Found 36 Results Sorted by Case Date
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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 – Cardiothoracic Surgery – Failure To Follow Up After Pathology Report Shows Abnormal Lymphadenopathy



On 1/25/2013, a 65-year-old male, underwent an artery bypass grafting procedure on his right leg by a cardiothoracic surgeon at a medical center.

During the course of the procedure, the cardiothoracic surgeon took a biopsy of the patient’s right groin lymph node, which was sent off to pathology for analysis.

The patient was never notified by the cardiothoracic surgeon that a biopsy of the right groin lymph node was taken during the procedure.

The cardiothoracic surgeon should have documented the right groin lymph node biopsy as part of the procedure in the operative report for the procedure but failed to do so.

On 1/29/2013, the pathology report for the biopsied tissue revealed a pathologic diagnosis of mantle cell lymphoma.  The pathology report was sent via facsimile to the cardiothoracic surgeon’s office.  The cardiothoracic surgeon should have listed “abnormal lymphadenopathy” as the post-operative diagnosis and failed to do so.

On 1/30/2013, the patient was discharged from the medical center.

The Board judged the cardiothoracic surgeons conduct to be below the minimal standard of competence given that he should have notified the patient of the pathology results and failed to do so.  He also should have obtained oncologic consultation for the patient and failed to do so.  The cardiothoracic surgeon should have provided the patient’s primary care physician and the referring physician with a copy of the pathology report and failed to do so.

The Board issued a letter of concern against the cardiothoracic surgeon’s license.  The Board ordered that the cardiothoracic surgeon pay a fine of $5,000 against his license and pay reimbursement costs for the case for a minimum of $5,063.26 but not to exceed $7,063.26.  The Board ordered that the cardiothoracic surgeon complete a board approved medical records course and complete five hours of continuing medical education in “risk management.”

State: Florida


Date: August 2017


Specialty: Cardiothoracic Surgery, Oncology


Symptom: N/A


Diagnosis: Cancer


Medical Error: Failure to follow up, Failure of communication with other providers, Referral failure to hospital or specialist, Failure of communication with patient or patient relations, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 4


Link to Original Case File: Download PDF



Florida – Oncology – Wrong Area Excised When Attempting To Remove Melanoma Of The Posterior Upper Left Arm



On 5/1/2013, a patient presented to an oncologist for a sentinel lymph node biopsy and a radical excision of a melanoma on the posterior aspect of her left upper arm.

When attempting to excise the melanoma on the posterior aspect of the patient’s left upper arm, the oncologist performed the excision on the wrong area of the posterior aspect of the patient’s left upper arm.

Post-operatively, the oncologist sent a specimen from the patient’s left upper arm excision to pathology.

On 5/6/2013, a surgical pathology report was issued stating that the specimen from the left upper arm excision was negative for melanoma.

On 5/6/2013, the patient underwent a second surgical procedure, and the melanoma was excised from the correct area of the posterior aspect of the patient’s left upper arm.

The Medical Board of Florida judged the oncologist’s conduct to be below the minimal standard of competence given that the oncologist performed the wrong site procedure when he performed a surgical excision on the wrong area of the posterior aspect of the patient’s left upper arm.

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

State: Florida


Date: April 2017


Specialty: Oncology, Dermatology


Symptom: N/A


Diagnosis: Cancer


Medical Error: Wrong site procedure


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



Florida – Oncology – Oncologist Unable To Load Up Images From Imaging Disc



In the months and/or years leading up to January 2013, an oncologist’s care for a patient included monitoring her for recurrence of lung cancer.

Sometime in 2012, the oncologist ordered diagnostic imaging services for the patient that were to be performed around January 2013.

On 1/8/2013, the patient received diagnostic imaging services.  The ensuing diagnostic imaging report noted abnormal densities/masses in the patient’s lungs that were indicative of malignant neoplasm.

On 1/21/2013, the patient presented to the oncologist for an appointment.  During the appointment, the oncologist failed to mention any of the January 2013 diagnostic imaging report findings to the patient.

On 1/22/2013, the oncologist electronically signed, and/or otherwise approved, a medical progress note for the patient that acknowledged the diagnostic imaging performed on 1/8/2013.  The progress note referenced in the preceding paragraph stated that the patient exhibited no evidence of recurrent disease.

