- 1 brother alive at 41 with CVD [cardiovascular disease], 2 sisters alive, 1 with diabetes another with CVD.

Allergies: Penicillin.

Meds:

acetaminophen-hydrocodone 325 mg.-7.5 mg. [Norco] oral tablet, folic acid 1 mg oral tablet, Xanax XR 0.5 mg oral tablet, extended release, zolpidem [ Ambien] 10 mg oral tablet.

Vitals: T [temperature]-98.2 F, Wt [weight]-341 lbs., Ht [height]-72 in., BP [Blood Pressure]-139/77, P [pulse]-84, RR [Respiratory Rate]-21, BMI [Body Mass Index]-46.3.

PE [Physical examination]: General-WD/WN [well­-developed/well-nourished] in NAD [no abnormality detected]; HEENT[head, eyes, ears, nose, throat]-PERRLA [Pupils equal, round & reactive to light & accommodation], EOMl, [extraocular movements intact], ENT [ear, nose, throat] wnl [within normal limits]; Neck-not thyromegally [enlargement of the thyroid gland] or masses, no ND [jugular venous distension] or bruits [a systolic murmur heard in the neck]; Chest-clear to auscultation and percussion; Cardiac-no murmur or gallop; Abdomen-no masses or organomegaly [enlargement of the viscera], non-tender; Extremities-no clubbing, cyanosis or edema, full range of motion; Neuro-grossly intact; Anorectal­: inspection showed posterior fissure, with spasm, no further exam. Large skin tag RPQ [right posterior quadrant]. Cannot rule out hemorrhoids.

A/P [assessment/plan]:

#ANAL fissure (565.0);

#HYPERLIPIDEMIA OT/UNSPEC (272.4);

#HYPERTENSION UNSPEC (401.9).

Fissurectomy, lateral sphincterotomy, possible hemorrhoidectomy. The risks, benefits, and alternatives, including the slight chance of incontinence, are discussed.

Following the examination, the patient signed two information and consent forms: Hemorrhoids-Surgical Hemorrhoidectomy and Anal Fissure-Fissurectomy and Sphincterotomy.

No surgery was scheduled, and the patient left the general surgeon’s office. The general surgeon did not request the patient’s medical file from the primary care doctor.

On 4/23/2014, at approximately 9:00 a.m., the patient called the general surgeon’s office, complaining of terrible pain and pleading for relief. At the time, the general surgeon was in surgery at a surgery center. The general surgeon was contacted in the operating room (OR) by his office on behalf of the patient. Although the general surgeon was scheduled for a full day of surgeries, he offered to operate on the patient at the end of his surgical schedule that day. The patient accepted. The general surgeon’s office transmitted a Pre-Admission form, with Physician’s Orders, to the surgery center at approximately 10:00 a.m., requesting the patient have the following tests prior to surgery: “EKG [electrocardiogram]; CBC [complete blood count], without Differential (includes Platelets); UA[urine analysis]/Culture if indicated.”

At 3:44 p.m., the patient was admitted to the surgery center for his surgical procedures. The Admission’s Nurse completed the Admission Profile with the patient and the wife, noting, among other things: “Previous hospitalizations/surgeries-microdiscectomy 2010, lumbar laminectomy 2009, with DVT after laminectomy; Comprehensive Pain Assessment­ pain scale 10, rectum, onset at 16 years old, burning; Cardiovascular-high blood pressure, weird heartbeat about 8 months ago at cardiologist; Hema/Hepatic/GI-hemorrhoids, fissure; Psychiatric-Anxiety; Social Habits-smoker 1 PPD [pack per day], alcohol 2-4 times per month.”

The general surgeon completed a Short Form history and physical for the patient, noting: “Chief Complaint-Anal pain; History of Present Illness-severe pain secondary to anal fissure. Past Medical/Surgical History: HTN [hypertension]; Current Medications and Allergies: See-home medication list; Physical Exam-Head/Neck-normal,-Airway normal,-Neuro normal, Chest/Lungs normal, Heart normal, GI normal, GU normal, Extremities normal; Significant findings-anal fissure with right posterior skin tag; Diagnosis-Anal fissure; Plan-fissurectomy, sphincterotomy, and hemorrhoidectomy; Pre-Sedation Assessment For Procedure Without an Anesthesiologist-ASA2 II – mild systemic disease.”

