Found 8 Results Sorted by Case Date
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New York – Physician Assistant – History Of Bipolar Disorder With Concern For Irregular Menses



On 8/13/2007, a 21-year-old female presented to a physician assistant for follow up treatment of bipolar disorder and concern for irregular menses.

During the examination, the patient advised the physician assistant that her most recent period was the prior November and that she had not had a gynecological examination in ten years. The physician assistant examined the patient’s abdomen, which he found to be benign.  In regard to the patient’s complaints of irregular menses, the physician assistant ordered a variety of blood work and stated that he would follow up with the patient in three months, unless otherwise indicated.  The blood work that he ordered did not include a hCG test.

On 8/16/2007, the patient arrived at the emergency department with a full-term pregnancy and delivered her baby on that same day.

The Board judged that the physician assistant’s medical care deviated from accepted standards of care given failure to perform an adequate physical examination, given failure to order a hCG test, and given failure to recognize signs of pregnancy.

State: New York


Date: July 2017


Specialty: Physician Assistant, Family Medicine, Internal Medicine


Symptom: Gynecological Symptoms


Diagnosis: N/A


Medical Error: Failure to order appropriate diagnostic test, Failure to examine or evaluate patient properly


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



New York – Physician Assistant – Lack Of Lab Work For Routine Visit For A 37-Year-Old Female



On 11/3/2008, a 37-year-old female presented to a physician assistant for a physical and PAP smear.  During the examination, the physician assistant performed a pelvic examination and found normal female genitalia without lesion or discharge.  A PAP smear was obtained without incident.  The physician assistant’s examination of the patient’s abdomen revealed the abdomen was soft and nontender.  The physician assistant’s plan was to reassess the patient in three months unless otherwise indicated.

The physician assistant did not order the patient to undergo any lab work, such as an hCG test.

On 11/12/2008, the patient presented to the hospital with a full-term pregnancy and delivered a baby on the same date.

The Board judged that the physician assistant’s medical care of the patient deviated from accepted standards of care given failure to recognize signs of pregnancy.

State: New York


Date: July 2017


Specialty: Physician Assistant, Family Medicine, Internal Medicine, Obstetrics


Symptom: N/A


Diagnosis: N/A


Medical Error: Failure to order appropriate diagnostic test, Failure to examine or evaluate patient properly


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



New York – Internal Medicine – Chronic Fatigue, Disturbed Sleep, Joint Pains, Nausea, Diarrhea, And An Abnormal MRI Diagnosed As Chronic Fatigue Syndrome



From 10/15/1998 to 3/7/2008, Physician A treated a 38-year-old female who presented with complaints of severe fatigue, disturbed sleep, irritability, joint pains, frequent sore throats, nausea, and diarrhea.  At her initial visit, the patient reported that 9 years earlier she had been told she had a borderline Lyme test and was treated with antibiotics.  In the past 5 years, she had frequent bouts of fatigue and was diagnosed with Chronic Fatigue Syndrome.

In December 1998, the patient was seen by a neurologist who, based on an abnormal MRI, recommended a lumbar puncture but one was not done.  In June 1999, the patient had an abnormal brain SPECT.  In January 2002, the patient had her first and only physical examination at Physician A’s practice.  In January 2008, ten years after the initial MRI, the patient had a second MRI, which was again abnormal.  A neurologist performed a lumbar puncture.

The results of the lumbar puncture were negative for Lyme disease but revealed positive oligoclonal band proteins which are consistent with the diagnosis of multiple sclerosis.

The Board judged Physician A’s conduct to have fallen below the standard of care given failure to take an adequate history of present illness, failure to obtain prior medical records, failure to perform a physical examination, failure to construct a differential diagnosis, failure of prescribing medications without appropriate medical conditions, failure to perform a lumbar puncture, and failure to timely diagnose the patient’s multiple sclerosis.

The Board charged Physician A with professional incompetence and gross negligence.

State: New York


Date: April 2017


Specialty: Internal Medicine, Family Medicine, Neurology


Symptom: Weakness/Fatigue, Nausea Or Vomiting, Joint Pain


Diagnosis: Neurological Disease, Autoimmune Disease


Medical Error: Diagnostic error


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



New York – Internal Medicine – Pain Associated With PICC Line



From 7/8/2008 to August 2008, Physician A treated a 46-year-old woman with a history of Parkinson’s disease diagnosed in May 2008.  At her initial visit, she reported that in early May 2008, she had a tick bite with subsequent bull’s eye rash.  She had been treated with antibiotics and intramuscular injections for approximately seven weeks.

Physician A ordered a PICC line for the administration of parenteral antibiotics, which was placed on 7/17/2008.  One week later, the patient complained of pain in her neck and shoulder.  On 7/31/2008, the patient reported extreme pain.  The patient had a venous Doppler study, which indicated deep vein thrombosis.  The patient was admitted to the hospital where the PICC line was removed, and the patient was placed on anticoagulant therapy.

The Board judged Physician A’s conduct as having fallen below the minimum level of competence given failure to take an appropriate history, failed to perform a physical exam, failure to construct a differential diagnosis, and failure to evaluate her pain in a timely fashion.

