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A 56-year-old female was referred by her primary care physician to a neurologist.  The patient’s primary care physician noted neck pain and numbness of the upper extremities, left greater than right, present for 1 year.  Her medications were lisinopril 5 mg daily, Lyrica 50 mg 3 times daily, Flexeril 10 mg 3 times daily, Mobic 15 mg daily, and Nexium 40 mg daily.  Her primary care physician noted that she had lumbar laminectomy for disk herniation in the past for low back pain and tingling of the left leg. He also noted that the MRI of her cervical spine was abnormal and requested a neurological evaluation.  It revealed an abnormal signal intensity C2-3 affecting posterior columns with the radiologist’s comment of “could account for arm numbness and tingling.” The x-ray of her cervical spine performed on 11/5/2012 ordered by her primary care physician showed moderate degenerative changes.  The x-ray of her lumbar spine performed on 2/23/2012 showed similar findings.

The neurologist first saw the patient on 12/10/2012 for the abnormal cervical spine MRI.  The patient’s complaints were “neck pain; left neck and arm numb; right arm and right knee; losing urine; and generalized weakness on the left.”  The patient also complained that she “also feels ‘dead’ hips down, [d]izzy spells several times, no energy, difficult to concentrate.” The neurologist noted the “neuro exam essentially normal.”  The neurologist’s diagnoses were demyelinating disease; paresthesias of face and her extremities, vertigo, and memory loss. The neurologist ordered the following tests: EMG/NCV lower extremities, though later she also did upper extremities; MRI of the brain; neuromuscular junction tests with EMG; BAER with vestibular testing; VEP; EEG, overnight; and EEG awake and sleep with digital analysis 95957.

The upper extremity EMG/NCV study was performed on 1/3/2013.  She tested 4 motor nerves, 5 sensory nerves, and F waves. The neurologist tested every muscle, which was present in the upper extremities.  The results of the study were normal.

The electrodiagnostic study of the lower extremities were performed on 1/10/2013.  The neurologist tested 4 motor nerves, 6 sensory nerves, 2 H reflexes, bilateral F waves of the motor nerves.  She did a needle EMG of all muscles in the lower extremities and paraspinal muscles. The results of the study were normal.

There was a report of a video-monitored EEG utilizing a 32-channel digital EEG system manufactured by Cadwell.  This test was performed on 12/26/2012. The report stated that the technician performed hyperventilation, but the patient reported she did not, and that the patient was videotaped, though the patient reported she was not.  It was read as normal.

The ambulatory EEG was performed on 2/5/2013 to 2/6/2013.  In the report, it was termed a 2-day ambulatory EEG despite lasting only 1 day.  The neurologist prepared the report. The report contained a printout of 1 page. It was timed 6:21 a.m., and it contained widespread artifacts lasting 10 seconds.  This was the exact time that the patient reported she stood in front of her microwaves. The neurologist read this as “Isolated sharp waves were noted in the frontal left hemispheric area. The isolated sharp waves may be epileptogenic in nature.”  The visual and brainstem auditory evoked potentials were normal.

On 2/26/2013, the neurologist saw the patient for a follow-up visit.  The test results were available to the neurologist at the visit. The neurologist noted that the EEG for the patient was normal for both awake and drowsy.  The neurologist also noted that the 2-day EEG, which lasted only 1 day and the MRI of the brain showed a corpus callosum lesion. Her assessment and plan contained the same diagnoses as the first visit of 12/10/2012, and she failed to consider new information that should have changed her initial diagnoses.

The neurologist did not diagnose seizures in the assessment and plan, but she prescribed Depakote.  The neurologist discussed with the patient that she met criteria for relapsing and remitting Multiple Sclerosis with an acute exacerbation.  The neurologist also noted that the patient had pain with neck movement, which was sharp and went to the toes. She believed that the symptom was consistent with the finding of the ambulatory EEG and thus started the patient on Depakote 500 mg b.i.d.  The neurologist failed to recognize Lhermitte’s sign, consistent with the myelopathy. The neurologist ordered laboratory studies for Lyme disease, lupus, and lumbar puncture. She ordered monitoring labs for Depakote, CBC, and liver function tests to be done before the next visit.

The MRI of the brain the neurologist referred to in the 2/26/2013 follow-up visit was performed at the neurologist’s request on 12/28/2012.  The report indicated 20 FLAIR hyperintensities and a possible tiny corpus callosum lesion. The neurologist concluded it was consistent with multiple sclerosis.  The 12/28/2012 report contained a comparison to a previous MRI of the brain performed on 7/1/2007. The radiologist thought the new MRI showed abnormalities “probably very slightly more numerous” than the 2007 MRI.  He further considered the appearance to be nonspecific, and the tiny lesion in the corpus callosum was considered possible.