At 4:12 p.m., a patient provided a urine sample and blood was taken for labs. At 4:53 p.m., labs revealed normal sodium, potassium, hemoglobin, and hematocrit. At 5:11 p.m., a pre-anesthetic evaluation was completed on the patient by an anesthesiologist. At 5:29 p.m., the patient was placed under general anesthesia. At 5:46 p.m., the general surgeon performed a hemorrhoidectomy, fissurectomy, and a right lateral sphincterotomy on the patient. The surgery was completed at 6:42 p.m., and the patient was in the recovery room at 7:00 p.m. The general surgeon prescribed the patient “Norco 10/325 mg., one tablet every four hours, as needed for pain; Valium 2 mg., one every six hours, as needed for pain; and Toredal (sic) 10 mg., one every six hours.” At 8:15 p.m., The patient was discharged.

The general surgeon drafted an Operative Report, noting, among other things:

“Preoperative Diagnosis-anal fissure; Postoperative Diagnosis-anal fissure and hemorrhoids; Procedures Performed-hemorrhoidectomy, fissurectomy, right lateral internal sphincterotomy; Anesthesia-general; Findings-anal stenosis with deep posterior anal fissure with large 3-quadrent (sic) hemorrhoids in the usual distribution, in the right anterior quadrant hemorrhoidal group there with chronic strangulation and gangrenous changes.”

On 4/24/2014, Post-Surgical Day 1 (PSDl), the patient’s wife called the general surgeon’s office four times: at 9:46 a.m., 10:32 a.m., 3:10 p.m., and 4:38 p.m. At 9:46 a.m., the patient’s wife reported that the patient had blood in his urine; the patient’s wife was told that the patient had a urinary catheter during surgery and blood in the urine was normal on PSDI. At 10:32 a.m., the patient’s wife reported the patient was vomiting and had diarrhea; the patient’s wife was told this was normal for PSDl. At 3:10 p.m., the patient’s wife reported the patient was still vomiting; a prescription for Reglan (anti-nausea) was called in. The patient’s wife collected the prescription, but the patient could not keep the Reglan down.

At 4:38 p.m., the patient’s wife reported the patient was still vomiting, with diarrhea, and feels hot, although his temperature is normal; the patient’s wife was told that the symptoms are normal for PSDl, and get fluids into the patient. The general surgeon did not return the calls from the patient’s wife on 4/24/2014.

On 4/25/2014, Post-Surgical Day 2 {PSD2); at 5:58 p.m., the patient’s wife called the surgery center and reported the patient was still vomiting, with diarrhea, and feels hot; the patient’s wife was told the symptoms were normal for PSD2, but to call the general surgeon’s office. The patient’s wife called the general surgeon’s office, spoke to the answering service, and requested a callback.

At 6:40 p.m., the general surgeon telephoned the patient’s wife. The patient’s wife reported pus at the surgical site and that the stitches looked ripped open and yellow; the general surgeon said they were breakaway stitches and the appearance was normal for PSD2. They did not discuss the patient’ s symptoms from PSD 1.

On 4/26/2014, the patient began speaking nonsensically. He complained about pain in his legs. The patient’s wife called the general surgeon’s office at 12:36 p.m. and 12:40 p.m., but the office was closed for lunch and the patient’s wife did not leave a message with the exchange.

The patient’s wife then telephoned the surgery center at 12:46 p.m. and 12:47 p.m. The patient’s wife reported the patient was speaking nonsensically, with purple, blotchy legs, purple lips, and slurred speech; the patient’s wife was told to bring the patient into the hospital. At 12:58 p.in., 911 was called. Paramedics appeared and transported the patient to the surgery center.

The patient arrived at the surgery center at 1:35 p.m. In the ambulance, the patient was intubated and described by EMS as “acutely cyanotic and mottled.” Upon arrival, the patient was treated by an ED physician in the ED for two hours.

The ED physician drafted an ED Report, indicating, among other things: “This is a 36-year-old white male who comes to the emergency room by ambulance in extremis [at the point of death]. He was intubated in the field by the paramedics.”

