Found 13 Results Sorted by Case Date
Page 1 of 2

Florida – Family Medicine – Treatment Of Elevated Blood Pressure And Headaches From Illicit Testosterone Injections



On 2/17/2014, a male patient in his early twenties presented to a family practitioner for medical assessment and/or treatment.

On 2/17/2014, the patient disclosed to the family practitioner that he was obtaining injectable testosterone from a source unknown to the family practitioner.  The patient indicated that he was utilizing the testosterone for bodybuilding purposes.

On 2/17/2014, the patient reported to the family practitioner that he was suffering from headaches and elevated blood pressure.

On 2/17/2014, the family practitioner surmised that the patient’s symptoms were likely the result of excess estrogen production secondary to the patient’s high-dose testosterone use.

On 2/17/2014, the family practitioner wrote the patient a prescription for Anastrozole, an estrogen-blocking substance.

On 2/20/2014, the patient presented to the family practitioner for medical assessment and/or treatment.  The family practitioner continued the patient on Anastrozole.

In February 2014, the family practitioner did not obtain or review any medical records establishing that the patient was experiencing excess estrogen production.  He also did not obtain bloodwork or perform other diagnostic testing to confirm whether the patient was experiencing excess estrogen production.

On 4/6/2014, the patient presented to the family practitioner for medical assessment and/or treatment.  The patient reported to the family practitioner that he was continuing to use testosterone, and that he was continuing to experience headaches.  The family practitioner surmised that the patient’s ongoing headaches were caused by elevated prolactin levels.  The family practitioner wrote the patient a prescription for Cabergoline, a prolactin-blocking substance.

On 4/10/2014, the patient presented to the family practitioner for medical assessment and/or treatment.  The family practitioner continued the patient on Cabergoline.

In April 2014, the family practitioner did not obtain or review any medical records establishing that the patient was experiencing elevated prolactin levels.  He did not obtain bloodwork or perform other diagnostic testing to confirm whether the patient was experiencing elevated prolactin levels.

On one or more occasions between 6/27/2014, and 1/9/2015, the family practitioner prescribed the following substances to the patient: clindamycin, Bactroban ointment, doxycycline, Zithromax, oral prednisone, Neurontin, and diazepam.  On one or more occasions in 2015, the family practitioner also prescribed the patient Anastrozole.

The family practitioner did not keep any contemporaneous medical records regarding the medical assessment and/or treatment that he provided to the patient between 2/17/2014 and 1/9/2015.

To the extent that the family practitioner had medical records regarding the medical assessment and/or treatment that he provided to the patient between 2/17/2014 to 1/9/2015, such records were all created in October 2015.

The Medical Board of Florida issued a letter of concern against the family practitioner’s license.  The Medical Board of Florida ordered that the family practitioner pay a fine of $8,000 and pay reimbursement costs for the case at a minimum of $1,457.57 and not to exceed $3,457.57.  The Medical Board of Florida ordered that the family practitioner complete a drug course, a medical records course, and five hours of continuing medical education in “risk management.”

State: Florida


Date: December 2017


Specialty: Family Medicine, Endocrinology, Internal Medicine


Symptom: Headache


Diagnosis: Drug Overdose, Side Effects, or Withdrawal


Medical Error: Failure to order appropriate diagnostic test, Improper medication management, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



Florida – Pain Management – Increase In Dosage Of Nature-Throid In A Patient With Normal TSH And T4 Levels



On 6/3/2013, a 67-year-old female presented to a pain management specialist for treatment of her previously diagnosed hypothyroidism.  The pain management specialist prescribed the patient 65 mg of Nature-Throid daily and drew blood for lab tests.  Each 65 mg Nature-Throid medication consists of 38 mcg of levothyroxine and 9 mcg of liothyronine.  The results of the patient’s blood tests showed normal TSH levels, normal T4 levels, and slightly elevated T3 levels.

On 6/18/2013, the pain management specialist increased the patient’s prescription for Nature-Throid to 130 mg daily.  The results of the patient’s blood tests did not justify increasing the dosage of Nature-Throid prescribed to the patient.  A reasonably prudent physician would only have increased the dosage of Nature-Throid prescribed to the patient with justification.  The pain management specialist did not document justification for increasing the dosage of Nature-Throid prescribed to the patient.  The blood tests did not justify prescribing the 130 mg of Nature-Throid daily.  A reasonably prudent physician would have waited for the patient’s hormone levels to properly balance and reach equilibrium before altering the dosage of Nature-Throid prescribed to the patient.

