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Florida – Oncology – Rectal Mass And Bloody Stool Misdiagnosed As Cancer Instead Of Endometriosis
On 4/15/2015, a 48-year-old female presented to the Mayo Clinic for an assessment regarding cancer treatment.
The patient presented with a history of a palpable rectal mass and bloody stool. The patient presented to an oncologist after undergoing a colonoscopy and after a CT scan at Borland Grover Clinic revealed tumors suspicious for metastases.
The Borland Grover Clinic took a biopsy of the affected area. Initial pathology indicated suspicion for adenocarcinoma. Borland Grover clinic sent the sample to Cleveland Clinic for confirmation. Cleveland Clinic returned a diagnosis of endometriosis, not cancer.
The oncologist did not obtain the pathology reports from Borland Grover Clinic or Cleveland Clinic. The oncologist diagnosed the patient with rectal cancer with possible spread to the liver, lungs, and mediastinum. The oncologist ordered an endobronchoscopic ultrasound (EBUS). The patient’s EBUS showed some concern for cancer, but the pathologist deemed the results of the EBUS insufficient for a definitive cancer diagnosis.
Despite not having a pathologic diagnosis of cancer, from May to July 2015, the oncologist ordered the patient receive a port placement and three chemotherapy treatments.
Due to continuing rectal pain, on 7/6/2015, the oncologist referred the patient to a colorectal surgeon. As part of his review, the colorectal surgeon obtained the patient’s pathologic results from Borland Grover Clinic and Cleveland Clinic, which showed that the patient had endometriosis and not cancer.
On 7/16/2015, a Mayo Clinic pathologist reviewed the patient’s previous biopsy sample and came to a final diagnosis of endometriosis. On 9/3/2015, two doctors performed a procedure to remove the endometrioma.
The Board judged that the oncologist’s conduct to be below the minimum standard of competence given her failure to obtain a pathologic diagnosis of cancer prior to initiating cancer treatment for the patient.
The Board ordered the oncologist have her license revoked, pay an administrative fine, and have remedial education.
State: Florida
Date: December 2017
Specialty: Oncology, Internal Medicine
Symptom: Blood in Stool, Mass (Breast Mass, Lump, etc.)
Diagnosis: Gynecological Disease
Medical Error: Diagnostic error
Significant Outcome: N/A
Case Rating: 4
Link to Original Case File: Download PDF
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 – Internal Medicine – Patient With Worsening Chronic Kidney Disease Presents With Arm Pain, Numbness, And Shortness Of Breath
From 2009 until 2014, an internist served as the patient’s primary care physician.
In 2009, the internist referred the patient to Cardiologist A for a cardiology evaluation. The results of the 2009 cardiology evaluation revealed that the patient’s electrocardiogram and stress test were both abnormal.
At this time, Cardiologist A recommended that the internist increase the patient’s medication as needed in order to get the patient’s cholesterol to below seventy.
The patient was evaluated by Cardiologist A again in June 2010.
The June 2010 cardiac evaluation revealed that the patient had shortness of breath on exertion at times, possibly related to hypertension and subclinical congestive heart failure.
On 7/17/2013, the patient underwent lab work, the results which showed that his glomerular filtration rate (GFR) was thirty-four. The internist staged the patient’s chronic kidney disease (CKD) at a stage III/IV.
The patient’s next set of lab work was conducted on 11/18/2013, the results of which showed that his GFR was twenty-two. The internist wrote in a progress note that the patient’s CKD was a stage III/IV.
On 1/13/2014, the patient had lab work done again, the results which showed that his GFR was twenty-six. In his progress note he wrote that the patient’s CKD was now a stage IV.
Despite a dramatic decline in the patient’s GFR levels indicative of worsening CKD, the internist did not refer the patient to a nephrologist.
On 1/13/2014, the patient presented to the internist complaining of left arm pain, numbness radiating to both hands, and shortness of breath. The internist ordered an EKG, chest x-ray, and lab work. His assessment of the patient at this time was dyspnea on exertion, questionable coronary artery disease, questionable pulmonary disease, and questionable anxiety.
On 1/14/2014, the patient returned to the office for an echocardiogram. After the echocardiogram, the internist referred the patient to Cardiologist B for a consult. The patient could not obtain an appointment with Cardiologist B until 2/3/2014.
The internist ordered that a stress test be conducted prior to the patient’s visit with Cardiologist B, and advised that the patient bring the results of the stress test to his appointment with Cardiologist B.
On 1/23/2014, the stress test was performed and the results were abnormal.
The Medical Board of Florida judged that the internist failed to adequately evaluate the patient’s symptoms and recognize the patient’s worsening coronary artery disease, development of congestive heart failure, and worsening chronic kidney disease. He failed to refer the patient to a nephrologist for further evaluation upon seeing a dramatic decline in the patient’s GFR levels. He also failed to send the patient to the emergency department for treatment when the patient presented to him with exhibiting cardiac symptoms and had a known history of heart disease.
