Found 8 Results Sorted by Case Date
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New Jersey – Gastroenterology – Pathology Diagnoses Polyp Removed During Colonoscopy As Adenocarcinoma

A payment of $775,000 had been made on the gastroenterologist’s behalf to settle a civil malpractice action brought against him by a patient.

It was alleged the gastroenterologist failed to follow-up on pathology results that revealed cancer after he had performed a colonoscopy on the patient, which led to a delay in the diagnosis of colorectal cancer.

On 8/12/2009, a 55-year-old woman presented to a gastroenterologist with complaints of abdominal pain and rectal bleeding.  The patient’s medical history revealed a family history of colon cancer.  The gastroenterologist recommended that the patient have a diagnostic colonoscopy to evaluate her persistent rectal symptoms.

On 9/17/2009, the gastroenterologist performed a colonoscopy on the patient.  During the procedure, the gastroenterologist identified internal hemorrhoids associated with a sessile polyp in the mid-rectum.  The gastroenterologist removed the polyp and submitted the specimen for pathologic analysis.  The patient was discharged from the hospital on 9/17/2009.

On 9/18/2009, pathology diagnosed the polyp to be a moderately differentiated adenocarcinoma arising within a tubular adenoma.  On 10/6/2009, the gastroenterologist entered a progress note in the patient’s hospital chart directly documenting the finding of adenocarcinoma made in the pathology report.  Despite entering that chart note, the gastroenterologist never advised the patient of the finding of adenocarcinoma that had been made.

The gastroenterologist thereafter had no further contact with the patient until he saw her in his office on 8/23/2010, approximately eleven months after the colonoscopy had been performed.  At that visit, the gastroenterologist diagnosed the patient with hemorrhoids and prescribed steroid suppositories; however, he once again failed to inform her of the finding of cancer that had been made following the September 2009 colonoscopy.  Additionally, the gastroenterologist did not then recommend that the patient schedule a repeat colonoscopy.

The patient ultimately had a repeat colonoscopy performed by another physician on 4/27/2011.  Following that procedure, she was found to have an invasive carcinoma of the mid-rectum, and she commenced receiving treatment for colon cancer.

When appearing before the panel, the gastroenterologist testified that he was aware of the pathology findings that had been made following the colonoscopy but did not specifically advise the patient of those findings because he considered the pathology findings to be “benign.”  The gastroenterologist further testified that he was confident that he had removed the entirety of the rectal polyp at the time of the colonoscopy.  The gastroenterologist maintains that, after completing the colonoscopy, he advised the patient that she would need to see him again in “about” a year, but there is no documentation in either the gastroenterologist’s medical record or the hospital chart which memorializes respondent’s having advised the patient to have a repeat colonoscopy within one year.  Further, although the gastroenterologist entered a note in the patient’s hospital chart on 10/6/2009 documenting the pathology findings, he failed to record the pathology findings in his office medical record, and he failed to obtain and/or maintain a copy of the pathology report in his office record.

The Board judged the gastroenterologist’s conduct to have fallen below the standard of care given failure to document that he advised the patient to have a repeat colonoscopy performed within one year of the date on which the original colonoscopy was performed and failure to have documented the pathology findings of adenocarcinoma in his office record.

The Board assessed a fine against the gastroenterologist with stipulations to complete courses in medical record keeping and medical ethics.

State: New Jersey

Date: March 3017

Specialty: Gastroenterology

Symptom: Blood in Stool, Abdominal Pain

Diagnosis: Colon Cancer

Medical Error: Failure to follow up, Failure of communication with patient or patient relations, Lack of proper documentation

Significant Outcome: N/A

Case Rating: 3

Link to Original Case File: Download PDF

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

Kansas – Physician Assistant – Lovenox Prescribed For DVT In A Patient With A History Of GI Bleeding

On 11/19/2015, a patient presented to a family care clinic with complaints of swelling and pain in the right lower extremity (“RLE”).

The patient was seen by the APRN who documented the patient’s history of GI bleeding, noting the patient had experienced a RLE deep vein thrombosis (“DVT”) and pulmonary embolism (“PE”) on October 2015, that had been treated with an IVC filter in a medical center.

The APRN further documented in the patient’s chart, “No [sic] on anticoagulants due to GI Bleed,” and “Recent [history] GI bleed.”

The patient was referred to cardiology for the management of his anticoagulation.  He was to follow up on the morning of 11/20/2015 to have a complete blood count (“CBC”) drawn.

