Found 211 Results Sorted by Case Date
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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 – Family Medicine – Patient With Kidney Stone Started On Morphine Along With Fluoxetine And Promethazine



A 27-year-old female was a patient of a family practitioner.  On 2/11/2014, the patient started complaining to the family practitioner about a potential kidney stone.

The family practitioner had records indicating that the patient was being treated with tramadol, Percocet, fluoxetine, and promethazine.

On 5/12/2014, the family practitioner prescribed morphine 60 mg, extended release, to the patient, to be taken twice a day, but the family practitioner never adequately documented medical justification for the prescription.  The standard starting dose for morphine is 15 mg every eight to twelve hours.

The patient was also taking fluoxetine and promethazine and the family practitioner signed a CVS form indicating the patient could start morphine despite possible contraindications.

The family practitioner did not take additional precautions to monitor the patient, despite her taking fluoxetine and promethazine in combination with morphine.

At 5:25 p.m. on 5/14/2014, the patient’s husband found her unresponsive in the bedroom and 911 was called immediately.

The patient ultimately was transported to a hospital and diagnosed with poisoning by opiates and related narcotics.

The Board judged the family practitioners conduct to be below the minimum standard of competence given his failure to prescribe morphine for medically justified reasons.  The family practitioner failed to start with an initial dose of morphine at 15 mg every eight to twelve hours.  The family practitioner failed to take additional precautions regarding monitoring for central nervous system or respiratory depression when the morphine was prescribed with the fluoxetine and promethazine.  The Board judged that the family practitioner failed to adequately create or maintain medical records that justified the course of treatment for the patient.

The Board ordered that the family practitioner have a reprimand against his license.  The Board ordered that the family physician pay a fine against his license of $7,500 and that the family practitioner pay reimbursement costs for the case between a minimum of $820.04 and a maximum of $2,820.04.  The Board ordered that the family practitioner complete a drug prescribing course and a medical records course and that the family practitioner complete five hours of continuing medical education in nephrology.

State: Florida


Date: November 2017


Specialty: Family Medicine, Internal Medicine


Symptom: Abdominal Pain


Diagnosis: Drug Overdose, Side Effects, or Withdrawal, Renal Disease


Medical Error: Improper medication management, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



Florida – Family Medicine – Three Patients Seen At Once Without Proper Examination and Documentation



On 9/21/2012, Patient A, Patient B, and Patient C presented to a geriatric practitioner at the same time in his office.  The geriatric practitioner saw the patients for less than nine minutes total.  At no time were the patients separated for individual assessments.  The patients were an undercover detective and two informants, using pseudonyms.  The appointment was audiotaped and videotaped.

The geriatric practitioner failed to perform a physical examination on any of the three patients.  The geriatric practitioner failed to create a treatment plan for any of the three patients.  He also sent the three patients for x-rays without a physical examination.  Per the geriatric practitioner’s instructions, all three patients presented for x-rays;  however, only Patient A and Patient C actually had x-rays performed.  The geriatric practitioner failed to create or maintain documentation of referring the three patients for x-rays.

On 10/30/2012, the three patients presented to the geriatric practitioner for a follow-up visit.  At that time, the geriatric practitioner failed to review readily available medical records from the patients’ first visit, failed to inquire about x-ray results, failed to review physical therapy results, failed to perform physical examinations and/or failed to create treatment plans for all three patients.

The Board judged the geriatric practitioner’s actions to be below the minimum standard of competence given his failure to perform a physical examination, perform a complete individual physical examination for each patient prior to referral for x-rays, other diagnostic testing, or further treatment.  Also, the geriatric practitioner failed to review any medical records or results at a follow-up visit, including x-rays, from prior visits, and/or procedures and review and analyze the physical therapy progress of the patients, and create treatments plans for each patient.

The Board ordered that the geriatric practitioner pay a fine of $12,000 against his license and pay reimbursement costs for the case for a minimum of $37,421.80 and not to exceed $39,421.80.  The Board also ordered that the geriatric practitioner complete a medical records course and complete five hours of continuing medical education on “Risk Management.”  The Board put the geriatric practitioner’s license on probation and required that he have indirect supervision to practice by a Board-approved physician.

