Found 22 Results Sorted by Case Date
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California – Cardiology – CT Coronary Angiogram On Hemodynamically Compromised Patient For Chest Pain, Abnormal Electrocardiogram, Right Atrial Enlargement, And Elevated Cardiac Enzymes



On 4/16/2012, a 23-year-old female presented to the emergency department with chest pain, acute nausea, vomiting, and diarrhea.  The patient had a history of pulmonary hypertension. Laboratory measurements were taken that revealed a hemoglobin of 17.2, hematocrit of 49.9, an acidotic pH of 7.12, an elevated WBC count of 15,900, potassium of 6.6, BUN of 31, and creatinine level of 1.4.  These measurements were consistent with mild renal insufficiency. An electrocardiogram test revealed sinus tachycardia, which was consistent with the findings of an electrocardiogram performed on the patient approximately 1 year earlier.

On 4/17/2012, the patient was admitted to the hospital.  The patient was initially treated with sodium bicarbonate to treat her lactic acidosis and IV fluids for dehydration.  The patient also received a dialysis catheter in her right femoral artery due to the increase in the BUN/creatinine measurements.  However, this catheter was never used.

On 4/17/2012, a cardiologist performed a telephonic cardiology consult with the hospitalist and ordered a CT coronary angiogram due to the patient’s chest pain, abnormal electrocardiogram, right atrial enlargement, and elevated cardiac enzymes (troponin).  The cardiologist also ordered 100 ml of ionic contrast to facilitate the CT angiogram despite the patient’s continued elevated BUN and creatinine levels. The cardiologist also ordered 50 mg of metoprolol orally and 5 mg intravenously to improve visualization on the CT angiogram despite the patient’s clinical condition.  The cardiologist did not perform a physical examination of the patient, measure the patient’s pulmonary pressure, or review the patient’s diagnostic or laboratory tests prior to ordering ionic contrast, CT angiogram, or administering metoprolol.

On 4/17/2012, the patient deteriorated and became hypotensive approximately 90 minutes after the CT angiogram and administration of metoprolol.  At approximately 8:00 p.m., the patient expired due to cardiac arrest.

The Medical Board of California judged that the obstetrician’s conduct departed from the standard of care because he failed to physically examine the patient prior to ordering a potentially dangerous procedure and drugs, review the patient’s previous diagnostic testing and laboratory testing prior to ordering a potentially dangerous procedure and drugs, and order a pulmonary artery catheter to measure pulmonary pressure in a hemodynamically compromised patient.

The Medical Board of California placed the cardiologist on probation for 3 years and ordered the cardiologist to complete a medical record keeping course and an education course (at least 40 hours per year for each year of probation).  The cardiologist was also assigned a practice monitor.

State: California


Date: March 2017


Specialty: Cardiology


Symptom: Chest Pain, Diarrhea, Nausea Or Vomiting


Diagnosis: Cardiovascular Disease, Renal Disease, Sepsis


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


Significant Outcome: Death


Case Rating: 5


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 – Gastroenterology – Second Colonoscopy Performed Within Days Of First Due To Concerns Of Suboptimal Bowel Preparation



On 1/6/2010, an 84-year-old patient was admitted to the hospital with complaints of dizziness, anemia, and possible GI bleeding.  On 1/8/2010, a gastroenterologist provided a GI consultation for the patient. The gastroenterologist’s handwritten note on that date was cursory and lacking in detail without documenting a comprehensive history, comprehensive physical examination, and/or the gastroenterologist’s medical decision-making.  The gastroenterologist submitted billing for the consultation using CPT billing code 99223, which was not supported by the gastroenterologist’s documentation of the visit.

On 1/9/2010, the patient underwent a gastroscopy.  Small gastric natural ulcers and a bulbar duodenal ulcer, which was 2.5 cm in size, were identified and cauterized.  Sometime later in January 2010, the patient was readmitted to the hospital with complaints of nausea, vomiting, diarrhea, weakness, and interval decline in hemoglobin.  The patient underwent laboratory tests, which showed anemia with borderline iron deficiency.

On 1/27/2010, the patient underwent both a gastroscopy and a colonoscopy.  Small oozing angiodysplasias were found in the duodenum and were cauterized.  Small adenomatous polyps were excised from the distal colon. On 2/1/2010, the patient underwent a second colonoscopy due to concerns that pathology may have been missed due to suboptimal bowel preparation during the first examination.