The 2007 MRI was requested by another physician.  It was read as showing “a few nonspecific scattered punctate of unlikely clinical significance.”  Multiple sclerosis was not raised as a possible cause. Referring diagnosis was “recent vertigo and left-sided dizziness.”  The neurologist failed to question the patient on symptoms that occurred in 2007.

On 3/12/2013, the patient was seen in the emergency room for nausea and vomiting.  She was diagnosed with Depakote toxicity with a level of 108. She was told to stop the medication.  She was scheduled for the lumbar puncture the following day and was told to keep that appointment. The day following the lumbar puncture, she developed symptoms consistent with a postspinal headache.  She was seen by the neurologist in her office on the same day and diagnosed with Depakote toxicity. At this point, the neurologist erroneously believed that the patient had “definite” multiple sclerosis.  She also erroneously believed that “the patient wrongfully assumed” Depakote caused her symptoms and believed that they were from the lumbar puncture.

The neurologist next saw the patient on 3/26/2013 for an office visit.  The neurologist noted that the patient had a postspinal headache. She noted that the spinal fluid was negative for oligoclonal bands, but incorrectly thought the IgG synthesis was abnormal.  She incorrectly diagnosed “primary stabbing headache” despite her earlier entry of postspinal headache.

In a subsequent interview with a Medical Board investigator, the neurologist was questioned as to why she did not take a history of previous symptoms, such as optic neuritis, that help to establish a diagnosis of multiple sclerosis.  She was questioned if the examination was normal and why she did not check the “saddle” area for sensory loss, and she reported, “Why should I check the saddle area?” There were no “incontinence of stools.” When asked if she would have documented Lhermitte’s symptom or sign if present, she answered yes.  She obtained a history of symptoms consistent with Lhermitte’s, but did not recognize it as such. Memory loss was given as a diagnosis, but when asked how it was based, she could not recall. When asked to explain the reasons that each test was ordered, she responded that the EMG was based on symptoms, the neuromuscular test was based on the possibility of myasthenia gravis causing general weakness, the BAER and VEP as part of the multiple sclerosis work-up, and the EEG to rule out seizures as the cause of numbness and weakness.  She stated video monitoring on EEG was standard practice. Hearing loss was her reason for performing the BAER, but no hearing loss or visual disturbance was documented. She stated that the 2007 MRI showed infratentorial and supratentorial lesions whereas there was no mention of an infratentorial lesion in the radiology report. She ordered the EMG of the upper extremities to “rule out any other diseases” and stated “EMG is part of differential diagnosis,” and the indication she believed was numbness and tingling in the hands. When asked why she did 24 upper extremity and 6 cervical paraspinal muscles on EMG, she stated she wanted to make sure there was “no polyradiculopathy,” but she admitted there were no findings to suggest that diagnosis.  Further, she believed that numbness and tingling and incontinence would indicate polyradiculopathy. When questioned regarding indications for EMG of the lower extremities, she stated back problems, numbness right arm and right knee, and feeling the hips on down were “dead.” In the lower extremities, she tested 12 different muscles and 6 paraspinal muscles. She was then questioned about what were the indications for the EEG, and she believed they were generalized weakness, dizzy spells, no energy to work, and difficulty focusing. She was questioned as to why the first EEG was not sufficient. She stated that on 2/26/2013 visit, she had findings of generalized seizure disorder, but this was not the wording in the EEG report nor was it in her letter to the Board.  She was not aware that a microwave can cause artifacts. Regarding indication for Depakote, her answer was because of the EEG and numbness and tingling. She thought it would be trial and error to see if it would help. She thought that the patient’s symptom of “neck killing her” would be consistent with a multiple sclerosis plaque. When asked why she ordered Lyme disease and lupus blood tests, she stated that they were “on my mind.”