State: Florida


Date: November 2017


Specialty: Family Medicine


Symptom: N/A


Diagnosis: N/A


Medical Error: Failure to examine or evaluate patient properly, Ethics violation, Failure to follow up, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



Florida – Family Medicine – Recurrent Chest Pain Diagnosed As Esophageal Spasm



On 8/27/2012 a 47-year-old female presented with complaints of hypertension, possible hyperlipidemia, and pain in her foot.  A family practitioner assessed the patient and diagnosed her with poor control of her hypertension and reinforced medical advice for the patient to increase her lisinopril.  Additionally, the family practitioner waited for the results of the previous laboratory work and recommended conservative management and stretching for the foot and ankle.

On 4/1/2013, the patient again presented to the family practitioner to address difficulties with concurrent chest pain.  The patient stated the chest pains were very severe and “stopped her in her tracks at times.”  The patient stated that she felt she was having a heart attack, although she reportedly realized that that was not the case.  The family practitioner deemed the chest pain was likely an esophageal spasm, for which he prescribed the patient Librax (chlordiazepoxide/clidinium) and recommended that she see a gastroenterologist for an endoscopy if the medication failed to provide relief.  The family practitioner also assessed the patient for hypertension and instructed the patient to stop taking hydrochlorothiazide.  The family practitioner provided the patient with a trial of Dyrenium (triamterene).

On 4/12/2013, the patient complained of chest pain and suffered a cardiac arrest.  Upon EMS arrival, the patient was unstable and unresponsive.  The patient was transported to a hospital where she was later pronounced deceased.

The Board judged the family practitioners conduct to be below the minimal standard of competence given that he failed to conduct an adequate history, which included a risk factor assessment for a patient complaining of chest pain, to order or perform an EKG on a patient complaining of chest pain, and send a patient complaining of chest pain to an emergency room or an expedited outpatient facility for a chest pain evaluation.

The Board ordered that the family practitioner pay a fine of $5,000 against his license and pay reimbursement costs for a minimum of $2,122.00 and not to exceed $4,122.00.  The Board also ordered that the family practitioner complete ten hours of continuing medical education in diagnosis in cardiology and five hours of continuing medical education in “Risk Management.”

State: Florida


Date: November 2017


Specialty: Family Medicine


Symptom: Chest Pain, Extremity Pain


Diagnosis: Cardiovascular Disease


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


Significant Outcome: Death


Case Rating: 3


Link to Original Case File: Download PDF



Washington – Internal Medicine – Proper Monitoring Of Thyroid Dysfunction And High Blood Pressure



Beginning in June 2014, a physician began treating Patients A and B for thyroid dysfunction and Patient C for high blood pressure. The physician communicated with Patient A and B through phone consultation and met Patient C in social situations and during at least two office visits. The physician reviewed previous lab work on thyroid functions for Patients A and B. The physician based Patient C’s treatment upon his physical observation of her conditions, two Zytoscans (device that measures electrical currents in the skin), and taking her blood pressure. Patient A and B’s lab work indicated both patients having lower than normal thyroid function. The physician started both Patients A and B on a thyroid hormone supplement. He prescribed medication commonly used for treating high blood pressure for Patient C based upon his observations, oral reports of Patient C, and the Zytoscans. The physician failed to do lab work, took minimal chart notes, and did not schedule follow-up examinations for Patients A, B, or C.

For several months, the physician continued prescribing for Patients A, B, and C without ever seeing the patients in person for further work up. The physician’s interactions with Patients A and B were solely over the phone, while the physician notes state that he had two office visits with Patient C. The physician did not order thyroid stimulating hormone (TSH) testing to further verify if continuing the thyroid hormone supplement would be appropriate in managing Patient A and B’s conditions.