The Medical Board of California judged that the gastroenterologist’s conduct departed from the standard of care because he performed a medically unnecessary second colonoscopy on 2/1/2010 within days of an initial colonoscopy, his documentation was cursory and some of the physician’s handwritten notes were illegible, and he submitted billing using the CPT billing code 99223, which was not supported by the physician’s documentation of his care and treatment of the patient.

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: Dizziness, Diarrhea, GI Symptoms (GERD, Abdominal Distention, Dysphagia), Nausea Or Vomiting, 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



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



North Carolina – Family Practice – Evaluation Of A Patient With Persistent Symptoms of Pneumonia



In May 2015, a patient with a remote history of smoking presented to a family practitioner with symptoms of worsening cough of two months duration.

The patient was diagnosed with seasonal allergies and offered empiric treatment for chronic cough.  Per the Board, the initial treatment complied with the applicable standard of care.

In early August 2015, the patient returned to the office complaining of diarrhea and a cough that had started one month earlier.

The family practitioner ordered a chest x-ray, diagnosed the patient with pneumonia, and treated her accordingly.

By September 2015, the patient developed additional symptoms such as dyspnea on exertion, low-grade fevers, and weight loss. On examination, the family practitioner noted decreased breath sounds and ordered a repeat chest x-ray that showed interval worsening with consolidation.

The family practitioner also ordered a CT scan that revealed enlarged mediastinal and hilar lymph nodes or mass with effusion. These findings were consistent with an infectious etiology, but also raised significant concern for an underlying neoplasm.

The Board noted that the standard of care for a patient with the patient’s presentation – worsening symptoms, radiologic findings, and past history of smoking – would have been to further evaluate the patient for possible lung cancer through referral to a pulmonologist; instead, the family practitioner continued to treat pneumonia.

Though the patient returned to your office in early October 2015 reporting significant improvement in her symptoms, by late October, the patient demonstrated recurrent symptoms of pneumonia and presented with a tongue mass.

At that point, the family practitioner referred the patient to a pulmonologist for a second opinion. The patient underwent another CT scan on 11/09/2015 and saw a pulmonologist on 11/11/2015.

The patient was diagnosed with Stage IV lung cancer and ultimately died in April 2016.

The Board issued a public letter of concern, which was reported to the Federation of State Medical Boards.  It was not reported to the National Practitioner Data Bank.

State: North Carolina


Date: December 2016


Specialty: Family Medicine, Internal Medicine


Symptom: Shortness of Breath, Cough, Diarrhea, Fever


Diagnosis: Lung Cancer, Pneumonia


Medical Error: Diagnostic error


Significant Outcome: Death


Case Rating: 4


Link to Original Case File: Download PDF



Kansas – Pediatrics – Improper Documentation For Reactive Airway Disease And Improper Use of Bactrim



On 2/4/2013 a 7-year-old female presented to a pediatrician and saw the advanced practice registered nurse (“APRN”).  The patient presented with chief complaints of allergies, congestion, and diarrhea.  The patient was prescribed albuterol, Qvar 40 mcg, Bactrim, and triamcinolone.  The Bactrim was prescribed inappropriately for diarrhea.  The pediatrician agreed but thought that he had perhaps forgotten to document otitis media.

On 2/19/2013, the pediatrician saw the patient for a follow-up appointment.  The pediatrician documented that the patient was there for a follow-up for her asthma, even though the patient previously presented with reactive airway disease.  The pediatrician did not document his thought process in how reactive airway disease developed in asthma.  The pediatrician did not electronically sign the record until 4/11/2013.

On 6/11/2013, the patient presented to the pediatrician for a school physical.  The pediatrician failed to document the patient’s asthma.  In the school health examination, the pediatrician stamped signature appears on the form with the date 6/11/2013.  The pediatrician stamped the document “No” to the question, “Is this student subject to any condition which might cause a possible classroom emergency such as seizures, fainting, diarrhea, diabetes, asthma, allergies, etc.”

The Board judged the pediatrician’s conduct to be below the minimum standard of competence given his failure to keep written medical records, and inappropriately prescribing a medication.

The Board ordered that the pediatrician attend and successfully complete the Medical Record Keeping Seminar at Center for Personalized Education for Physicians (“CPEP”). Also, the Board ordered that the pediatrician hire a medical scribe. Finally, the Board ordered that the pediatrician have a pediatrician monitor his work.