The Medical Board of California judged that the neurologist’s conduct departed from the standard of care because she failed to recognize symptoms and findings on the MRI of a partial transverse cervical myelopathy, ordered an EMG for the upper and lower extremities, video EEG, and ambulatory EEG without medical indication, conducted an excessive number of nerve tests for any diagnosis, misdiagnosed epilepsy, lacked knowledge in reading EEGs, and had no knowledge and/or did not consider the important interaction between Depakote and the patient’s other medications.  The neurologist also lacked knowledge in several fundamental areas.  She failed to recognize symptoms of a partial transverse cervical myelopathy and Lhermitte’s symptoms even though it was described to her by the patient.  She did not recognize or, if she did, did not reflect in her records that almost all of the patient’s symptoms were caused by the cervical myelopathy. The neurologist erroneously believed that a multiple sclerosis plaque could cause severe neck pain and that IgG synthesis could indicate active or inactive multiple sclerosis.  She diagnosed multiple sclerosis on the basis of the McDonald criteria, and she included the original report, but she gave no information in her records how those criteria fit the patient. She failed to question the patient for previous symptoms, which might establish an initial exacerbation of multiple sclerosis. The neurologist was aware that the patient had an MRI in 2007 and did not question the patient regarding her symptoms at that time.  She ordered laboratory studies for possible Lyme disease or “lupus” and a monophasic cervical myelopathy despite the fact that it was exceedingly unlikely to be caused by any of those disorders. She failed to consider alternative causes for the patient’s presentation, specifically B12 deficiency or adrenomyeloneuropathy.

For this case and others, the Medical Board of California placed the neurologist on probation and ordered the neurologist to complete a medical record keeping course, a professionalism program (ethics course), an education course (at least 40 hours per year for each year of probation), and a clinical training program equivalent to the Physician Assessment and Clinical Education Program offered at the University of California San Diego School of Medicine.  The neurologist was assigned a practice monitor and was prohibited from supervising physician assistants and advanced practice nurses.

State: California

Date: January 2018

Specialty: Neurology

Symptom: Head/Neck Pain, Dizziness, Headache, Nausea Or Vomiting, Numbness, Urinary Problems, Weakness/Fatigue

Diagnosis: Spinal Injury Or Disorder, Drug Overdose, Side Effects, or Withdrawal

Medical Error: Diagnostic error, Failure to examine or evaluate patient properly, Unnecessary or excessive diagnostic tests, Improper medication management

Significant Outcome: N/A

Case Rating: 4

Link to Original Case File: Download PDF

On 4/30/2013, a 54-year-old female (5’6” tall weighing approximately 210 pounds) went to a clinic for a consultation with an internist.  The patient was interested in Smart-Lipo to her chin/neck/jowls, front and back bra rolls, upper arms, inner and outer thighs, hips, waist/abdomen, knees, and pubic regions.  The patient indicated that she had previously undergone a “tummy tuck with liposuction.” The medical record did not indicate when she underwent this procedure. The patient also indicated that she suffered from diabetes and took aspirin regularly.  Smart-Lipo surgery was scheduled for 5/31/2013, and the patient paid for the surgery to be performed on the 7 areas initially requested.

That same day, the patient underwent her pre-operative procedures and testing, which included blood work, an incomplete history, and an extremely limited physical examination conducted by a Licensed Vocational Nurse (LVN).  The patient completed a two page “Medical Intake” form, a one page medication list, and a written consent form specifically for patients with a high body mass index. The LVN also completed a 2 page “Pre-Procedural Evaluation for Smart-Lipo” form that involved checking boxes and filling in blanks for vital signs and what areas would benefit from Smart-Lipo procedure.  The patient did not meet with the internist until the day of surgery.

On 5/31/2013, the internist only performed Smart-Lipo on the patient’s chin/neck, upper and lower abdomen, and pubic areas, rather than all 7 areas scheduled.  The medical records did not clearly indicate what areas the internist operated on as all seven areas were circled on a “Body Regions” form. According to the patient, when the internist first came into the surgery room, she asked the patient what procedures she was having done.  The patient told the internist “it says in the file.” The internist and her assistant then had to locate the medical file. The patient’s medical records did not include an operative report or summary written by the internist about the procedure. The records did not indicate why only 5 of the 7 areas scheduled were operated on.

The patient complained that she was in severe pain throughout the entire procedure and requested multiple times that the internist stop.  According to the patient, the internist told her this was the price of beauty and continued with the procedure. During the internist’s interview with the Medical Board on 12/9/2014, the internist did not remember if the patient complained about being in pain during the procedure, but the “Physician Charting” form indicated that the patient’s pain level was between a 6 and a 10 out of 10.  There was also a notation in the chart that when the patient complained about the 10 out of 10 pain, she was laughing. The internist said she would have stopped the procedure if the patient asked for it to be stopped and if “I thought that she was actually in pain.”

On 6/3/2013, the patient returned to the internist’s clinic for post-surgical follow-up.  During this appointment, the patient indicated that she was not sure whether she was happy with the results, that she was in pain, she was dizzy, and that she had “light bruising” to her abdomen.  The patient also noted that she had a lot of post-surgery drainage requiring her to change the bandages several times.