“On arrival in the department he was purple mottled, unresponsive with a heart rate in the 60s which later proceeded to become bradycardic into the 20s.” ” … [A] temperature of 41 Centigrade [105.8 Fahrenheit] was noted.”

“Examination of the rectum revealed maceration and postoperative changes. It does appear consistent with an infection in the area.”

“Labs later returned showing renal failure with a creatinine of 9. Potassium was elevated.”

“Diagnosis-septic shock, renal failure, perineal infection, status post hemorrhoidectomy. His prognosis seems exceedingly poor.”

“Total critical care time 120 minutes.”

At 2:50 p.m., the ED physician contacted the general surgeon regarding the patient, reporting sepsis, renal failure, hyperlipidemia, recent hemorrhoidectomy with local infection. The general surgeon telephoned the surgery center to reserve an OR for the patient, scheduling the first available OR at 5 p.m.

At approximately 3:30 p.m., the patient was admitted to the surgery center and his care was transferred to an internist. After 5:00 p.m., the patient was taken to interventional radiology (IR) for placement of an IVC [inferior vena cava] filter (5:35 p.m.) and a temporary dialysis catheter (5:43 p.m.).

At 5:50 p.m., the patient was moved from IR into the OR, where the general surgeon waited. On arrival to the OR, the transport staff reported a change in heart rhythm. A Code Blue was called at 6:05 p.m. Resuscitative measures commenced but were unsuccessful, and time of death was called at 6:41 p.m.

The internist charted a Discharge Summary, noting: “Discharge Diagnosis-(1) patient died, (2) severe septic shock, (3) most likely perirectal phlegmon [inflammatory process with pus] versus fasciitis [inflammation of connective tissue]. History of Hospital Stay-This was a 36-year-old gentleman admitted at [the hospital] with septic shock. He was hypotensive, unresponsive, intubated in the field. While in the emergency room, the patient had episodes of bradycardia [abnormally slow heart action]. He was found to have multi-organ system failure with acute kidney insufficiency. He was taken to the OR for an emergent exploratory laparotomy [a surgical incision into the abdominal cavity, for diagnosis or in preparation for surgery]. Unfortunately, he coded on the OR table.”

The general surgeon wrote a Death Note in the chart, indicating: “Patient came in with septic shock. Code blue called in route to OR. CPR commenced in the OR per ACLS [advanced cardiac life support] protocol. Planned perineal debridement and colostomy never took place. Code was called after 22 min of resuscitative effort then resumed after seemingly having spontaneous cardiac electrical activity and pulse, but this was transient, and soon patient became pulseless without meaningful cardiac activity. Patient after hemorrhoidectomy and has perineal gangrene.”

An autopsy was performed on April 28, 2012, at the Fresno County Coroner’s Office. A blood culture was taken, revealing gram-negative rods isolated [bacterial infection]. The cause of death is listed as probable cardiac arrhythmia due to idiopathic hypertrophic cardiomyopathy.

The general surgeon was placed on probation for three years with stipulations of completing an education course and undergoing monitoring by another physician.

State: California


Date: May 2017


Specialty: General Surgery, Internal Medicine


Symptom: GI Symptoms (GERD, Abdominal Distention, Dysphagia), Fever, Nausea Or Vomiting, Pain, Urinary Problems


Diagnosis: Sepsis


Medical Error: Delay in proper treatment, Failure of communication with patient or patient relations, Improper treatment


Significant Outcome: Death


Case Rating: 4


Link to Original Case File: Download PDF



California – Cardiology – Inferior Wall Myocardial Infarction With Wire Placed In Small Side Branch And Balloon Dilated



On 7/5/2013, a 67-year-old female was brought by ambulance to a medical center for severe chest pains.  An electrocardiogram (EKG) was obtained and was consistent with inferior wall myocardial infarction.  The patient was immediately brought to the cardiac catheterization lab for angiography and angioplasty.

A cardiologist was noted to by the Board to have placed a wire in a small side branch and not in the distal right posterior descending artery, where the culprit lesion was located.  He inflated the balloon in the small side branch leading to a small perforation.  He then moved his wire and made another inflation, which resulted in a larger perforation.  After causing these four perforations and a large pericardial effusion, the cardiologist proceeded to inflate the balloon an additional four times.