In May 2013, the patient telephoned the oncologist’s office and advised that one of her other physicians was concerned about areas of growth in her lung(s) shown on the patient’s January 2013 diagnostic images.

Personnel affiliated with the oncologist’s office indicated that the oncologist would be advised of the patient’s call.

In the time between the oncologist’s May 2013 telephone call and 1/10/2014, the oncologist did not order or perform any additional diagnostic services for the patient.  He did not indicate/communicate concern that the patient’s cancer was returning.

On 1/10/2014, the patient returned to the imaging center for diagnostic imaging services.  The ensuing diagnostic imaging report noted an enlarging mass in the patient’s lungs that was concerning for recurrent cancer.

On 1/14/2014, the patient presented to the oncologist for an appointment.  During the appointment, the oncologist was unable to load an imaging disc provided by the imaging center.  The oncologist instructed the patient that she could follow up with a local oncologist.

Between 1/10/2014 and May 2014, the oncologist did not obtain and/or review the January 2014 diagnostic imaging report for the patient.

Between 1/10/2014 and May 2014, the oncologist did not order or perform any additional diagnostic services for the patient, nor did he indicate/communicate concern that the patient’s cancer was returning.

In May 2014, the patient presented to and was diagnosed with lung cancer by a different physician.

The Medical Board of Florida judged the oncologists conduct to be below the minimal standard of competence given that he failed to accurately interpret or characterize all known and available diagnostic imaging reports of the patient’s lungs.  He failed to timely obtain, review, and communicate with the patient regarding any ordered but unreviewed diagnostic imaging reports of the patient’s lungs.

The Medical Board of Florida ordered that the oncologist pay an administrative fine of $7,000 to the Board.  He also was ordered to complete five hours of continuing medical education in “risk management” and complete five hours of continuing medical education in the area of diagnosis and treatment of lung cancer.  The Medical Board of Florida also placed the oncologist’s license on probation for a period of one year.

State: Florida


Date: February 2017


Specialty: Oncology, Internal Medicine


Symptom: N/A


Diagnosis: Lung Cancer


Medical Error: Failure to follow up, 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



Arizona – Internal Medicine – History Of Breast Cancer And Cervical Cancer With Calcium Level At 13.1 On Calcium Supplements And Diuretics



In July 2014, a 58-year-old woman with a history of breast cancer, prior right mastectomy, status post chemotherapy, cervical cancer with prior hysterectomy, and family history of lymphoma was seen by her internist.  The patient had been previously followed by the internist at a different practice since 2012.  Calcium level was noted to be 13.1.  Her records reveal that she had lost a significant amount of weight over the last year.  She was noted to be taking calcium supplements and diuretics.  The calcium level was reported to the internist that evening.  He recommended that she return for a one week follow-up appointment.  There was no management plan located in the chart regarding the elevated calcium level.

In August 2014, the patient returned with confusion, abdominal pain, and diarrhea.  The internist documented that he had advised the patient in July to have her calcium levels rechecked.  However, she had taken an extended trip out of town.  Her calcium was noted to be 14.5 with a low parathyroid hormone.  The internist referred her to the emergency department.  She was treated for severe hypercalcemia with mental status changes and was found to have a large mass in her spleen with retroperitoneal and mesenteric adenopathy.  She was ultimately diagnosed with diffuse large B-cell Non-Hodgkin’s Lymphoma.

At a hearing, the internist testified that he saw the patient and her daughter after office hours and instructed the patient regarding the high calcium levels.  He did not document the encounter.

The Board judged the internist’s conduct to be below the minimum standard of competence given failure to discontinue calcium supplements and diuretics based on the calcium level of 13.1 and given failure to investigate the cause of hypercalcemia.

State: Arizona


Date: January 2017


Specialty: Internal Medicine, Oncology


Symptom: Abdominal Pain, Confusion, Diarrhea


Diagnosis: Cancer


Medical Error: Failure to follow up, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 4


Link to Original Case File: Download PDF



Arizona – Internal Medicine – Elevated Calcium And Low PTH Accompanied By Confusion, Aching, And Fatigue



On 06/26/2014, a 67-year-old man with a history of hyperlipidemia presented to an internist for management of fatigue and generalized aching.  The patient had been previously followed by the internist at a prior practice.  Records from the internist’s prior practice showed that labs draw on 11/08/2013 revealed a calcium level of 11.5 and PTH of 4.4.  A repeat PTH taken on 11/18/2013 was found to be 3.5.