On 7/16/2013, the pain management specialist increased the patient’s prescription for Nature-Throid to 195 mg daily.  A reasonably prudent physician would not have altered the dosage of Nature-Throid prescribed to the patient without having ordered blood tests for the patient.  The pain management specialist did not document justification for increasing the dosage of Nature-Throid prescribed to the patient.  A reasonably prudent physician would have waited for the patient’s hormone levels to properly balance and reach equilibrium before altering the dosage of Nature-Throid prescribed to the patient.

On 7/16/2013, the pain management specialist informed the patient that he was increasing her dosage of Nature-Throid based on her body temperature.  A reasonably prudent physician would not have increased the dosage of Nature-Throid prescribed to the patient based on the patient’s body temperature.  Also, a reasonably prudent physician would have ordered blood tests for the patient, and he did not order or document ordering any blood tests for the patient.

The Board issued a letter of concern against the pain management specialist’s license.  The Board ordered that he pay a fine of $5,000 against his license and pay reimbursement costs for a minimum of $5,857.09 and not to exceed $7,857.09.  The Board also ordered that he complete a records course and complete ten hours of continuing medical education in endocrinology and complete a course in quality assurance consultation/risk management assessment.

State: Florida


Date: June 2017


Specialty: Pain Management, Endocrinology


Symptom: N/A


Diagnosis: Endocrine Disease


Medical Error: Improper medication management


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



Florida – Internal Medicine – Failure To Order Appropriate Diagnostic Testing For A Patient With Migraine Headaches And Suspicion For Adrenal Insufficiency



On 1/24/2014, a patient presented to an internist with symptoms of intractable migraine headaches.  The internist proceeded to test cortisol levels in the patient.

The Board judged the internists conduct to be below the minimal standard of competence given that he failed to use the proper lab data for diagnosing Addison’s disease or any related conditions, treat the patient with a standard dosage treatment of prednisone to start with, and utilize a taper of the prednisone dosage within a few days of starting.

It was requested that the Board 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 Board deemed appropriate.

State: Florida


Date: June 2017


Specialty: Internal Medicine, Endocrinology


Symptom: Headache


Diagnosis: Endocrine Disease


Medical Error: Failure to order appropriate diagnostic test, Improper medication management


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



Florida – Internal Medicine – Use Of Diltiazem In A Tachycardic And Hypotensive Patient



On 2/20/2012, a 31-year-old female presented to the medical emergency department with abdominal pain and shortness of breath.

On 2/20/2012 at 2:06 p.m., the patient had a blood pressure of 147/81 and a heart rate of 165 beats per minute.  At 2:52 p.m., the patient had a heart rate of 153 beats per minute.  At 3:24 p.m., the patient had a blood pressure of 94/40 and a heart rate of 132 beats per minute.  At 4:08 p.m., the patient had a heart rate of 157 beats per minute.  At 6:04 p.m., the patient had a blood pressure of 98/50 and a heart rate of 145 beats per minute.

From 2:06 p.m. until 6:04 p.m., the patient was sinus tachycardic and hypotensive.

At 6:52 p.m., an internal medicine practitioner on the unit was advised of the patient’s consistent elevated heart rate.  From 6:52 p.m., the internist was the physician treating the patient.

At 7:00 p.m., the internist ordered the administration of 10 mg of diltiazem to the patient one time, over two minutes.

At 7:10 p.m., the patient had a palpated systolic pressure of 80 and a heart rate of 125 beats per minute.  The patient’s medical records indicated that due to the patient’s low blood pressure, 5 mg of diltiazem was administered over five minutes.

Diltiazem is not indicated for the treatment of sinus tachycardia. Diltiazem is contraindicated in the setting of hypotension. Diltiazem is contraindicated in the setting of hypotension and sinus tachycardia.

The patient’s medical records include a correction that indicates that additional vital signs were obtained at 6:43 on 2/20/2012.  According to that record, the patient had a blood pressure of 186/76 and a heart rate of 82 beats per minute.

Diltiazem is not indicated for a patient with a blood pressure of 186/76 and a heart rate of 82 beats per minute.