In June 2015, Patient A presented to another provider with concerns of heart palpitations. Patient A told the provider he noticed the palpitations reduced when he reduced his thyroid hormone supplement dosage. During this consultation, Patient A disclosed his treatment with the physician which alerted the provider to have Patient A’s TSH levels checked. Patient A’s lower than normal TSH result prompted the provider to immediately begin weaning Patient A off of his thyroid hormone supplement.

Patient B also presented to the same provider in June 2015. At her visit, Patient B presented with a rash on her chest which she had for over a month. The new provider assessed the rash being unrelated to her treatment with the physician; however, due to her receiving similar treatment as Patient A, the provider had Patient B’s TSH level tested. Patient B’s results indicated her TSH level was below the normal range.

On 8/26/2015, the physician saw Patient C for what he thought was a urinary tract infection. The physician first prescribed Keflex but changed it to ciprofloxacin based upon the results of a Zytoscan. Caution is required when giving ciprofloxacin to patients with hypokalemia.

On or about 9/9/2015, Patient C presented to the hospital emergency department where she was diagnosed with significant hypokalemia (lowered levels of potassium in the blood) and hyponatremia (lowered levels of sodium in the blood) which caused Patient C to suffer fatigue and heart palpitations. Patient C went immediately from the emergency department to a new care provider. After an oral interview with Patient C, the new care provider learned that Patient C was taking a number of medications prescribed by the physician. The new care provider attempted to contact the physician a number of times to obtain the physician’s chart notes, lab studies, and other medical records for Patient C but was unsuccessful. Patient C told her new care provider that the physician had been giving her medications for a number of years. She stated, “I tell him what I need.” In the physician’s response to the Commission, he stated that “if [Patient C] called me to have a prescription filled, I would do that for her.”

The Commission stipulated the physician reimburse costs to the Commission and write and submit a paper of at least 2000 words, with references and annotated bibliography, regarding Washington State rules for physicians forming and maintaining patient/physician relationships, the differential diagnosis of hyperthyroidism and hypothyroidism, the proper monitoring of electrolyte levels for patients with high blood pressure, and the importance of complying with Commission sanctions.

State: Washington


Date: November 2017


Specialty: Internal Medicine, Family Medicine


Symptom: Palpitations, Rash


Diagnosis: Endocrine Disease


Medical Error: Failure to follow up, Failure to properly monitor patient, Improper medication management


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



Florida – Family Medicine – Diagnosis Of Deep Cellular Fibrous Histiocytoma With A Differential Diagnosis Of Myofibroblastic Sarcoma



On 3/28/2014, a patient presented to a family practitioner with complaints of a right forearm mass.

On 4/4/2014, the family practitioner excised a 3-4 cm mass from the patient’s right forearm.  The family practitioner sent the specimen out for review by a pathologist.

On 4/15/2014, the pathologist via a pathology report listed a diagnosis of deep cellular fibrous histiocytoma with a differential diagnosis of low grade myofibroblastic sarcoma.  The pathology report further stated that re-excision was ‘“strongly recommended.”

On 4/16/2014, at a follow-up appointment, the family practitioner informed the patient that the mass was benign.  He informed the patient that a wait-and-see approach would be appropriate, and, if the mass returned, further excision would be recommended.  The family practitioner did not inform the patient of the differential diagnosis listed on the pathology report.  He also did not advise the patient that a re-excision was strongly recommended by the pathologist.

On 1/30/2015, the mass on the patient’s forearm returned and was larger.

On 3/5/2015, a general surgeon performed a second excision on the patient.

On 3/11/2015, the pathology report of the second excision stated a diagnosis of high grade myxofibrosarcoma.

The Board judged the family practitioners conduct to be below the minimum standard of competence given that he failed to fully inform the patient of the pathology report findings and advise the patient that re-excision wass strongly recommended.

It was requested that the Board order one or more of the following penalties for the family practitioner:  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: November 2017


Specialty: Family Medicine


Symptom: Mass (Breast Mass, Lump, etc.)