State: Kansas


Date: October 2016


Specialty: Pediatrics


Symptom: Allergic Reaction Symptoms, Diarrhea


Diagnosis: Asthma


Medical Error: Lack of proper documentation, Improper medication management


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



North Carolina – Emergency Medicine – Obese Patient With Abnormal Lab Values, Abdominal Pain, Fever, Nausea, And A Fainting Episode Discharged Twice



The Board was notified of a professional liability payment made on 11/16/2015.

At 11:54 a.m. on 05/08/2014, a 44-year-old male with a history of morbid obesity, insulin-dependent diabetes, and hypertension presented to his primary care provider with abdominal pain.  He failed to report that he had fainted in the parking lot of the provider before coming to the hospital, and was generally a poor historian.  He was advised to go to the emergency department.

In the emergency department, the patient was managed by Physician A.  The patient reported having moderate abdominal pain that started the night prior and radiated down his back.  He reported decreased food and liquid intake as well as associated fever, nausea, and an episode of diarrhea.  A physical examination revealed a height of 6’0”, weight of 320 pounds, a temperature of 102.1 degrees Fahrenheit, a heart rate of 120 bpm, a blood pressure of 160/77, and an oxygen saturation of 92%.  Lab revealed WBC 16.7, glucose 433 mg/dL, sodium 130 mEq/L, and a chloride of 89 mEq/L.  A CT scan of the abdomen and pelvis revealed no acute findings.  Chest x-ray demonstrated low lung volume and left basilar atelectasis.  While the patient’s workup was proceeding, he was treated with acetaminophen, hydromorphone, ondansetron, ibuprofen, and normal saline.  The patient was diagnosed with abdominal pain, morbid obesity, and type 2 diabetes, and discharged home with prescriptions for oxycodone with acetaminophen, promethazine, and famotidine.

On 05/08/2014, an internist treated the patient in the same emergency department several hours later at 10:02 p.m.  The patient had not complied with the discharge instructions from the prior visit by filling the prescriptions he had been given.  In fact, the patient had been sitting in his car, which was in the hospital parking lot, during the interim.  The patient had the same complaints of abdominal pain and his pain was described as a level 10 out of 10.  The internist reviewed the patient’s medical chart from earlier in the day, noted that the CT scan, chest x-ray, and laboratory values were “normal” and performed a physical examination where he noted that the patient was “difficult to arouse”, although at the time of the exam he now had no complaints of pain.

At 12:22 a.m. on 05/09/2014, without repeating any of the previously abnormal laboratory work, the internist discharged the patient with a diagnosis of abdominal pain and advised follow-up with another physician.

At 9:00 p.m. on 05/09/2014, the patient was brought back to the emergency department by ambulance with a diagnosis of sepsis.  The patient was transferred to an intensive care unit at another hospital and treated for sepsis, complicated by hypotension, respiratory failure, renal failure, and heart failure.

The Board obtained the patient’s records and sent them to a qualified independent medical expert for review.  The independent medical expert judged the internist’s conduct to be below the minimum standard of competence given failure to document the patient’s response to treatment, to repeat vital signs and lab tests, to document in detail why the patient was safe for discharge in the presence of abnormal vital signs, and to arrange for close follow-up if discharge was appropriate.

The Board issued a public letter of concern, which was reported to the Federation of State Medical Boards.  It was not reported to the National Practitioner Data Bank.

State: North Carolina


Date: June 2016


Specialty: Emergency Medicine, Internal Medicine


Symptom: Abdominal Pain, Diarrhea, Fever, Syncope


Diagnosis: Sepsis


Medical Error: Diagnostic error, Lack of proper documentation


Significant Outcome: Hospital Bounce Back


Case Rating: 3


Link to Original Case File: Download PDF



California – Family Medicine – Fever, Right Arm Swelling, Vomiting, Diarrhea, Dizziness, And Reluctance To Go To The Emergency Department



On 5/6/2009, a 35-year-old male was treated by a nurse practitioner for gout and received an order for further laboratory testing.  On 5/10/2008, the patient had laboratory testing done, which confirmed his chief complaint of gout.