Ultimately, the patient died after a hospitalization lasting 4 weeks.  A lawsuit was filed alleging the patient was not transferred to an ICU in a timely fashion.  There were no ICU beds available at the hospital where she had been treated.  The suit alleged the hospital should have transferred the patient to another hospital with an available ICU bed.

In the lawsuit, it was noted that the patient had developed diabetic ketoacidosis, severe metabolic acidosis, and pancreatitis.  After she was administered the doses of diltiazem mentioned above, she went into cardiac arrest before transfer to an ICU.  It was noted that the patient was held in the emergency department from the time of her arrival at 1:52 p.m. until her transfer at 12:10 a.m. the following day (for a total of over 10 hours).  On 3/18/2012, she died.

The Board judged the internists conduct to be below the minimal standard of competence given that he ordered the administration of diltiazem to a patient when diltiazem was not indicated and/or was contraindicated.

The Board issued a letter of concern against the internist’s license.  The Board ordered that the internist pay an administrative fine of $5,000 against his license and pay reimbursement costs for the case for $10,000.  The Board also ordered that the internist complete ten hours of continuing medical education in “internal medicine” and five hours of continuing medical education in “risk management.”

State: Florida


Date: June 2017


Specialty: Internal Medicine, Emergency Medicine, Endocrinology


Symptom: Palpitations, Abdominal Pain


Diagnosis: Cardiovascular Disease


Medical Error: Improper medication management


Significant Outcome: Death


Case Rating: 4


Link to Original Case File: Download PDF



Florida – Emergency Medicine – Pelvic Pain And Vaginal Bleeding With Urinalysis Revealing A Glucose Level >1000



On 8/21/2014, a patient presented with complaints of pelvic pain and vaginal bleeding.  The patient was examined by a physician assistant supervised by an ED physician.

The physician assistant ordered laboratory evaluation for the patient, which included bloodwork, cervical/vaginal swabs, pelvic ultrasound, and urinalysis.

The urinalysis revealed the patient’s glucose level to be >1000, which was so high that it could not be measured.

The physician assistant gave the patient a prescription for Flagyl, an antibiotic, gave her education materials on uterine bleeding, bacterial vaginosis, dehydration, and ovarian cysts, and instructed her to follow up with her primary care physician and gynecologist.   The physician assistant discussed the patient’s case with the ED physician and the ED physician agreed with the plan of care.

The ED physician did not perform or order a finger stick glucose test or a basic metabolic panel.

The ED physician did not discuss and/or did not order the physician assistant to discuss the patient’s glucose level in relation to her possible new onset of diabetes and did not recommend or order the physician assistant to recommend further evaluation and treatment of her elevated glucose levels.

The ED physician did not administer or order the administration of intravenous fluid and insulin.

On 8/26/2014, the patient expired due to diabetic ketoacidosis.

The Medical Board of Florida judged the ED physician’s conduct to be below the minimal standard of competence give that she failed to administer or order the administration of a finger stick glucose test or basic metabolic panel, discuss or instruct the physician assistant to discuss the patient’s glucose levels in relation to her possible new onset of diabetes and recommend further evaluation and/or treatment of her elevated glucose levels, and failed to administer or order the administration of intravenous fluid and insulin.

It was requested that the Medical Board of Florida order one or more of the following penalties for the ED physician: permanent revocation or suspension of her license, restriction of practice, imposition of an administrative fine, issuance of a reprimand, probation, corrective action, payment of fees, remedial education, and/or any other relief that the Medical Board of Florida deemed appropriate.

State: Florida


Date: April 2017


Specialty: Emergency Medicine, Endocrinology, Physician Assistant


Symptom: Pelvic/Groin Pain, Abnormal Vaginal Bleeding


Diagnosis: Diabetes


Medical Error: Failure to follow up, Failure to order appropriate diagnostic test, Failure of communication with other providers, Improper supervision, Improper medication management


Significant Outcome: Death


Case Rating: 4


Link to Original Case File: Download PDF



Washington – Endocrinology – Lack Of Communication Of Blood Test Results With Patient



On 7/16/2014, a patient saw an endocrinologist after being referred by her gynecologist for concerns about “not feeling well” and for questions about whether her hypothyroidism needed additional evaluation and management.