On 11/20/2015, the patient presented to a physician assistant with right leg and foot swelling with new onset pain rated a 1/10.  The physician assistant did not document a patient history and did not review the APRN’s notes from 11/19/2015.  The physician assistant diagnosed the patient with DVT of the right popliteal vein and mild anemia.  The physician assistant improperly prescribed Lovenox 60 mg SQ twice a day for one week with a follow-up to confirm dissolution of the clot.

On 11/23/2015, the patient awoke during the night with chest pain and was transported via ambulance to the emergency department where it was determined the patient had a GI bleed.  The patient’s hemoglobin (“HGB”) dropped abnormally low to 7.7, and his hematocrit (“HCT”) was also abnormally low at 27.4%.

The physician assistant’s response, received by the Board on 3/29/2016, noted, “There was no indication in the note from the previous day, nor in any clinic note that he was not a candidate for anticoagulation therapy.”  However, the original notes received by the Board on 10/6/2016 from the hospital indicated that the patient had a history of GI bleed and no anticoagulants should have been prescribed.

The Board judged the physician assistant’s conduct to be below the minimum standard of competence given his inappropriate prescribing of Lovenox.

For this allegation and others, the Board ordered the physician assistant to contact The Center for Personalized Education for Physicians, (“CPEP”) for a competence assessment, follow all recommendations of the CPEP assessment, and complete a medical record keeping seminar.

State: Kansas

Date: April 2017

Specialty: Physician Assistant, Emergency Medicine, Internal Medicine

Symptom: Blood in Stool, Extremity Pain, Swelling

Diagnosis: Drug Overdose, Side Effects, or Withdrawal, Deep Vein Thrombosis/Intracardiac Thrombus, Pulmonary Embolism

Medical Error: Improper medication management, Lack of proper documentation

Significant Outcome: N/A

Case Rating: 2

Link to Original Case File: Download PDF

California – Gastroenterology – Hemorrhoids Cauterized During Multiple Colonoscopies

A 58-year-old had a history of diabetes and generalized atherosclerotic vascular disease.  On 12/18/2009, the patient underwent an outpatient colonoscopy to assess complaints of diarrhea and abdominal pain.  The study was interpreted to show mild colitis, but biopsies were normal.

On 2/10/2010, the patient complained of abdominal discomfort and reflux-type symptoms.  The patient underwent a gastroscopy with finding of mild esophagitis and gastritis. Following placement of a stent and initiation of anticoagulation therapy, the patient presented with GI bleeding with bloody stools and hemoglobin decline necessitating multiple transfusions.

On 3/15/2010, the patient underwent a second gastroscopy, which the gastroenterologist interpreted to show multiple bleeding gastric ulcers.  The gastroenterologist cauterized the bleeding gastric ulcers with a BICAP probe. The patient continued to have bloody stools.

On 3/18/2010, the patient underwent a second colonoscopy and a third gastroscopy.  The gastroenterologist again interpreted the gastroscopy to show hemorrhagic erosions, which he again cauterized.  The colonoscopy was technically inadequate due to retained blood and debris.

On 3/20/2010, the patient underwent a third colonoscopy.  The gastroenterologist interpreted a finding of sigmoid diverticulosis.  On 6/4/2010, the patient was re-hospitalized with complaints of nausea, vomiting, weakness, and dark stools.  The patient was receiving antiplatelet therapy following a vascular intervention. On 6/4/2010 or 6/5/2010, the patient was seen by the gastroenterologist for GI consultation.  The gastroenterologist’s dictated consultation note was cursory, making no mention of the patient’s complaints or contributory medications. The gastroenterologist billed for the consultation using CPT billing code 99254, indicating a Level 4 consultation, which was not documented in the gastroenterologist’s consultation note.

On 6/5/2010, the patient underwent a fourth gastroscopy.  The gastroenterologist, again, cauterized “hemorrhagic erosion with evidence of slow bleed.”  On 6/7/2010, the patient underwent a fourth colonoscopy due to concerns of a lower GI tract contribution to bleeding.  The patient was found out have internal hemorrhoids, which the gastroenterologist cauterized.

The Medical Board of California judged that the gastroenterologist’s conduct departed from the standard of care because he performed repeated upper and lower endoscopic examinations of the patient in the absence of important pathology to justify the repeat studies, failed to maintain adequate and accurate medical records of his care and treatment to the patient, and submitted billing for his care and treatment of the patient using the CPT billing code 99254, which was not supported by the physician’s documentation.