The Medical Board of Florida issued a letter of concern against the internist’s license. The Medical Board of Florida ordered that the internist pay a fine of $2,500 against his license and pay reimbursement costs for the case at a minimum of $5,756.36 and not to exceed $7,756.36. The Medical Board of Florida also ordered that the internist complete five hours of continuing medical education in the treatment of patients with chronic kidney disease and chronic heart disease.
State: Florida
Date: December 2017
Specialty: Internal Medicine
Symptom: Extremity Pain, Numbness, Shortness of Breath
Diagnosis: Heart Failure, Cardiovascular Disease, Renal Disease
Medical Error: Failure to examine or evaluate patient properly, Referral failure to hospital or specialist
Significant Outcome: N/A
Case Rating: 2
Link to Original Case File: Download PDF
Florida – Internal Medicine – Worsening Chronic Kidney Disease, Abnormal Stress Test, And Cardiac Symptoms
From 2009 until 2014, an internist served as a patient’s primary care physician.
In 2009, the internist referred the patient to Cardiologist A for a cardiology evaluation. The results of the 2009 cardiology evaluation revealed that the patient’s electrocardiogram and stress test were both abnormal. At this time Cardiologist A recommended that the internist increase the patient’s medication as needed in order to get the patient’s LDL cholesterol below seventy.
The patient was evaluated by Cardiologist A again in June 2010. The June 2010 cardiac evaluation revealed that the patient had shortness of breath on exertion at times, possibly related to hypertension and subclinical congestive heart failure.
On 7/17/2013, the patient underwent lab work, the results which showed that his glomerular filtration rate (“GFR”) was thirty-four. The internist stated the patient’s chronic kidney disease (“CKD”) as stage III/IV.
The patient’s next set of lab work was conducted on 11/18/2013, the results of which showed that his GFR was twenty-two. The internist wrote in a progress note that the patient’s CKD was stage III/IV.
The patient had lab work done again on 1/13/2014, the results of which showed that his GFR was twenty-six. In a progress noted created on 1/13/2014, the internist wrote that the patient’s CKD was now at stage IV.
Despite the dramatic decline in the patient’s GFR levels indicative of worsening CKD, the internist did not refer the patient to a nephrologist.
On 1/13/2014, the patient presented to the internist complaining of left arm pain, numbness radiating to both hands, and shortness of breath. The internist ordered an EKG, chest x-ray, and lab work. The internist’s assessment of the patient at this time was dyspnea on exertion, questionable coronary artery disease, questionable pulmonary issue, and questionable anxiety.
The internist had the patient return to the office on 1/14/2014 for an echocardiogram. After the echocardiogram, the internist referred the patient to Cardiologist B for a consult.
The patient could not obtain an appointment with Cardiologist B until 2/3/2014.
The internist ordered that a stress test be conducted prior to the patient’s visit to Cardiologist B, and advised that the patient bring the results of the stress test to his appointment with Cardiologist B. The stress test was performed on 1/23/2014, and the results were abnormal.
The Board judged the internist’s conduct to be below the minimum standard of competence given that the internist failed to adequately evaluate the patient’s symptoms and recognize the patient’s worsening coronary artery disease, development of congestive heart failure, and worsening of chronic kidney disease. The internist should have referred the patient to a nephrologist for further evaluation upon seeing a dramatic decline in the patient’s GFR levels. When the patient, with a known history of cardiac disease, presented with cardiac symptoms, the internist should have should have sent the patient to an emergency department for treatment.
The Board ordered that the internist pay a fine of $2,000 imposed against his license. The Board also ordered that the internist pay reimbursement costs of a minimum of $5,756.36 and not to exceed $7,756.36. The internist was ordered to complete five hours of continuing medical education in the treatment of patients with chronic kidney disease and five hours of continuing medical education in the treatment of patients with chronic heart disease.
State: Florida
Date: December 2017
Specialty: Internal Medicine
Symptom: Extremity Pain, Numbness, Shortness of Breath
Diagnosis: Renal Disease, Cardiovascular Disease
Medical Error: Referral failure to hospital or specialist
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 – Internal Medicine – Retained Guide Wire Found After Replacement Of Dialysis Catheter
On 3/19/2015, a patient presented to a hospital with complaints of chest pain, history of acute stent thrombosis, and renal failure.
On 3/21/2015, a physician referred the patient to an internist for replacement of temporary dialysis catheter to address her acute kidney failure. The internist placed a double-lumen dialysis catheter in the patient’s left subclavian vein.