On 9/16/2013, the internist conducted a follow-up on the patient’s upper arms, upper abdomen, and pubic region.  The “Six-Month Follow-Up Report” indicated that the patient was still suffering from pain and was not happy with the results.  The patient wanted the internist to fix the areas that she was unhappy with, but the report did not specify if those were all the regions where the Smart-Lipo was performed or just on some of the areas.

On 11/16/2013, the patient saw the internist for the last follow-up.  During this appointment, the medical note indicated that the patient refused to allow any measurements or her weight to be taken and remained unhappy with the results.  According to the note, the patient wanted her arms to “look like [the internist’s]” and was promised that another doctor could do that. The note further stated “it is impossible to make her arms look absolutely perfect.”

During the internist’s interview with the Medical Board, she indicated that she offered to do a revision on the patient’s arms, but could not promise to make her arms look perfect.  The internist claimed that the patient rejected the revision surgery. There was no notation in the file that the internist offered the patient a revision surgery to try to correct the problems that the patient noted.  The internist refunded the patient for 2 of the 7 regions paid for that were not operated on.

The Medical Board of California judged that the internist’s conduct departed from the standard of care because she failed to maintain adequate and accurate medical records and lacked sufficient skills and knowledge to perform Smart-Lipo safely.

For this case and others, the Medical Board of California placed the internist on probation for 4 years and ordered the internist to complete a professionalism program (ethics course), a medical record keeping course, an education course (at least 25 hours per year for each year of probation), and a clinical training program equivalent to the Physician Assessment and Clinical Education Program offered at the University of California San Diego School of Medicine.  The internist was assigned a monitor for practice and billing, and she was prohibited from practicing or attempting to perform liposuction or laser skin treatments. The internist was also prohibited from supervising physician assistants.

State: California

Date: April 2017

Specialty: Internal Medicine, Plastic Surgery

Symptom: Dizziness, Pain, Wound Drainage

Diagnosis: N/A

Medical Error: Lack of proper documentation

Significant Outcome: N/A

Case Rating: 1

Link to Original Case File: Download PDF

On 9/18/2014, a 32-year-old female had a Smart-Lipo consultation with an internist.  On the patient registration form, the patient indicated that she was interested in Smart-Lipo to her upper and lower abdomen, hips, waist/flank area, back bra rolls, outer thighs, and upper arms.  She indicated that she had a history of anemia, cold sores, keloid scarring, irregular periods, and depression. On the “Smart-Lipo History Intake” form, the patient indicated that she was 5’0.5” tall and weighed 178 pounds.  Under a list of possible medical conditions that the patient had, the patient circled chest pain, recent weight loss or gain, cold sores, back pain, difficulty swallowing, depression, heart murmur, Lap-Band surgery in 2008, removal of Lap-Band in 2011, gastric sleeve in 2013, and removal of her gallbladder in 2014.  The patient indicated that she took Latuda for depression and has an ultrasound of her heart done every 5 years.

On 12/9/2014, the patient completed a second “Smart-Lipo History Intake” form.  On this form, the patient now indicated that she was suffering from anemia and “microvalve prolapse.”  She also listed her height as 5’1” with a weight of 190 pounds. On the “Pre-Operative Screening” form, the patient stated that she was taking Adderall, lansoprazole, and Latuda.  The patient’s weight was noted as 193.5 pounds with a BMI of 36.6. Measurements were also taken of the areas where surgery was to be performed. Blood was also collected for standard blood testing as well as an EKG.  The patient also completed a Smart Lipo “Pre-Operative Screening” form/High BMI consent form. The form explained what a high BMI is, what obesity is, and why an obese patient should have Smart-Lipo performed.

Also, the form stated that the patient must obtain medical clearance from her primary care provider before the internist performed the procedure.  The internist admitted during the interview with investigators on behalf of the Board that she never obtained medical clearance from any of the patient’s medical provides, despite the notation on the form.  The informed consent forms were completed by the patient and an LVN. The internist never went through the informed consent forms or discussed the risks and benefits of the surgery with the patient before the day or surgery.  The records also did not contain any documentation that the internist even discussed the risks and benefits of the surgery with the patient at any time.