For this case and others, the Medical Board of California issued a public reprimand and ordered the gastroenterologist to complete an education course (at least 40 hours) and clinical training program equivalent to the Physician Assessment and Clinical Education Program offered at the University of California San Diego School of Medicine.

State: California

Date: February 2017

Specialty: Gastroenterology

Symptom: Diarrhea, Blood in Stool, GI Symptoms (GERD, Abdominal Distention, Dysphagia), Nausea Or Vomiting, Abdominal Pain, Weakness/Fatigue

Diagnosis: Gastrointestinal Disease

Medical Error: Unnecessary or excessive diagnostic tests, Lack of proper documentation

Significant Outcome: Hospital Bounce Back

Case Rating: 2

Link to Original Case File: Download PDF

California – Family Medicine – Recurring Hemorrhoids And Blood In the Stool

A family practitioner saw a patient for various medical reasons from 1986 to 2009 with the first visit on 8/24/1984.  During the period of 1986-2009, the patient also saw the family practitioner at least once a year for treatment of seasonal allergies.  The family practitioner treated the patient’s allergies with non-sedating antihistamines and nasal steroids.  During the period of 1986-2009, the family practitioner gave the patient yearly injections of steroids.

On 5/16/2000, the patient, who was 56-years-old, presented to the hospital complaining of chest pain.  Another physician noted that his physical examination was unremarkable.  A rectal examination showed external hemorrhoid, normal sphincter tone, mildly enlarged prostate, and a “ring” appreciated on rectal exam as well as heme-positive stool.  The physician recommended a colonoscopy.  The family practitioner saw the patient on 10/21/2003 for an evaluation.  The family practitioner noted that the patient had been going to an outpatient clinic for a period of time and was not back under the care of the family practitioner.  The family practitioner noted to recheck his blood studies in about a week.

On 11/5/2003, the family practitioner saw the patient and noted that the patient “has some rectal bleeding, appears to be hemorrhoidal.”  The family practitioner also noted that “[the patient] is quite spooky and it is difficult to do a rectal on him”  The family practitioner administered Procto-HC Cream for hemorrhoids and scheduled the patient for a colonoscopy for 12/8/2003 at 7:45 a.m.  On 11/11/2003, the family practitioner saw the patient for an injured right toe. The x-rays were negative.

The colonoscopy scheduled for 12/8/2003 was canceled by the family practitioner.  The family practitioner did not communicate to the patient why the colonoscopy was canceled nor did he try to reschedule the colonoscopy.  On 7/2/2004, the family practitioner saw the patient for a complete physical examination.  At this time, the patient was 61-years-old and presented with a chief complaint of “arthritis, recent shoulder surgery.”  The physical examination was unremarkable.  The family practitioner documented an enlarged prostate that was “typical for age and no other masses.”

On 2/18/2005, the family practitioner saw the patient, who presented with allergies, which began in the spring.  The family practitioner noted that the review of systems was unremarkable.  The family practitioner noted that the patient denied abdominal pain, melena, or bright red blood, nausea, vomiting, diarrhea, or constipation.  The family practitioner didn’t document that he performed a rectal examination at this visit.  The family practitioner noted: “Assessment: Allergic Rhinitis. Plan: Depo Medrol 80mg IM.”

The family practitioner next saw the patient on 2/23/2005.  He documented that the “exam shows some hemorrhoid tissue. Prostate is slightly enlarged but palpates smoothly.”  Lab work showed that the patient was positive for occult blood.  On 3/25/2005, the family practitioner noted “patient in for review of lab studies. He is feeling better than he has in years.”  The family practitioner didn’t discuss the positive occult blood report.

On 4/17/2006, the family practitioner saw the patient for a complete physical examination.  The patient presented with a chief complaint of “some hemorrhoid irritation and bleeding at times and mild hypertension that is well controlled.”  The physical examination was unremarkable.  The family practitioner noted that the rectal examination was “negative, except for some hemorrhoidal tissue and somewhat enlarged prostate. No other masses.”  The family practitioner prescribed Procto-HC cream to use for hemorrhoids.