On 6/27/2008, the patient was evaluated by a family practitioner.  The family practitioner evaluated the patient in the presence of the patient’s wife and their four boys.  The patient’s complaints included “fever, arm problem (swollen under right arm), vomiting, diarrhea,  dizziness, perspiration problem, and test results (labs).”  The family practitioner noted that the patient reported a fever the previous night of 103 F, had cold sweats and right arm pain.  The family practitioner noted that the patient had taken ibuprofen for his fever.  On examination, the patient appeared “malaised with profuse [sic] sweating.”  The patient’s pulse was 139, his blood pressure was 98/60, and he had a temperature of 99.68 F.  The patient kept his right arm raised throughout the exam because of pain and complained of shortness of breath.  The patient appeared seriously ill and presented with both hypotension and tachycardia.

The family practitioner informed the patient that he needed to seek medical treatment at the emergency department because he may have a serious bacterial infection.  The exam became confrontational with the patient’s wife demanded that the family practitioner provide treatment to the patient after the patient refused to go to the emergency department.  The exam was further truncated because the clinic was in the process of closing for the weekend, and the family practitioner needed to pick up her children from childcare.  The family practitioner refused to provide treatment, either parenteral antibiotics or oral antibiotics, at the clinic because she didn’t believe she could provide any treatments that would treat the patient’s illness.  The family practitioner failed to perform an examination of the patient’s right upper extremity for a portal of entry of infection or for active infection.  The family practitioner also didn’t accurately record information in the patient’s electronic medical record.

The Medical Board of California judged that the family practitioner’s treatment of the patient departed from the standard of care because she failed to immediately begin life-stabilization and treatment of the patient upon realizing that he was seriously ill, allowed outside logistical considerations to limit her ability to provide treatment to the patient, allowed the electronic medical record-keeping software to interfere with her treatment of the patient, allowed her relationship to become confrontational with the patient, did not administer a dose of parenteral antibiotics to the patient, did not prescribe oral antibiotics despite the patient asserting that he was not going to the emergency department, and didnot examine the patient’s right upper extremity for evidence of a portal of entry for infection or for active infection.  The family practitioner also failed to properly manage a noncompliant patient, never activated the Emergency Medical System when she realized that the patient was seriously ill, never had the patient sign a written formal acknowledgment form that the patient understood that the family practitioner believed he would die unless he received immediate emergency department treatment, never attempted to provide a dose of parenteral antibiotics or oral antibiotics to the patient after he asserted that he was refusing to go to the emergency department, lacked familiarity with how to discharge a patient Against Medical Advice, and failed to note that the patient was discharged Against Medical Advice.

The Medical Board of California also judged that the family practitioner’s record keeping departed from the standard of care because she didn’t record respiratory rate, did not carefully document the axillary examination, failed to document the examination of the upper right extremity, failed to document an accurate diagnosis in the medical record, failed to discuss the management options for the patient’s condition in the medical record, failed to document the patient’s refusal to comply with the family practitioner’s request that he go to the emergency department.  The family practitioner also failed to document the physical findings and care of the patient, document the patient’s respiratory rate, document that the patient may have been suffering from Systemic Inflammatory Response Syndrome or early stages of septic shock, document that the patient was holding his right arm away from his body at a 90 degree level of abduction, and document whether she performed a detailed examination of the patient’s right upper extremity.  The family practitioner documented that the patient’s resting heart rate was a “normal rate” despite having a pulse of 139, documented her discharge instructions only for mild to moderate acute gastroenteritis, and failed to document her actual clinical diagnosis: serious bacterial infection with impending septic shock.  The family practitioner did not document that she planned on sending the patient to the emergency department and had requested that he go to the emergency department, did not document that the patient refused to go to the emergency department, did not document that the patient left her office AMA, did not document provide the patient with an informed refusal of treatment, did not document that she considered activating EMS, did not document that she considered and rejected administering parenteral antibiotics in the clinic or prescribe oral antibiotics, and did not document that she had a discussion with the patient regarding his treatment options.

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

State: California


Date: September 2015


Specialty: Family Medicine, Internal Medicine


Symptom: Fever, Diarrhea, Dizziness, Nausea Or Vomiting, Extremity Pain, Shortness of Breath, Swelling


Diagnosis: Infectious Disease, Gout


Medical Error: Physician concern overridden, Failure to examine or evaluate patient properly, Improper treatment, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 4


Link to Original Case File: Download PDF



Washington – Internal Medicine – Incidental Finding Of Glucose Level Of 283 mg/dl Without Fasting



On 2/11/2011, a 76-year-old man saw an internist in a clinic to address the patient’s report of a wound on his head that was not healing, hand lesions, diarrhea and white stools, gassiness, and having to go to the bathroom more frequently than normal.  The internist was the patient’s primary care provider and ordered a complete blood count (CBC) and complete metabolic panel.  The lab work identified that the patient had worsening renal function and a blood glucose level of 132 mg/dl (non-fasting).  The internist asked the patient to return in one month for a follow-up basic metabolic panel.