The patient described how the endocrinologist told her to throw out her other medications prescribed by her trusted long-term gynecologist, go on an antidepressant, and see a therapist.  This advice was upsetting to the patient.

At the close of the visit, the patient went to the laboratory and gave a blood sample for testing.  When the patient did not hear of the test results from the clinic after about 10 days, she contacted the clinic and was told that the results could not be found.

In a response to the complaint by the patient that she did not receive timely test results from the endocrinologist, the endocrinologist stated, through her lawyer, that the results were available through a patient electronic record portal called eCare.  However, the patient had not enrolled in eCare and thus did not have access to the test results.  The endocrinologist stated she planned to disclose and review the test results with the patient at a return visit in 3 months.  The patient eventually established care with another endocrinologist.

The endocrinologist’s treatment of the patient fell below the standard of care when the endocrinologist failed to timely communicate the test results which showed the patient’s Hemoglobin A1C was at 6.1%.  This test result is within a range that can be characterized as “prediabetes,” signifying that a patient may develop a diagnosis of diabetes within 10 years.  A diagnosis of diabetes requires a test result of 6.5% or higher.

The Commission stipulated the endocrinologist reimburse costs to the Commission, complete a course on how to maintain and improve communication between physician and patient, and write and submit a paper of at least 1000 words, with annotated bibliography, on the importance of timely communication of laboratory results to patients and others with a need to know.

State: Washington


Date: October 2016


Specialty: Endocrinology


Symptom: N/A


Diagnosis: Diabetes


Medical Error: Failure of communication with patient or patient relations


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



North Carolina – Endocrinology – Concern Raised Over Dosing Of Norditropin For Short Stature



The Board received a complaint regarding the care of a patient.

On 04/03/2013, an 8-year-old boy was referred to an endocrinologist for the evaluation of possible low testosterone.  The boy weighed 20.4 kg and was 46 inches tall.  The endocrinologist examined the patient and noted that he had significant short stature.  He recommended laboratory and radiographic testing in order to develop a definitive plan of care.

On 05/01/2013, the endocrinologist reviewed the patient’s laboratory results with the patient’s parents and explained that the patient’s bone age was approximately 66 months, yet his chronological age was 98 months.  The endocrinologist decided to obtain a growth hormone stimulation test, which was done in June 2013.

On 07/08/2013, the patient presented to the endocrinologist for a follow-up.  The patient weighed 21.1 kg and was 46.5 inches tall.  The endocrinologist reviewed the patient’s laboratory and radiographic results and diagnosed growth hormone deficiency.  The endocrinologist prescribed the growth hormone drug Norditropin (somatropin [rDNA origin] injection).  This treatment involved the patient’s parents injecting the drug Norditropin into the patient’s body.

On 08/16/2013, Norditropin was started on the patient at a dose of 0.6 mg daily (0.23 mg/kg/week).

On 11/27/2013, the patient presented for a follow-up.  The parents mentioned no problems with injecting the Norditropin.  Height was 46.75 inches.  The patient’s Insulin-Like Growth Factor I (“IGF-1”) was 98 ng/ml (normal for this age was 49-351).  The endocrinologist increased the patient’s Norditropin dose to 1.4 mg daily (0.45 mg/kg/week) for one month and then 2 mg daily (0.64 mg/kg/week) until the patient’s next follow-up visit.

On 01/27/2014, the patient presented for a follow-up.  Height was 47.75 inches.  IGF-1 was 146 ng/ml (normal for age was 72-323).  The endocrinologist increased the patient’s Norditropin dose to 3 mg daily (0.9 mg/kg/week).

On 04/07/2014, the patient, now 9 years old, presented for a follow-up.  Height was 48.25 inches and IGF-1 was 210 ng/ml (normal for age was 84-362).  His dose was increased to 4 mg (1.1 mg/kg/week).

On 06/11/2014, the patient presented for a follow-up.  Height was 50 inches and IGF-1 was 203 ng/ml (normal for age was 84-362).  The endocrinologist recommended increasing the Norditropin to 6 mg daily (1.59 mg/kg/week) and wrote prescriptive instructions to that effect.  However, the specialty pharmacy that had been providing the patient’s Norditropin refused to fill the prescription at that dose and the patient never received the 6 mg daily dose.