On 5/8/2007, the family practitioner saw the patient for a complete physical examination.  At this time, the patient was 64-years-old and had elevated lipids and a decrease in urinary stream.  The family practitioner suspected the decrease in urinary stream was caused by allergy medication and noted the rectal examination was “negative, except for slightly enlarged prostate, but smooth and PSA was normal.”  On 5/8/2008, the family practitioner saw the patient for a complete medical examination.  The patient’s note for this visit listed in the rectal examination that the patient “shows very tight sphincter with perhaps some slight enlargement of prostate.”  The patient next saw the family practitioner on 4/13/2009 for strain of the right knee related to playing softball.

On 7/16/2009, the family practitioner saw the patient at which time the patient’s chief complaint was chronic pain and swelling on the right knee and some erection difficulties.  The family practitioner noted the rectal examination was “Negative exam. No masses noted.”

On 1/1/2010, the patient saw Physician A for rectal pain.  Physician A noted that the patient “…just got back from Las Vegas and he feels like he has to go to the bathroom six to eight times a day and does not completely void very well, though he does get the stool out without too much difficulty.”  Physician A noted that he suspected a “thrombosed hemorrhoid,” but did not see any evidence of that and, instead, on the rectal exam, observed a “nearly, if not circumferential firm mass that has reddish ting [sic] on it.”  Physician A noted that he suspected rectal cancer and thought it was past being able to do a colonoscopy.

On 2/1/2010, the patient was seen in consultation by Physician B after the referral from Physician A.  The patient had a chief complaint of probable rectal cancer adenocarcinoma.  On the note under “history of present illness,” Physician B wrote that the patient reported that he had suffered from intermittent bleeding rectally for a long time, attributed to hemorrhoids.  The patient had never had a colonoscopy.  For several months, there was more frequent bleeding with bowel movements and some mid-sacral pain.  Physician B performed a rectal exam and noted that there was an “annular ulcerating firm lesion starting at the top of the sphincter, highly suspicious for a lower third rectal cancer.”  Physician B scheduled the patient for a colonoscopy and biopsy within the week.

On 2/2/2010, the patient underwent a CT scan of the abdomen and pelvis with contrast.  The findings were “rectal cancer in a 55-year-old.”  Impressions were noted as “circumferential thickening of the rectosigmoid junction.  Suggestion of infiltrate change in the perirectal fat. Small nodularity seen with one node slightly enlarged suggesting the possibility of early adenopathy to the left pelvic sidewall area.”

On 2/5/2010, Physician B performed a colonoscopy and discovered a mass in the rectum that was 6 cm long and was palpated 4-10 cm from the anal verge.  The mass was circumferential with residual lumen around 1.5 cm in diameter.  The mass was biopsied.  The pathology report on the biopsy reported “a poorly differentiated adenocarcinoma, focus suspicious for lymphovascular invasion.”  A lower endoscopic ultrasound was done on 2/19/2010.  A rectal mass was found.  There was an extension of the mass into adjacent structures including internal and external anal sphincter muscles and prostate.  Multiple malignant-appearing lymph nodes in the perirectal region, in the left iliac region and adjacent to the rectal mass, were also observed.  The patient underwent preoperative radiation to shrink his tumor.  The patient later required diverting colostomy in May 2010 and later hemodialysis.  At the time of surgery, his cancer was noted to have invaded the local tissues and was deemed unresectable.  The patient passed away on 6/22/2010.

The Medical Board of California judged that the family practitioner committed gross negligence in his care and treatment of the patient because he failed to provide appropriate colon cancer screening despite multiple opportunities to do so, diagnose colon cancer, evaluate and document undiagnosed rectal bleeding as a problem on the medical history form provided for that purpose, reschedule a colonoscopy that was ordered for rectal bleeding, properly address allergies on serial evaluations, and refer the patient to an allergy specialist despite non-response of the patient to daily nasal steroid and antihistamines.

The Medical Board of California ordered the family practitioner to surrender his license.

State: California

Date: March 2015

Specialty: Family Medicine, Internal Medicine

Symptom: Blood in Stool, Allergic Reaction Symptoms, Chest Pain, Extremity Pain, Joint Pain, Pelvic/Groin Pain, Urinary Problems

Diagnosis: Colon Cancer

Medical Error: Failure to order appropriate diagnostic test, Failure to examine or evaluate patient properly, Referral failure to hospital or specialist, Failure of communication with patient or patient relations, Failure to follow up, Lack of proper documentation

Significant Outcome: Death

Case Rating: 4

Link to Original Case File: Download PDF

Wisconsin – Family Practice – 45-Year-Old Male With Anal Itching, Bleeding, And Anal Protrusion After Bowel Movement

On 12/26/2006, a 45-year-old male patient saw his family practitioner for a comprehensive physical exam.  The patient complained of anal itching, usually at bedtime.  The family practitioner visually inspected the patient’s anal area, but did not do a digital examination.  He ordered an assessment for pinworms and a follow-up visit in five months to recheck lipids.