On 12/16/2014, the internist performed Smart-Lipo on the patient’s hips, upper arm, upper and lower abdomen, and waist/flanks.  On the pre-printed Smart-Lipo OR Package form, it was noted that the patient “had a light meal before coming.” The NP checking in the patient did not document exactly what the “light meal” consisted of or when it was consumed.  The internist wrote that the patient had keloid scarring, but the location of the scarring was not legible. She also wrote that the patient was planning on having a tummy tuck in the future and had excessive skin laxity on her abdomen.  The internist listed the patient as ASA Category I. Prior to surgery, the pictures were taken of the patient showing “bat wing” deformity of the arms (hanging skin), truncal obesity, and smooth abdominal skin contour with small keloids.

According to the progress note, the procedure started at 1:00 p.m. and finished at 3:25 p.m.  About 30 minutes into the procedure, the patient complained of 8 out of 10 pain, and the comment portion of the note read ‘VV (2-3 sec).”  Then about an hour and twenty minutes into the procedure, the patient reported pain on a scale of 4 out of 10. During the two-hour and 15-minute surgery, the patient’s vital signs were not continuously monitored.

During the internist’s subject interview on 3/15/2016, the internist initially did not know what “VV (2-3 sec)” meant, but she eventually stated that she believed it meant the patient had a vasovagal episode, meaning she passed out during the procedure.  This is generally caused by sudden drops of blood pressure and heart rate.

According to the progress note, 10,720 ml of tumescent fluid was infused into the patient’s body, which contained 3,090 mg of lidocaine (the safe dose of lidocaine should never exceed 3,076.5 mg), and 4,240 ml of fluid was removed from the patient’s arms and abdomen, of which 1,900 ml was fat, which left 6,470 ml of tumescent fluid remaining in the patient.  The medical record failed to indicate where and how much fat was removed from each region the internist performed Smart-Lipo surgery on.

There was no indication in the medical record that the internist warmed the tumescent fluid to body temperature before infusing it into the patient.  There was also no indication in the medical record that the patient utilized compression boots during the surgery. The patient was discharged from the facility at 3:40 p.m. following a 30-minute observation period.

On 12/17/2014, the patient returned for her follow-up appointment.  She indicated that she was weak, her pain over the night was a 6 out of 10, approximately 2 cups of fluid drained from the surgical sites, and she was light headed.  It was difficult to determine from the medical record whether the internist ever saw the patient, but it did not appear that she did.

On 1/16/2015, the patient returned for her one-month follow-up appointment.  The measurements were taken, along with a height and weight. The patient still weighed 193 pounds with a BMI of 36.5.  In response to the question “How do you feel about your results”, the patient answered ‘good.”

On 6/8/2015, the patient returned for her 6-month follow-up appointment.  The patient reported that while she had seen improvements, she was not happy with the results of the Smart-Lipo surgery.  Measurements were taken along with the patient’s weight, showing a 7 pound weight gain. The internist wrote “skin laxity is an issue, will pursue tummy tuck.”  the internist did not recommend a revision surgery, and the patient never returned. According to the patient, the internist told her “she wasn’t a good candidate [for Smart-Lipo] to being with.”  She also complained that at the 6-month post-procedure mark, she gained 7 pounds, but her arms looked the same, and her stomach was deformed and protruded from her abdomen. Pictures were taken of the patient at several visits, but none of the photographs were dated making it impossible to determine the progress of the patient’s recovery.

The Medical Board of California judged that the internist’s conduct departed from the standard of care because she failed to maintain adequate and accurate medical records and warm the tumescent fluid to body temperature to avoid life-threatening arrhythmias and left an unsafe amount of fluid remaining in the patient.  The patient was not an appropriate candidate for the procedure, the internist lacked knowledge or understanding of the risks posed by infusing large amounts of tumescent fluid containing lidocaine while the patient was also taking Latuda and Adderall, a potentially fatal drug interaction.  Also, the internist failed to meet with the patient before the day of surgery to discuss the risks and benefits of the surgery with the patient and allowed an LVN to go through the informed consent process.

For this case and others, the Medical Board of California placed the internist on probation for 4 years and ordered the internist to complete a professionalism program (ethics course), a medical record keeping course, an education course (at least 25 hours per year for each year of probation), and a clinical training program equivalent to the Physician Assessment and Clinical Education Program offered at the University of California San Diego School of Medicine.  The internist was assigned a monitor for practice and billing, and she was prohibited from practicing or attempting to perform liposuction or laser skin treatments. The internist was also prohibited from supervising physician assistants.