On 06/27/2014, lab results revealed a calcium of 14.8.  The internist’s plan was to confirm that the on-call physician had referred the patient to the emergency department, and if not, to obtain a PTH, hydrate the patient aggressively, and have the patient follow up in a week.

On 07/03/2016, the patient followed up with the internist.  The internist documented that the patient had been asked to return to discuss abnormal lab results.  The patient denied a change in symptoms but reported mild confusion and intermittent mild generalized aching.  The internist ordered labs including a repeat PTH, but not a repeat calcium level.  The patient’s PTH was low at 3.8.

On 07/15/2014, the patient followed up with the internist to discuss a recent liver MRI.  The patient continued to report fatigue and some difficulty thinking.  The MRI showed a 10 x 12 cm mass to the left lobe of the liver with a satellite nodule.  The patient’s labs revealed a calcium level of 15.3.  The internist’s plan was a liver biopsy and urgent correction of hypercalcemia.  The internist recommended that the patient go to the hospital for immediate treatment.

From 07/16/2014 to 07/18/2014, the patient was admitted for fatigue, lethargy, hypercalcemia, and liver mass.  He was given IV fluids and zoledronic acid.  A CT guided biopsy was performed which revealed intrahepatic bile duct carcinoma.

On 07/31/2014, the patient was again hospitalized.  The history and physical noted that in November 2013, the patient had a baseline calcium level of 11.1 as tested by the internist.  During the hospitalization, the patient underwent a laparoscopic surgical ablation of one or more liver tumors and extensive radiofrequency ablation.

During a hearing and in response to a question from the Board member, the internist stated that when a patient presents with hypercalcemia, there should always be a concern regarding underlying malignancy.

The Board judged the internist’s conduct to be below the minimum standard of competence given failure to address hypercalcemia in a timely fashion leading to a delay in diagnosis.

On 04/2016, an interim order was issued for the internist to complete a competency evaluation.The internist appealed.  On 08/04/2016, the Board denied the internist’s appeal of the interim order.  The provider submitted his intention to retire.  Given concern that the internist had also performed below the standard of care in a multitude of cases, the Board elected to restrict his practice and prohibited from practicing medicine in the state of Arizona.  They ordered that he complete and pass a competency evaluation in order to reverse the practice restriction.

State: Arizona


Date: January 2017


Specialty: Internal Medicine, Oncology


Symptom: Confusion


Diagnosis: Cancer


Medical Error: Failure to follow up


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



Arizona – Internal Medicine – Syncope, Weight Loss, Ataxia, Pancytopenia, And Hypotension



On 04/28/2014, a 71-year-old man with a history of hyperlipidemia, hypothyroidism, and gastrointestinal reflux disease presented to an internist with complaints of unexplained fatigue, weakness, an 18-pound weight loss over two months, and anemia.  The patient also reported that two years prior, he had a syncopal episode, recurrent hospitalizations, colon surgery, and colostomy with subsequent take-down surgery possibly related to diverticulitis.  His weight was 140.9 pounds.  No physical examination was documented.  The internist’s plan was to obtain prior medical records and then have the patient follow up in a month.

On 05/05/2014, the patient presented to the emergency department for hypotension and syncope.  His CBC with differential showed a white blood cell count with a reduced percentage of lymphocytes and a low platelet count.  The patient was also felt to be anemic and hypotensive.  His blood pressure medication was discontinued.

On 05/20/2014, the patient followed up with the internist, who changed his medication and ordered a CBC.  The patient’s weight was recorded as 133.8 pounds.

On 06/18/2014, a CBC was obtained and revealed a WBC of 1.4K.  These results were reported to the internist, who documented that the patient had pancytopenia and should be referred to hematology.

On 06/23/2014, the patient followed up with the internist.  The patient reported weakness with difficulty getting up and down.  He had blacked out in the shower that day and his equilibrium was off.  The patient was noted to be ataxic by the internist’s medical assistant.  His weight was noted to be 128.56 pounds.  The internist documented that the patient appeared pale, weak, and imbalanced.  He required help getting onto the examination table.  The internist ordered a CBC which revealed a WBC of 2K.  The internist referred the patient to an oncologist and sent a copy of the lab to a hematologist.

