Found 13 Results Sorted by Case Date
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Wisconsin – Family Medicine – Sinus Pain And Tachycardia With Patient Seeing Her 6th Health Care Provider



On 01/31/2010, a 38-year-old woman presented to a family practitioner with persistent sinusitis after a 2 week course of Augmentin.  She had no improvement.  Vitals revealed a blood pressure of 180/100, heart rate 135, and temperature of 98.9.  There was no documentation of a respiratory rate.  The family practitioner was the 6th health care provider the patient had seen in the prior 7 days.  The family practitioner documented “Extraocular motions were intact without pain.  Conjunctiva are clear.  Tympanic membranes are clear.  She has some erythema and swelling below the right eye and maybe some mild tenderness in that area.  There is no crepitation or fluctuance.  Nasal mucosa appears normal.  Oropharynx appears normal.  Neck: supple.  There is no adenopathy.  Lungs: clear.”  Moxifloxacin, prednisone, and hydrocodone 5 mg/acetaminophen 500 mg were prescribed.  There was no comment documented regarding the abnormal vital signs.

While under investigation, the family practitioner testified that he offered hospitalization, ENT consult, and CT scan.  He reported that the patient had declined these options and preferred outpatient management.  There is no documentation of this discussion.

Less than 50 minutes after the visit, the patient presented to the emergency department of a nearby community hospital.  Vitals revealed a blood pressure of 150/105, heart rate of 76, temperature of 97.5, and a respirator rate of 26-28.

The nurse practitioner documented: “oropharyngeal inspection revealing what appears to be findings consistent with ANUG [acute necrotizing ulcerative gingivitis].  She has necrotic-appearing tissue as well as some punched out lesions along the buccal gingiva and the papillae are necrotic in appearance…respirations are deep and certainly suggesting the possibility of a Kussmaul’s type respiration pattern.”  Bicarbonate was 6.  Glucose was 592.  She was diagnosed with diabetic ketoacidosis and acute necrotizing ulcerative gingivostomatitis.  She was flown to a tertiary care hospital and treated in the intensive care unit where she recovered.

The Board reprimanded the family practitioner for conduct considered below the minimum standard of care.

State: Wisconsin


Date: February 2013


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


Symptom: Pain


Diagnosis: Diabetes


Medical Error: Failure to examine or evaluate patient properly, Lack of proper documentation


Significant Outcome: Hospital Bounce Back


Case Rating: 3


Link to Original Case File: Download PDF



Wisconsin – Endocrinology – Work Up Performed For Hyperparathyroidism With Incidental Finding Found In The Liver



On 12/29/2006, a patient was referred to an endocrinologist given a parathyroid level of 363 and calcium level of 12.3.

On 01/05/2007, the patient presented to the endocrinologist for repeat calcium, phosphorous, parathyroid hormone level, a parathyroid sestamibi scan, a neck ultrasound, a DEXA scan, and 24-hour urine screening for calcium and creatinine.

The patient was hospitalized based on the endocrinologist’s recommendation, for treatment of an elevated ionized calcium of 7.4, calcium of 12.4, and a parathyroid hormone level of 441.

On 01/12/2007, the patient underwent an ultrasound of the anterior neck, a CT Pelvis without contrast, and a CT Stone Study, all ordered by the endocrinologist.

“There is a somewhat subtly mixed attenuation mass-like area identified within the high liver to basically in junction area between right lobe and left lobe.  On this unenhanced examination, it is relative indeterminate in character. It measures approximately 4.5 x 4.4 cm on image 7.  Further evaluation is needed.  I would start with a formal multiphase CT of the upper abdomen to further characterize the mass.  The patient may well also need MR depending on characteristics.  Moderate degenerative changes are noted through the lumbar spine…”

The patient presented to the endocrinologist for follow-up.  The endocrinologist noted: “There are some changes in the liver as well as the aorta and spleen which are detailed in the ultrasound.”  The clinical impression included severe hypercalcemia, hyperparathyroidism, and ultrasound consistent with parathyroid adenoma.  The sestamibi scan for parathyroid adenoma was negative.  The endocrinologist referred the patient for possible parathyroid surgery.