On 08/06/2014, the patient went to see a pediatric endocrinologist physician who has specialty training and certification in the field of pediatric endocrinology.  This physician lowered the patient’s Norditropin dosage as follows:

“For management of the short stature, I have decreased the growth hormone (Norditropin) to 1.1 mg at night time (0.300 mg/kg/wk as recommended for children with growth hormone deficiency).”

This pediatric endocrinologist treated the patient three months later on 11/3/2014 and noted that he had grown 2 cm (0.79 inches) on the 1.1 mg Norditropin dosage.

The Board obtained the patient’s records and sent them to two qualified independent medical experts for review.  The independent medical experts judged the endocrinologist’s conduct to be below the minimum standard of competence given failure to prescribe the correct Norditropin dosage to the patient.  They did not think the endocrinologist should have increased the dosage based solely on the patient’s IGF-1 levels.  The endocrinologist disagreed with the experts.  The Board notes that the patient was not harmed by the IGF-1, although they acknowledged that there was potential harm if high dose Norditropin therapy is administered in the long term.

The endocrinologist had his care reviewed by three independent medical experts who felt that the care of the endocrinologist was within the standard of care.  One expert wrote that the care of the patient was “evidence-based and follows standard of care.”  One of those experts was the pediatric endocrinologist who lowered the dose of Norditropin from 4 to 1.1 mg.  It is noted that this expert has worked with the endocrinologist over eight years and the endocrinologist referred patients to this expert.  She wrote that her adjustment of the dose “does not imply that [your]dosage was wrong or outside the standard of care” and wrote that the endocrinologist was “a dedicated doctor who provides elite care to his patients.”

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: August 2016


Specialty: Endocrinology, Pediatrics


Symptom: N/A


Diagnosis: N/A


Medical Error: Improper medication management


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



Florida – Obstetrics – Pregnant Patient With TSH Of 0.10 MIU/L



On 1/9/2013, a 25-year-old female patient began her first pregnancy care at a medical center where she was examined by a physician.  The patient was in her first trimester of pregnancy.  The patient weighed 154 pounds.  The physician ordered laboratory analysis of the patient’s thyroid stimulating hormone (TSH) blood level.

On 2/1/2013, a sample of the patient’s blood was collected for TSH analysis.

On 2/5/2013, the TSH level result was reported low at 0.10 MIU/L with a first trimester reference range of 0.26-2.66 MIU/L.

On 2/7/2013, the patient returned to the medical center for obstetric follow-up and complained that she could not hold down food.  The patient weighed 150 pounds.  An obstetrician evaluated the patient.

The medical records document that on 1/22/2013 the patient had been prescribed Zofran 8 mg, with instructions to take one tablet every eight hours for fifteen days.  Zofran is the brand name for ondansetron, an anti-emetic used during pregnancy for treatment of morning sickness, nausea, and vomiting.

On 2/7/2013, the medical records document that the patient would be traveling for three months.

The obstetrician prescribed Phenergan suppositories to the patient.  Phenergan is the brand name for promethazine, an antihistamine with antiemetic properties used during pregnancy to treat morning sickness, nausea, and vomiting.

On 2/7/2013, the medical centers records documented the patient’s low TSH test result from 2/1/2013.  The obstetrician failed to recognize the significance of the patient’s complaints and TSH test results.  The obstetrician did not order additional tests to evaluate the patient’s low TSH at any time during his care of the patient.  The obstetrician did not inform the patient of her low TSH result at any time during his care of the patient.  The obstetrician instructed the patient to return as needed.  The obstetrician did not plan close follow-up of the patient’s complaints of weight loss.  The obstetrician did not refer the patient to a specialist for evaluation of her low TSH.

Following her 2/7/2013 visit with the obstetrician, the patient was diagnosed with and began treatment for hyperthyroidism while visiting Iran.

The Board judged the obstetrician’s conduct to be below the minimum standard of competence given his failure to recognize the significance of the patient’s symptoms and test results, advise the patient of her low TSH, order laboratory analysis of T3 and T4 blood levels, plan close monitoring of the patient’s symptoms and thyroid hormone levels to prevent a delay in diagnosis of hyperthyroidism, diagnose the patient’s hyperthyroidism, or refer the patient to an endocrinologist for evaluation.