On 06/25/2014, the patient was hospitalized and subsequently discharged to a rehabilitation facility and then hospitalized again on 07/07/2014.  The attending physician at the subsequent hospitalization ordered a brain MRI, which revealed a 2.9 cm mass in the left cerebellum.  Pathology of the mass after removal revealed diffuse large B cell CNS lymphoma.

During a hearing, the internist testified that the recent CT head scan showed no intracranial abnormalities.  The Board noted that the physician did not document gait testing or tandem gait testing to evaluate the ataxia noted by the medical assistant.

The Board judged the internist’s conduct to be below the minimum standard of competence given failure to promptly diagnose the patient’s recurrent syncope and ataxia.

On 04/2016, an interim order was issued for the internist to complete a competency evaluation.  The internist appealed.  On 08/04/2016, the Board denied the internist’s appeal of the interim order.  The provider submitted his intention to retire.  Given concern that the internist had also performed below the standard of care in a multitude of cases, the Board elected to restrict his practice and prohibited from practicing medicine in the state of Arizona.  They ordered that he complete and pass a competency evaluation in order to reverse the practice restriction.

State: Arizona


Date: January 2017


Specialty: Internal Medicine, Oncology


Symptom: Syncope, Weakness/Fatigue


Diagnosis: Cancer


Medical Error: Failure to order appropriate diagnostic test


Significant Outcome: N/A


Case Rating: 4


Link to Original Case File: Download PDF



Arizona – Urology – Hepatic Artery, Portal Vein, and Common Bile Duct Transected During Partial Nephrectomy



The Board was notified of a malpractice settlement regarding the treatment of a 76-year-old woman.

On 02/14/2012, a woman was evaluated by a urology regarding a renal lesion that had been found on a CT scan.  The urologist ordered a CT scan which was performed on 11/28/2012 and which revealed no no significant change in size of the 0.9 cm lesion located on the upper pole of the right kidney.  The lesion had a slightly thickened and irregular enhancing wall.  There was a small ventral wall hernia.  The urologist documented the renal lesion as being complex and enhancing with no significant enlargement.  It was around 1 cm in diameter and was not causing the patient any symptoms.  The urologist recommended a biopsy.

On 01/24/2013, the patient underwent a right renal biopsy.  Pathology revealed probable clear cell renal cell carcinoma Fuhrman grade 2.

On 01/30/2013, the urologist documented that he discussed the risks and benefits with the patient regarding surgery.  The urologist offered a hand assisted approach to allow for repair of the patient’s hernia.  The patient gave consent for the procedure.

On 04/17/2013, the patient was admitted for right nephrectomy via hand assisted laparoscopy.  Per the anesthesia record, the anesthesia start time was 1:51 p.m. and surgery start time was 2:26 p.m.  The surgery end time was 5:54 p.m.  The urologist’s operative note documented adhesions and significant bleeding he initially thought was due to injury of the inferior vena cava.  The patient received two packed red blood cell transfusions and the operation was converted to an open procedure.

At 3:00 p.m., the anesthesia record stated that the blood pressure was 60/30.

At 3:47 p.m., a general surgeon was consulted and arrived in the operating room.  The surgeon noted that there was bleeding along the anterolateral edge of the patient’s duodenum and pancreas.  The portal vein, common bile duct, and hepatic artery were transected.  The urologist stated that he proceeded with a radical nephrectomy prior to liver vascular repair to avoid further liver vascular damage.  Per the general surgeon’s note, hepatic warm ischemia time was one hour and fifteen minutes.  After the nephrectomy was completed, the hepatic artery, portal vein, and common bile duct were repaired, including graft replacement.

At 5:30 a.m. on 04/18/2013, the urologist dictated his operative report.

On 04/18/2013, the patient was taken back to surgery after sanguineous fluid was found in the drain output.  The general surgeon’s intraoperative findings included 1500 ml of intra-abdominal blood along with bleeding from a gonadal vessel and from the insertion of the renal vein on the vena cava.  The family requested DNR status for the patient.  The patient subsequently died.

The Board judged urologist’s conduct to be below the minimum standard of competence given failure to use proper surgical technique with correct tissue transection/ligation, failure to timely convert to an open procedure, and failure to consider hepatic artery and portal vein repair prior to proceeding with the performance of the nephrectomy.

The Board ordered the urologist to be reprimanded.