State: California

Date: April 2017

Specialty: Internal Medicine, Plastic Surgery

Symptom: Weakness/Fatigue, Dermatological Abnormality, Dizziness, Chest Pain, Wound Drainage

Diagnosis: Post-operative/Operative Complication

Medical Error: Unnecessary or excessive treatment or surgery, Failure of communication with patient or patient relations, Failure to properly monitor patient, Improper medication management, Lack of proper documentation, Procedural error

Significant Outcome: N/A

Case Rating: 2

Link to Original Case File: Download PDF

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

A 13-year-old female was initially seen by a pediatric cardiologist on 10/28/2009 for frequent dizzy episodes.  She had an echocardiogram, which showed trivial mitral insufficiency. The patient also underwent a stress echocardiogram.  The pediatric cardiologist noted that he felt the patient did not have any cardiac condition. There was no clinical or echocardiographic suggestion of mitral valve prolapse.  The pediatric cardiologist, however, diagnosed the patient with mitral valve prolapse. He did not explore any other diagnoses.

The consultation letter to the patient’s primary care physician for the 10/28/2009 visit was not generated until 11/7/2009 and was not signed by the pediatric cardiologist until 11/9/2009.  The pediatric cardiologist saw the patient on 1/4/2012. The consultation letter, however, was not generated until 3/4/2012 and not signed by the pediatric cardiologist until 3/7/2012.

The Medical Board of California judged that the pediatric cardiologist’s conduct departed from the standard of care because he diagnosed the patient with mitral valve prolapse in the absence of clinical or echocardiographic indication, failed to explore alternative diagnoses, delayed the production of the consultation letters, and ordered a stress echocardiogram work-up for pre-syncope in a teenager with a normal cardiac examination.

For this case and others, the Medical Board of California ordered the pediatric cardiologist to surrender his license.

State: California

Date: January 2017

Specialty: Cardiology, Pediatrics

Symptom: Dizziness

Diagnosis: N/A

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

Significant Outcome: N/A

Case Rating: 1

Link to Original Case File: Download PDF

On 9/8/2011, a patient presented to an otolaryngologist on referral from another physician for a vertigo evaluation.  The patient had a 2-year history of vertigo at the time the patient was seen by the otolaryngologist.  The otolaryngologist diagnosed the patient with chronic sinusitis and septal deviation, and that the patient’s vertigo was secondary to sinusitis.  The otolaryngologist did not order audiological testing, an MRI, or vestibular testing as well as not documenting an appropriate history to support a diagnosis of vertigo.

On 10/12/2011, the patient underwent a CT scan that did not show any significant sinus disease.  On 3/1/2012, the otolaryngologist performed an endoscopic sinus surgery on the patient.  After this surgery, the patient continued to suffer from vertigo.  On 7/24/2012, the patient underwent another CT scan, which now showed left-sided maxillary and frontal sinus disease consistent with findings expected in a patient who underwent sinus surgery in the absence of chronic sinusitis.  On 11/6/2012, the otolaryngologist performed a revision endoscopic sinus surgery on the patient.  This surgery was complicated by a left-sided CSF leak.  The otolaryngologist treated the CSF leak but did not admit the patient to the hospital.  After the surgery, the otolaryngologist documented that the patient continued to have chronic sinusitis.

On 8/14/2012, the patient underwent another postoperative CT scan that revealed findings consistent with previous endoscopic medial maxillectomy surgery, not endoscopic sinus surgery.  Despite the absence of CT findings consistent with chronic sinusitis, the otolaryngologist recommended that the patient undergo another sinus surgery, but that surgery was ultimately canceled.

The Medical Board of California judged that the otolaryngologist committed gross negligence in his care and treatment of the patient given that he failed to consider other etiologies or pursue further evaluation of the patient’s vertigo and performed endoscopic sinus surgery on the patient without an appropriate medical indication.  The otolaryngologist also failed to admit the patient to the hospital after she suffered a CSF leak during endoscopic surgery.

For allegations in this case and others, the Medical Board of California requested a hearing be held for the otolaryngologist and issue a decision on permanent revocation or suspension of his license, revoking or denying approval of his authority to supervise physician assistants, placing him on probation, or taking other and further action as deemed necessary and proper.

State: California

Date: December 2016

Specialty: Otolaryngology

Symptom: Dizziness

Diagnosis: Ear, Nose, or Throat Disease, Post-operative/Operative Complication

Medical Error: Unnecessary or excessive treatment or surgery, Failure to order appropriate diagnostic test, Referral failure to hospital or specialist, Lack of proper documentation

Significant Outcome: N/A

Case Rating: 2

Link to Original Case File: Download PDF

On 10/27/2011, a patient presented to an otolaryngologist on referral for a vertigo evaluation. The otolaryngologist noted additional symptoms of bilateral tinnitus, migraine headaches, post-nasal drip, and pus inside patient’s nose.  The otolaryngologist diagnosed the patient with chronic sinusitis and ordered hypertonic saline solution and Afrin spray to treat the patient’s diagnosis of chronic sinusitis.  The otolaryngologist did not order audiological testing, an MRI, or vestibular testing and did not document an appropriate history to support a diagnosis of vertigo.