Diagnosis: Cancer


Medical Error: Underestimation of likelihood or severity, Failure of communication with patient or patient relations


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



California – Family Practice – Providing Medical Clearance For A Tummy Tuck Procedure



A family practitioner cleared a patient for a tummy tuck procedures.  The patient had a history of sickle cell anemia and a respiratory infection.

The Board judged the family practitioner’s conduct as having fallen below the minimum level of competence given failure to address the status of the patient’s sickle cell anemia and failure to assess the patient’s respiratory infection.

The Board issued a public letter of reprimand.

State: California


Date: October 2017


Specialty: Family Medicine, Internal Medicine


Symptom: N/A


Diagnosis: Hematological Disease, Infectious Disease


Medical Error: Improper treatment


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



Vermont – Family Practice – Oversight In Anorexia Nervosa Monitoring



A patient was treated by a family practitioner from May 2012 to September 2012.

On the first office visit, the patient presented with symptoms and behaviors that met the DSM-IV criteria of anorexia nervosa, as well as the National Institute for Mental Health criteria of Pediatric Acute Neuropsychiatric Syndrome (PANS).  The patient’s medical records from the patient’s prior primary care physician included a diagnosis of anorexia nervosa and a prior recommendation for inpatient mental health treatment for anorexia.

The family practitioner made the following diagnoses:  systemic inflammatory syndrome with multi-systemic symptoms and marked neuropsychiatric dysfunction with probable underlying infectious triggers; PANS (Pediatric Acute Neuropsychiatric Syndrome); and probable PITANDs (Pediatric Infection-Triggered Autoimmune Neuropsychiatric Disorders).  Anorexia nervosa was not documented as a primary or differential diagnosis.  The family practitioner indicated that he considered the possibility of a purely behavioral syndrome like anorexia nervosa, but felt that the patient’s anorexia was “part of a more complex multi-system picture.”

The family practitioner based his diagnosis on the patient’s history and symptoms meeting the diagnostic criteria for PANS, testing positive to three infectious agents, and an initial response positive response to PITANDs treatment, in addition to a lack of positive response to anorexia nervosa focused management with the patient’s prior primary care physician and other consultants.

The family practitioner saw the patient on three occasions over a four month period, which the Board believes is inadequate for management of anorexia for an adolescent.  The family practitioner relied on his nurse to call the patient on weekly updates and weight checks.

In addition to three office visits, the family practitioner’s treatment included ordering numerous blood tests, and the prescribing of medications, antibiotics, herbal supplements, and vitamins for the infection etiologies and the inflammatory conditions.  However, he did not prescribe any medications for the treatment of anorexia nervosa. While the family practitioner believed that the patient was being treated by his primary care physician, this was not confirmed with any other provider, and the family practitioner did not communicate directly with any other provider beyond sending his initial office visit note and lab results to the patient’s primary care physician.

The Board judged the family practitioner’s medical records and communication with the patient’s primary care physician concerning his treatment of the patient were inadequate. The family practitioner’s office notes did not document past surgical and family history, temperature, height, BMI calculation, and growth curve charting.

Based on review of the family practitioner’s medical records concerning his treatment of the patient and the documentation of his communication with the patient’s parents, it appears that the family practitioner did not clearly explain his role in the patient’s care to the patient’s parents until the end of his treatment.  Is it possible that the patient’s parents believed that the family practitioner had taken over the role as the primary care physician and was actively managing the patient’s care.

The family practitioner’s position was that he believed that he was participating in the care of the patient in the role as a consultant to his primary care physician and that the patient’s primary care physician was concurrently monitoring the patient.  With the exception of the provision of his initial office note and lab results, the family practitioner did not communicate with the patient’s primary care provider during the course of his treatment.  After sending his initial note and lab results, the family practitioner did not communicate with the patient’s primary care provider or any other medical professionals until the patient had an acute worsening of the condition on 9/13/2012.

The Board judged that the family practitioner failed to appropriately monitor, manage, and maintain comprehensive medical records on a juvenile patient with a severe eating disorder.

The Board ordered that the family practitioner be reprimanded, complete one hour of continuing medical education on cognitive bias, and that he shall only practice medicine in a structured, group setting for a period of three years.