On 3/13/2011, the patient’s follow-up lab work identified improved kidney function; however, the patient’s blood glucose level increased to 283 mg/dl, indicative of diabetes even if the patient had not fasted prior to the lab test.  Medical staff documented that the clinic’s physician assistant called and spoke with the patient’s wife regarding the improved kidney results only.  The patient’s high glucose level was not identified as an issue and the staff did not raise it with his wife.  The internist did not see or speak to the patient following the lab results for the next ten months.

The internist saw the patient on 11/20/2011 to address the patient’s wife’s concerns about changes in the patient’s mentation, including a time when he got lost coming home.  The internist administered the Mini-Mental State Exam, on which the patient scored 28/30.  The internist did not order any lab tests.  The internist failed to discuss the March lab results and failed to review the patient’s significantly increased blood glucose level from February to March 2011.  The internist’s notes indicated that he reviewed medications, allergies, and past medical history as reported during the February 2011 visit, and social history as reported during a December 2009 visit.  The internist’s notes did not indicate that he reviewed the February 2011 lab results or the March 2011 lab results.

On 12/27/2011, the patient called the clinic to request a fasting blood sugar test because he reported he had lost seven pounds in a week and was thirsty all the time.  When his glucose level tested at 655 mg/dl, the clinic staff called the patient and directed him to be seen immediately, either at the clinic or at the emergency department (ED).  The patient was seen in the clinic and was diagnosed with Diabetes Mellitus Type 2.  Due to his altered mental state, the patient was directed to go to the ED for insulin and IV fluids.

The patient was diagnosed with acute renal injury secondary to dehydration.  The patient’s A1C test result indicated that he had had elevated blood sugars at least over the past three months.  The patient was discharged the following day without evidence of diabetic ketoacidosis or a hyperosmolar state.

The Commission stipulated the internist reimburse costs to the Commission and develop and submit a protocol which will ensure that the internist reviews the results of any lab work or tests he orders, follows up on forwarded reports and pertinent test results, documents his review of all lab work, test results and reports, and follows up in a timely manner with patients about test results or missed tests which had been ordered.

State: Washington


Date: September 2015


Specialty: Internal Medicine, Family Medicine


Symptom: Urinary Problems, Confusion, Diarrhea


Diagnosis: Diabetes, Renal Disease


Medical Error: Diagnostic error, Failure to follow up


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



California – Obstetrics – Post-Partum Abdominal Pain, Fever, Diarrhea, Low WBC, And Abnormal Electrolytes



On 8/7/2011, a 34-year-old patient presented by an ambulance to the emergency department.  The patient complained of sharp, constant right lower quadrant pain. The patient was at 38-weeks gestation.  An immediate ultrasound was obtained to rule out placental abruption. Prophylactic ampicillin was administered IV for her positive GBS (Group B streptococcus) status.  A physician covering for the patient’s obstetrician delivered a healthy baby girl weighing 7 pounds and 1 ounce with an 8/9 APGAR score after a rapid and uneventful labor.  During the patient’s labor and delivery hospital stay, nursing notes described right-sided pain, continuing abdominal distention, and changes in vital signs.

On 8/8/2011, the obstetrician re-assumed the care of the patient following her uneventful vaginal delivery.  The patient complained of right flank and back pain. The exam was reported as negative, and the patient’s back pain was attributed to chronic muscle strain.  Pathology reported a normal placenta. The patient’s WBC count was 4.1.

On 8/9/2011, the patient complained of back pain for 3 days that had decreased.  The patient had a temperature of 100.1 F, respiration at 118, and a pulse of 120.  The patient’s right-sided pain, which was present on admission, persisted, but had decreased to a 4/10.  The obstetrician was notified by nursing of a change in the patient’s vital signs when the patient’s pulse increased to 124 beats per minute, her respiration was at 118, and her temperature was 100.1 F.  The patient required further observation.  Evaluation for infection was warranted. Further studies, including a CBC and urinalysis, were indicated.