Later in the day on 12/26/2006, the patient called the family practitioner and reported that he had strained to pass a hard bowel movement and “something briefly bulged out and bled.”  The family practitioner noted that the patient was “alarmed, but sounds like he had an internal hemorrhoid that prolapsed.”  He did not see the patient, but recommended stool softeners.

On 1/8/2007, laboratory reports reported the patient was negative for pinworms.  The nurse notified the patient the next day.  The family practitioner did not offer further examination or testing.

On 4/26/2007, the patient called the family practitioner to report he’d had blood in his stool for approximately a month.  He had also just learned that his father and grandmother had both had colon cancer, and he requested a colonoscopy.  The family practitioner ordered a colonoscopy the same day.

On 5/3/2007, the patient underwent a colonoscopy which resulted in the discovery of a large sessile rectal polyp.  Biopsies revealed a villous adenoma with high grade dysplasia.  No carcinoma was noted by examination or biopsy.

On 5/7/2007, a digital examination by another physician revealed a palpable mass located in the right posterolateral position.  The mass began 6 cm from the anal verge and extended approximately 3.5 cm.  The mass was soft, mobile, sessile and completely encompassed approximately 25% of the anal circumference.  The specialist recommended a transanal excision.

On 8/1/2007, the patient was diagnosed with rectal carcinoma.  The patient underwent a near total prostatectomy, distal colorectal anastomosis, and diverting loop ileostomy.

The family practitioner told the Division he did not think anal itching warranted a digital examination because the patient was under fifty years of age, and because he did not think a digital rectal examination would explain anal itching.

The Board judged the family practitioner’s conduct to be below the minimum standard of competence given failure to offer the patient a digital rectal examination in response to the patient’s telephone call reporting a protrusion from his anus with rectal bleeding.  He had failed to offer the digital rectal examination on 12/26/2006 and 1/8/2007.

The Board ordered the family practitioner be reprimanded, pay the costs of the proceeding, and take 20.5 hours of continuing education on proper assessment of colorectal cancer.

State: Wisconsin

Date: July 2010

Specialty: Family Medicine

Symptom: Blood in Stool

Diagnosis: Colon Cancer

Medical Error: Failure to examine or evaluate patient properly

Significant Outcome: N/A

Case Rating: 4

Link to Original Case File: Download PDF

Wisconsin – Emergency Medicine – 4-Year-Old Infant With Diarrhea, Fever, And Persistent Vomiting

On 11/25/1996, 4-year-old infant was taken to his primary pediatrician for a routine checkup and immunizations.  The patient had had a cold and stuffy nose for a couple of days and was more fussy than usual.  The pediatrician’s examination disclosed that the patient was afebrile, his lungs were clear, and his abdomen was soft and nontender with positive bowel sounds.  The pediatrician diagnosed a viral syndrome and elected to delay administering the immunizations.  The patient remained fussy on 11/26/1996.

On 11/27/1996, following the patient’s afternoon nap, the patient’s mother noted two small spots of blood in his stool when she changed his diaper.  He also had developed diarrhea.  When she attempted to feed him, he vomited and continued to vomit with each attempt to feed him thereafter.  He continued to have diarrhea.  He became more fussy as the day went on with more crying episodes and he became more difficult to console.

On the evening of 11/27/1996, the patient’s mother contacted the emergency department at the hospital.  The emergency department referred her to the pediatrician on call and she spoke with him by telephone at approximately 9:00 p.m. on 11/27/1996.  She reported the patient’s symptoms to her pediatrician and also reported that the patient had a low grade fever.  The pediatrician recommended that she give Tylenol and that she spoon feed Pedialyte every 15 minutes.

The patient remained fussy throughout the night of 11/27/1996 – 11/28/1996 and continued to vomit.  The patient remained fussy and continued to cry and to vomit on the morning of 11/28/1996.  At 4:43 p.m. on 11/28/1996, the patient’s mother and father took him to the emergency department at the hospital with continuing complaints of vomiting, diarrhea, and fever.