At 7:47 p.m., the pericardial effusion was documented.  However, pericardiocentesis was not performed until 8:21 p.m.  The delay occurred even though the patient’s blood pressure continued to decline.

The Medical Board of California judged the cardiologist’s conduct as having fallen below the standard of care given failure to perform a pericardiocentesis in a timely manner, failure to identify the pericardial effusion in a timely manner, failure to place the wire in the correct location, and failure to address the culprit lesion.

The Medical Board of California placed the cardiologist on probation with stipulations to complete 40 hours annually while on probation of continuing medical education in the areas of deficiency, complete a clinical competence assessment program, and complete a professional enhancement program.  The professional enhancement program would include a quarterly chart review, semi-annual practice assessment, and semi-annual review of professional growth and education.

State: California


Date: April 2017


Specialty: Cardiology


Symptom: Chest Pain


Diagnosis: Acute Myocardial Infarction, Post-operative/Operative Complication


Medical Error: Wrong site procedure, Delay in proper treatment, Diagnostic error, Procedural error


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



Kansas – Physician Assistant – Inappropriate Altering Of Medical Records In A Patient With Diverticulitis



On October 2015, a patient had been hospitalized for eight days with acute sigmoid diverticulitis.

On 11/9/2015, the patient was seen by an internist at a clinic for a hospital follow-up. The internist noted that the patient still had abdominal pain in the left lower quadrant (“LLQ”), but was improved.  Further, the internist noted that the patient had tenderness to palpation to the LLQ and the right lower quadrant (“RLQ”) with no guarding or rebound.  The internist documented that the patient’s diverticulitis was improved and his plan was for the patient to finish taking his prescribed Levaquin.

On 11/13/2015, the patient presented to the emergency department with abdominal pain rated 10/10.   A physician assistant noted that the patient “Does pause episode to speak and answer questions,” and “guards throughout exam.”  The physician assistant’s impression was “Non-Acute Long Standing.”  The physician assistant ordered a “GI-Cocktail” on the ED physician order sheet and then discharged the patient with a diagnosis of abdominal pain with a plan for a CT in the morning.

It is unclear why the physician assistant did not obtain the CT at that time.  At some point, the physician assistant added an untimed order for Dilaudid 2 mg IV to a copy of the original ED physician order sheet.

The patient returned that morning on 11/13/2015 and had a CT scan that indicated bowel perforation and possible entero-colonic fistula.

The physician assistant took the patient to the ED, the patient was crying in pain, and the physician reported that the patient had a CT and needed to be transferred for surgery.

The physician assistant altered the patient’s medical records including the following: altered the time the patient was seen in the ED, changed the diagnosis from “Non-Acute Long Standing” to “Now-Acute/Long Standing” on the emergency physician record, crossed out the checkbox “home” and circled the checkbox “transfer” on the emergency physician record, and crossed out the ED number and wrote “From clinic.”  The physician assistant did not initial the alterations, indicate when the alterations were made, nor why the alterations were made.

The Board judged that the physician assistant likely deceived, defrauded, or caused harm to the patient by inappropriately altering the patient’s medical records.

For this allegation and others, the Board ordered the physician assistant to contact The Center for Personalized Education for Physicians, (“CPEP”) for a competence assessment, follow all recommendations of the CPEP assessment, and complete a medical record keeping seminar.

State: Kansas


Date: April 2017


Specialty: Physician Assistant, Emergency Medicine, Internal Medicine


Symptom: Abdominal Pain


Diagnosis: Acute Abdomen


Medical Error: Ethics violation, Delay in proper treatment, Diagnostic error, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



Florida – Internal Medicine – History Of Atrial Fibrillation On Warfarin With INR Of 4.3 Started On Levofloxacin



On 3/26/2013, an 80-year-old female presented to a medical center with complaints of epigastric and right upper quadrant pain related to acute diverticulitis.

Upon the patient’s admission to the medical center, her medical records noted a history of atrial fibrillation and seizure disorder.  The records also indicated that she was on warfarin.

On 3/26/2013, the patient’s INR (admission INR) was recorded in the therapeutic range between 2.0 and 3.0.

On 3/26/2013, an internist improperly assessed the daily amount of warfarin that the patient was receiving prior to her admission to the medical center.  The internist increased the amount of the patient’s daily warfarin dosage.