Upon resuming care of the patient post-partum, the obstetrician failed to adequately evaluate the patient’s status.  He described being unaware of the patient’s elevated temperature, change in vital signs, and continuous right-sided pain.  The obstetrician discharged the patient home to her newborn. He later admitted that he never read the nurses notes documenting the patient’s 3-day history of pain and change in vital signs.  Doing so would not be part of his custom and practice.

Two days later, on 8/11/2011 at 6:20 a.m., the patient was brought back to the emergency department.  She complained again of sharp, right lower quadrant pain. The emergency department evaluated the patient and identified it as “acute abdomen”, which required hospital admission.  In addition to her right-sided abdominal pain, the patient complained of nausea and vomiting and gave a 3-day history of diarrhea. Her fever had risen to 102 F.  An ultrasound was ordered.  Initial labs identified a stable hemoglobin, a depressed WBC count, and abnormal electrolytes.  Also, the patient was both hypotensive, with a blood pressure at 90/58, and tachycardic, with her heart racing at 148 beats per minute.

The obstetrician assumed care of the patient via a text message at 8:49 a.m., which stated a patient was admitted via the emergency department “SVD 2 days? With abd pain.”  The obstetrician texted “What do they think is the diagnosis?” and received a response, “Unclear. CT suggested hemoperitoneum, but not obvious. Perhaps endomyometritis, but no fever” and “Normal H/H, VVS,” “VSS.”  The CT was actually an ultrasound, which demonstrated material in the uterus and diffuse fluid in the abdomen. In fact, the patient was febrile, hypotensive, and tachycardic with immunosuppression. She complained of nausea, diarrhea, and abdominal pain for days.  Urinalysis showed stable hemoglobin, a low WBC, and abnormal electrolytes.

Nursing staff called the obstetrician four times during the day and requested him to come evaluate his patient.  The obstetrician was not responsive. The obstetrician also failed to respond to the patient’s family members’ three documented calls to his office requesting him to evaluate the patient at the hospital.  Instead, the obstetrician remained in his office during the day. At 7 p.m. on 8/11/2011, the obstetrician saw his patient. A pelvic ultrasound that had been performed demonstrated material in the patient’s endometrial cavity (clots in her uterus) and a large fluid collection in her abdomen.

Ten hours after the obstetrician assumed care of the patient, he saw the patient.  Despite the objective information referenced above, the obstetrician continued with the endometritis and hemoperitoneum diagnosis.  The patient had a normal, uncomplicated vaginal delivery and had two previous children, making most etiologies of blood in the abdomen slim.  Further, the patient’s normal post-partum hemoglobin level had remained stable. Although the patient was not bleeding, the obstetrician would carry the diagnosis of endometritis and hemoperitoneum from the patient’s second admission to the hospital, through her surgery, and finally to her “record of death.”

The interpretation on the ultrasound report done 8/11/2011, which the obstetrician read (without viewing the films) and took as fact, was endometritis and hemoperitoneum.  On exam, the obstetrician found that her abdomen was distended and tender with rebound. There was no evidence that the obstetrician made himself aware of the patient’s depressed WBC or abnormal electrolytes.  Coupled with her history and physical, the patient’s depressed WBC and abnormal electrolytes indicated sepsis. Although she was in the midst of a gynecologist emergency, the obstetrician failed to ever perform a pelvic exam on the patient.

The obstetrician ordered a CT scan.  Results were reported at 9:38 p.m. as hematoma in the endometrial cavity, diffuse intra-peritoneal free fluid, distended bowel, and intraperitoneal (inside the abdominal cavity) air bubbles.  The obstetrician received the results by telephone. The patient’s vital signs remained unstable. Despite demonstrated diffuse free fluid and air bubbles in the patient’s abdomen, the obstetrician did not consider it a surgical emergency.  The obstetrician failed to seek any surgical consult, and instead, he scheduled to perform a D&C and laparoscopy himself without surgical assistance the next day, when he normally performs surgeries.

The CT scan identified diffuse fluid in the abdomen plus air bubbles.  These findings indicated a ruptured viscus. There was no evidence that the diagnosis was considered.  Since the patient was septic with stable hemoglobins, the differential diagnosis should have explored infectious etiologies, including endometritis and appendicitis.  The patient’s hemoglobin at 11 was normal and remained stable. Her WBC was 3.1 with bands, and her bicarb was low. The nurse’s notes described a significantly distended abdomen that was firm and tender.