State: New York


Date: April 2017


Specialty: Internal Medicine, Family Medicine


Symptom: Extremity Pain, Head/Neck Pain


Diagnosis: Deep Vein Thrombosis/Intracardiac Thrombus


Medical Error: Diagnostic error


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



New York – Emergency Medicine – Two To Three Day Headache With Frequent Vomiting



On 07/27/2001, the patient presented to the emergency department with two to three days of headache.  He had never had this headache before.  It was associated with frequent vomiting.  The ED physician sent the patient home with a diagnosis of cephalgia and tension.

On 07/28/2001, the patient returned to the emergency department and was diagnosed with intracranial hemorrhage secondary to an anterior communicating artery aneurysm.

The Board judged the ED physician’s conduct as falling below the minimum standard of competence in this instance of care among others.  The ED physician failed to order a CT head scan to evaluate for intracranial hemorrhage.  He failed to maintain an adequate medical record for the patient.

He was ordered to complete an educational program in medical recordkeeping, to only practice medicine when monitored by a licensed physician, and to maintain medical malpractice insurance coverage with limits no less than $2 million per occurrence and $6 million per policy year.

State: New York


Date: October 2007


Specialty: Emergency Medicine, Neurosurgery


Symptom: Headache


Diagnosis: Intracranial Hemorrhage


Medical Error: Diagnostic error, Failure to order appropriate diagnostic test


Significant Outcome: Hospital Bounce Back


Case Rating: 2


Link to Original Case File: Download PDF



New York – Emergency Medicine – Abdominal Pain With A History Of Metastatic Colon Cancer And Bowel Obstructions



On 12/19/2004, a patient with a history of metastatic colon cancer presented to the emergency department with abdominal pain and nausea for one day.  He also had a history of multiple episodes of bowel obstruction, although the ED physician failed to obtain the pertinent medical records to obtain this information.  The patient said he had had no stool in his ostomy for 48 hours.  The ED physician prescribed anti-nausea medications and IV fluids.

Later that day, the patient returned to the emergency department and was admitted for small bowel obstruction.

The Board judged the ED physician’s conduct as failing to meet the standard of care given failure to adequately interpret the x-rays of the patient, failing to order a CT scan, failing to adequately treat the patient, and failing to maintain an adequate medical record for the patient.

He was ordered to complete an educational program in medical recordkeeping, to only practice medicine when monitored by a licensed physician, and to maintain medical malpractice insurance coverage with limits no less than $2 million per occurrence and $6 million per policy year.

State: New York


Date: October 2007


Specialty: Emergency Medicine


Symptom: Abdominal Pain


Diagnosis: Acute Abdomen


Medical Error: Diagnostic error


Significant Outcome: Hospital Bounce Back


Case Rating: 2


Link to Original Case File: Download PDF



New York – Emergency Medicine – Neck Swelling With An Indwelling Subclavian Catheter



On 09/02/2002, a patient with a history of right sided mastectomy secondary to breast cancer and an indwelling subclavian catheter presented to the emergency department with right sided neck swelling for three days.  The ED physician diagnosed the patient with supraclavicular soft tissue swelling of unknown etiology and discharged her home.

On 09/03/2002, the patient was admitted for treatment of a superior vena cava thrombosis secondary to the indwelling subclavian catheter.

The Board judged the ED physician’s conduct as failing to meet the standard of care given failure to correctly diagnose the patient and failure to maintain an adequate medical record for the patient.

He was ordered to complete an educational program in medical recordkeeping, to only practice medicine when monitored by a licensed physician, and to maintain medical malpractice insurance coverage with limits no less than $2 million per occurrence and $6 million per policy year.

State: New York


Date: October 2007


Specialty: Emergency Medicine


Symptom: Swelling


Diagnosis: Deep Vein Thrombosis/Intracardiac Thrombus


Medical Error: Diagnostic error


Significant Outcome: Hospital Bounce Back


Case Rating: 2


Link to Original Case File: Download PDF



New York – Emergency Medicine – Elbow Pain After Having Arm Pulled In Pediatric patient



On 10/17/1999, a six-year-old boy presented to the emergency department with right elbow pain after having been pulled by his right arm.  X-rays were performed, after which the ED physician discharged the patient with an arm sling and instructions to follow-up in a clinic in 2 days.

On 10/19/1999, the patient was diagnosed with radial head subluxation and underwent reduction.

The Board judged the ED physician’s conduct as failing to meet the standard of care given failure to correctly diagnose the patient and failure to maintain an adequate medical record for the patient.

He was ordered to complete an educational program in medical recordkeeping, to only practice medicine when monitored by a licensed physician, and to maintain medical malpractice insurance coverage with limits no less than $2 million per occurrence and $6 million per policy year.

State: New York


Date: October 2007


Specialty: Emergency Medicine


Symptom: Extremity Pain


Diagnosis: Trauma Injury


Medical Error: Diagnostic error


Significant Outcome: Hospital Bounce Back


Case Rating: 2


Link to Original Case File: Download PDF



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