On 02/13/2007, the patient underwent a parathyroidectomy with pathology revealing left superior parathyroid adenoma.

On 02/22/2007, the patient presented to the endocrinologist for a follow-up.  Ionized calcium level was 5.2, total calcium level was 8.8, and phosphorous was 2.7.

On 08/22/2007, the patient presented to the endocrinologist for a follow-up.  The ionized calcium, calcium, and phosphorous levels were within normal limits.  The endocrinologist recommended annual calcium level checks.

On 07/31/2008, the patient underwent a CT scan as ordered by his primary care physician, which revealed extensive hepatic metastatic disease.  The patient was diagnosed with metastatic adenocarcinoma.

On 11/28/2009, the patient died secondary to metastatic liver cancer.

The Board judged that the endocrinologist fell below the minimum standards of competence by failing to follow up on the results of the January 2007 CT scan and failing to follow the recommendations of further testing.

The endocrinologist was reprimanded and ordered to obtain 4 hours of education in addressing abnormal physical and laboratory findings as well as 8 hours of education in the early diagnosis and management of cancers.

State: Wisconsin


Date: February 2011


Specialty: Endocrinology, Family Medicine, Internal Medicine


Symptom: N/A


Diagnosis: Cancer


Medical Error: Failure to follow up


Significant Outcome: Death


Case Rating: 3


Link to Original Case File: Download PDF



Florida – Plastic Surgery – Pre-operative Liposuction Hyperglycemia And Glucosuria



On 06/08/2005, a 32-year-old woman presented to a plastic surgeon for pre-operative consultation to schedule elective liposuction to the abdomen, thighs, and buttocks.

On 06/13/2005, the plastic surgeon ordered pre-operative laboratory results and an EKG.

On 06/14/2005, the pre-operative laboratory results revealed a urine positive for glucose and ketones.  Random blood glucose level was 352 mg/dl.

Between 06/08/2005 and 06/21/2005, the plastic surgeon was the sole treating physician for the patient.

On 06/21/2005, the plastic surgeon performed liposuction.  Following surgery, the patient developed tachycardia and was admitted to the hospital.  She developed diabetic ketoacidosis.

On 06/23/2005, she was transferred to a different hospital for septic shock, respiratory failure, and renal failure.

On 08/05/2005, the patient was discharged from the hospital.

The Board judged the plastic surgeon’s conduct below the minimum standard of competence for failing to review urine, blood, and EKG studies prior to surgery, clearing the patient despite hyperglycemia, failing to order additional lab results given initial abnormal lab values, failing to obtain consultation regarding the hyperglycemia, and failing to maintain adequate medical records.

The Board ordered 50 hours of community service, six hours of continuing medical education in diabetic surgical patients, and five hours of continuing medical education in risk management.  His license was suspended for a period of one year with 9 months stayed.  After suspension, his license was to be placed on probation.  During probation, a boarded physician was to indirectly supervise the plastic surgeon and review at least 25% of the plastic surgeon’s patient records.  Surgical restrictions were ordered including only performing minor liposuction surgery, performing at an accredited outpatient facility or at a hospital, and using an anesthesiologist for all procedures.  The plastic surgeon was also ordered to submit quarterly reports including the following:

1) A brief statement of why he is on probation.

2) A description of the practice location.

3) A description of current practice.

4) A brief statement of compliance with probationary terms.

5) A description of the relationship with monitoring physician.

6) A statement advising the Board of any problems which have arisen.

7) A statement addressing compliance with any restrictions or requirements imposed.

State: Florida


Date: January 2009


Specialty: Plastic Surgery, Endocrinology, Internal Medicine


Symptom: N/A


Diagnosis: Diabetes, Post-operative/Operative Complication


Medical Error: Diagnostic error, Failure to follow up, Improper treatment


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



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