State: Arizona


Date: November 2016


Specialty: Urology, General Surgery, Nephrology, Oncology


Symptom: N/A


Diagnosis: Post-operative/Operative Complication, Cancer


Medical Error: Procedural error


Significant Outcome: Death


Case Rating: 3


Link to Original Case File: Download PDF



California – Pediatrics – Persistent Left Thigh Pain After A Fall Diagnosed As Possible Fibromyalgia



On 4/22/2008, a twelve-year-old female presented to the emergency department after falling down a small grass-covered hill in front of the local library, landing hard on her left side causing severe pain and limping.  The patient was diagnosed with a left thigh contusion and strain, prescribed pain medications, and was given a written note to be out of school for the next two days.  On 8/19/2008, the patient presented to a pediatrician, who documented that she had fallen four months earlier in a library and injured her right thigh (she actually injured her left thigh), which was still hurting.  However, the pediatrician failed to document the level or severity of the pain or any characteristics of the pain.  He documented that he examined her head, face, eyes, ears, nose, throat, mouth, teeth, neck, chest, heart, lungs, abdomen, genitalia, extremities, hip, skin, back, lymph nodes, and central nervous system, which were all normal.  The pediatrician prescribed liquid Motrin for the pain; however, he failed to maintain a copy of the prescription in the chart.

On 9/24/2008, the patient returned with a fever and a sore throat. In an interview later with the Board, the pediatrician stated that he also examined the patient’s ears, nose neck, heart and lungs; however, he failed to document the examination and his findings in the chart.  The pediatrician prescribed liquid Motrin for the fever along with Amoxicillin; however, he failed to maintain copies of the prescriptions in the chart.

On 4/27/2009, the patient again presented to the pediatrician who noted that her left thigh had been hurting for ten months.  The pediatrician failed to inquire about and document the level or severity of the pain or any other characteristics of the pain.  During an interview with the Board, the pediatrician stated that he examined her lower extremities; however, he failed to document his examination and his findings in the chart.  The pediatrician’s impression was that the patient had “pain on leg.”  The pediatrician prescribed liquid Motrin again, but failed to maintain a copy of the prescription in the chart, the pediatrician also ordered x-rays of her left femur, and wrote a note excusing her from physical education at school for the next two weeks.

On 9/8/2009, the patient again presented to the pediatrician who noted that the back of her thigh still hurt; however, the pediatrician failed to document which thigh the patient was complaining of and failed to document any characteristics of or the level or severity of the pain.  The pediatrician has two separate progress notes for this visit.  On the first note, no physical examination is documented; however, on the second note, the pediatrician documented that he examined her head, face, eyes, ears, nose, throat, mouth, teeth, neck, chest, heart, lungs, abdomen, genitalia, extremities, hip, skin, back, lymph nodes, and central nervous system which were all reportedly normal. The pediatrician’s impression was “muscle spasm’ and again prescribed liquid Motrin, but failed to maintain a copy of the prescription in the chart.  Additionally, the patient had a comprehensive metabolic blood panel which showed significantly abnormal AST and ALT which were more than ten times the normal values; however, the pediatrician failed to document his plan to follow up on these abnormal lab findings and failed to address their etiology with further testing.

On 9/16/2009, the patient again presented to the pediatrician who noted that the back of her thigh hurt when she sat down.  However, the pediatrician failed to document which thigh the patient was complaining about and failed to document any characteristics of or the level or severity of the pain, the pediatrician documented that he examined her head, face, eyes, ears, nose, throat, mouth, teeth, neck, chest, heart, lungs, abdomen, genitalia, extremities, hip, skin, back, lymph nodes, and central nervous system again even though he had examined them eight days earlier.  The pediatrician’s impression was “pain on thigh” and diagnosed the patient with fibromyalgia, a condition which is very rare in adolescents and children.  The pediatrician requested approval for the patient to see an orthopedist and considered starting her on pregabalin to treat the fibromyalgia.

On 9/24/2009, the patient again presented to the emergency department and was noted to have pain and soreness in her left inner thigh and was favoring her right leg.  Upon examination, she was noted to have pain in the medial left thigh on left hip abductor on adduction and hyper-abduction, and tenderness and light spasms were palpated on the left medial thigh.  She was diagnosed with an acute left thigh strain, her thigh was wrapped with an Ace bandage, and she was discharged with a written note to school restricting her from physical education and sports for seven days.