The internist also prescribed Levaquin, an antibiotic, to treat the patient’s diverticulitis.  Levaquin can increase the anticoagulant effect of Warfarin.  On 3/28/2013, the patient’s INR was recorded as 4.3  On 3/29/2013, the patient’s INR was recorded as 8.9.

The administration of vitamin K and/or fresh frozen plasma is associated with anticoagulant reversal or moderation.  On 3/29/2013, the internist facilitated the oral administration of vitamin K to the patient.  Parenteral administration of vitamin K is indicated over oral administration in treating acute coagulopathy of the nature then-exhibited by the patient.

On 4/1/2013, the patient suffered an intracranial hemorrhage.

The internist did not facilitate the administration of fresh frozen plasma until 4/1/2013, after the patient exhibited neurologic change.  He did not facilitate the parenteral administration of vitamin K until 4/2/2013.

On 4/9/2013, the patient died from an intracranial hemorrhage due to Coumadin coagulopathy.

The Medical Board of Florida judged the internists conduct to be below the minimal standard of competence given that he failed to accurately assess the amount of warfarin that the patient was receiving prior to admission and treat with appropriate dosages accordingly.  The internist failed to recognize that the patient’s treatment for an acute infection, ingestion of Levaquin, and age put her at increased risk for acute coagulopathy, and treat accordingly.  He also failed to treat earlier for acute coagulopathy and with more aggressive methods, especially including earlier parenteral vitamin K and/or fresh frozen plasma.

It was requested that the Medical Board of Florida order one or more of the following penalties for the internist: 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 Medical Board of Florida deemed appropriate.

State: Florida


Date: March 2017


Specialty: Internal Medicine


Symptom: Abdominal Pain


Diagnosis: Drug Overdose, Side Effects, or Withdrawal, Cardiac Arrhythmia, Acute Abdomen


Medical Error: Improper medication management, Delay in proper treatment


Significant Outcome: Death


Case Rating: 4


Link to Original Case File: Download PDF



California – Hospitalist – Post-Operative Complications Of Tachycardia, Abdominal Swelling, And Respiratory Distress After Knee Replacement Surgery



On 12/5/2011, a patient underwent knee replacement surgery.  In the course of his post-operative recovery in the hospital, the patient developed a rapid heartbeat.

On 12/6/2011, he was seen by Hospitalist A in the morning.  Hospitalist A attributed the patient’s rapid heart rate to his pre-existing atrial fibrillation and ordered an oral beta-blocker.  The patient’s heart rate was soon restored to a more moderate level.  The patient was transferred to the telemetry unit for closer monitoring at about 11:00 a.m.  Hospitalist A saw the patient again the following morning, noting that the patient was on nasally-administered supplemental oxygen, that his cardiac rhythm was irregular, that he was anemic, and that he had diminished bilateral breath sounds.  The hospitalist ordered chest x-rays and a blood transfusion.  The hospitalist’s order for a chest x-ray read “?chf” under “Indications.”

On 12/8/2017 at 8:40 a.m., nursing notes stated that the patient was receiving 2 liters of oxygen per minute via nasal cannula and his oxygen saturation level was 94%.  Hospitalist A’s chart entries made at about 10:40 a.m. indicate the patient was anemic, displayed some mental confusion, and had abdominal distention.  Hospitalist A opined that the distention “(m)ay be ileus due to oral morphine SR plus PRNs But r/o bleeding.”

Hospitalist A ordered x-rays of the patient’s abdomen, which confirmed the presence of an intestinal ileus.  Hospitalist A did not obtain a CT scan of the patient’s abdomen.  At about 3:50 p.m., Hospitalist A directed a nasogastric tube be placed to decompress the ileus.  Nursing notes from that evening indicate that the patient’s abdomen was “very distended, rounded” with hypoactive bowel sounds.

On 12/9/2017 at 2:30 a.m., a chart entry by Hospitalist B noted that the patient was “extremely uncomfortable with increased abdominal distention.”  She ordered a Harris flush procedure to reduce the patient’s intestinal pressure.