The Board ordered that the obstetrician pay a fine of $5,000 against his license and pay reimbursement costs for the case for a minimum of $3,076.77 and not to exceed $5,076.77.  The Board also ordered that the obstetrician complete a medical records course in “Quality Medical Record Keeping for Health Care Professionals” and complete five hours of continuing medical education in “Risk Management.”  The Board ordered that the obstetrician complete one hour lecture/seminar on prenatal screening, including screening for hyperthyroidism.

State: Florida


Date: February 2015


Specialty: Obstetrics, Endocrinology


Symptom: Weight Loss


Diagnosis: Endocrine Disease


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


Significant Outcome: N/A


Case Rating: 3


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



Wisconsin – Emergency Medicine – 9-Year-Old Boy With Abdominal Pain, Nausea, And Vomiting For 4 Days



On 2/23/2008, at 11:34 a.m., a 9-year-old boy presented to the emergency department with abdominal pain, nausea, and vomiting for 4 days.  The patient had been drinking water “by the gallons,” had increased urinary frequency, and dry heaves.  Urinalysis revealed 4+ ketones, 2+ glucose, sodium 125, potassium 5.8, chloride 80, bicarbonate 7, albumin 5.6, alkaline phosphatase 502, BUN 34, creatinine 1.4, and glucose 978.9.  The patient was diagnosed with diabetic ketoacidosis and initiated on an insulin drip at 6 units per hour.

At 2:25 p.m., the nurses notified Family Practitioner A that they were unable to place an IV line.  Family Practitioner A ordered placement of the IV line in the patient’s foot.  Orders for IV insulin and lab draws were not administered until the IV line was placed.

At 7:40 p.m., the nurses documented: “Has started seizure-like activity where he’ll stiffen up for approx 10-20 sec then relax, along with Kussmaul respiratory pattern.  Also incontinent at intervals and small emesis of [illegible] pinkish opaque liquid which comes out of nose at times.  Ox to 80’s when stiffens up but back up to 95-100% when relaxed.  Does not respond to verbal stimuli.  [Family Practitioner A] made aware.  Orders received and instituted.”

Family Practitioner A ordered medications, the specifics of which were not noted.  At 8:30 p.m., it was documented that the patient was not responsive along with further objective findings: “Blood pressure was 110/70, pulse 150, T 98.5 ap, clear lungs, Kussmaul breathing, Na 142, Cl 103, and venous PH 7.18.”

Diagnosis was diabetic ketoacidosis with coma.  Further medication and laboratories were ordered.  The patient did not regain consciousness over the next several hours.  Despite administration of acetaminophen and aspirin suppositories, he developed a temperature of 105 rectal at 11:30 p.m., 104 rectal at 12:10 a.m., 105 rectal at 3:10 a.m., and 104.5 rectal at 6:30 a.m.  At 7:15 a.m., it was documented by Family Practitioner A that the fever was persistent along with the following: “BP 110/70, P 160, localized pain, heart RRR, lungs clear, Na+ 165, Cl 134, Phos 2.5, K+ 4.1, glucose 121.”  He documented plans to consult pediatrics, transfer the patient to a tertiary care facility, and obtain a CT scan of the head.  The CT head without contrast revealed: “Nonhemorrhagic right lacunar infarct and nonhemorrhagic thalamic infarct duration undetermined.”

At 10:45 a.m., the patient was transferred to a tertiary care facility.  He was diagnosed with extensive bilateral infarcts involving the basal ganglia, thalamus, splenium, parietal and temporal lobes thought to be secondary to severe dehydration, hypernatremia, and possible diabetes insipidus.

After 2 weeks, MRI revealed bilateral infarcts and there was no improvement in his condition.  Life support was removed and the patient expired.

A lawsuit was initiated against Family Practitioner A with the outcome of a confidential settlement.  The Board elected to reprimand Family Practitioner A with concerns that a delay in transfer increased the patient’s risk for harm, injury and death.  His license was limited to a work setting pre-approved by the Board and which excluded solo practice.  His conduct and work should allow for formal and informal peer review.

State: Wisconsin


Date: December 2013


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


Symptom: Nausea Or Vomiting, Urinary Problems


Diagnosis: Diabetes


Medical Error: Delay in proper treatment


Significant Outcome: Death


Case Rating: 4


Link to Original Case File: Download PDF



Page 1 of 2