On 9/28/2009, the patient presented to the pediatrician who noted her chief complaint was pain on her inner thighs; however, he failed to document the level or severity of the pain or any other information or characteristics of the pain.  The pediatrician noted that she was seen at the emergency room four days earlier and the emergency room doctor recommended crutches.  The pediatrician has two different progress notes for this visit.  On the first progress note, no physical examination is documented; however, on the second progress note the pediatrician documented that he examined the patient’s head, face, eyes, ears, nose, throat, mouth, teeth, neck, chest, heart, lungs, abdomen, genitalia, extremities, hip, skin, back, lymph nodes, and central nervous system areas he had examined two weeks earlier.  On both progress notes, the pediatrician’s impression is fibromyalgia; however, the first progress note lists his plan to prescribe Lyrica, and on the second progress note Lyrica is crossed out and the pediatrician wrote that he prescribed gabapentin; however, the pediatrician failed to date and initial the changes.  The pediatrician also failed to maintain a copy of the gabapentin prescription in the chart.  The pediatrician also requested authorization for crutches, which were approved.

On 9/30/2009, the pediatrician’s office requested authorization for a prescription of Lyrica to treat the patient’s fibromyalgia, and noted the medical necessity as “severe pain” left thigh and back “now walks with crutches.”  During an interview with the Board, the pediatrician stated that the patient never complained of severe pain and that his office manager wrote that in order to get authorization from the insurance company.

On 10/20/2009, the pediatrician’s office manager completed a preauthorization request form for the patient which stated that the clinic indications for the request was “13 yr. old c/o pain (severe) left thigh and back” who “needs crutches to help” ambulate.  The pediatrician, however, during an interview with the Board, stated that the patient, never complained of severe pain and that his office manager wrote that in order to get authorization from the insurance company.

On 10/21/2009, the patient again presented to the pediatrician who noted that she was still having pain in her thigh and it was not better.  The pediatrician failed to document which thigh the patient was complaining of and failed to document the level or severity of the pain or any other information or characteristics of the pain, the pediatrician documented that he examined her head, face, eyes, ears, nose, throat, mouth, teeth, neck, chest, heart, lungs, abdomen, genitalia, extremities, hip, skin, back, lymph nodes, and central nervous system areas, which he examined three weeks earlier.

The pediatrician’s impression was fibromyalgia, and continued prescribing gabapentin, but failed to maintain a copy of the prescription in the chart.  On 11/4/2009, the patient again presented to the pediatrician who noted she was doing well and was not having much pain in her thigh; however, the pediatrician failed to document which thigh the patient was complaining of.  The pediatrician documented that he again examined her face, eyes, ears, nose, throat, mouth, teeth, neck, chest, heart, lungs, abdomen, genitalia, extremities, hip, skin, back, lymph nodes, and central nervous system, areas he examined two weeks earlier. The pediatrician’s impression was fibromyalgia, and continued her prescription medication, but failed to maintain a copy of the prescription in the chart.

On 11/30/2009, the patient was again seen by the pediatrician who noted that her left thigh still hurt and she now had a fever.  The pediatrician examined her extremities and noted that her left thigh was slightly tender and had large swelling; however, the pediatrician failed to take any measurements of her thigh on this visit.  The pediatrician noted his impression as fibromyalgia, but stated during an interview with the Board that that was a very unlikely impression at the time.  The pediatrician decreased the dosage of gabapentin and prescribed liquid Motrin for her fever; however, the pediatrician failed to maintain copies of the prescriptions in the chart.

On 12/7/2009, the patient was again seen by the pediatrician who noted that her leg was still swollen and hurting.  The pediatrician examined her extremities and noted hard swelling on the left inner thigh.  The pediatrician documented that her right thigh measured 53% centimeters (cm) in circumference and her left thigh 57 cm; however, the pediatrician could not recall exactly how he took the measurements.

The pediatrician’s impression was fibromyalgia and his plan was to decrease the gabapentin and order an ultrasound of her right thigh.  In his chart note, the pediatrician documented that the ultrasound (performed on 12/22/2009) showed multifocal soft tissue cysts probably due to trauma and hematoma on the right thigh; however, the pediatrician failed to date this late entry.  Additionally, during an interview with the Board, the pediatrician stated that his notes under “Tests and Treatment’ section of the progress note referencing the right thigh ultrasound results was incorrect and that it should have said the left thigh; however, the pediatrician ordered an ultrasound of the patient’s right thigh not the left.