On 12/9/2017 at 3:58 p.m., the patient’s oxygen monitor alarm was sounding.  His oxygen saturation was 74% despite 2 liters per minute of supplemental oxygen.  Nurses repositioned the patient in bed and increased the oxygen flow rate to 5 liters per minute.  The indicated oxygen saturation increased to 88%.  The nasal cannula was moved to the patient’s mouth and the indicated oxygen saturation increased to 91-93%.  Hospitalist A was notified of the patient’s condition.

At 4:30 p.m., the attending nurse again called Hospitalist A to report that the patient was extremely short of breath with “labored” respirations and an indicated oxygen saturation “in the low to mid 80s.”  Hospitalist A directed that the patient be repositioned higher in bed; the nurse informed Hospitalist A that the patient was in the highest possible position.  Hospitalist A gave no new orders regarding the patient’s care.

The attending nurse’s chart entry for 5:10 p.m. states the following:

“(p)t’s condition continues to worsen.  Pt unable to hold O2 sats about low to mid 80’s on 5 liters NC.  Respiratory called to put on non-rebreather mask.  Pt’s LOC is decreased.  Pt repositioned up in bed.  NG tube flushed.  Pt requiring one-to-one nursing care.  Follow-up call to break and relief nurse’s call to [Hospitalist A] to ask that he come to the floor to see pt, d/t pt’s deteriorating respiratory status.  [Hospitalist A] still not answering the phone.”

The attending nurse placed a “Rapid Response” call to summon a physician to assess the patient at 5:20 p.m.  Hospitalist A came to the patient’s room, and his notes state that the patient’s oxygen saturation improved when he was repositioned in bed, “up to the 90s and stayed above 92” per measurement by the respiratory care provider.  Hospitalist A decided to continue with the current treatment on the medical floor rather than transferring the patient to the intensive care unit.

The medical record indicates that at 5:50 p.m., the patient’s oxygen saturation level is “in the 90’s but the O2 sat is variable with sat going down into the 80’s.”  The patient was still receiving supplemental oxygen via the 100% non-rebreathing mask.  The nursing notes for this time state that the patient’s daughter, a nurse, believed the patient should be monitored in the intensive care unit rather than on the medical floor and conveyed that desire for transfer to nursing staff, the nursing supervisor, and to Hospitalist A.

Nursing notes for 6:45 p.m. state the following:

“BP 92/63 HR 120’s.  Pt minimally responsive, respirations increasingly labored.  Telemetry and O2 sat monitors frequently alarming.  Pt requiring RN at bedside at all times.  pt hands cyanotic and remain cool to touch and forehead now appears slightly bluish in color.  [Hospitalist A] aware.  Family tearful, verbalizing anger w/staff regarding pt not being transferred to ICU.”

At 7:05 p.m., Hospitalist B ordered the patient to be transferred to the intensive care unit, apparently in deference to the fact that the “family, rn, supervisor want the pt moved to icu though it was discussed with all by the rounding hbs that there are not criteria for icu…”  The patient was taken to the intensive care unit at about 7:35 p.m.

The intensive care nurse’s notes state that the patient arrived at the ICU unresponsive with his oxygen saturation reading in the 70% range despite being on 15 liters of supplemental oxygen per minute via non-rebreather mask.  The patient’s fingers and toes were cyanotic and his body mottled.

On 12/10/2011 at 3:10 a.m., the patient died despite additional care.

The Board expressed concern that Hospitalist A practiced below the standard of care by failing to order an abdominal CT scan in a patient with an identified bowel obstruction that was not responding to care.  He failed to recognize clinical indicators of early septic shock and make a timely transfer of the patient to a higher level of care.  He failed to recognize and respond to the patient’s acute respiratory distress.

The Board issued a public reprimand.  He was ordered to take a course in early recognition of septic shock.

State: California


Date: January 2017


Specialty: Hospitalist, Internal Medicine


Symptom: Shortness of Breath, GI Symptoms (GERD, Abdominal Distention, Dysphagia)


Diagnosis: Sepsis, Acute Abdomen


Medical Error: Delay in proper treatment, Diagnostic error, Failure to order appropriate diagnostic test, Failure of communication with patient or patient relations, Failure to properly monitor patient


Significant Outcome: Death


Case Rating: 3


Link to Original Case File: Download PDF



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