The emergency department nurse obtained a medical history from the patient’s mother.  The patient’s mother reported that the patient was fussy and had had diarrhea for 2 days with 4 to 5 watery diarrhea stools the prior day but no incidents of diarrhea on the day of the emergency department visit.  The patient’s mother noted that the patient’s diarrhea had been brownish-reddish in color and the nurse observed a small amount of the brownish-reddish diarrhea in the patient’s diaper at the time of his admission to the emergency department.  The patient’s mother also reported that the patient had begun vomiting the prior day and was continuing to vomit with 3 episodes of vomiting earlier on the day of the emergency department visit.  The patient’s mother reported that the patient had had a fever the previous evening.  The nurse noted that the patient was awake, active, alert, and smiling when she assessed him in the emergency department.  The nurse’s assessment disclosed that the patient’s lungs were equal and clear bilaterally and he had bowel sounds in all 4 quadrants.

The ED Physician obtained a medical history from the patient’s mother and spoke with the emergency department nurse about her findings.  The ED Physician ascertained from the patient’s mother that the patient began to develop loose stools on 11/25/1996, but did not have diarrhea.  On 11/26/1996 and 11/27/1996, the patient had diarrhea with 5 stools on 11/27/1996 and 1 stool on 11/28/1996 prior to the patient’s arrival in the emergency department.  The ED Physician was told by the patient’s mother that the patient’s stool might have blood in it.  The ED Physician also ascertained from the patient’s mother that the patient had been vomiting since 3:00 p.m. on 11/27/1996 and had vomited at least 6 times on 11/27/96 and 3 times since awakening on 11/28/1996.  The ED Physician was told by the patient’s mother that she had been giving Tylenol every 4 hours to control the patient’s fever.

The ED Physician examined the patient in the emergency department on 11/28/96.  The ED Physician’s differential diagnosis was gastroenteritis, intussusception, [appendix], Meckel’s diverticulum, pyloric stenosis, and a secondary diagnosis of dehydration.  The differential diagnosis did not include an inguinal hernia.

The ED Physician conducted the examination while the patient was being held supine on his mother’s lap, not positioned on an examining table.  She did not listen for the patient’s bowel sounds.  She did not perform a visual inspection of the patient’s rectal area.  She did not perform a visual inspection the patient’s inguinal area.  She visualized the patient’s abdomen during her examination.  She palpated the patient’s abdomen with hand to patient skin contact during her examination.

The ED Physician noted that at the time of the examination, the patient was interactive, sleepy, and in no acute distress.  The ED Physician recorded in the emergency department record that the patient’s lungs were clear with good aeration and his abdomen was soft and nontender without masses.  The ED Physician observed reddish-brown stool in the patient’s diaper but noted no frank blood.  The ED Physician was of the opinion that the stool in the diaper did have blood in it, but she saw no indication that it had a currant-jelly appearance.  The ED Physician also examined the patient’s fontanel, the membranes of the patient’s mouth and lips, and the patient’s eyes for evidence of dehydration. The ED Physician also noted that the patient had tears. The ED Physician concluded that the patient was not dehydrated.

The ED Physician’s diagnosis in the emergency department on 11/28/1996 was viral gastroenteritis.  She recommended that the patient return home and remain on clear liquids for 24 hours and then be given % strength formula for the next 24 hours and then return to full strength formula as tolerated.  The ED Physician also recommended that the patient’s mother follow up with the patient’s regular pediatrician the following morning.  The ED Physician told the patient’s parents to return to the emergency department if the patient’s condition worsened or if the patient developed signs of dehydration.

On the night of 11/28/1996 – 11/29/1996, the patient slept for brief periods of time but frequently woke up crying. At approximately 6:30 a.m. on 11/29/1996, the patient’s mother observed some brown foul smelling emesis trickling out of the side of the patient’s mouth.  The patient’s mother determined that they should take the patient back to the emergency department.  While she was changing the patient’s clothes, she noted that the patient was breathing abnormally and his eyes were fixed straight ahead.  While in the car on the way to the emergency department, the patient stopped breathing.  Attempts at resuscitation at the emergency department at the hospital were unsuccessful.  The patient was pronounced dead at 7:14 a.m. on 11/29/1996.