Although a perforation of a viscus was identified, the obstetrician ordered a soft diet for the patient until she was made NPO after midnight in preparation for the surgery.  No lab work was ordered to be taken until the next morning. The obstetrician failed to reinterpret the radiologist’s differential diagnosis to conform to known objective findings of the patient.  Instead, the obstetrician simply took the differential diagnosis provided by radiology as fact; he continued with a diagnosis of endometritis and hemoporitoneum. The obstetrician failed to evaluate the patient’s stable hemoglobin of 11 and evidence of sepsis.  The obstetrician never performed a pelvic examination, and he never proposed a plausible differential diagnosis.

Following an uncomplicated vaginal delivery without prolonged rupture of membranes, endometritis is characterized by pelvic pain accompanied by foul vaginal discharge and/or heavy bleeding.  Work-up requires a pelvic exam. Endometrial sampling is for cytology and cultures for proper diagnosis and treatment. Removal of retained secundines is often the only treatment required. In this case, a diagnosis of endometritis was made in the absence of classic symptomatology.  It was never evaluated via pelvic exam or cervical cultures. A D&C was scheduled to be after a 24-hour delay. Pathology was negative for an infectious process or retained tissue.

On 8/12/2011 at 10:00 a.m., the patient was taken for the scheduled D&C and laparoscopy.  Aware that the patient’s belly was filled with fluid, the obstetrician had nonetheless opted to do a laparoscopy without any surgical consultation and without a surgeon readily available.  A general surgeon should be present or available during any surgical intervention involving an acute abdomen with sepsis and/or a perforated viscus. The obstetrician had placed the differential diagnosis provided by radiology as the diagnosis on the surgical note even though other objective data did not support that conclusion.  The obstetrician failed to obtain informed consent for an open procedure.

Although the pathology had been negative, the obstetrician performed a D&C to obtain products of conception.  The obstetrician tried to perform a diagnostic laparoscopy, but it was precluded by adhesions and purulent fluid.  The obstetrician finally sought surgical consultation. The unplanned consultation resulted in a one-hour intra-operative delay.  When a surgeon was called to the surgery, one was not available for an hour. As a result, the patient remained under anesthesia for 4 hours total.

A general surgeon arrived. The surgeon confirmed that the patient’s appendix had burst and completed an appendectomy.  Subsequently, the obstetrician failed to perform a post-operative evaluation of the patient and failed to have her sent to an acute care unit.  Instead, following the laparotomy for a ruptured appendix with diffuse purulent fluid, the obstetrician wrote a post-operative order sending her to the medical surgical nursing unit, where the patient would receive routine post-operative care.  Critical care consultation for this septic patient with hemodynamic instability, who had just undergone four hours of anesthesia and surgery, were only requested several hours later. The patient’s monitoring results were not checked. An on-call physician assumed care of the patient at 5:00 p.m. without receiving any communication from the obstetrician.  The on-call physician, covering for the obstetrician, transferred the patient to the ICU at 10:15 p.m. that night and wrote a chart note to the obstetrician recommending that the patient’s incision be reopened in light of the known infectious process.

The following day, 8/13/2011, because of acute renal failure, a renal specialist was consulted.  A pulmonologist consultation was sought. An infectious disease consult was elicited, and further antibiotic recommendations were given at 7:20 a.m.  At the same time, the patient went into cardiopulmonary arrest and was pronounced dead at 8:00 a.m.

The Medical Board of California judged that the obstetrician’s conduct departed from the standard of care because he failed to recognize the patient’s acute abdomen and waited 12 hours to intervene, obtain a surgical consult upon admission, have a general surgeon available at surgery, properly integrate objective data when formulating a plan of treatment, and provide a prompt evaluation, diagnostic studies, interventions, and follow-up.  The obstetrician also maintained an unsubstantiated differential diagnosis in spite of contradictory evidence and the patient’s clinical course, and he failed to adequately evaluate this patient.

The Medical Board of California issued a public reprimand and ordered the general surgeon to complete a medical record-keeping course 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: April 2015


Specialty: Obstetrics


Symptom: Back Pain, Diarrhea, Fever, Nausea Or Vomiting, Abdominal Pain


Diagnosis: Acute Abdomen


Medical Error: Failure to examine or evaluate patient properly, Failure to order appropriate diagnostic test, Referral failure to hospital or specialist, Failure of communication with patient or patient relations, Improper treatment


Significant Outcome: Death, Hospital Bounce Back


Case Rating: 5


Link to Original Case File: Download PDF



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