State: Vermont


Date: September 2017


Specialty: Family Medicine, Psychiatry


Symptom: Weight Loss


Diagnosis: Psychiatric Disorder


Medical Error: Improper treatment, Failure of communication with other providers, Failure of communication with patient or patient relations, Failure to properly monitor patient, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



Florida – Family Practice – Unnecessary Excisions Performed For Multiple Lesions



On 6/15/2012, a 47-year-old female presented to a family practitioner with multiple lesions on her back, chest, and arms.

The family practitioner informed the patient that the lesions on her left humerus, right upper abdomen, mid upper back, left anterior mid chest, lower back, right lower back, and/or right upper anterior chest were malignant and/or potentially malignant.

On 7/6/2012, the family practitioner documented that the patient had a history of keloid formation after surgical excision.

On 6/15/2012, the family practitioner excised a lesion on the patient’s left humerus.  The lesion excised from the patient’s left humerus measured approximately 3 mm by 3 mm.  The family practitioner made an excision 4 cm by 4 cm or sixteen square centimeters to excise the lesion on the patient’s left humerus.

On 6/19/2012, a dermatopathology report determined that the excision taken from the patient’s left humerus was not malignant or premalignant.

On 6/27/2012, the family practitioner excised a lesion on the patient’s right upper abdomen.  The lesion on the patient’s right upper abdomen measured 3 mm.   The family practitioner made an excision 7 cm by 6 cm, or forty-two square centimeters to excise the lesion on the patient’s right upper abdomen.

On 6/29/2012, a dermatopathology report determined that the excision taken from the patient’s right upper abdomen was not malignant or premalignant.

On 7/6/2012, the family practitioner excised a lesion the patient’s mid upper back.  The lesion on the patient’s back measured approximately 3 mm.   The family practitioner made an excision 5 cm by 7 cm, or thirty-five square centimeters to excise the lesion on the patient’s mid upper back.

On 7/13/2012, the family practitioner excised a lesion on the patient’s left anterior mid chest.  The lesion on the patient’s left anterior mid chest measured approximately 4 mm by 4 mm.
The family practitioner made an excision 8 cm by 6 cm or forty-eight square centimeters to excise the lesion on the patient’s left anterior mid chest. He referred the patient for radiation treatment to prevent keloid formation.

On 7/20/2012, a dermatopathology report determined that the excision taken from the patient’s left anterior mid chest was not malignant or premalignant.

On 8/3/2012, the family practitioner excised a lesion the patient’s left lower back.  The lesion on the patient’s left lower back measured 5 mm by 4 mm.  The family practitioner made an excision 9 cm by 7 cm or sixty-three square centimeters to excise the lesion on the patient’s left lower back.

On 8/7/2012, a dermatopathology report determined that the excision taken from the patient’s left lower back was not malignant or premalignant.

On 8/10/2012, the family practitioner excised a lesion on the patient’s right lower back.  The lesion on the patient’s right lower back measured 4 mm by 4 mm.  The family practitioner made an excision 9 cm by 8 cm or seventy-two square centimeters to excise the lesion on the patient’s right lower back.

On 8/14/2012, a dermatopathology report determined that the excision taken from the patient’s right lower back was not malignant or premalignant.

On 8/27/2012, the family practitioner excised a lesion on the patient’s right upper anterior chest.  The lesion on the patient’s right upper anterior chest measured 2 mm by 2 mm.   He made an excision 10 cm by 7 cm, or seventy square centimeters to excise the lesion on the patient’s right upper anterior chest.

On 8/29/2012 a dermatopathology report determined that the excision taken from the patient’s right upper anterior chest was not malignant or premalignant.