On 12/6/2011, the patient underwent a CT scan that did not show any significant sinus disease.  Despite these negative findings, the otolaryngologist recommended endoscopic sinus surgery.  On 3/6/2012, the otolaryngologist performed an endoscopic sinus surgery on the patient, which was complicated by right-sided CSF leak.  The otolaryngologist attempted to repair the leak intra-operatively.  On 3/7/2012, the otolaryngologist saw the patient postoperatively and noted signs of an active right-sided CSF leak.  The otolaryngologist recommended saline irrigation and Afrin spray as needed.  The patient developed post-operative nasal polyps as a result of the otolaryngologist’s sinus surgery.

The Medical Board of California judged that the otolaryngologist committed gross negligence in his care and treatment of the patient given that he failed to consider other etiologies or pursue further evaluation of the patient’s vertigo, appropriately diagnose chronic sinusitis, and admit the patient to the hospital after suffering a CSF leak during endoscopic sinus surgery.

For allegations in this case and others, the Medical Board of California requested a hearing be held for the otolaryngologist and issue a decision on: permanent revocation or suspension of his license, revoking or denying approval of his authority to supervise physician assistants, placing him on probation, or taking other and further action as deemed necessary and proper.

State: California

Date: December 2016

Specialty: Otolaryngology

Symptom: Hearing Problems, Dizziness, Headache

Diagnosis: Ear, Nose, or Throat Disease, Post-operative/Operative Complication

Medical Error: Unnecessary or excessive treatment or surgery, Failure to order appropriate diagnostic test, Referral failure to hospital or specialist

Significant Outcome: N/A

Case Rating: 3

Link to Original Case File: Download PDF

On 11/17/2008, a family practitioner first began treating the patient.  The family practitioner treated the patient for anxiety, panic disorder, neuropathic pain from an old left thigh stab wound, post-traumatic stress disorder, bipolar disorder, chronic insomnia, obesity, and hypothyroidism.

On 7/18/2013, the patient was seen in an emergency department.  The laboratory results from that visit indicated that the patient had a very low platelet count of 63,000 versus a normal platelet count of 140,000 to 150,000.  The laboratory results also stated that the mean corpuscular volume (MCV) was found to be 106.6.  The MCV is the average volume of red cells in a specimen.

On 7/19/2013, the patient was treated by the family practitioner.  The medical notes for that visit state that the patient “returns for follow up on an ER visit yesterday for abdominal pain.”  The notes also state, “Labs reveal macrocytic RBC indices.”

Red blood cell (RBC) indices are part of the complete blood count (CBC) test.  The indices also include MCV, hemoglobin amount per red blood cell (MCH), and the amount of hemoglobin relative to the size of the cell (hemoglobin concentration) per red blood cell (MCHC).

The MCV, MCH, and MCHC were all recorded in the patient’s laboratory results from the 7/18/2013 emergency department visit.

On 8/9/2013, the patient commenced treatment for rheumatoid arthritis by using the drug Enbrel, which was prescribed by the family practitioner, even though Enbrel can cause a low platelet count and even though the family practitioner knew or should have known that as of 7/19/2013, the patient’s platelet count was low.

On 10/8/2013, the patient informed the family practitioner that another clinic treating the patient noted that the patient’s platelet count was dropping and advised the patient to go directly to the hospital for a blood draw.  The family practitioner then discontinued the patient’s use of Enbrel, writing, “discussed fact that thrombocytopenia is a rare but recognized adverse side effect of Enbrel treatment.”

Additionally, any patient treated with Enbrel should have a Tuberculosis (TB) skin test prior to commencing therapy in order to confirm the absence of disease.

Contrary to standards, the family practitioner provided no documentation for the required pretreatment negative tuberculin skin test prior to the commencement of treatment with Enbrel.  In fact, not until 9/17/2014, more than one month after treatment with Enbrel commenced, was a negative TB skin test noted in the patient’s medical record.

On 10/18/2011, the family practitioner noted in the patient’s medical records that the patient was positive for hepatitis C.  Yet, the family practitioner never referred the patient to a liver specialist for hepatitis C.

The family practitioner allowed the patient to dictate the treatment by prescribing, on multiple occasions, medications that the patient had requested.