On 12/22/2009, an ultrasound of the patient’s right lower extremity was performed showing multifocal soft tissue cysts.

On 12/31/2009, the patient presented to the pediatrician again who noted that her left thigh was more swollen and she had pain on her right thigh during walking.  The pediatrician examined her extremities and noted that her left thigh was tender with swelling.  Her right thigh measured 55 cm and her left thigh 66 cm; however, the pediatrician did not recall exactly how he took the measurements. The pediatrician failed to document the level or severity of or any characteristics of the pain.  The pediatrician documented his impression as fibromyalgia, although during an interview with the Board, he stated that his impression was actually a cyst, based upon the ultrasound results of the right thigh.  The pediatrician’s plan was to discontinue the gabapentin and refer the patient to a pediatric rheumatologist for a second opinion.

On 1/13/2010, the patient saw the pediatrician again who noted that she complained of severe pain in her left thigh, which was more swollen.  The pediatrician examined her extremities, but noted no abnormalities or swelling.  The pediatrician again measured her thighs and noted that her right thigh now measured 51 cm and her left thigh 68 cm; however, the pediatrician could not fully explain how the patient’s right thigh measures changed from 53 cm on 12/7/2009, to 55 cm on 12/31/2009, and decreased to 51 cm in January 2010.

The pediatrician stated that maybe he measured 15 inches from the knee joint up and then measured the circumference the first time, and then he might have measured from a different level the second time, maybe only 10 inches up from the knee joint.  The pediatrician documented his impression as fibromyalgia, although during his interview he stated that his impression was actually a cyst based upon the ultrasound results.  The pediatrician’s plan was to continue her prescription for liquid Motrin for the pain and to have her return in five weeks.

On 1/14/2010, the patient was seen by a pediatric rheumatologist at the Long Beach Memorial Medical Center/Miller Children’s Hospital, who noted that the patient was having severe pain about once a week causing her difficulty when standing up.  The rheumatologist’s examination revealed that the patient’s left thigh was significantly swollen with a mass in the posterior aspect to the medial superior area with a circumference measuring approximately 70 cm.  The rheumatologist was concerned as the patient’s history and physical examination were not suggestive of fibromyalgia and the swelling and the mass was inconsistent with fibromyalgia.

The rheumatologist felt the 12/9/2009 ultrasound findings could be consistent with an infectious process and felt that the patient would benefit from hospitalization for further evaluation.  The rheumatologist expressed her concerns to the pediatrician and emphasized that such swelling cannot be attributed to fibromyalgia.

On 1/15/2010, the patient again presented to the pediatrician who noted she complained of swelling and pain in her left thigh.  The pediatrician examined her extremities and noted that her left thigh was swollen with a mass present; however, two days earlier, the pediatrician documented that he examined her extremities but did not note any swelling or mass.

The pediatrician’s impression was that she had a tumor in her left thigh and his plan was to admit her to a hospital for further evaluation.  Subsequently, the pediatrician added his first diagnosis as hematoma/lymphoma, and his second diagnoses as sarcoma; however, he failed to date these late entries.

On 1/15/2010, the patient presented to the hospital wherein she underwent a bilateral Magnetic Resonance Imaging of her left leg which reflected an elongated soft tissue mass measuring approximately 18 x 14 X 14 cm along with multiple cystic areas with fluid.  She also underwent a Magnetic Resonance Angiogram which reflected abnormal vasculature surrounding and partially coursing through the mass,

On 1/18/2010, the patient underwent a biopsy of her left thigh mass.  The final results reported that the patient had synovial cell sarcoma which had metastasized to her lungs.

The patient underwent a course of chemotherapy and surgery of her left thigh tumor at a children’s hospital; however, her pulmonary tumors continued to increase in size and the patient died of her illness on 1/15/2012.

The Board judged the pediatrician’s conduct as having fallen below the standard of care given failure to adequately perform further work-up of her persistent left leg complaints and order further diagnostic studies and tests, failure to follow up on the significantly abnormal AST and ALT results, and given failure to maintain adequate and accurate medical records.

The Board revoked the pediatrician’s license and placed him on probation for three years with stipulations to complete at least 45 hours of continuing medical education per year in areas of deficiencies, to complete a medical record keeping course, and to undergo monitoring.