The Board judged that the family medicine practitioners conduct to be below the minimal standard of competence given that he failed to perform a complete and comprehensive physical examination of the patient’s lesions; adequately consider the characteristics of the lesions, including the size, color, regularity, and degree of pigmentation; refer the patient for consultation with a dermatologist; refrain from diagnosing the patient with malignant and/or potentially malignant lesions without having adequate justification; accurately and appropriately diagnose the patient’s condition; confirm that each of the lesions on the patient was malignant or premalignant prior to excising the lesion; perform a shave biopsy, punch biopsy, or limited excisional biopsy with 1 mm margins on each of the lesions on the patient to determine whether the lesion was malignant or premalignant; make an excision with margins no greater than 5 mm to excise each of the lesion on the patient; refrain from making an excision on the patient without having adequate justification; avoid potential keloid formation on the patient, by making the fewest and/or smallest excisions appropriate and/or justifiable.

The family practitioner agreed to voluntarily cease practicing medicine and agreed to never reapply for licensure as a medical doctor in the state of Florida.

State: Florida


Date: August 2017


Specialty: Family Medicine, Dermatology


Symptom: Dermatological Abnormality


Diagnosis: Dermatological Issues


Medical Error: Unnecessary or excessive treatment or surgery, Failure to examine or evaluate patient properly, Failure to order appropriate diagnostic test, Referral failure to hospital or specialist, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



Florida – Family Medicine – Improper Prescribing Of Controlled Substances To A Patient With Drug Seeking Behavior, Dependence, and Withdrawals



On 7/13/2006 through 8/6/2013, a family practitioner treated a 37-year-old female for chronic neck and back pain.  The patient presented to the family practitioner with a history of hypertension, depression, anxiety, and back pain from a 2004 motor vehicle accident.

The patient’s medical records from her previous treating physicians indicated that the patient was addicted to Xanax, had attempted suicide via overdose of alcohol and Tylenol in 2004, and was a high-risk patient with regards to controlled substances.

Throughout the course of the treatment, the family practitioner prescribed controlled substances to the patient including Nucynta, Percocet, Xanax, Klonopin, Vicodin, and Soma.

On 10/7/2008, the family practitioner noted that the patient exhibited drug seeking behavior, had undergone physical withdrawals, and was having psychological dependence.  The family practitioner documented “no further controlled substances after this.”

On 10/7/2008, the family practitioner referred the patient to a pain management specialist.

From 10/17/2008 to 5/6/2010, the patient presented to a pain management specialist for her chronic pain.

Beginning on 5/17/2010, the patient discontinued treatment with the pain management specialist and resumed her treatment with the family practitioner for her chronic pain.

From 9/2/2011 through 8/6/2013, the patient presented to the family practitioner approximately every three months.  Despite the patient only presenting every three months, the family practitioner prescribed monthly refills of controlled substances for the patient.  The family practitioner prescribed Nucynta, Percocet, Xanax, Klonopin, Vicodin, and Soma to the patient in various combinations and amounts.

The prevailing standard of care requires that a physician treating a patient for chronic pain prescribe controlled substances appropriately.  The quantity and/or combination of controlled substances the family practitioner prescribed to the patient on one or more occasions from 9/2/2011 through 8/6/2013 were inappropriate.

The prevailing standard of care requires that a physician treating a high-risk patient for chronic pain create and implement an appropriate treatment plan.

The family practitioner did not create or implement, or did not document creating or implementing, an appropriate treatment plan for the patient.  The prevailing standard of care requires that a physician treating a high-risk patient for chronic pain evaluate the patient prior to refilling prescriptions for controlled substances.  On one or more occasions, the family practitioner prescribed multiple refills of controlled substances for the patient at a single office visit.

The prevailing standard of care required that a family physician treating a high-risk patient for chronic pain refer the patient to a chronic pain specialist.  The family practitioner did not refer, or did not document referring, the patient to a chronic pain specialist on or after 9/2/2011.

It was requested that the Board order one or more of the following penalties for the family practitioner: 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: August 2017


Specialty: Family Medicine


Symptom: Head/Neck Pain, Back Pain, Psychiatric Symptoms


Diagnosis: Drug Overdose, Side Effects, or Withdrawal


Medical Error: Improper medication management, Referral failure to hospital or specialist, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



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