An autopsy was performed at 11:00 a.m. on 11/29/96, which disclosed intussusception with 4.5 centimeters of the ileum telescoped into the cecum.  The entire wall of the telescoped terminal ileum and cecum were markedly dark, edematous, and friable; consistent with ischemia. The patient’s lungs were markedly congested and other organs showed generalized congestion. A blood culture taken from the right ventricle of the patient’s heart grew Enterococcus faecalis.

The allegation against the ED Physician was not a failure to diagnose, but a failure to do a competent examination. After an investigation, the Board determined the ED physician’s assessment of the patient’s medical condition as set forth above met the minimum standards of competence accepted in the profession and did not create an unacceptable risk to the patient in the following respects:

1) The ED Physician performed a minimally competent abdominal examination.

2) The ED Physician was not required to listen for bowel sound, because in the absence of any tenderness upon palpation of the abdomen, the presence or absence of bowel sounds and their quality would mean little in differentiating between diagnoses, especially owing to the fact that the patient recently had had a bowel movement.

3) The ED Physician was not required to perform a rectal evaluation in this instance given the patient’s history and presenting symptoms.

4) The ED Physician was not required to visualize the patient’s inguinal area because an inguinal hernia was not a part of her differential diagnosis and the Board stipulated that she was not subject to discipline based upon a failure to diagnose, or based upon a failure to create a minimally competent differential diagnosis.

The Board ordered that the disciplinary action against the ED physician be dismissed.

State: Wisconsin

Date: December 2004

Specialty: Emergency Medicine, Pediatrics

Symptom: Fever, Blood in Stool, Diarrhea, Nausea Or Vomiting

Diagnosis: Acute Abdomen

Medical Error: No error found

Significant Outcome: Death

Case Rating: 3

Link to Original Case File: Download PDF

Wisconsin – Internal Medicine – Waiting For Medicare Before Ordering A Colonoscopy With Rectal Bleeding

An internist was a primary care physician for a female patient born on 10/9/1934.  His efforts at screening the patient for evidence of colorectal cancer included hemoccult stool tests done in his office and digital rectal examinations.  This included, but was not limited to, testing on 3/16/1995.

On 10/22/1996, the patient presented to the internist in preparation for a carpal tunnel repair operation.  The internist noted a family history of cancer, performed an in-office hemoccult stool examination and a rectal examination, and noted a negative result to the hemoccult test and a normal rectal examination.

On 1/29/1998, the patient presented to the internist with complaints of bleeding from the rectum and known hemorrhoids.  The internist performed an in-office hemoccult stool test that returned a strongly positive result.  The internist performed a digital rectal examination, which he determined to be negative.

The internist documented in his records telling the patient to wait until she was on Medicare to have a colonoscopy or sigmoidoscopy.  The internist scheduled a follow-up visit with the patient for 2/25/1998, but this visit was canceled.

The internist did recommend that the patient schedule a mammogram, and she had a mammogram performed on 3/3/1998.

On 3/5/1998, the patient received a telephone call from the internist’s office to schedule additional mammography views for 3/10/1998.  On 3/9/1998, the internist referred the patient for a gastroenterology workup to be done 4/3/1998.

On 3/13/1998, on her own initiative, the patient went to another physician for evaluation of her abnormal mammogram.  During his examination of the patient, the physician detected a mass that he described as large and easily palpated, approximately 4 x 6 cm just inside the anal verge, covering approximately one-third of the circumference of the rectal wall.  The physician recorded an “impression” of rectal tumor, and recommended an urgent colonoscopy which led to a diagnosis of the cancer of the colon and total resection of the patient’s colon with an ileostomy.  On follow-up care, metastases were discovered in both of the patient’s lungs.  The patient died on 7/6/2001, as a result of the metastatic cancer in her lungs.

At the time the internist was caring for the patient, there was debate in the medical profession with regard to the type, amount, and frequency of colorectal cancer screening required by the standards of reasonable medical care.

The Board judged the internist’s conduct to be below the minimum standard of competence given his failure to offer or order a colonoscopy or sigmoidoscopy for the patient no later than 1/29/1998.

The Board ordered that the internist pay for the costs of the proceeding and complete 24 hours of continuing education in assessment of gastrointestinal blood loss and indications of and screening for gastrointestinal cancers.

State: Wisconsin

Date: May 2004

Specialty: Internal Medicine, Oncology

Symptom: Blood in Stool

Diagnosis: Colon Cancer

Medical Error: Delay in proper treatment, Failure to examine or evaluate patient properly

Significant Outcome: Death

Case Rating: 3

Link to Original Case File: Download PDF

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