State: California


Date: October 2016


Specialty: Pediatrics, Oncology


Symptom: Extremity Pain, Fever


Diagnosis: Cancer


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


Significant Outcome: Death


Case Rating: 5


Link to Original Case File: Download PDF



California – Oncology – New Onset Of Coughing And Shortness Of Breath After Stage III Hodgkin’s Lymphoma Treated With Adriamycin, Bleomycin, Vinblastine, And Dacarbazine



A 56-year-old male presented to a hematologist-oncologist with a 6-month history of a left neck mass and 3 years of progressive back pain in July 2013.  Later that month, the patient was diagnosed with Stage III Hodgkin’s lymphoma, nodular sclerosis. The hematologist-oncologist started the patient on a standard chemotherapy protocol on 7/24/2013 with adriamycin, bleomycin, vinblastine, and dacarbazine.  The hematologist-oncologist did not document obtaining informed consent from the patient for the chemotherapy, including the use of bleomycin and its attendant risks of lung injury. Bleomycin is a key component of curative chemotherapy regimens used to treat curable cancers, such as Hodgkin’s lymphoma.  Its use may cause bleomycin-induced lung injury, including life-threatening interstitial pulmonary fibrosis in up to 10% of patients receiving the drug.

The hematologist-oncologist noted that the patient complained of new symptoms on his 9/30/2010 visits, including a persistent cough for 2 weeks.  The patient received another cycle of chemotherapy, including bleomycin, on 10/4/2013.

The patient was admitted from 10/18/2013 until 10/21/2013 and was treated for presumptive pneumonia.  A progress note entered by the hematologist-oncologist on 10/21/2013 stated that a chest x-ray and a CT scan revealed changes in the patient’s radiologic appearance.  A chest x-ray taken on 10/18/2013 showed bibasilar airspace disease, and a high-resolution CT scan taken on 10/20/2013 showed interstitial fibrosis with areas of patchy ground glass density consistent with bleomycin toxicity.

The patient returned home and had gradual progressive shortness of breath and an increased dry cough.  He presented to the emergency department on 10/28/2013 with dyspnea. He was found to be tachypneic but not hypoxic.  A chest x-ray showed low lung volumes and extensive bilateral lung opacities, indicating worsening interstitial fibrosis, consistent with bleomycin toxicity.  The patient was admitted to the ICU for further treatment. His condition continued to deteriorate, and he died on 11/19/2013. The Death Summary reported that the patient had bleomycin lung toxicity with severe acute respiratory distress syndrome.

The Medical Board of California judged that the hematologist-oncologist’s conduct departed from the standard of care because he ignored signs of possible pulmonary toxicity from bleomycin that warranted further evaluation with pulmonary function tests, high-resolution CT scans, and/or pulmonary consultation.  Instead, the hematologist-oncologist proceeded to administer an additional dose of bleomycin.  The hematologist-oncologist also did not order a pulmonary function test or a chest x-ray to rule out bleomycin toxicity before proceeding with an additional chemotherapy treatment on 10/4/2013 even though a PET/CT exam taken on 10/2/2013 was abnormal and showed mild diffuse lung uptake, which was not present on a prior July 2013 PET/CT exam, and which was suggestive of new lung toxicities.  Also, after the high-resolution CT scan on 10/20/2013 demonstrated interstitial fibrosis with areas of patchy ground glass density consistent with bleomycin toxicity, the hematologist-oncologist failed to consider and carry out a therapy directed at bleomycin toxicity. The patient should have been promptly started on steroids. Corticosteroids have been the mainstay of intervention for bleomycin toxicity and have been found to be more successful earlier in the evolution of the process.  The hematologist-oncologist additionally failed to inform the patient of the dangerous risks of his chemotherapy treatment.

The Medical Board of California issued a public reprimand and ordered the hematologist-oncologist to complete a medical record keeping course.

State: California


Date: October 2016


Specialty: Oncology


Symptom: Cough, Mass (Breast Mass, Lump, etc.), Back Pain, Shortness of Breath


Diagnosis: Drug Overdose, Side Effects, or Withdrawal, Cancer, Pulmonary Disease


Medical Error: Improper medication management, Diagnostic error, Failure to order appropriate diagnostic test, Failure of communication with patient or patient relations, Improper treatment


Significant Outcome: Death, Hospital Bounce Back


Case Rating: 4


Link to Original Case File: Download PDF



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