Due to the catheter not functioning properly, another physician performed a catheter exchange procedure on the patient on 3/23/2015. After the procedure, the inspection of the catheter revealed that the guide wire remained in one of the lumens of the catheter.
Neither the internist nor his staff removed the guide wire from the catheter prior to the insertion of the catheter into the patient’s left subclavian vein.
The Board judged the internist’s conduct to be below the minimum standard of competence given that he left a foreign body in a patient.
The Board ordered that the internist pay a fine of $3,500 against his license and pay reimbursement costs for the case for a minimum of $3,419.35 and not to exceed $5,419.35. The Board also ordered that the internist complete five hours of continuing education in “Risk Management” and complete a lecture/seminar on retained foreign body objects to medical staff.
State: Florida
Date: November 2017
Specialty: Internal Medicine, Nephrology
Symptom: Chest Pain
Diagnosis: Renal Disease
Medical Error: Retained foreign body after surgery
Significant Outcome: N/A
Case Rating: 2
Link to Original Case File: Download PDF
Florida – Internal Medicine – Inadequate Monitoring For Post-Operative Care After Thyroid Lobectomy
On 8/12/2011, a patient was admitted to a medical center for post-operative care after a right thyroid lobectomy.
The patient presented with multiple risk factors for coronary artery disease, including obesity and tobacco use. She had a prolonged and difficult time with extubation after the surgery and complained of shortness of breath.
An internist was consulted for medical management. The internist diagnosed the patient with questionable and mild pulmonary edema. The internist’s plan of care for the patient was to admit her to the hospital, obtain ventilation/perfusion (V/Q) scan, perform cardiology and deep vein thrombosis evaluations, and perform peptic ulcer disease prophylaxis. The internist did not order telemetry monitoring for the patient.
On 8/12/2011, the patient was found slumped over the left side of her hospital bed and unresponsive. Staff initiated resuscitative efforts but they were unsuccessful and the patient expired.
The Board judged the internists conduct to be below the minimum standard of competence given that he failed to order telemetry monitoring for her upon her admission to the medical center.
The Board ordered that the internist pay a fine of $5,000 against his license and pay reimbursement costs for the case for a minimum of $2,378.85 and not to exceed $4,378.85. The Board also ordered that the internist complete five hours of continuing medical education in “Risk Management” and complete a one hour lecture/seminar on “Risk Management.”
State: Florida
Date: November 2017
Specialty: Internal Medicine
Symptom: Shortness of Breath
Diagnosis: Pulmonary Disease
Medical Error: Failure to properly monitor patient
Significant Outcome: Death
Case Rating: 1
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 – Internal Medicine – Failure To Justify Suboxone Prescribing Practices
From 7/8/2011 to 8/13/2015, an internist treated a 37-year-old female with an opioid dependency for seven years with Suboxone therapy. During the treatment period, the internist prescribed the controlled substance Suboxone to the patient on one or more occasions. During the treatment period, the internist failed to substantiate, by test or positive exam, the patient’s history of opiate use to justify the use of Suboxone.
During the treatment period, the internist did not obtain a history of substance abuse, including illicit substances, or a complete medical history from the patient’s prior healthcare provider to support his diagnosis of opioid dependence and opiate withdrawal.
During the treatment period, the internist inappropriately diagnosed the patient, as his physical examination of the patient failed to indicate clinical opiate withdrawal symptoms, to help support his diagnosis of continuous opioid dependence and opiate withdrawal.
During the treatment period, the internist failed to perform tests, including screening for hepatitis B and C, complete metabolic panel, and complete blood count, to completely assess the patient’s condition.
During the treatment period, the internist failed to completely and accurately maintain medical records that justify Suboxone therapy as a proper course of treatment.
During the treatment period, the internist failed to document a clear treatment plan and time frame for detoxification, and/or thoroughly educate the patient about additional recovery.
During the treatment period, the internist failed to perform and/or maintain records of frequent urine toxicology for the patient to prevent noncompliance, dependence, addition, or diversion of controlled substances.
During the treatment period, the internist failed to document, incorporate in the medical records, or comment on all urine toxicology screens performed on the patient on one or more occasions.
During the treatment period, the internist failed to include all logs of prescriptions within his electronic medical record (“EMR”).
During the treatment period, the internist did not pursue, or document pursuing, psychological counseling, prescription drug monitoring (“PDMP”) and follow-up urine toxicology screens to guide optimal therapy.
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: October 2017
Specialty: Internal Medicine
Symptom: N/A
Diagnosis: Drug Overdose, Side Effects, or Withdrawal
Medical Error: Failure to properly monitor patient, Failure to order appropriate diagnostic test, Failure of communication with patient or patient relations, Improper medication management, Lack of proper documentation
Significant Outcome: N/A
Case Rating: 1
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