On 7/8/2009, the family practitioner prescribed clonidine for the patient for insomnia.  Clonidine is a drug normally used to treat hypertension, but it has been effectively used in low doses to treat insomnia in children on ADHD medications.  At that time, the patient’s blood pressure was charted as 110/60.

On 7/15/2009, the family practitioner discontinued the patient’s use of clonidine when the patient reported that the medicine was not effective for sleep and that it caused dizziness.  On that same date, the patient’s blood pressure was charted as 80/60.

Between 7/8/2009 and 7/15/2009, the patient was using the following medications with the family practitioner’s knowledge: fluoxetine, diphenhydramine, clonidine, and olanzapine.

On 8/16/2011, the family practitioner prescribed Saphris for the patient for insomnia, even though insomnia is a known side effect of Saphris.  By 9/9/2011, the patient stopped taking Saphris after claiming to have developed a tolerance for the medication.

The Board judged the family practitioner’s conduct as having fallen below the standard of care for multiple patients given failure to record a physical exam in the progress notes, failure to revise and update assessments or plans for those patients, and failure to include a problem list or medication list in his progress notes.

The family practitioner was placed on probation for 5 years with the stipulations of completing 40 hours annually of continuing medical education in the areas of deficient practice, a prescribing practices course at the Physician Assessment and Clinical Education Program, a medical record keeping course, an ethics course, a clinical training program equivalent to the Physician Assessment and Clinical Education Program, and undergo clinical practice monitoring.

State: California

Date: November 2016

Specialty: Family Medicine, Internal Medicine, Psychiatry

Symptom: Psychiatric Symptoms, Dizziness

Diagnosis: Drug Overdose, Side Effects, or Withdrawal, Psychiatric Disorder

Medical Error: Improper medication management

Significant Outcome: N/A

Case Rating: 2

Link to Original Case File: Download PDF

In October of 2012, a 48-year-old obese man with a history of cardiomyopathy presented to Cardiologist A with dizziness.  An echocardiogram revealed normal left ventricular (LV) function and no significant valvular disease.  A nuclear scan showed normal LV function with an apical perfusion defect.  On an exercise stress test, the patient achieved 12 METS and reached a peak heart rate of 164 beats per minute.  An EKG revealed sinus rhythm with a rate of 60 beats per minute.  A Holter monitor revealed nighttime bradycardia.  Cardiologist A recommended a pacemaker and was referred to Cardiologist B.  Cardiologist B implanted a pacemaker.

The Board judged Cardiologist B’s conduct to be below the minimum standard of competence given failure to conduct a thorough evaluation prior to pacemaker implantation and given failure to justify implantation of a pacemaker.

On review of other patient charts, the Board noted that Cardiologist B lacked fundamental EKG reading skills.

The Board ordered the cardiologist be reprimanded and take 6 hours of continuing education in EKG interpretation.

State: Arizona

Date: August 2016

Specialty: Cardiology

Symptom: Dizziness

Diagnosis: Cardiovascular Disease

Medical Error: Unnecessary or excessive treatment or surgery, Failure to order appropriate diagnostic test

Significant Outcome: N/A

Case Rating: 3

Link to Original Case File: Download PDF

In July of 2012, an 83-year-old man with hypertension and COPD presented to Cardiologist A with dizziness and fall of unknown etiology.

In 2008, the patient had a normal EKG.  In 2009, he had a normal nuclear perfusion scan.

In May 2012, the patient’s primary care physician ordered a Holter monitor, which revealed sinus rhythm of 60-70 beats per minute during the daytime and 50 minutes during the nighttime.  No critical bradycardia was noted.

In August 2012, a follow-up EKG was performed, which revealed an episode of supraventricular tachycardia (SVT) at a rate of 130 beats per minute.  Cardiologist A recommended a pacemaker and referred the patient to Cardiologist B.

The Board judged Cardiologist B’s conduct to be below the minimum standard of competence given failure to conduct a thorough evaluation prior to pacemaker implantation and given failure to justify implantation of a pacemaker.

On review of other patient charts, the Board noted that Cardiologist B lacked fundamental EKG reading skills.

The Board ordered the cardiologist to be reprimanded and take 6 hours of continuing education in EKG interpretation.

State: Arizona

Date: August 2016

Specialty: Cardiology

Symptom: Dizziness

Diagnosis: Cardiovascular Disease

Medical Error: Unnecessary or excessive treatment or surgery

Significant Outcome: N/A

Case Rating: 3

Link to Original Case File: Download PDF